How Effective Is AIDS Education?

June 1988

NTIS order #PB88-243530
The impact of AIDS on the Nation’s health and health care resources continues

unabated. Congress has responded to the AIDS crisis with large increases in Federal funds for

basic and applied research and education, and has begun to grapple with the difficult issues

involved in financing AIDS-related health care. AIDS is also appearing on the agenda of an

increasing number of congressional committees and raises numerous important issues that will

require further congressional attention and decisions. These developments led to a

recommendation by OTA’s Technology Assessment Board, with encouragement from the

Legislative Subcommittee of the House Appropriations Committee, that OTA provide assistance

on AIDS-related issues to the Congress on a sustained basis.

This third paper in OTA’s series of AIDS-related issues reviews what is known about

the effectiveness of AIDS education for the general population and for people with certain

behaviors that put them at high risk of becoming infected with the AIDS virus. AIDS

education consists of communicating how the virus is and is not spread, counseling people to

change behaviors that put them at high risk of becoming infected, and perhaps testing for HIV

infection and providing devices such as condoms or bleach to prevent infection. This paper

summarizes what is known about the effectiveness of AIDS education programs and programs in

other health-related areas. Also documented are AIDS education programs currently being

funded by selected Federal agencies. What is known and not known about the effectiveness of

past education can guide the design of future AIDS education and the research agendas of

Federal agencies.

The preceding Staff Papers in this series were: Do Insects Transmit AIDS?

(September 1987) and AIDS and Health Insurance - An OTA Survey (February 1988)(see inside

back cover for information on how to order these publications). A subsequent Staff Paper, The

Impact of AIDS on the Kaiser Permanente Medical Care Program (Northern California Region),

will analyze the cost impact of the AIDS epidemic on one of the largest prepaid health care

systems in the country. Previous OTA reports addressing AIDS-related issues include: 1) Blood

Policy and Technology (January 1985), 2) Review of the Public Health Service’s Response to

AIDS (Technical Memorandum, February 1985), and 3) The Costs of AIDS and Other HIV

Infections: Review of the Estimates (Staff Paper, May 1987).

JOHN H. GIBBONS

Director
HOW EFFECTIVE IS AIDS EDUCATION?

Health Program

Office of Technology Assessment

U.S. Congress

Washington, D.C.

May 1988

A Staff Paper in OTA’s Series on

AIDS-Related Issues

The views expressed in this Staff Paper do not

necessarily represent those of the Technology

Assessment Board, the Technology Assessment

Advisory Council, or their individual members.
OTA Staff Paper-- How Effective Is AIDS Education?

Project Staff

Jane E. Sisk, Study Director

Maria Hewitt, Analyst

Kelly L. Metcalf, Research Assistant

Clyde J. Behney, Health Program Manager

Other Contributing Staff

Carol Ann Guntow, P.C. Specialist

Katherine Eddy Cox, Research Assistant

Virginia Cwalina, Administrative Assistant

Karen T. Davis, Secretary/Word Processor Specialist

Carolyn Martin, Clerical Assistant

Contractors

Thomas J. Coates, Ronald D. Stall, Colleen Hoff,

University of California, San Francisco

Don Des Jarlais, Narcotic and Drug Research, Inc.

Jill G. Joseph, University of Michigan

Douglas Kirby, Center for Population Options

Stephen Margolis, Margolis & Associates
CONTENTS

Chapter Page

1. Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....... 1

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Summary of Findings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

2. Effectiveness of Educational Interventions to Change Risky Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Certain Practices of Homosexual and Bisexual Men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

IV Drug Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Certain Practices of Heterosexual Adults. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Certain Practices of School-Age Youth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

3. Education for the General Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

The General Population and Risk Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Public Knowledge and Attitudes Towards AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Goals of AIDS Education for the General Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Educational Interventions Specific to AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Other Public Education Programs ..........................................................................................62

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Appendix

A. Recommended Behavior Changes and Principles of Health-Related Behavior ......................67

B. AIDS Education Funded by the Federal Government . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

C. Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... 111

Tables

Table

2-1.

2-2.

2-3.

3-1.

3-2.

B-1.

B-2.

B-3.

B-4.

Page

Effectiveness of Educational Interventions Targeted to IV Drug Users . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Effectiveness of Educational Interventions Targeted to Attendees of

Sexually Transmitted Disease Clinics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Effectiveness of AIDS and Sexuality Educational Interventions

Targeted to Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Selected Studies of HIV Seroprevalence in the U.S. Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Knowledge Regarding Human Immunodeficiency Virus (HIV) Transmission

from the National Health Interview Survey by Race . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

AIDS Education Programs Funded by Alcohol, Drug Abuse, and Mental

Health Administration (ADAMHA), May 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

AIDS Education Programs Funded by the Centers for Disease Control

(CDC), May 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

AIDS Education Programs Funded by the Department of Defense (DoD),

May 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

AIDS Education Programs Funded by the Department of Education,

May 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
CONTENTS (cent’d)

B-5. AIDS Education Programs Funded by Health Resources and Services

Administration (HRSA), May 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

B-6. AIDS Education Programs Funded by the National Institutes of

Health, May 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

02

03

B-7. AIDS Education Programs

Secretary for Health, May

Figures

Figure Page

3-1. U.S. Condom Sales, 1981-1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

3-2. Calls to the National AIDS Hotline, September 1987-January 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

3-3. CDC PSAs Aired on Television, October 1987-January 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

3-4. News Media Coverage of AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
1. SUMMARY

INTRODUCTION

Blood, semen, and vaginal fluid are the

principal routes through which the human

immunodeficiency virus (HIV), which causes

acquired immunodeficiency syndrome (AIDS)

and other disease symptoms, is transmitted

from an infected to a previously uninfected

person. Since testing blood donations began

in 1985, a person in the United States becomes at risk of infection chiefly by engaging

in practices that transfer these substances

from an infected person, through sexual behavior or by sharing equipment associated

with intravenous (IV) drug use. Similarly,

infected women may transmit the virus to

their babies during pregnancy or shortly after

birth. HIV appears to be much more difficult to transmit per exposure than other

sexually transmitted diseases, such a s

gonorrhea, or than other blood-borne diseases, such as hepatitis B. 1 HIV also appears

to be much more deadly than these other diseases. In slightly over 7 years, as many as 36

percent of homosexual men with HIV infection have developed outright AIDS, and an

additional 40 percent have developed other

symptoms of disease (90). By May 1988, at

least 92 percent of the people with AIDS

diagnosed during 1981 had died (192).

Ever-increasing knowledge of HIV indicates not only the gravity of this newlydetected disease but also the means to check

its spread.

infectious

infections

individuall

Unlike the control of some other

diseases, prevention of new HIV

lies largely within the control of

s and their behaviors. As is the

1 Researchers have estimated that the chance of transmitting HIV from an infected man to an uninfected woman

during each episode of sexual intercourse is 1 in 500 (88).

Following a needlestick involving an infected person, a

health care worker’s risk of becoming infected ranges from

6-30 percent for hepatitis B virus compared with less than

1 percent for HIV (180).

case for other sexually transmitted diseases

(STDs), governments and communities using

educational interventions can also play important roles in HIV control by communicating

information, fostering social support, and

providing the means for people to change and

maintain certain behaviors. At present, control of HIV infection, however, depends

mainly on the personal behavior of individuals.

This situation has led public health officials in the United States, the World Health

Organization, and many foreign countries to

stress education as the means to prevent further spread of HIV. Health education is a

component of health promotion and disease

prevention (1 17). Education regarding AIDS

clearly includes the communication of information about how HIV is and is not transmitted and how to stay healthy or, if a person

is already infected, how to avoid transmitting

HIV to others. As used in this staff paper,

the term AIDS education may also entail

other activities to support behavioral changes

related to disease prevention, such as testing

to determine HIV antibody status and provision of devices, including condoms to reduce

viral transmission through sexual behavior or

bleach to reduce transmission through needlesharing. Excluded from consideration here

are aspects of prevention that do not relate to

people’s voluntary behavior, such as research

to develop vaccines and screening of the

blood SUPPlY. Education and individual behavior change are clearly important in the

absence of effective medical interventions to

prevent or cure HIV infection and AIDS. As

shown by the history of and recent rise in

syphilis rates, education and individual behavior will remain important even after effective preventive and therapeutic measures

have been developed.
2 ● How Effective Is AIDS Education?

AIDS education has two purposes. First,

educational programs are intended to influence people to adopt or maintain behaviors

that prevent HIV transmission. This purpose

applies to AIDS education for all groups, including efforts directed to people with risky

behaviors and to the general population,

which consists mostly of people at low risk.

By changing their risky behaviors, people

who are already infected can avoid transmitting the virus to others, and people who are

not infected can protect themselves from the

virus. Communicating accurate information

on how HIV is spread and how to prevent

transmission, providing the skills to effect

desired behavior changes, and offering support for new behavior are methods to further

this goal.

The second purpose of educational programs is to maintain and promote social

cohesion, a goal that relates mainly to education for the general population. Correcting

misconceptions about transmission and conveying information on how HIV is and is not

spread are intended to relieve anxiety among

people at little or no risk and to further the

second goal. Possible changes in response to

more accurate information include changes in

knowledge about AIDS and changes in attitudes and behavior towards people who may

be infected.

This OTA staff paper reviews what is

known about the effectiveness of education

for the general population and for people

with certain behaviors that put them at higher risk of HIV infection: certain male

homosexual practices, IV drug use, certain

heterosexual practices among adults, and

certain practices among school-age youth.

The remainder of this chapter summarizes the

findings and discusses their implications for

further work. The body of the paper reviews

what is known about the effectiveness of education among the four groups with risky behaviors and among the general population.

Appendix A contains an overview of behaviors associated with HIV transmission and

principles of health behavior that may be applied to AIDS education. Append ix Balescribes studies related to AIDS education that

are currently being funded by the Federal

Government. Appendix C acknowledges the

valuable assistance of many individuals in

preparing this staff paper.

SUMMARY OF FINDINGS

Changes in Knowledge and

Behavior

The General Population

Considerable changes in knowledge and

behavior have occurred in the United States

since 1981 when the first AIDS cases were

diagnosed here. By mid 1987, virtually

every adult was aware of AIDS, and all but a

few percent knew the major means of spread

(50). The growth in knowledge among the

general population testifies primarily to the

ability of the mass media, chiefly television,

to communicate information.

Despite these changes, however, the general population continues to hold substantial

misconceptions about HIV transmission

(18,50). Many of these misconceptions relate

to infection through routine activities, such as

believing that a person can become infected

by working near someone with AIDS. Other

misconceptions relate to preventive measures,

such as not knowing that using condoms and

spermicide can prevent infection. A persistent misconception is that one can become infected by donating blood. Accurate improved knowledge has not necessarily been

associated with effective changes in behavior.

It may be appropriate that only a small portion of the general population has reported

changing behavior in order to prevent HIV

infection, since most people are at little or no

risk. Most of the changes that people have

reported, however, are ineffective, such as

avoiding public places. People who may consider themselves at greater risk--blacks,

young adults, and single people--have expressed more concern about AIDS and

reported more behavior change, in both ef -
How Effective Is AIDS Education? ● 3

fective and ineffective ways. People reporting any change in sexual behavior were in the

minority, but the percentage was sizable: 25

percent among blacks, 16 percent among

young adults, and 16 percent among single

people ( 18). Particularly noteworthy is the

finding that decreases in people’s misconceptions about HIV transmission paralleled

declines in their support for governmental

restrictions on people with AIDS, such as

quarantine or mandatory testing (18).

People With Risky Behaviors

Dramatic behavioral change has occurred

among homosexual males in response to the

AIDS epidemic (37). In San Francisco, one

study recorded that from 1985 to 1987 the

proportion of homosexual men who engaged

in receptive anal intercourse fell from 34

percent to 8 percent, and the proportion who

engaged in insertive anal intercourse fell from

37 percent to 3 percent (68). 2 By 1988, less

than 2 percent of uninfected homosexual men

were becoming infected annually. Reports

from other areas where the prevalence of

HIV infection is lower (e.g., Los Angeles,

Chicago, Baltimore, Pittsburgh) showed that

as of 1986-1987, 55 percent of mal e

homosexuals continued to engage in insertive

anal intercourse, and 48 percent in receptive

anal intercourse (78), sometimes despite

knowledge regarding safer sex (202). Although more recent data on risk behaviors are

not available from these areas, annual rates of

new HIV infections among homosexual men

enrolled in epidemiological studies are about

1 percent (150), rates comparable to the low

rates recorded in San Francisco.

Many IV drug users had learned about

AIDS from the mass media and from the oral

communication networks within the drug-use

2 Information on these and other changes in risky behaviors is typically based on reports from the respondents

themselves. The validity of such self-reported behavior

change is unknown. People may respond to surveys with

the answers that they believe others want, or people may

not practice the new behavior consistently or maintain it

over time. Self-reports of high-risk sexual behavior and

drug use, however, have been correlated with HIV infection

(56,220).

subculture by as early as 1983, prior to the

implementation of official education programs, and by 1984, had begun to change

some AIDS-related behaviors (56,58). In

New York City, for example, more than half

of a group of methadone patients reported

that they had made some change in their injection behavior. Few (14 percent), however,

reported having changed their sexual behavior

(82).

Where the prevalence of HIV infection

among IV drug users is high (e. g., the

prevalence of infection in the New York City

area may be as high as 60 percent (1 85),

reductions in risky drug-use behaviors may

have occurred too late or may be insufficient

to stem sharply the spread of the infection

within the IV drug use community. As most

IV drug users are male heterosexuals (56),

their lack of adherence to safer sexual practices may cause their female partners to become infected. IV drug users report more

changes in sexual behavior with casual sexual

contacts (e.g. , use of condoms wit h

prostitutes) than with partners with whom

they have a long-term relationship (56). This

may, in part, be explained by evidence suggesting that when IV drug users who have

learned that they are HIV antibody positive

have attempted to adopt safer sex practices,

such as condom use, with their long-term

partners, the relationship has been disrupted

(29). This finding is of concern because it is

within the long-term relationship that children are likely to be conceived, and potentially infected with HIV, because contraception is often not practiced (56).

There is virtually no reliable information

on the prevalence of high-risk behaviors

among heterosexuals, and for heterosexuals at

risk, on their level of AIDS-related knowledge and attitudes. One San Francisco survey

suggests that as many as 17 percent of adult

residents there are at risk for AIDS by virtue

of their multiple or high-risk sex partners.

Results from this survey show that those at

risk do not perceive themselves to be at risk;

although many respondents reported sex partners in AIDS risk groups, less than one-third

reported feeling personally threatened by
4 ● How Effective Is AIDS Education?

AIDS, and only one-fifth had sought information on how to reduce their risk of getting AIDS (38). Many heterosexuals at risk

for AIDS may be served by public STD

clinics, Although these sites have been

targeted for AIDS educational and testing activities, little is known regarding the AIDSrelated knowledge and behaviors of STD

clinic attendees ( 123). Similarly, although

reproductive-age women attending family

planning clinics have been targeted for AIDSrelated educational activities, there is very

little information available regarding this

group’s characteristics and specific risk factors that can be used to guide those designing

AIDS educational programs.

Studies of HIV seroprevalence (the

presence of HIV antibody in the blood) and

AIDS risk factors among female prostitutes

have shown that IV drug use is their major

risk factor for HIV infection. In fact, HIV

infection in non-drug using prostitutes tends

to be low or absent. Many prostitutes have

routinely used condoms with their customers

since the 1970s in response to concerns

regarding herpes infections and other sexually

transmitted disease. Barrier contraception,

however, is generally not used with steady

sexual partners who may be HIV-infected

(157).

Teenagers engage in both sex and drug

behaviors that can transmit the HIV virus.

For example, teenagers acquire more than

one-quarter of the annual 20 million cases of

STDS. Surveys have found adolescents very

knowledgeable about how HIV is transmitted,

but they are much less likely to know how

HIV is not transmitted (11 2). Few students

reporting sexual activity appear to be changing their sexual behavior because of the

threat of AIDS, and of those who are, few

have implemented effective changes. Of particular concern are youths at relatively high

risk by virtue of a history of sexually transmitted disease and involvement in prostitution

or IV drug use. Little information is available on black and Hispanic youth, but one

survey found them less knowledgeable than

whites about HIV transmission (62).

Effectiveness of Educational

Interventions

For AIDS education and for education in

related areas of health behavior, efforts to

judge the effectiveness of interventions have

been handicapped by program designs that do

not lend themselves to evaluation. Many factors besides a particular educational program

are likely to influence a person’s knowledge,

attitudes, and behavior. To gauge the effectiveness of a specific program requires

separating the effects of the program from

the effects of other factors. Research methods call for comparing changes within a

group that received an intervention (the experimental group) with changes within a

comparable group that did not (the control

group). Alternatively, researchers may

evaluate different educational strategies by

comparing changes among groups tha t

received different interventions. Rarely have

such research designs been applied to evaluate

AIDS education for the general population or

for people with certain risky behaviors.

Perhaps it is not surprising that early

AIDS education programs lacked rigorous research designs. Faced with a new and usually

fatal disease, the immediate concern of organizations funding programs and public health

workers implementing them was to curtail the

spread of HIV infection. As a result, however, knowledge about the effectiveness of

particular programs and of specific elements

of programs has been slow to accumulate.

The dearth of basic information on sexual

behaviors in the United States has exacerbated the situation. Some Federal agencies, such as the National Institute on Drug

Abuse (NIDA) and the National Institute of

Mental Health , are requiring some of their

AIDS education programs to include evaluations that conform to principles of research

methodology (see appendix B).

General Population

Although substantial gains in AIDSrelated knowledge and behavioral change
How Effective Is AIDS Education? ● 5

occurred within both the general population

and among AIDS risk groups prior to the implementation of AIDS educational interventions, the experience of programs related to

HIV transmission and to other public health

concerns suggests that education has the

potential to promote further changes in

knowledge and behavior.

Although several public health campaigns

for the general population have not produced

the behavior change desired, others have

shown that education through the mass media

can change health-related beliefs and behaviors. Use of the mass media achieved success

in reducing smoking prevalence and in reducing people’s risk of cardiovascular disease

(69,75). Furthermore, the effectiveness of an

educational program has been greater when

the use of mass media has been supplemented

with interpersonal communication and development of skills to implement new beliefs

and motivations.

As illustrated by dissemination of AIDS

information, the media can set a social

agenda, that is, their coverage can heighten

public awareness of an issue and stimulate

people to ponder and discuss it. Factual information provided by the media can reduce

misconceptions and fear about HIV transmission and can alert people with risky behaviors

to their susceptibility and direct them to more

detailed information. Media presentations

can also legitimize efforts to reduce the

stigma associated with HIV infection and to

prevent further spread of HIV.

A particular problem regarding AIDS education is the skepticism that people have

reported about messages from public health

experts (147). A survey to be conducted by

the National Center for Health Statistics in

June 1988 will collect information on the

public’s perception of the credibility of AIDS

information from Federal public health officials. Like other health education to promote

behavior change, AIDS education also faces

the problem of retaining people’s interest and

maintaining safer behaviors over time.

Certain Sexual Practices of Homosexual and

Bisexual Men

Community-based educational approaches

to controlling HIV transmission seek to provide people with information, skills, and social support conducive to adopting behaviors

that will reduce the spread of infection.

Some analysts have attributed the dramatic

changes in sexual norms within the San Francisco homosexual community in part to

community-based AIDS risk reduction programs. At least six elements characterize the

model: 1) strong leadership from within the

homosexual community; 2) market research

techniques to identify appropriate messages

and communication channels for reaching the

target audience; 3) implementation of programs to inform and motivate targe t

audiences; 4) a focus on facilitating social and

cultural change; 5) reliance on multiple channels of communication, including both media,

such as print and broadcast, and face-to-face

interventions; and 6) broad-scale, grass-roots

participation in program design and implementation (37). At the same time, continual

research documented initial levels of highrisk behaviors, changes over time, and factors

related to failure to change.

Unfortunately, there is limited evidence

to link any aspect of the program to the behavioral change observed. Furthermore,

given the unique composition of the San

Francisco homosexual community, even if the

model was found to be successful there, it

might not be applied successfully in areas

where homosexuals are not open about their

sexual orientation and do not identify with

the homosexual community. On the other

hand, the success of San Francisco’s

community-based program is consistent with

the results of similar programs to reduce

pregnancy among teenagers and to reduce

cardiovascular risk among the general population, as described below. The results of

evaluations of six CDC-funded AIDS Community Demonstration Projects and several

Innovative Projects for Risk Reduction

should provide some information on the
6 ● How Effective Is AIDS Education?

effectiveness of community-based programs

implemented in other geographical areas (see

appendix B).

There is some evidence that homosexual

men who have learned that they are HIV

antibody positive through voluntary testing

programs have reduced risky behaviors more

than men who have learned that they are

seronegative or who have remained unaware

of their antibody status (35,1 33,216). Not all

studies, however, report a positive effect of

HIV antibody notification; some indicate that

those learning of positive HIV antibody status

increase risky sexual behaviors (104). Moreover, some mental health problems may be

associated with learning of one’s positive test

results (105). In low prevalence areas, tracing

the sexual contacts of those testing positive

and offering them counseling and testing may

help identify individuals unaware that they

are at risk. Behavioral followup could be incorporated into such programs to see if they

are, in fact, successful in reducing high-risk

behavior.

Special interventions are needed to assist

those having difficulty adopting or maintaining safe sexual practices. Multi-session,

face-to-face programs show promise (108,37);

however, longitudinal studies will be needed

to assess their long-term impact on risk behaviors.

The Federal Government is funding

several studies that examine the effects of

HIV testing on behavior. For example, this

issue is being considered in the CDC’s AIDS

Community Demonstration Projects and AIDS

Prevention Projects (see appendix B).

IV Drug Use

The most effective method for IV drug

users to avoid HIV infection is to stop injecting drugs, and for most, this requires formal

treatment. The longer a person spends in

treatment, the greater have been the reductions in IV drug use (56). A New Jersey

program that provided vouchers for treatment

was successful in getting many IV drug users

into long-term treatment (56). Furthermore,

the program brought young black males into

treatment , a group previously un -

derrepresented in the State treatment system

because of financial barriers (99).

Although the threat of AIDS appears to

be motivating IV drug users to enter treatment, further research on the long-term outcomes of drug treatments is needed. NIDA is

currently funding programs targeted to IV

drug users in treatment as well as out of

treatment. Some programs will chart the natural history of drug use, others will evaluate

interventions to curtail the practice (see appendix B).

A shortage of treatment programs has

prevented some IV drug users from entering

treatment, and some have rejected treatment

as an option. For drug users who continue to

inject, alternative approaches to reducing

HIV transmission are to distribute bleach that

IV drug users can use to clean their equipment and to exchange their used needles for

sterile ones. Almost half the IV drug users in

a San Francisco project reported using bleach

that was distributed (31 ). It is not clear from

the study design and the information available, however, whether using bleach slowed

HIV spread. Needle-exchange programs have

not been officially attempted in the United

States. The results from other countries suggest that use of such programs has increased,

but do not indicate whether providing sterile

needles has slowed HIV transmission. Since

new infections have occurred in areas where

only bleach distribution has been tried, researchers have suggested evaluating a combined program of bleach distribution and

needle exchange (31 ).

Some uncertainty exists regarding the

impact of IV drug users’ learning of their

HIV antibody status. In some areas, IV drug

users who knew their positive antibody status

showed greater risk reduction than those testing negative (29,42). In other areas, however,

after an educational program, IV drug users

in treatment reduced their risky behaviors,

and the behavior changes occurred irrespective of the drug user’s antibody status or

awareness of the results of the HIV antibody
How Effective Is AIDS Educatiotl? ● 7

test ( 125). More long-term followup is required to understand fully the impact of HIV

testing in different areas. When testing is

available, programs to assist those IV drug

users identified as positive to seek ap -

propriate medical care and to minimize risk

to others are needed. Preliminary data from

one study showed significant changes in the

use of condoms with in long- term relationsips when one-on-one counseling was

provided to infected IV drug users and their

primary sexual partners ( 125).

NIDA is funding several projects to

study HIV testing and the IV drug user. This

well - designed research incorporates experi -

mental and control groups, which will permit

analysis of the effects of the interventions.

Some projects will be evaluated individually

as well as by

appendix B).

Certain Pract

No form

an independent organization (see

ices of Heterosexual Adults

al evaluations of AIDS educational programs implemented within clinics

serving high-risk heterosexuals are available.

Data are available, however, from evaluations

of STD-related educational programs implemented within STD clinics. Although one

would expect patient motivation to change

behavior in the face of a treatable STD to be

less than the motivation to change in the face

of a fatal illness such as AIDS, some of the

findings from evaluations of STD educational

interventions may be relevant to AIDS intervent ions.

The results of evaluations of educational

interventions in STD clinics suggest that special educational interventions can improve

knowledge and can affect attitudes toward

preventive behavior. Person-to-person interviews appear to be more effective than other

methods, such as the use of videotapes and

special educational materials. Results have

not been encouraging from studies that have

attempted to measure actual changes in risk

behavior attributable to an educational program. For example, neither distribution of

free condoms nor special counseling was effective in reducing STD reinfection (46,171).

Provider performance, however, has i n -

fluenced patient compliance with a recommendation to return to clinic ( 11 8). Given

that the provider-client interview appears to

be a preferred medium of communicating

STD information and that the performance of

the counselor affects client compliance,

resources may be effectively used to ensure

the quality of providers of AIDS and STD

services (e. g., comprehensive training, continued education opportunities, interventions

aimed at reducing provider stress and

burnout). Developing and providing interventions that are sensitive to cultural differences among minority groups merit particular attention.

Innovative approaches are required to facilitate behavioral change for certai n

heterosexuals considered at high risk of HIV

i n f ec t i o n. For example, interventions to

“empo we r“ women who may be involved in

dependent relationships (e. g., prostitutes and

partners of IV drug users) to encourage their

partners to use condoms without, at the same

time, jeopardizing themselves are being

evaluated (see append ix B). Within family

planning clinics, the CDC is funding activities related to AIDS education for women

who may be at high- risk of HIV infection

(21). The clinics assess women’s risk, counsel

them on ways to reduce their risk, and offer

to test them for HIV antibodies.

Certain Practices of Schol-Age Youth

AIDS educational programs implemented

within schools have been successful in im -

proving adolescent knowledge, but the impact

on changes in risk behaviors has not yet been

evaluated. The goals of sexuality education

are similar to those of AIDS educat ion: to

reduce or modify teen sexual activities to

curb pregnancy and STDS other than AIDS,

and to improve teens’ sexual self-awareness

and communication skills. It is therefore instructive to look at the evidence of success of

these programs.

Results from numerous evaluations indicate that sexuality education programs increase factual knowledge about sexuality and
8 ● How Effective Is AIDS Education?

sexually transmitted disease but, in general,

have little measurable impact on attitudes or

behaviors (1 12). There are some important

except ions. One program using intensive

cognitive-behavioral training that taught

communication and problem-solving skills

through role playing and rehearsal seems to

have been effective in improving communication skills and attitudes compatible with

lowering the risk of pregnancy (160). Particularly noteworthy are the results of a

community-based program implemented in a

rural South Carolina community. Using

parents, churches, schools, the media, and

other community organizations, this program

seems to have been successful in lowering

teen pregnancy rates (205). Further research

to replicate these results is important because

the contribution of different elements of the

program is not clear, and the number of

teenagers involved was small.

Although education on AIDS an d

sexuality appears to increase adolescent

knowledge, there is little evidence that youth

translate such knowledge into changes in their

risk behaviors. That teens often do not apply

their knowledge of risks to their personal

situations is a recognized impediment to behavioral change. In the case of HIV, students

may not consider infection a personal threat

because most teens do not know someone

with AIDS. Some have suggested that information about AIDS be presented within

the context of other, more prevalent STDs,

such as gonorrhea and herpes simplex, with

which adolescents may have greater familiarity (61 ). Programs most likely to succeed

in changing adolescents’ behavior are those

that relate the information to their personal

situations and that use techniques such as role

playing to teach communication skills and to

reinforce new peer group norms.

AIDS educational efforts could be integrated into community-wide programs that

reinforce the adoption of different behavior.

That many adolescents initiate sexual activity

before high school suggests that educational

programs be implemented in elementary and

middle schools. Because some high-risk

adolescents may not be reached through

school-based AIDS educational interventions,

programs could be targeted to adolescents in

settings, such as juvenile detention centers

and shelters for the homeless, that include

teenage runaways. The National Institute of

Mental Health is funding evaluations of AIDS

prevention activities for adolescents who seek

services at shelters for runaways or at agencies serving homosexual youth (see appendix

B). The CDC is funding 15 State education

agencies, 12 local education agencies, and

community demonstration projects that are

focusing on youth in and out of school (see

appendix B).

Implications for Further Work

Studies Designed for Evaluation

Although experience indicates that public

health campaigns can achieve knowledge and

behavior change, it is not clear which components account for successful vs. unsuccessful results or which combinations of components are more effective than others. This

gap in understanding pertains to educational

interventions for people at high risk and for

the general population.

The problem with AIDS education and

other programs of public health education is

that programs have rarely been designed to

evaluate the effectiveness of interventions or

to isolate the effects of different components.

Without such insights, those planning educational interventions cannot determine which

components are vital for success and which

can be eliminated. Such information is especially important because public health programs at all levels of government face

restricted budgets; formulating AIDS education programs and allocating resources among

AIDS education and other health activities require knowledge of the effectiveness of different interventions.

The National A IDS Informatio n

Campaign being conducted by the CDC illustrates this situation and how it is being addressed. During fall 1987, the CDC distributed public service announcements to broad-
How Effective Is AIDS Education? ● 9

cast media throughout the country. NCHS

conducted surveys of AIDS knowledge before

and after the campaign, but it would be difficult to attribute any changes to the

campaign as opposed to other information

sources. More information to evaluate the

program will be available from a survey

planned for summer 1988, after the CDC

sends an AIDS pamphlet to every household.

In that survey, NCHS will examine whether

people received and read the information.

Some measures of the process of the

campaign are available to the CDC. Although

total press stories on AIDS decreased during

the last quarter of 1987 (190), during this period television and radio continuously increased their broadcast of the CDC’S public

service announcements, and calls to the AIDS

hotline rose greatly (204). Correlations between the use of the announcements and hotline calls within local areas could provide a

measure of public response to the campaign.

To evaluate the effectiveness of different

components of the campaign, the CDC could

systematically vary the content or dissemination of messages within an area. With the

concurrence of the States, different approaches might be tried within a State or

across States. The insights gained could be

used to increase the effectiveness of subsequent phases of the campaign.

Even when AIDS education programs

have been evaluated, most have not used

rigorous research methods. Rarely have those

undertaking educational programs compared

changes within a group that received an intervention (the experimental group) with

changes within a group that did not (the control group). Nor have they systematically

varied the intervention among different

groups and compared the results. For the

most part, educators aware of the risks of

AIDS have understandably concentrated on

implementing programs intended to change

behavior. In the absence of appropriate research designs, it is difficult to interpret the

results of evaluations that have been performed. It is also difficult to interpret the

potential impact of a program if the characteristics of program participants and how they

differ from the risk group at large are not

provided. An educational program may appear to be successful in changing risk behaviors if the experience of a group of selfselected program volunteers is studied. Program success, however, may be more a function of the characteristics of the participants

than of the program itself.

Some recently-funded research projects

will employ research designs to avoid such

potentially misleading results. For example,

one investigator funded by NIDA will randomly assign IV drug users admitted to a

residential detoxification program to one of

three different interventions to evaluate their

relative effectiveness (see appendix B). Although such an approach may not always be

feasible, careful design of the evaluation

component of an educational intervention,

before a program is implemented, is key to

gaining an understanding of what elements

are effective and ineffective.

To facilitate comparisons of the results

of evaluations conducted in different areas, it

would be helpful to standardize the measurement of outcomes of interest (e.g., changes in

specific types of sexual behavior). For example, simply standardizing the interval and

length of followup of subjects involved in research studies would be helpful (37). The

type of data that is advisable to collect might

change over time. For example, since HIV

antibody testing is more widely available, it

would be helpful if those evaluating intervent ions to change the b eh a v io r of

homosexual men, in addition to recording the

number of encounters of unprotected anal intercourse, recorded whether their partners

were infected with the virus. Although unprotected anal intercourse between two

seropositive individuals is inadvisable, it does

not contribute to new cases of infection.

Targeting Information to Specific Groups

Developing effective educational interventions requires that planners know for each

target group what knowledge and behavior

they wish to change. Such insights are espe-
10 ● How Effective Is AIDS Education?

cially important with AIDS education, since

the populace already has a high level of

knowledge (accurate and inaccurate) about

AIDS and HIV infection (18,52). Moreover,

such information is needed to develop culturally sensitive messages for different ethnic

groups.

For the general population, NCHS surveys can provide continuing information to

identify which beliefs and attitudes to address

in future programs, and NCHS is exploring

appropriate methods to collect information

about behaviors that put people at risk of

HIV infection (21 7). These data, however,

are not likely to be adequate for program

planners at the local level. For example,

those planning to implement educational interventions within family planning or STD

clinics will need to conduct baseline surveys

of client knowledge, attitudes, and behaviors

so that the programs can be tailored to meet

specific community needs. Furthermore,

some community-based surveys may be

needed to see if AIDS programs located

within the community are appropriate and

accessible to members of high-risk groups located within the community.

An important aspect of having education

reach the intended audience is tailoring the

content and dissemination of messages to

reach people at high risk. AIDS has disproportionately affected blacks and Hispanics.

It is important that educational messages associate HIV infection with certain risky behaviors rather than with membership in a

certain group. At the same time, communicating information effectively requires that

messages take into account the language, literacy level, and cultural sensitivities of the

people to whom they are targeted.

Reaching people in various social and

cultural subgroups requires different approaches. Further research is required to understand the characteristics and risk behaviors

of people in different groups. Among IV

drug users, further research is required to

understand the impediments to changes in

sexual behavior, especially within long-term

relationships. Few educational programs have

been targeted to homosexual and bisexual

males who are black and Hispanic, who have

low educational levels and low incomes, or

who are adolescents, and little is known about

how to reach these groups. 3 Such research

may suggest new counseling approaches.

Within the Department of Health and Human

Services, the Office of Minority Health and

the CDC National Information and Education

Program are planning special efforts targeted

to people in minority groups (see appendix

B). Given the importance of reaching people

who are disadvantaged and who are members

of minorities, it is essential to adequately

evaluate these projects and to incorporate

their findings into future educational programs.

3 Most homosexual men studied to date have had high

educational attainment and have been upper-middle class.
2. EFFECTIVENESS OF EDUCATIONAL INTERVENTIONS

TO CHANGE RISKY BEHAVIORS

CERTAIN PRACTICES

OF HOMOSEXUAL AND

BISEXUAL MEN

Introduction

AIDS was first identified amon g

homosexual and bisexual men and continues

to be a disease primarily affecting this group;

a total of 63 percent of the reported adult

cases in the United States are among

homosexual and bisexual men without other

known risk factors. An additional 7 percent

of cases have occurred among men who are

both homosexual and IV drug users (192).

Epidemiologic studies have demonstrated that

for homosexual men, anal intercourse practiced without the use of condoms is the major

risk factor for HIV infection. In one study,

unprotected receptive anal intercourse could

account for nearly all of the 95 new infections detected among 2,507 initially seronegative men after six months of followup. The

gradient of risk of seroconversion accelerated

in proportion to the number of receptive anal

partners, from about three-fold for one partner to 18-fold for those with five or more

partners (1 10). The risks associated with

oral -genital, manual -anal (“fasting”), and

other sexual activities other than unprotected

anal intercourse are unknown. Epidemiologic

studies have not been large enough to include

sufficient numbers of men engaging in these

practices to detect a small relative risk associated with such practices (37).

Safer-sex guidelines generally list the use

of condoms during anal intercourse as “possibly safe” rather than “unsafe. ” Although

several laboratory studies have demonstrated

that latex condoms are effective physical barriers to HIV, the effectiveness of condoms in

preventing HIV transmission is not established. Data from epidemiologic investigations, however, do show consistent previous

condom use to be associated wit h

seronegativity (189).

1 The spermicidal agent,

nonoxynol - 9, has bee n shown in the

laboratory to inactivate HIV and when used

with condoms, may enhance their effectiveness (37).2

The prevalence of infection among

homosexual/bisexual men varies greatly by

geographic region. In San Francisco, about

half of the homosexual men are infected.

(New York City may have a similar seroprevalence rate (37).) This level of infection

was recognized by the latter half of 1984 and

has remained relatively stable (i.e., there have

been relatively few new infections) (220),

Evidence from epidemiologic studies in San

Francisco suggest that by 1988, less than 2

percent of seronegative homosexual men were

being infected annually (21 8). The current

rate of new infections among homosexual

men in some areas of intermediate prevalence

also appears to be very low (150). Areas of

intermediate prevalence ( 10 to 30 percent

homosexual men infected) include Miami/

Fort Lauderdale, Los Angeles, Houston, and

Washington, D.C. (37). Seroconversion rates

may be higher than these epidemiologic investigations suggest. Participation in studies

in which detailed questions about sexual behavior are asked may, in itself, modify risky

behavior (37).

The exact size of the population of men

at risk for HIV infection because of their

1 The effect of condom use among the heterosexual

spouses of patients with AIDS was evaluated (189).

2 Studies designed to estimate the effectiveness of condoms in preventing HIV transmission are underway (37),

11
12 ● How Effective Is AIDS Education?

homosexual practices is unknown. Although

recognized as unreliable, data from the late

1940s (11 1 ) are usually used to estimate the

size of the U.S. homosexual male population.

Using these data, the Public Health Service

estimated that 4 percent of all males were exclusively homosexual (representing 2.5 million

men between the ages of 16 and 55) and a

total of 5 to 10 million men had at least some

homosexual experience (185).

Changes in AIDS-Related

Behaviors

Dramatic AIDS-related behavior changes

have been documented within the male

homosexual/bisexual community. In fact, the

degree and kinds of behavioral changes that

have occurred exceed anything documented to

date in the public health field (35). The extent of behavioral change, however, varies

substantially by geographic area. At one extreme is San Francisco, where a 92-percent

reduction in unprotected insertive anal intercourse and a 76-percent reduction in unprotected receptive anal intercourse was recorded from 1985 to 1987 (68). Lesser degrees of behavioral change, however, have

been recorded in areas of intermediate

prevalence. For example, there was only a

28-percent decline in unprotected receptive

anal intercourse among participants of a multicenter study (Baltimore, Chicago ,

Pittsburgh, and Los Angeles) from 1984 to

1986-1987, with 48 percent of the men still

engaged in this practice at last assessment (in

April 1986 to March 1987)(78). In January

of 1986 and 1987, only 19 percent and 8 percent respectively, of men participating in the

San Francisco Men’s Study reported unprotected receptive anal intercourse (68). A

particularly disturbing finding from a study

of men in Pittsburgh is that although 91 percent identified receptive anal intercourse as

3 The proportion of men engaged in unprotected anal insertive intercourse fell from 37.4 percent in January 1985

to 3.0 percent in January 1987.

f? The proportion of men engaged in unprotected anal

receptive intercourse fell from 33.9 percent in January 1985

to 8.3 percent in January 1987.

the highest risk sexual activity for AIDS

transmission and 90 percent endorsed the

belief that condoms can reduce the spread of

AIDS, 65 percent reported at least one

episode of anal intercourse during a sixmonth period in 1986, and 62 percent of

these men reported that they “never” or

“hardly ever” used condoms during anal intercourse. Reasons for not using condoms included: condoms are used only by straights

(26 percent); condoms are not readily available (22 percent); condoms spoil sex (22 percent); purchasing condoms is embarrassing (18

percent); and using condoms turns partners

off (16 percent) (202).

The combination of alcohol or other

drugs with sexual activity has been associated

with high -risk sex (166). In a telephone survey of homosexual men in San Francisco,

those who continued to practice unsafe sex

were more likely to combine drugs and/or alcohol with sexual activity. Furthermore, men

who combined drugs and/or alcohol with sex

were the least likely to have changed the frequency of engaging in unsafe anal intercourse

since 1984 (39). In another study, the com -

bination of drugs and sexual activity was

found to be the most significant contributor

to unsafe sex among a group of New York

City homosexual men (more important than

perceptions of emotional support and of difficulty in modifying sexual behavior) (164).

The National Institute on Alcohol Abuse and

Alcoholism (NIAAA) is funding research on

alcohol’s effect on high risk-behavior among

groups at high risk for AIDS (see appendix

B).

Homosexual men reporting increases in

unsafe sexual practices (i.e., anonymous sexual encounters) appear to hold different beliefs

about AIDS than those adopting safer sex. In

one longitudinal study in which changes in

beliefs and sexual practices were monitored,

men reporting increases in unsafe sex were

more likely to say that they perceived themselves to be at high AIDS risk than men not

engaging in unsafe sex. Men that reported

risk reduction were more likely to hold the

perception that one’s peers were reducing

risk, and the belief that one is capable of
How Effective Is AIDS Education? ● 13

making necessary behavioral changes to

reduce risk and/or improve health. Those

reporting that their perception of risk for

AIDS increased with time did not reduce

risky behaviors but did demonstrate a wide

variety of psychological impairments. This

seems to indicate that using techniques to increase the perception of risk for AIDS may

not necessarily have the desired effect on

sexual behavior ( 104, 105). However, it is

difficult to establish the temporal association

between reported beliefs and behaviors

(which came first, the belief or the behavior?) and whether the relationship is causal

(i.e., did the change in belief lead to the

change in behavior?). Furthermore, these relationships between certain beliefs and risk

behavior should not be regarded as static. As

the AIDS epidemic progresses, different

beliefs can be anticipated to emerge as correlates of risky behavior (37).

Effectiveness of Specific

Interventions

Evidence suggests that during the initial

period of the epidemic, dissemination of

AIDS health information was relatively important, but that later, the acceptance of new

behaviors in one’s peer network became more

important ( 105). A number of techniques

have been employed to change individual risk

behavior and community norms. In this section, these programs and their effectiveness

are examined.

Community-Based AIDS Risk Reduction

Programs

Community-based approaches are aimed

at simultaneously providing individuals with

information and skills for behavior change

and creating a social environment that supports behaviors that prevent the spread of

AIDS. Behavioral theory suggests that when

specific health-related behaviors become less

socially acceptable in a community (and

others are sanctioned to take their place), and

when perceived social sanctions regarding unhealthy behaviors are persistent and inescapable, individuals are much more likely

to both initiate and maintain healthful behaviors (37).

The dramatic behavioral change documented in San Francisco has in part been attributed to a shift in community norms

resulting from the adoption of a multifaceted,

community-based approach (sometime s

referred to as the San Francisco model). At

least six elements characterize this model: 1)

strong leadership from within the homosexual

community; 2) market research techniques to

identify appropriate messages and communication channels for reaching the target

audience; 3) programs to inform and motivate

target audiences; 4) a focus on facilitating social and cultural change; 5) reliance on multiple channels of communication including

print, broadcast, and face-to-face channels of

communication; and 6) broad-scale, grassroots participation. In addition, research was

conducted documenting baseline levels of

high-risk behavior, changes over time, and

the factors related to failure to change (37).

Although many programs have been implemented in San Francisco, few of them

have been formally evaluated. Consequently,

it is not clear what the relative contribution

of the various elements of the San Francisco

model have been in changing risk behaviors.

Moreover, although community surveys have

been undertaken and have documented improvements in AIDS-related knowledge and

changes in behaviors, these changes cannot be

directly linked to any particular component

of the San Francisco model.

The Centers for Disease Control (CDC) is

funding AIDS Community Demonstration

Projects in six locations across the country

(Denver, Seattle-King County, Dallas County,

Denver City and County, New York State and

City, Long Beach, Chicago) (see project descriptions in appendix B). Although the range

of activities employed differs from site to

site, the interventions include public health

communications to provide factual information about HIV infection and to create the

impression that prevailing social norms support changes to lower risk behaviors. The in-
14 ● How Effective Is AIDS Education?

terventions also include antibody testing to

provide a cue to change behavior. Finally,

the interventions include a variety of methods

targeted to individuals resistant to change, individuals requiring additional help or skills to

make changes, or individuals who have

trouble maintaining the changed behaviors

they have adopted. Evaluations of these programs are underway (see appendix B).

Members of risk groups targeted by

community-based educational campaigns have

reported that they are effective. A campaign

to promote safer sexual practices among

Montreal’s homosexual population included

AIDS education activities and condom distribution. In a survey completed one month

following the campaign, three-quarters of

respondents indicated that the campaign had

influenced their behavior; however, 36 percent and 18 percent reported still engaging in

active and passive anal intercourse without a

condom, respectively(l). There may have

been a tendency for some survey respondents

to provide socially acceptable responses to the

survey.

HIV Antibody Testing

Proponents of antibody testing claim that

testing will motivate reductions in high-risk

behavior. Opponents have claimed that the

risks of discrimination or psychological distress outweigh the benefits of testing and that

high-risk persons are motivated to reduce risk

of infection without testing.

Several studies have shown that testing

appears to considerably reduce levels of highrisk behavior. For example, in a study of

over 1,000 homosexual men from the Baltimore/Washington D.C. area, 67 percent

elected to learn their HIV antibody status.

Those aware of their HIV seropositive status5

decreased unprotected insertive intercourse to

42 percent of baseline levels (compared to 59

percent for seronegatives and 52 percent for

the uninformed group). 6 A study of the effects of HIV antibody testing on subsequent

sexual behavior among 270 homosexual men

in Boston showed that levels of all sexual activities (except the number of steady partners) declined over a one-year period for all

men irrespective of awareness of antibody

status. Elimination of unprotected active anal

intercourse was reported somewhat more

often among seropositive men who became

aware of their test result and discontinuation

of unprotected receptive anal intercourse was

reported slightly more often by men who became aware of a negative test result (133).

Other studies have also shown significant differences in behavioral change between those

informed and not informed of their HIV

antibody status (216). In these observational

studies, however, subjects chose to be tested

and chose whether or not to be informed of

their HIV antibody test results. There is

some evidence to suggest that men already

predisposed to risk-reducing behavior are

more likely to choose to know their test result

(133).

Not all studies, however, report a positive effect of HIV antibody notification on

behavior. In a study of 74 homosexual men

in Chicago that had learned of their antibody

status, those who were positive and received

their results increased receptive anal contact

as compared to those who were positive and

did not receive their results. In addition,

some informed HIV-positive individuals

manifested increased mental health problems

(104,133). Some researchers have suggested

that HIV antibody negative men increase

risky activity due to the belief that they are

somehow invulnerable to the effects of HIV

(128).

5 The term HIV seropositive status refera to the interpretation of enzyme immunoassay and confirmatory tests

(e.g., Western blot or immunofluorescence assay) aa positivefor HIV antibodies. Seronegative status refera to the

interpretation of enzyme immunoassay tests as negative

(186a).

6 Because those finding out that they are seropositive are

more likely to have been more sexually active and to have

engaged in high-risk sex at baaeline than those finding out

that they are seronegative, the results of these analyses are

presented in terms of percent change at follow-up from

baseline in the number of persons with whom an individual

engaged in unprotected anal intercourse.
How Effective Is AIDS Education? ● 15

Partner Notification

Notifying the sexual partners or needle

sharing contacts of those found to be HIV

positive may inform a group of individuals

that are unaware of their risk of HIV infection. The intention of partner notification is

to provide education and counseling to the

infected and susceptible contacts and thereby

prevent further transmission. Sexual partner

notification has been implemented successfully for STDs other than AIDS. Although partner notification would be very difficult when

individuals have had large numbers of sexual

partners (whose names or addresses might not

even be known), it may be especially useful

for high-risk seropositive individuals with

few contacts in areas of low prevalence of

infection.

Different models of partner notification

have been adopted. In some States the names

of those with HIV positive test results are

reported to the State health officials who in

turn identify, trace, notify, and counsel

named contacts (e. g., Colorado). In other

States, health officials selectively follow up

contacts who fall into certain groups (e. g.,

women of child-bearing age, bisexual contacts) (97). Sometimes, the HIV-infected individual has the responsibility of notifying

contacts himself and health officials only

contact partners if they are asked for assistance. For partner notification programs to

be successful, confidentiality of information

must be assured. Without assurances of confidentiality, high-risk individuals may avoid

testing or fail to report or refer at-risk contacts (106).

A partner notification program instituted

by the Colorado Department of Health

identified 42 HIV positive individuals from a

total of 453 partners reported by 265 HIVpositive individuals. These 42 identified

cases had not previously been tested or had

been previously tested and found to be negative (37). No behavioral followup was conducted on these or the negative contacts

identified through this program.

Face-to-Face Programs

The results of evaluations of two interventions suggest that face-to-face programs

with multiple sessions can reduce high-risk

behavior. Men with a history of frequent

high-risk behavior reported fewer episodes of

unprotected anal intercourse following participation in 12 weekly, group sessions covering

AIDS risk education, cognitive behavioral

self-management training to refuse coercions,

and discussions regarding the development of

steady and self-affirming social supports than

men in a control group (men randomly assigned to a program waiting list)’ ( 108).

Other researchers employed an 8-week stress

management program and a retreat emphasizing meditation, relaxation, positive health

habits, and coping with stress for a group of

seropositive men. Again, following the intervention, participants reported fewer partners

in the previous month than men in the control group8 (36).

The STOP AIDS Project, a face-to-face

program implemented in San Francisco, although not formally evaluated, was successful

in reaching large numbers of homosexual

men. The project uses a focus group model

to bring people together to engender a personal commitment to safer sex and personal

participation toward ending the AIDS

epidemic. In a survey of San Francisco

homosexual men, over half of the men had

heard of the project and 20 percent had attended a meeting. Records show that over

7,000 men have attended a meeting (37).

There are no data available, however, regarding the specific impact of the program on behavior.

Conclusions

There have been few formal evaluations

of the effectiveness of educational interventions to reduce the risk of HIV transmission

7 Program participants reported an average of 0.2 vs. 1.2

episodes of unprotected anal intercourse reported by controls in the previous month.

8 Participants reported an average of O.S vs. 1.09 partners

reported by controls in the previous month.
16 ● How Effective Is AIDS Education?

among homosexual and bisexual men.

Evaluations are needed to determine which

approaches are effective for homosexual men

in general and for men who are resistant to

change. Considerable behavioral change has

occurred in areas of highest HIV prevalence

(e.g., San Francisco); however, a small minority

g of men continue to engage in high-risk

behaviors there, despite the conduct of a variety of educational interventions.

Analyses of the distinctions between

those homosexual men who continue to

maintain adopted behavioral changes over

time and those who do not will be central to

the design of new preventive interventions.

Based upon what is currently known regarding the correlates of risky behavior, more

work is merited on understanding how highrisk sex is associated with concurrent alcohol

and other drug use, beliefs regarding AIDS

risk, sexual impulse, and perceptions of personal efficacy and social norms. In addition,

research on the social and environmental contexts under which homosexual men do not

comply with safer sex can be expected to

identify heretofore unsuspected correlates of

high-risk behavior.

Specific approaches that could be implemented and formally evaluated include community intervention approaches and face-toface, multisession programs targeted to those

having difficulty adopting or maintaining

safer-sexual practices. Although the

community-based intervention model implemented in San Francisco may have shifted

community norms and contributed to behavioral change, the model needs to be replicated

and evaluated in middle and high prevalence

cities. The extent of behavioral change in the

San Francisco area, in part, may be attributable to the unique characteristics of the

population there. Homosexual males in San

Francisco, many of them migrants from other

areas, tend to be well-educated, professionals,

who identify with the homosexual community. In other areas, community leadership

and community networks may be less well

defined and the community-based approach

more difficult to implement. Beyond providing education and social support, programs

could provide the means with which behavioral change can be implemented. For example, methods of making condoms more available to risk groups and evaluations of the efficacy of these programs could be undertaken.

Data Collection and Evaluation

In order to gauge the effectiveness of

educational interventions, information on

baseline and current behavior of high-risk

groups is necessary. Data on prevalent

homosexual practices are available from only

10 Many cities in the middle-to -

a few cities.

high ranges of AIDS prevalence could benefit

enormously from better estimates of sexual

behavior among homosexual and bisexual

men. Such data were collected in San Francisco and used to design educationa l

campaigns, to determine the effectiveness of

the programs, and to identify pockets of individuals who were not responding to them

(37).

Uniform reporting of data would facilitate comparison of outcomes from different

areas. At present, longitudinal studies of

AIDS-related behaviors may use different periods of followup (i.e., periods of 1, 3, 4, 6,

and 12 months). Furthermore, researchers

vary in the detail with which they gather and

report behavior. At a minimum, it would be

useful for each study to record the frequency

of specific sexual activities that are known to

be high risk, and to report both mean frequencies (along with standard deviations) and

percentages of individuals engaging in these

activities at baseline and at followup (37). As

a subject’s risk of HIV infection varies by

many characteristics of the contact (i.e., the

HIV serologic status of the subject and partner, the type of sexual contact, whether the

subject assumed an active or passive role, and

9 An estimated 3 percent of men in the San Francisco

Men’s Health Study continued to practice unprotected active intercourse and 8 percent practiced unprotected

receptive intercourse as of January 1987 (68).

10 Cities for which data on prevalent homosexual practices are available include San Francisco, Los Angeles,

Chicago, Baltimore, Pittsburgh, and New York (37).
How Effective Is AIDS Education? ● 17

condom use), contact-specific, rather than

summary reports of risk behavior may be

necessary. For example, when high-risk sexual practices are reported, it is important to

document the extent to which HIV negative

individuals might be selecting only other HIV

negative individuals for sexual relations and

likewise, HIV positive individuals may be

limiting their partners to those that are HIV

positive.

11,12 T. understand why condoms

are not used during high-risk sexual encounters, it is important to document whether

the study subject is himself non-compliant or

whether the subject’s sexual partner is noncompliant. The types of interventions needed

to encourage condom use would differ in the

two situations (i.e., motivating the subject to

use condoms versus motivating the subject to

insist that his partner use condoms). The

CDC is developing a uniform data collection

format that is to be used by State-funded

programs by the end of 1988 (21).

Specific Groups Needing Special

Research Attention

Black and Hispanic Homosexual and

Bisexual Men --- About half (48 percent) of

black or Hispanic adults and adolescents with

AIDS are homosexual males (7 percent of

these homosexual males are also IV drug

users). Of all those at risk for AIDS, black

and Hispanic homosexual males may be the

least studied. The limited data that are available suggest that race and ethnicity are not

significantly related to participation in highrisk sex (37,39,63). Blacks however, appear

to be at greater risk for seroconversion than

whites (158, 159). More research is needed to

explain the higher rates of seropositivity

among blacks.

Black homosexual males may be less informed about the AIDS epidemic than their

white counterparts. In one community survey

in Detroit, only 13 percent of 62 black

11 Although it is inadvisable for HIV positive individuals

to have unprotected anal intercourse, those limiting their

sexual partners to individuals who are also HIV positive

will not infect previously uninfected individuals.

12 The MACS study investigatora began to record this

information, when available, in 1987 (150).

homosexual respondents correctly identified

that the AIDS virus was transmitted through

blood and semen, and only 19 percent were

very worried that they might get AIDS (37

percent reported they were not worried about

possible infection) (215). Given a relative

lack of data regarding minority group members’ AIDS-related knowledge, attitudes, and

sexual practices, there are few clues about

how targeted prevention strategies aimed at

alerting minority men to the dangers of

certain behaviors might be developed. Furthermore, minority group members’ response

to available educational interventions has not

been adequately monitored.

Individuals with Low Incomes and Low

Educational Attain merit.- -Studies of

homosexual and bisexual men have generally

included those individuals most likely to

respond to educational programs: individuals

with moderate to high incomes with college

education . Numerous studies hav e

determined that response to knowledge of

health risk are correlated with these two variables. Data are needed on the prevalence of

high-risk behaviors among members of other

socioeconomic strata, so that the appropriateness of current programs for these individuals

can be assessed.

Homosexual Adolescents. --Little attention is being given to the problems of

homosexual adolescents. There are no

specific data on the prevalence of HIV infection among homosexual youth. A study of

homosexual/bisexual male teens found that

they had an average of 7 sex partners annually, with 45 percent reporting a past history of

sexually transmitted diseases. Adolescents

who are not yet infected with HIV and who

are newly exploring their homosexual lifestyles are among those most likely to benefit

from preventive efforts (154).

Bisexuals. --Specific data regarding the

prevalence of male bisexuality in the population, the prevalence of HIV infection among

male bisexuals, the degree to which this

group has been influenced by AIDS risk

reduction education, and the potential for
18 ● How Effective Is AIDS Education?

spread of infection to heterosexuals by

bisexuals do not yet exist.

IV DRUG USE

Introduction

Intravenous drug users are the second

largest group of persons who have developed

AIDS in the United States. As of May 2,

1988, the CDC reported 11,045 cases attributed to IV drug use, representing 18 percent of all adult/adolescent AIDS cases. Of

these, 80 percent are black or Hispanic (192).

An additional 7 percent of adult/adolescent

AIDS cases occur among homosexual/bisexual

males who also report IV drug use. The

prevalence of HIV infection among IV drug

users varies by geographic area; rates range

from 50 to 60 percent in the New York City

area to below 5 percent in most areas of the

country other than the East Coast (185). 13

The potential for further spread of HIVtoIV

drug users, their sexual partners, and offspring is great. There are an estimated 1.1

million IV drug users in the United States

(185), many of them concentrated in large,

economically depressed urban areas. The

great majority - -approximately three -

quarters --of IV drug users are male. Most

have their primary sexual relationships with

women who do not inject drugs. The number

of females who do not inject drugs but who

are regular sexual partners of male IV drug

users is at least half as large as the number of

IV drug users (59) or about 550,000.

Most IV drug users use heroin, but a

substantial number also inject other drugs,

such as cocaine. Stopping drug use or adopting safer drug injection practices will reduce

the risk of HIV infection for IV drug users.

If IV drug users adopt safer sex practices,

13 These estimates are based on blood tests performed at

IV drug treatment programs. At any one time only about

15 percent of IV drug users are undergoing drug treatment.

Habitual user are not in treatment may be at even higher

risk. In contrast, the estimated 200,000 intermittent users

may bc a; lower risk (185).

transmission of the virus from IV drug users

to others will be reduced.

Sharing HIV-contaminated needles,

syringes, and other drug injection equipment

is the source of infection for most HIVinfected IV drug users. Prior to AIDS,

needle-sharing occurred as part of initiation

into IV drug use and as a symbol of positive

social relationships among some IV drug

users. Furthermore, in many areas drug injection equipment is difficult to obtain14 

and

illegal to possess. As a result, drug users are

disinclined to carry injection equipment with

them; they tend to obtain drugs first and then

worry about obtaining the injection equipment (56).

In cities with large numbers of IV drug

users, there are “shooting galleries,” where a

semi-private space and injection equipment

may be available for a fee. A single needle

and syringe can often be used by many drug

users before the needle becomes too worn for

further use. In one survey of IV drug users

in treatment (conducted over a 19-month period between 1983-1985 ), 68 percent

(131/ 193) reported engaging in needlesharing, and they did so during 40 percent of

their drug-use episodes ( 17). The use of

shooting galleries has been linked to HIV exposure in several studies of IV drug users

(126,161).

Complex interactions exist among drug

use, functional status, and sexual activity.

Heavily addicted drug users, often physically

debilitated, may experience a loss of libido

and tend not to be sexually active. For the

majority of IV drug users not so heavily addicted, drug use may enhance sexual pleasure

and contribute to considerable sexual activity

outside of committed relationships (56). Drug

use may also lead to a disinhibition effect

against safer sex practices. Most IV drug

users develop relatively stable relationships

with a single partner. In one New York City

study, over 90 percent of IV drug users entering treatment reported that they had a

1A Most States with large numbers of IV drug users require prescriptions for needle and syringe purchase (56).
How Effective Is AIDS Education? ● 19

stable sexual relationship, and the average

duration of their relationship was over 5

years (59). The two partners often do not

live together, and mutual monogamy is rare.

In many cases there is no use of contraception, and the relationships frequently involve

children. In one study, IV drug users in

treatment reported an average of 2 children

(54).

Goals of AIDS Education

Reaching IV drug users with information

about AIDS is, in itself, a challenge. Most

educational programs have utilized ex-addict

outreach workers to provide information

relevant to IV drug users in their own communities. Program success appears to depend

on imparting new information, providing the

means for behavior change, and reinforcing

changes in AIDS-risk behavior (56). The establishment of new norms within the drug

use community is a desired outcome of AIDS

educational efforts. These norms include cessation or reduction of drug injection and if

injection continues, using sterile injection

equipment and eliminating or reducing the

number of persons with whom equipment is

shared. To reduce transmission of the HIV

virus from the IV drug user to his or her

sexual partner, adherence to safer sex practices is required.

AIDS education efforts will not necessarily lead all IV drug users to seek treatment, not all of those who seek treatment will

be admitted, and treatment will not immediately be effective for all of those who do enter it. Therefore, AIDS education efforts for

IV drug users promote means for “safer” drug

inject ion. Promotional methods include

teaching social skills and strategies for refusing to share equipment when injecting,

providing information on how to sterilize

previously used injection equipment, providing bleach or alcohol for de-contaminating

used equipment, and actually providing sterile

equipment for injecting drugs. The ready

accessibility of means for safer injection, especially when an IV drug user is entering

withdrawal, may be the critical factor in the

effectiveness of an educational program.

Similarly, condoms provide a means to practice safer sex and can be made easily available through AIDS outreach workers and drug

abuse treatment programs.

Effectiveness of Specific

Educational Interventions

Substantial knowledge gains and behavioral change occurred within the IV drug use

community prior to the implementation of

official AIDS education programs. In New

York City, for example, many IV drug users

not in treatment knew that AIDS was associated with injection of drugs as early as the fall

of 1983 (58). They had learned about AIDS

from the mass media and from the oral communication networks within the drug use

subculture. By 1984, more than half of a

group of 59 methadone patients in New York

City reported that they had made some

change in their injection behavior; they

usually reported increasing their use of sterile

needles, cleaning their needles more frequently, and reducing the number of persons

with whom they would share drug injection

equipment. Only 14 percent, however,

reported having changed their sexual behavior

(82). A later study of IV drug users not in

treatment in New York found 41 percent

reporting changes in injection behavior compared to 31 percent reporting sexual behavior

changes (1 15).

Knowledge about AIDS, by itself, does

not appear to motivate IV drug users to

change AIDS-risk behaviors. In one study,

the majority of IV drug users were sharing

equipment even though over 90 percent of

them knew that HIV transmission could occur

through sharing equipment (76). Similarly, in

a very well-designed study of the effectiveness of an educational program using outreach workers, changes in knowledge were

not accompanied by behavioral change (131).

This has been attributed to the lack of attention to providing the means of behavioral

change; the outreach workers did not distribute bleach or clean equipment and did not
20 ● How Effective Is AIDS Education?

provide access to drug treatment programs

(56). The lesson is clear--to facilitate behavioral change, knowledge does not appear to

be sufficient. It is likely that the means for

implementing changes must also be addressed

within the context of the AIDS educational

effort. (See table 2-1 for a description of

selected interventions and results of program

evaluations.)

That is not to say that providing the

means for change is sufficient. Providing information relevant to the concerns and

misapprehensions of IV drug users must be

emphasized. For example, many IV drug

users mistakenly believe that as long as they

are not sharing drug injection equipment with

people who “look sick,” they are protecting

themselves against AIDS. Consequently,

communicating information concerning the

long-term asymptomatic carrier status is

needed. The likelihood of developing AIDS

after exposure to HIV needs to be emphasized. If an IV drug user believes that there

is a very low likelihood of developing AIDS

after HIV exposure, then motivation to

change behavior is not likely to be very

strong. Conversely, the belief that all persons

exposed to HIV will develop AIDS or the

belief that exposure to HIV is the same as

having AIDS may create such anxiety that

risk reduction efforts will be undermined.

Given the exigencies of daily life for an IV

drug user, it is unlikely that new risk reduction behavior can always be maintained.

Thus, IV drug users must also realize that the

occasional slip in risk reduction behavior does

not negate the need for continuing risk

reduction (56).

Drug Treatment

The IV drug users’ most effective method of avoiding AIDS is to stop injecting

drugs. For most, this will require formal

treatment. Entry into treatment is often associated with immediate reductions in IV

drug use, but a single episode of treatment is

not likely, by itself, to lead to permanent

cessation of drug use. Length of time in

treatment is associated with significant reductions in drug use that are maintained over a

long period of time. The lack of availability

of suitable drug abuse treatment is a recognized problem. In New York City, approximately 3,000 new permanent treatment positions have been added to the drug abuse

treatment system. All of these have been

filled, and there continues to be a waiting list

of approximately 1,000 persons. Current

plans call for an additional 5,000 treatment

positions to be opened by mid-1989 (56).

The Presidential Commission on the Human

Immunodeficiency Virus Epidemic ha s

recommended expanding the capacity and improving the quality of IV drug treatment programs (21 1).

Increasing the availability and accessibility of drug treatment for IV drug users

through AIDS outreach programs appears to

be effective. A treatment voucher program

developed by the New Jersey State drug

abuse agency has proven to be effective in

extending treatment services to those concerned about the risk of AIDS and in bringing into treatment young black males, a group

previously underrepresented in the State

treatment system.

15 Over 80 percent of ‘he

first 1,000 vouchers distributed by AIDS outreach workers were redeemed for a free

episode of detoxification treatment. Over a

quarter of those entering treatment through

the voucher program went on to longer-term

treatment (99). As length of time in treatment is associated with greater reductions in

drug injection, this program has probably had

a long-term effect on drug injection behavior

(56). Surveys of those entering treatment indicate that about half are largely motivated

by the threat of AIDS (81).

Bleach Distribution

In some areas, outreach workers, in addition to providing education, are distributing

small bottles of bleach that can be used to

sterilize drug injection equipment .16 From

1986 to 1987, outreach workers in San Francisco distributed 15,000 vials of bleach, most

15 Imposition of patient fees in 1981 resulted in a loss of

black males in treatment (99).

16 Household bleach rapidly inactivates HIV outside of

the body (155).
How Effective Is AIDS Education? ● 21

of them to addicts not in treatment. Although the proportion of addicts (in treatment) reporting needle-sharing remained the

same (71 percent), needle-sharers reporting

“usually” or “always” using bleach went from

6 percent before (in 1985) to 47 percent after

(in 1987) the bleach distribution program began. During this period, the proportion never

using bleach fell from 76 percent to 36 percent. Despite the apparent success of this

community-based outreach program, serological studies showed that the prevalence of HIV

positivity among respondents rose from 10 to

15 percent. Consequently, although sterilization is recognized as an important component

of AIDS prevention, the researchers recommend other risk-modification measures be

evaluated, including more widespread

availability of sterile hypodermic needles (31).

During the same period, others have found

somewhat higher levels of bleach use among

San Francisco IV drug users not in treatment

(212). Bleach use may be higher among those

not in treatment because the bleach distribution program was targeted to those not in

treatment. Evaluations of the effectiveness of

street outreach efforts in New York City that

include the distribution of sterilization agents

are in progress (56).

Needle-Exchange Programs

Official needle-exchange programs for

IV drug users have not yet been established

in the United States. Prior to the onset of

the AIDS epidemic, IV drug users in Amsterdam worked with public health officials to

set up a needle-exchange system in which

drug users could return used injection equipment and exchange it for new equipment

without cost. This effort was initiated to

reduce the spread of hepatitis B within the

IV drug use community. The needle -

exchange system operated on a small scale

and did not substantially reduce the spread of

hepatitis B among IV drug users (26). Concern about AIDS, however, has led to a

greater demand for sterile equipment and an

expansion of the needle-exchange system.

The proportion of IV drug users using the

exchange system has increased from less than

10 percent to almost 50 percent (203). The

needle-exchange system did not lead to an

increase in drug injection. In fact, evidence

suggests that since the implementation of the

needle-exchange program, IV drug users in

Amsterdam have decreased their frequency of

injection; the proportion injecting more than

once per day dropped from almost 90 percent

to less than 50 percent. This decline in drug

injection is attributed to attempts by IV drug

users to prevent HIV infection. There are no

data to show that the needle-exchange program has reduced the transmission of HIV.

HIV Antibody Counseling and Testing

Some uncertainty exists regarding the

impact of IV drug users’ learning their HIV

antibody status. In some areas, IV drug users

who learned their positive antibody status

have shown greater risk reduction than those

testing negative (29,42). Risk reduction included reducing or eliminating drug injection

or, among those continuing to inject, reducing or eliminating equipment sharing. Adherence to safer sexual practices also increased. In some cases, however, attempts at

changing sexual practices after learning of

positive HIV antibody test results led to the

break-up of some long-term relationships

(29). Seropositive individuals suffered distress, social isolation, and stigmatization upon

learning of their HIV test results, but distress

declined over a period of several weeks.

It is unclear whether learning individual

test results, per se, led to the observed behavior change. A comparison group of untested individuals from the same drug abuse

treatment program showed comparable risk

reduction to those who were tested (29).

Thus, it may be that increased awareness and

personal concern about AIDS among IV drug

users in the local area stems from knowing

that personal risk information is available and

knowing persons who test positive rather than

from individuals’ learning their own antibody

status (56).

Some have advocated antibody testing for

IV drug users for cities in which HIV

seroprevalence among IV drug users is low

(31 ). In San Francisco, for example ,
22 ● How Effective Is AIDS Education?

voluntary antibody testing has been made

widely available. A concerted effort is made

to provide medical care to seropositive individuals, to place them in treatment, and to

counsel them intensively regarding equipment

sharing and safer sexual practices. This

strategy is based on the traditional public

health approach of locating infectious persons

and then intervening to prevent transmission

from those persons to others. In San Francisco, where this strategy has been implemented,

an estimated one-third of IV heroin users

have been tested in the first two years of the

program. There are no available data on how

HIV antibody testing in San Francisco has affected IV drug users’ risk behaviors.

Preliminary data from one area 17 wher e

this strategy was implemented suggest that

education contributes more to changing drug

use behavior than knowledge of ones’ HIV

antibody testing results. An investigator

compared the risk behaviors of thre e

matche d

1 8

groups of 25 IV drug users in

treatment and provided with AIDS education;

those who had been tested and learned that

they were HIV antibody positive, those had

been tested and learned they were HIV negative, and those who had elected not to be

tested. After three months of followup, 18

of aware seropositive IV drug users returned

to drug use despite the opportunity to receive

methadone maintenance, long-term counseling, and medical followup. Ten of these HIV

seropositive IV drug users, however, returned

to treatment by nine to 12 months of fol10WUP and by this time, positive changes in

drug use behaviors had been adopted by all

three groups. Evaluations of innovative

models aimed at changing the risk behaviors

of those identified as seropositive are needed

(124,125). The National Institute on Drug

Abuse is funding AIDS Comprehensive Community Outreach Demonstration Projects that

include evaluations of HIV antibody testing

programs (see appendix B).

Changes in Sexual Behavior

There have not been substantial changes

in sexual behavior among IV drug users, especially with sexual partners with whom the

IV drug user has a long-term relationship. In

studies where both drug and sex behaviors

were monitored, changes in sexual behavior

lag behind changes in drug-use behaviors.

For example, in San Francisco, while reported

use of bleach to sterilize drug injection

equipment rose from 3 to 67 percent before

and after a community-based outreach program was implemented, reported “safer sex”

practices increased only slightly, from 5 percent to 15 percent (212).

Drug users have reported reductions in

their number of casual sexual partners and

increased use of condoms with casual partners. Male IV drug users have also reported

changes in their use of prostitutes. They are

more likely to use condoms when with a

prostitute, more likely to select a “regular”

prostitute rather than seeing many different

prostitutes, and more likely to insist that the

prostitute they use “look clean” and in apparent good health (56). The least amount of

AIDS-related behavioral change has occurred

within long-term, committed relationships.

This may be explained by the threat to the

relationship that behavioral change may pose.

In a study of antibody testing, in which HIV

seropositive individuals were strongly

counseled to use condoms, about half of the

long-term relationships dissolved after the IV

drug users introduced condom use into the

relationship (29). New counseling approaches

appear to be needed to assist IV drug users in

initiating and maintaining safer sexual practices within their long-term relationships. It

is within the long-term relationship that

transmission of HIV is most likely to occur,

to both the sexual partner and to children

likely to be conceived because of a lack of

contraception.

17 The experience of a small-sized city in a nonmetropolitan area in New England is reported (124).

18 IV drug users were matched by age, sex, and drug use

(124).
How Effective Is AIDS Education? ● 23

Preliminary data from one investigator

suggest that providing one-on-one counseling

to seropositive IV drug users and their primary sexual partner is effective. Marlink

reports that seropositive IV drug users in

treatment significantly increased their reports

of “always” using condoms after participating

in one-on-one counseling with their sexual

partner. A comparison group of IV drug

users in treatment who were either HIV

antibody negative, or who had elected not to

be tested, did not increase reports of “always”

using condoms. Because IV drug users in the

comparison groups did not have partner

counseling, it is not clear what the relative

contributions were of the counseling intervention and knowledge of HIV antibody

status (125).

Conclusions

Evidence suggests that IV drug users

have changed their behavior to reduce their

chances of developing AIDS. Behavioral

change depends upon learning that they are at

risk for AIDS and the ways the disease is

transmit ted. Risk reduction also depends

upon the availability of means for behavior

change. Means may include drug abuse

treatment and equipment sterilization methods

or clean injection equipment. Behavioral

theory suggests that sustaining behavioral

change requires reinforcement through a

belief system that the new behavior is effective in preventing AIDS and through social

approval from peers (56).

No single intervention appears to have

maximal effectiveness, even within a single

geographic area. Instead, most programs have

relied on multiple approaches. Reinforcement of risk reduction is needed for a successful AIDS education program. Here, peer

approval of behavioral change may play an

important role. The decision to engage in

AIDS risk reduction is sometimes made

within a group context rather than by IV

drug users individually. In one study,

whether or not friends were practicing AIDS

risk reduction was the strongest predictor of

behavioral change (82). This finding is not

surprising in light of the importance of peer

approval in IV drug use initiation, injection

equipment sharing, and drug abuse treatment

programs.

To evaluate the effectiveness of interventions in terms of reduced HIV infection,

cohort and ongoing seroprevalence surveys

will be needed. To supplement these studies,

continued ethnographic research is required

to monitor behavioral responses to interventions. Ethnographic research (observations of

a group’s beliefs and practices by trained observers) has yielded invaluable insight into

drug use behaviors and patterns of social and

sexual relationships that suggest new approaches to educational intervention. For example, the evident importance of peer group

approval suggests that interventions aimed at

a group of IV drug users rather than at individuals might be effective. Similarly, the

lack of significant change in sexual practices

among IV drug users and their long- term

partners suggests a need for involving sexual

partners in counseling. Once promising interventions have been identified for implementation, rigorous methods (e.g., experimental or quasi-experimental designs) need to be

employed to evaluate their success.

The threat of AIDS appears to have

motivated many IV drug users to seek treatment. Research is needed to determine the

long-term effectiveness of treatment programs for the increasing number of IV drug

users entering them. In addition, as some IV

drug users are at risk of AIDS because they

inject drugs other than heroin, types of treatment that may eliminate or reduce their

habits are needed.19

When drug abuse treatment is not effectively utilized, methods of safer injection

need to be adopted to reduce AIDS risk.

Both distribution of sterilization agents and

needle-exchange programs have been implemented in different areas. It appears that

both approaches have been accepted by more

19 Most IV drug users in treatment programs are heroin

users for whom methadone is effective in curbing the incentive to use heroin.
24 ● How Effective Is AIDS Education?

than half of IV drug users in the affected

areas. HIV transmission continues to occur,

however, in areas where outreach workers

have effectively distributed bleach. Although

needle-exchange programs remain controversial in the United States, their comparative worth or the effectiveness of using both

interventions simultaneously could be

evaluated.

For areas where there are few infected

IV drug users, the strategy of making

voluntary HIV antibody testing easily accessible and providing intensive followup for

those identified as positive needs to be

evaluated further. Preliminary data from one

study of this approach suggest that providing

education to IV drug users in treatment alters

risky drug taking practices irrespective of

HIV antibody status. More information on

the social consequences of being identified as

seropositive and its effects on behavioral

recidivism is needed, especially in light of

evidence that IV drug users in treatment may

return to drug use soon after learning of their

HIV infection (124). Furthermore, evaluations are needed of innovative approaches to

providing education and counseling to

participants of voluntary HIV antibody testing in areas of both low and high HIV

prevalence.

Particular attention needs to be paid to

educational interventions aimed at changing

the sexual behaviors of IV drug users. Although some changes have occurred, they are

modest in comparison to changes in IV drugrelated behaviors. Of special concern is the

observation that changes in sexual behavior

have been less frequent within committed relationships than within casual sexual relationships. Without changes in condom use

and use of other forms of contraception,

heterosexual partners will be infected and

perinatal transmission may occur, since childbearing is more likely within longer-term relationships. Preliminary data from a study of

one-on-one counseling of HIV seropositive

IV drug users in treatment with their sexual

partners suggest that this technique is very

effective in promoting condom use (125).

Further research in this area is needed.

IV drug use is associated with much of

the AIDS transmission among blacks and

Hispanics in the United States. Consequently,

culturally sensitive educational approaches are

needed for these groups. What is known

regarding the geographic distribution of AIDS

cases should help to target these efforts. For

example, almost two-thirds of black (58 percent) and Hispanic (61 percent) adults who

have AIDS live in three States--New York,

New Jersey, and Florida. Among Hispanics

affected by AIDS in the northeastern United

States, 80 to 90 percent were born in Puerto

Rico (94). There are few data regarding differential impact of interventions on specific

racial/ethnic groups (83) or on specific

age/drug use groups (e. g., young IV drug

users with relatively new drug habits vs. older

IV drug users with longer-term drug habits)

(55).

CERTAIN PRACTICES OF

HETEROSEXUAL ADULTS

Introduction

Heterosexually Transmitted AIDS Cases

There is controversy surrounding the degree of risk that the AIDS epidemic poses to

the heterosexual community. There are few

recent data regarding either the prevalence of

high-risk, AIDS-related behaviors, or the extent of infection among heterosexuals. According to the CDC AIDS case surveillance

data, 4 percent of AIDS cases reported to

date (2,463 of 59,897 adult/adolescent cases

as of May 2, 1988) represent those transmitted via heterosexual contact (192). 20 Although a small proportion of all cases,

heterosexually transmitted cases represent the

fastest growing segment of AIDS cases.

20 These include 1,003 persons without other identified

risks who were born in countries in which heterosexual

transmission is believed to play a major role.
How Effective Is AIDS Education? Ž25

The cumulative incidence

21 of AIDS

cases in heterosexual adults and adolescents is

highest (above 1 case per 10,000 population)

in four States/areas: New York, New Jersey,

the District of Columbia, and Florida (185).

Most of the heterosexually transmitted cases

in these areas arose as a consequence of sexual contact with infected IV drug users (56).

There are a disproportionate number of minority group members represented among

heterosexually transmitted AIDS cases--69

percent of cases occur among blacks and 14

percent among Hispanics.

The characteristics of AIDS cases do not

necessarily give an accurate depiction of who

is now at risk of developing AIDS. Because

the period between infection and onset of

symptoms of disease may be seven years or

longer, the characteristics of AIDS cases are

those of a group who engaged in high-risk

behaviors several years ago. To understand

the future spread of AIDS amon g

heterosexuals, it is important to have information regarding HIV infection and on the

occurrence of high-risk behaviors among a

group of heterosexuals representative of the

general population.

The Prevalence of HIV Infection

There are no data on the prevalence of

infection among a group of heterosexuals that

are similar to the general population of

United States heterosexuals. Instead ,

seroprevalence data from testing programs

within the military and blood donor programs

are used to estimate infection rates within the

low-risk heterosexual community (individuals

at known risk of AIDS are asked not to

donate blood), and data from voluntary HIV

antibody testing programs and STD clinics

have been used to estimate infection rates

within high-risk heterosexual populations. In

addition, newborn surveillance programs have

served as indicators of infection among

reproductive-age women. According to blood

donor testing data, the prevalence of HIV in21 The cumulative incidence of AIDS cases is the total

number of reported AIDS cases in an area divided by the

number of individuals in the area at the onset of the

epidemic.

fection for first-time donors is 4.3 per

10,00 0

22 ( 185). Infection rates among

heterosexuals attending STD clinics and not

admitting to AIDS risk behaviors 23

are as

high as one percent (185). In Massachusetts,

where blood from newborns was tested for

HIV antibodies in 1986 and 1987, 2.1 per

1,000 mothers of neonates were determined to

have been infected.

24 In inner-city hospitals,

8 per 1,000 women were infected (92).

To improve estimates of HIV infection

within the general community, the CDC is

conducting seroprevalence surveys in hospitals, family planning and STD clinics, drug

treatment centers, and other sites located in

both high- and low-risk areas (129).

The Prevalence of High-Risk Behaviors

There are very poor data available on the

sexual behavior of the American population.

The data on sexual behaviors collected by

Kinsey in the 1940s are recognized as flawed

because investigators did not use probability

sampling, and because respondents were disproportionately drawn from the Midwest and

college campuses (143). A national survey of

American adult sexual behavior is being conducted

25 and information from a representative group of 20,000 adults should be available by mid- 1989. Preliminary data on a

sample of 2,000 adults should be available by

fall 1988 (28). The results of a survey of

sexual attitudes and behaviors of over 3,000

American men and women conducted for the

Kinsey Institute in 1970 were never published

and the survey data has only recently been

made available to researchers (19).

22 Data are baaed on HIV antibody tests performed on

blood donations from 1985 to 1987,

23 Risk behaviors included homosexual contact, IV drug

use, and known sexual contact with a person from these

groups. When self-reported risk behaviora of HIV

seropositive individuals attending STD clinics were confirmed with a reinterview after testing, HIV infection rates

among those not admitting to risk behaviors ranged from O

to 1.2 percent.

24 Antibodies in maternal blood are contained in neonatal

blood specimens routinely collected for other purposes,

such as screening for phenylketonuria (92).

25 The survey is being conducted by the National Opinion

Research Center with support from the National Institute

of Child Health and Development (NICHD), and the CDC,

National Center for Health Statistics (28).
26 ● How Effective Is AIDS Education?

Some regional data have been collected

regarding high-risk heterosexual behavior.

For example, a survey was conducted in 1986

using a probability sample 26 to estimate the

size, demographic composition, and sexual

behavior of the multiple/high-risk partner

heterosexual population27 in San Francisco

(38) . Results indicated that approximately

17 percent of San Francisco adult residents

are heterosexuals with multiple or high-risk

sex partners (58 percent of them men and 42

percent of them women).

Sexual practices, attitudes about risk of

HIV infection, and sources of AIDS information reported by this group of “high-risk”

heterosexuals, while limited to the unique

population of San Francisco, offer some insight into what kind of educational programs

targeted to this risk group might be effective.

The survey revealed that although risk group

members were very sexually active, with

many reporting partners in AIDS risk groups,

less than one-third reported feeling personally

threatened by AIDS. Nevertheless, sizable

numbers of heterosexuals at risk for AIDS

reported that they had reduced their number

of sex partners and decreased anal sex since

the onset of the epidemic. High-risk

heterosexuals are also at risk for AIDS because of IV drug use. At least eight percent

of risk group members reported having used

IV drugs, with two percent having done so in

the six months immediately prior to the interview. In addition, alcohol and drug use

prior to sexual encounters was associated with

engaging in higher-risk sexual practices (38).

Overall, the importance of reducing the

chances of contracting or spreading AIDS was

rated highly, 8.4 on a 10-point scale. Few

believed that “using a condom is a turn-off,”

26 Probability sampling is a technique that yields a study

Y7

oup that is representative of the area.

Thin population consisted of adults (aged 18 or older)

reporting two or more sex partners of the opposite sex for

the last year, or opposite sex partnera whom they believed

to be IV drug usem. In addition, men were included if they

had sexual contact with a female prostitute in the previous

year and women were included if they had sexual contact

with a male prostitute or bisexual male partner in the

previous year.

and condom-resistant attitudes were held by

one-quarter of respondents. Approximately

three-quarters of respondents indicated they

were familiar with the concept of safer sex.

There was less awareness of safer sex among

blacks and Hispanics, however. The level of

enjoyment of unsafe practices was correlated

with respondents’ sexual behavior, which suggests that a communication strategy of emphasizing the pleasurability of safer sex may

be an effective way to bring about behavioral

change. Beliefs about social norms regarding

specific sex practices were not strongly linked

with sexual behavior (38).

Only 20 percent of risk group members

reported seeking specific information on how

to reduce their risk of getting AIDS. Most

have relied on their physicians or friends as

sources of information. There was considerable interest expressed in workplace-focused

educational programs, particularly among less

well-educated risk group members. Thirtyone percent said they would attend a riskreduction presentation during lunchtime or

after working hours at their place of employment. Twenty-six percent indicated they

were likely to call a toll-free AIDS information hotline. Health professionals and the

media were identified as preferred sources of

information. Eighty-eight percent approved

of the use of sexually explicit risk-reduction

messages.

Although over two-thirds of respondents

were aware that antibody screening was

available, only 5 percent indicated that they

had been tested. Only 22 percent stated that

they were likely to use the test in the future.

Relatively low levels of test use are explained

by the perception that heterosexuals are not

at risk for AIDS.

Although the findings of this survey

conducted in 1986 may be dated, there are

some important lessons to be learned regarding educational interventions targeted to

high-risk heterosexuals.

o Educational interventions that increase

the high-risk individual’s perception of
How Effective Is AIDS Education? ● 27

0

0

0

risk may increase their solicitation of

HIV information and use of the HIV

antibody test.

There is considerable overlap in risk

behaviors. Therefore, educational efforts may be effective if simultaneously

directed at changing sex and drug use

practices. Controlling alcohol and drug

use may increase compliance with safer

sex recommendations.

There is interest in AIDS educational

efforts located at the worksite and at

family planning and STD clinics. Hotlines were named as useful sources of

AIDS information.

Educational approaches that emphasize

pleasure associated with safer sex might

be effective. Explicit risk reduction

messages may be useful.

Because the high-risk heterosexuals surveyed were identified through a probability

sample, investigators can generalize findings

to the high-risk heterosexuals of San Francisco who are estimated to comprise 17 percent

of the population. Given the unique characteristics of San Francisco, however, the findings may not be generalizable to other areas

in the country. The results of a followup

survey of high-risk heterosexuals conducted

by the same group of investigators should be

available in mid 1988 ( 145). With this survey, any temporal changes in sexual attitudes

and behaviors will be documented, but only

for San Francisco.

Effectiveness of Specific

Educational Interventions

Persons attending STD clinics and

sexually active women of childbearing age

(i.e., those with multiple or at-risk partners,

or with a history of drug use) are two groups

of high-risk heterosexuals that have been

identified for AIDS prevention activities

(183). In this section, what is known about

the effectiveness of education and counseling

interventions relevant to adult members of

these groups is reviewed. In the next section,

the effectiveness of interventions targeted to

adolescents is discussed.

Persons Who May Have Sexually

Transmitted Diseases

Individuals infected with sexually transmitted diseases (STDS) other than AIDS are at

increased risk of HIV infection by virtue of

their sexual practices (e.g., multiple partners)

and because open genital lesions present in

some STDS facilitate HIV transmission (123).

In light of the similarities in risk-reduction

services related to STDS and HIV infection

and the high-risk nature of the population

served by public STD clinics, 28 CDC ha s

targeted these sites for AIDS educational and

testing activities. In fact, an estimated 42

percent of all HIV antibody testing and

counseling centers are located in STD clinics

(123).

Education provided at STD clinics can

reach a large number of high-risk individuals; approximately half of all annually

reported cases of STD are treated within the

nearly 3,500 public STD clinics (1 23).29 O f

considerable concern are recent STD surveillance data indicating that the number of new

STD cases is increasing. For example,

through the first 46 weeks of 1987, there was

a 32-percent increase in the number of cases

of infectious syphilis reported as compared to

the same period in 1986. A marked increase

of syphilis was noted among inner-city,

heterosexual, minority group members suggesting that high-risk sexual activity is increasing in these groups despite the risk of

HIV infection (187).

To date, no specific AIDS education programs offered within STD clinics have been

formally evaluated (123). The CDC’s Division of STDs is providing funding to Innovative Projects for Risk Reduction, AIDS Prevention Projects to the States, and AIDS

28 Sociodemographic characteristics of public STD attendees are similar to those of heterosexually transmitted

AIDS caaes, both tend to be young, urban, heterosexual

individuals from lower socio-economic groups (123).

29 These clinics manage approximately 5 million patient

visits a year (123).
28 ● How Effective Is AIDS Education?

Community Demonstration Projects. Grant

recipients are conducting program evaluations

that should be completed in late 1988 or in

1989 (see appendix B).

Given the similarity in risk reduction

messages imparted to prevent HIV infection

and other STDS, it is instructive to look at

evaluations of innovative educational approaches aimed at preventing STD infection.

Pertinent to the conduct of AIDS education

are those interventions that attempt to improve knowledge of STDs and their prevention, to change attitudes regarding prevention, to alter high-risk sexual practices, to

improve return-to-clinic rates, and to improve client referral of potentially infected

partners. Examples of educational approaches

that have been evaluated include the use of

printed educational materials, videotapes,

programmed learning guides, in-depth faceto-face discussions, self-administered behavioral checklists, condom distribution,

clinician-patient contracts, and patient referral cards (see table 2-2 for a description of,

and results from, evaluations of STD clinic

educational interventions). Several of the

evaluation studies employed designs (e.g.,

randomized clinical trials) and included sufficient numbers of clinic patients to derive

statistically meaningful results. Most studies,

however, were conducted in the mid-to-late

1970s in unique localities, a factor limiting

the generalizability of results.

To improve knowledge related to STDs,

one group of investigators (7) evaluated the

relative effectiveness of a programmed learning guide, an audiovisual technique, and a

person-to-person interview. The three interventions accounted for a 20-percent increase

on post-test knowledge scores, and the interview technique was the most effective.

Interventions aimed at changing attitudes

have also been effective. In one study, men

and women were urged to use condoms or to

encourage their partners to do so through the

use of videotapes, in-depth discussions, informational checklists, and free condom distribution (66). There were marked differences in attitudes compatible with prevention

between those exposed to the interventions

and the control group (71 percent of individuals in experimental groups demonstrated attitudes compatible with prevention compared

with 33 percent of those in the control

group). Unfortunately, there are no data in

either this study or the former study regarding actual changes in behavior.

The results of two studies in which the

effectiveness of an educational intervention

was measured in terms of evidence of behavioral change are not encouraging. In one

descriptive study (the behavior of a group of

clinic attendees were described before and

after the implementation of the educational

intervention without the use of a comparison

group), the acceptance of free condoms at the

STD clinic did not reduce the number of

returns to clinic with another STD as compared with those that did not accept the condoms (47). In another study, a group of men

experiencing a gonnorhea reinfection (i. e.,

they did not comply with behavioral recommendations) were randomly assigned to a special counseling intervention or to a control

group (171). The rate of gonorrhea reinfection among men in the special intervention

group was the same as that observed in the

control group.

In terms of motivating patients to return

to the clinic for followup, one study showed

that provider performance was very influential (11 8). In the study, the effect of new

educational materials and the use of patientclinician contracts outlining preventive

patient behaviors were evaluated. Although

rates of return improved for women (pre -

intervention, 35 percent vs. post-intervention,

73 percent), the return rate for men was

similar before and after (33 percent and 37

percent) the interventions were initiated.

During a two week period, patient/clinician

interactions were directly observed to see if

the new educational materials were being

used. During this two week observation period, patient return rates were very high; 67

percent for men and 97 percent for women,

suggesting that improved provider per-
How Effective Is AIDS Education? ● 29

formance 30 was responsible for the improvement (123).

These studies suggest that special educational interventions can improve STD-related

knowledge and can affect attitudes toward

preventive behavior. Here, the person-toperson interview appears to be relatively

more effective than other methods. Results

have not been encouraging from studies that

have attempted to measure actual changes in

risk behavior. Neither distribution of free

condoms nor special counseling was effective

in reducing STD reinfection. Provider performance, however, may influence compliance with a recommendation to return to

clinic. Interventions aimed at maintaining

high levels of provider performance may be

effective in improving patient knowledge, attitudes, and compliance with behavioral

recommendations.

Sexually Active Women of Childbearing Age

Although most adults with AIDS are men

(92 percent), women represent the fastest

growing segment of the population with

AIDS. Seventy-one percent of women with

AIDS are black and Hispanic (86). One-half

(51 percent) of women with AIDS are IV

drug users and nearly one-third (29 percent)

contracted the disease through sexual contact

with an infected male (most of whom contracted AIDS through IV drug use) (192).

Clearly, curbing IV drug use among women

and changing the sexual practices of IV drug

users would reduce HIV transmission among

women.

Researchers and practitioners attending a

recent workshop31 concluded that “while educational campaigns featuring brief, clear information are a first step, increased knowledge by itself does not lead to needed behavior change (177). Changing women’s sexual

behaviors may require interventions that

30 Provider performance is thought to have improved as a

result of having an observer present during the

31

patient/clinician encounter.

The workshop, “Women and AIDS: Promoting Healthy

Behaviors,” was cosponsored by The National Institute of

Mental Health and The National Institute on Drug Abuse.

“em pow e r“ women to have more control

within their sexual relationships. For example, interventions that help women assert

themselves with their sex partners or develop

communication skills effective in getting their

partners to consistently and properly use condoms and engage in other safer sex practices

may be effective. Although studies of such

approaches are currently underway, there are

no published data regarding the effectiveness 32,33 In addition to a p of these approaches.

preaches to help women initiate change, other

interventions, such as support groups, may be

needed to sustain behavioral change.

Recognizing that high-risk ,

reproductive-age women may be reached

through federally-funded family planning

Clinics,

34 Title X funds have recently been

made available to support AIDS-related educational activities (27). CDC also funds riskassessment, and risk-reduction counseling,

and HIV testing for women in family planning clinics (21 ). One educational needs assessment conducted within a San Francisco

family planning clinic in 1987 revealed that

such clinics serve a population at high risk

for AIDS; of 545 women aged 13-49 surveyed, 7 percent reported using IV drugs, 10

percent reported sex with a bisexual male, 9

percent reported sex with an IV drug user, 34

percent reported multiple sexual partners, and

30 percent reported sexual intercourse with a

partner whose sexual history was unknown.

Despite the high prevalence of risk behaviors,

more than half (55 percent) reported that

their sexual partners “never” use condoms

(148). A 1987 statewide survey of women attending Planned Parenthood clinics in

Pennsylvania revealed that 1.5 percent were

32 For example, J. Mondanaro is using empowerment

techniques in interventions targeted to partners of IV drug

users and prostitutes (see description of her NIDA-funded

reject in appendix B).

53 The potential untoward consequences of increasing the

assertiveness of women in dependent relationships must

also be monitored (e.g., physical abuse of prostitutes by

54

imps).

Title X provides family planning services to 4.3 million

sexually active women annually. Most of these women are

young, many are members of minority groups, and 85

percent are members of low-income families. These women

are thought to be at high risk of HIV infection (27).
30 ● How Effective Is AIDS Education?

IV drug users and 4.3 percent were sex partners of IV drug users (21).

Within family planning clinics, evaluation

research in the following areas would assist in

developing effective educational programs:

evaluation of protocols for risk assessment

that may be used as a part of client education; evaluation of acceptance of AIDS

counseling and testing offered on site vs.

upon referral; evaluation of various counseling approaches (individual and group

counseling, support programs for infected and

non-infected high-risk women); evaluation of

client contraceptive choices following AIDS

counseling and testing; and evaluation of the

provision of contraceptive services on an outreach basis to IV drug use clinics/programs

(135).

In an effort to prevent perinatal transmission of AIDS, the CDC has recommended

that all women of childbearing age with

identifiable risks for HIV infection be

routinely counseled and tested

35 for HIV

antibodies ( 183). As part of this effort,

AIDS-risk assessment, education, and

counseling could be conducted at a number of

clinical facilities serving women including

physicians’ offices, family planning clinics,

STD clinics, drug treatment clinics, Women,

Infants, and Children Program (WIC) clinics,

and prenatal clinics (32). The CDC is funding several Perinatal AIDS Prevention Community Demonstration Projects that include

evaluations of how well women at risk of

HIV infection are identified and how contraceptive practices are affected by AIDS educational interventions (see appendix B).

Women who exchange sex for money or

drugs are at risk of HIV infection through IV

drug use and through their multiple and

potentially high-risk sex partners. If infected, these women may transmit HIV infection to their babies and to male clients. CDC

is collaborating with others in an ongoing,

cross-sectional study of women who have

engaged in prostitution in several geographic

areas (182). 36 prostitutes have been recruited

for participation in the study of HIV

seroprevalence and AIDS risk factors through

STD clinics, prisons, or outreach efforts, such

as newspaper advertising and street contacts.

Results of the study show that the major risk

factor for HIV infection in prostitutes is IVdrug use, and not exposure to infected partners. Only 13 percent of women tested have

returned to learn their test results. The

return rate is better in San Francisco where

outreach workers visit neighborhoods where

the women are working than in other sites

where study participants must travel to medical facilities to receive their test results (182).

This suggests that education efforts targeted

to prostitutes may be more effective when

delivered by community role models and

peers. Most prostitutes report some use of

condoms by their customers, but efforts at

maintaining safer sex practices may be

hampered by customers’ offering higher fees

for unsafe sex practices. Customer education

may therefore be key to improving compliance with safer sex recommendations (6).

Barrier contraception, however, is generally

not used with steady sexual partners who may

be HIV infected (157).

Conclusions

No formal evaluations of AIDS educational programs implemented within clinics

serving high-risk heterosexuals are available.

Results of evaluations of STD clinic educational interventions, however, suggest that

special educational interventions can improve

knowledge and can affect attitudes toward

preventive behavior. Here, the person-toperson interview appears to be relatively

more effective than other methods, such as

use of videotapes and special educational

materials.

35 “Routine counseling and testing” is defined as a policy

to provide these services. to all clients after informing them

that testing will be done. Except where testing is required

by law, individuals have the right to decline to be tested

without being denied health care or other services.

36 The areas are Atlanta, Colorado Springs, Las Vegas,

Los Angeles, San Francisco, Miami, and the tri-city area

including Newark, Jersey City, and Patterson (182).
How Effective Is AIDS Education? ● 31

Results have not been encouraging from

studies that have attempted to measure actual

changes in risk behavior attributable to an

educational program. For example, neither

distribution of free condoms nor special

counseling were effective in reducing STD

reinfection (46, 171 ). Provider performance,

however, may have influenced patient compliance with a recommendation to return to

the clinic (118). Given that the providerclient interview appears to be a preferred

medium of communicating STD information

and that the performance of the counselor affects client compliance, resources may be effectively used to ensure the quality of providers of AIDS and STD services (e.g., comprehensive training, continued education opportunities, interventions aimed at reducing

provider stress, and burnout).

There are limited data on the size and

characteristics of the high-risk heterosexual

population. Certain groups, however, are

recognized as being at high risk, and within

these groups, innovative approaches are required to facilitate behavioral change. For

example, interventions to “empower” women

that may be involved in dependent relationships (e. g., partners of IV drug users;

prostitutes) to encourage their partners to use

condoms without, at the same time, jeopardizing themselves are being evaluated (see

appendix B).

entering AIDS risk groups may be the most

effective method of AIDS primary prevention

because much of what teenagers learn and do

as adolescents will affect their sexual and

other risk-taking behaviors in later years.

Evidence suggests that this will be a major

challenge as many teenagers are now engaging

in behaviors involving both sex and drugs

that can transmit HIV.

School-Age Youth AIDS-Related

Risk Behaviors

Risky sexual behavior is widespread

among teens. According to national survey

data, 78 percent of males and 63 percent of

females have sex while teenagers (93). Although most teenagers do not have sex until

they are age 16 or 17, in some communities

the average age of first intercourse is 12 (33).

For a substantial number of teens, sexual activity is not infrequent; among teens 15 years

of age and older, at least one-third report

having sex once a week or more (93). Of

those that are sexually active, over 50 percent

report having two or more partners (223) and

less than half say they used any method of

birth control at first intercourse (1 52). These

behaviors have resulted in alarming rates of

sexually transmitted diseases (STDs) among

teens; teenagers acquire more than one-fourth

of the estimated annual 20 million STD cases

(222).

CERTAIN PRACTICES OF

SCHOOL-AGE YOUTH

Introduction

Very few teenagers have AIDS.

37 A s

about one-fifth of all people with AIDS are

in their twenties, however, many are likely to

have contracted HIV while teenagers. Preventing the 29 million U.S. teenagers from

Teens at very high risk include the

estimated 125,000 to 200,000 who become

involved in prostitution each year ( 120) and

those using intravenous drugs. One national

survey indicates that 1 percent of United

States high school seniors have used heroin

(9). Of special concern are those living in

communities where HIV is already prevalent,

where there is more IV drug use, and where

sexual intercourse is initiated earlier, is more

frequent, is not protected by condoms, and is

experienced with more partners.

37 As of May 2, 1988, 257 out of a total of 60,852 AIDS

cases reported to CDC occurred among those age 13 to 19

(192).
32 ● How Effective Is AIDS Education?

The Effectiveness of Specific

Educational Interventions

In response to the threat AIDS poses to

young people, by March 1988, 18 states had

passed legislation requiring AIDS education in

schools. Information about AIDS is being

disseminated in schools; 51 percent of parents

report that their 10-17 year-old children have

already had some AIDS instruction (53). Because AIDS education is relatively new and

curricula are still being developed, however,

little specific information is available regarding what is actually being taught, at what

grade level, within what classes, and to how

many students. Furthermore, there is virtually no information regarding how effective

school-based AIDS educational programs are

in changing student risk behaviors. The

CDC’s Center for Health Promotion and Education, Office of School Health and Special

Projects has funded 15 national organizations,

15 State education agencies, and 12 local education agencies to examine AIDS education

within the public schools. Changes in knowledge and attitudes, and in some cases,

reported behavioral intentions and behaviors,

will be monitored through the use of pre -

and post-intervention surveys (see appendix

B).

Until data from AIDS education evaluations are available, it is worthwhile to examine the effectiveness of sexuality education

programs that often include many of the same

goals as AIDS education programs; to delay

sexual intercourse, to reduce the number of

sexual partners, and to increase the use of

methods of birth control, such as condoms.

Moreover, many of the decisionmaking and

communication skills that sexuality educators

teach are the same skills that some AIDS

educators believe should be taught to reduce

the transmission of the HIV virus.

This section reviews what is known

regarding: 1 ) current levels of adolescent

AIDS-related knowledge, attitudes, and

beliefs; 2) the effectiveness of AIDS interventions aimed at improving knowledge and

changing attitudes; and 3) the success of

sexuality education in changing sexual behaviors.

AIDS Knowledge, Attitudes, and Beliefs

Several studies have demonstrated that

adolescents are quite knowledgeable about

AIDS, particularly about the fact that vaginal

and anal intercourse with an infected partner

can transmit HIV. For example, a 1986 random telephone survey of 963 adolescents 16

to 19 years old in Massachusetts revealed that

98 percent knew that anal intercourse could

transmit HIV and 92 percent knew that

vaginal intercourse could transmit the virus

(168). Some school-based surveys, however,

suggest that there are important knowledge

deficits. For example, in a 1986 survey of

Connecticut secondary school students only

half knew that people who shoot drugs

(325/638) represented a high-risk group (89).

A survey conducted one year earlier in San

Francisco showed that while 92 percent

(1213/1313) of the students correctly indicated that “sexual intercourse was one mode

of contracting A ID S,” only 60 percent

(782/1303) were aware that “use of a condom

during sexual intercourse may lower the risk

of getting the disease” (62). Black and

Hispanic adolescents were less knowledgeable

about AIDS and were more likely to have

misconceptions about transmission than white

students (60). Most students reported wanting to learn more about AIDS, and many indicated that information about AIDS should

be presented in public schools. Although

more recent survey data are not available, researchers report that AIDS knowledge is likely to have improved (1 12).

Available data suggest that teenagers

have initiated little behavioral change in

response to AIDS. For example, the survey

of Massachusetts adolescents conducted in

1986 revealed that of the 70 percent reporting

sexual activity, only 15 percent had changed

their sexual behavior because of concern

about contracting AIDS, and of these, only 20

percent had implemented effective changes.

Many adolescents, including those in the

highest-risk subgroups of sexually active or

psychoactive drug users, did not know what
How Effective Is AIDS Education? ● 33

sexual and drug precautions are needed to

prevent transmission of the virus (168). TO

ascertain changes in knowledge, attitudes, and

use of condoms in response to the threat of

AIDS, a survey was conducted among sexually active adolescents attending a university or

a health maintenance organization in San

Francisco in 1984/85 and again in 1985/86.

Although the perception that condoms prevent STDs and the value and importance

placed on avoiding STDs remained high,

adolescents did not report increased use, or

intentions to use condoms over the study period (107).

Effectiveness of AIDS Education in

Changing Knowledge and Attitudes

Thus far, evaluations of AIDS education

programs in schools have focused upon

changes in knowledge and attitudes (see table

2-3 for a description of evaluations of AIDS

educational interventions). Significant increases in knowledge have occurred as

measured before and immediately following

AIDS education programs. For example, in

one study, the percentage of students knowing that using condoms during intercourse is

one way to help prevent the spread of AIDS

increased from 70 to 87 percent (61). In another study, AIDS- related knowledge increased markedly, and students’ perceptions

regarding personal risk of AIDS declined

slightly following the AIDS program (136).

In neither study was the impact of the educational intervention on changes in risk behaviors evaluated.

Whether educational programs will affect

teens’ AIDS risk behaviors is uncertain. Some

evidence suggests that young people who have

not been exposed to an educational program

overestimate both the number of cases of

AIDS and the chances of getting AIDS from a

single unprotected act of heterosexual intercourse (80). A 1985 survey of black and

Hispanic adolescents showed that more

knowledge about AIDS was associated with a

lower perceived risk of contracting AIDS

(60). AIDS-educated youth are probably

more aware that they will not contract AIDS

from casual contact with others.

Effectiveness of Sexuality Education

Lessons relevant to AIDS education can

be learned from the literature regarding the

effectiveness of sexuality education programs

designed to reduce teen pregnancy and STDs

other than AIDS, and to improve teens’ sexual self-awareness and communication skills.

Evidence from numerous studies indicate that

sexuality education increases factual knowledge about sexuality and sexually transmitted

disease but has little measurable impact upon

attitudes (112). Few studies have adequately

measured communication and other skills

thought to be necessary to implement behavioral change, and the results of these are

mixed.

One intervention, a 1 4-part, intensive

cognitive-behavioral training course, used

role playing and rehearsal to improve communication skills and attitudes compatible

with lowering risk of pregnancy. At sixmonth followup, the 18 participants reported

practicing more effective contraceptive methods and exhibited better communication skills

than the control group. The evaluation of the

intervention relied upon excellent measurement techniques, but its findings are limited

because few students were involved in the

program (160). Another study of several

comprehensive sexuality courses found no

impact on skills even though considerable

time was devoted to teaching and practicing

those skills in the courses. This study included a larger number of students but

employed less valid methods of measurement

than the smaller study reported above (1 13).

The results of an intervention aimed at postponing sexual involvement among adolescents

should be available in the near future (112).

Investigators are evaluating an educational

series designed to help adolescents resist social and peer pressures that can lead to early

sexual involvement. A companion program

for parents helps adults better understand the

pressures experienced by adolescents and assists parents in reinforcing the information

given to their children in school (96).

Sexuality education programs do not appear to have had an impact upon sexual in-
34 ● How Effective Is AIDS Education?

tercourse, either initiation or subsequent frequency. Although one major national study

did find that among 15 and 16 year old females, those who had previously taken a

sexuality education course were somewhat

more likely than those who had not to initiate

sexual activity at ages 15 and 16 (127), other

national surveys have not found such a relationship (224). Preliminary findings from an

evaluation of at least one community-based

program specifically designed to reduce teen

pregnancy suggest that the program may have

succeeded in that effort (205). Here, an educational campaign intended to curb high teen

pregnancy rates included the involvement of

parents, churches, schools, the media, and

other community organizations. Pregnancy

rates dropped by more than half in the rural

South Carolina county where the intervention

was implemented. Whether the drop can be

attributed to the program is, however, uncertain. Pregnancy rates in small populations

may fluctuate from year to year. Furthermore, the unique program setting limits the

generalizability of results.

In general, studies suggest that sexuality

education may have a modest impact upon

use of birth control during the first episode

of sexual intercourse, and upon ever using it,

but not upon current use. In one study of

high school students, students who were more

knowledgeable about the probability of becoming pregnant did not report unprotected

intercourse less frequently than those students

who were less knowledgeable. Similarly, students who were more knowledgeable about

birth control were not more likely to use it

(142). None of three major studies that

evaluated the effect of educational interventions upon the incidence of pregnancy found

a measurable impact (127,224,49).

The results of evaluations of sexuality

education are consistent with studies of other

kinds of educational programs designed to

improve healthy adolescent behaviors. For

example, driver education increases knowledge, but does not measurably reduc e

automobile accidents among teenagers. Other

programs targeted to adolescents, however,

have been successful. For example, some

anti-smoking programs for young adolescents

have helped them delay or refrain from

smoking, and a few drug education programs,

particularly those that focused upon skills,

have had some success (20,73).

There are a number of reasons why increases in knowledge from sexuality educational programs have limited impact upon behavior. First and foremost, there are many

important factors other than knowledge that

affect teenage sexual and contraceptive behavior. Over many years, teenagers are

socialized by parents and peers and exposed

to television and other media of popular culture. Their behavior is affected by a myriad

of internal factors, such as physical development and sexual desires, emotional needs for

affection and physical contact, ego strength,

plans for the future, perceived ability to control one’s own future, and attitudes toward

parents and society. Other factors such as the

availability of birth control may affect behavior. It is not surprising therefore, that a

small amount of school-supplied information

about sexuality has limited impact, especially

since many programs produce only modest

increases in knowledge and that knowledge

may diminish with time.

Although most students know even before they take a sexuality education class that

sexual intercourse can lead to pregnancy and

that pregnancy can be avoided by using birth

control methods, many young people do not

apply their knowledge to their own behavior.

As evidence that teenagers do not apply information to their personal situations, one investigator found that sexually active adolescents who could correctly answer questions

about the timing of ovulation and pregnancy

were not more likely to assess accurately their

own probability of becoming pregnant. In

fact, those that did not know whether or not

they would get pregnant were more likely to

use birth control ( 142). These findings suggest that those that are unaware of their actual risk may overestimate their risk and

therefore be motivated to use birth control.

Another factor contributing to failure to

use effective contraception is that sex among
How Effective Is AIDS Education? ● 35

sexually active young people may occur infrequently and is often unplanned. Teenagers

who have sex infrequently may not have yet

fully accepted the fact that they are sexually

active and therefore may be inhibited about

seeking information on contraception (112).

Conclusions

Whether the findings from research on

sexuality education can be used to guide

AIDS educational interventions depends in

part upon teenagers’ perceptions of the burden and risk posed by AIDS. Teens may be

more highly motivated to adopt preventive

behaviors to prevent a life-threatening disease

than to prevent pregnancy or a treatable

sexually transmitted disease. If teenagers do

not believe that they are personally at risk of

getting AIDS, however, then they may not

respond to educational efforts.

In reality, for most teenagers, the probability of having sex with someone infected

with HIV is quite small, and the probability

of actually contracting HIV from that person

is still smaller. Because teenagers, like adults,

have difficulty making decisions when probabilities are small, they may be unlikely to

change their behavior when provided accurate

information. Educational programs may be

more effective in high- risk communities

where a higher percentage of people have

AIDS. In such communities, the actual risk

of contracting AIDS is higher and thus

represents a more serious threat to teenagers.

Moreover, the teenagers are more likely to

know personally someone who is HIVinfected or has AIDS and thus apply the risk

and costs of contracting AIDS to their own

situations. To help make the risk of AIDS

more personal, information about AIDS can

be presented within the context of other,

more prevalent STDs, such as gonorrhea and

herpes simplex, with which adolescents may

have greater familiarity (61 ).

To be effective at reducing risk-taking

behavior, AIDS education programs must do

much more than simply increase knowledge.

Programs that use role playing extensively to

improve decision making and communication

skills and possibly reinforce particular norms

may be effective (160). In the case of AIDS,

role playing may involve students’ practicing

how to say “no” to sex, how to refrain from

having sex when condoms are not available,

how to discuss the threat of AIDS without

offending their sex partners, and how to insist upon the use of condoms when having

sex.

AIDS educational efforts could be integrated into much more comprehensive

community-wide programs that reinforce it.

In addition to involving schools, such programs can include parents, radio and television stations, newspapers, churches, youthserving agencies, family planning agencies,

and other community groups or organizations.

School programs are much more likely to be

effective if the norms expressed in those programs are supported and reinforced by the

larger social environment. At least one study

indicates that such programs do affect behavior (205). When AIDS educational programs

are implemented in the schools, teachers need

to be trained to communicate sensitive information. Teachers who are uncomfortable

discussing sexuality and specific sexual and

drug-related behaviors are not likely to be

effective in facilitating frank, open discussions (62).

There is evidence from other health

areas, such as smoking, indicating that when

programs are implemented earlier, they may

be more effective. AIDS educational programs could be implemented in elementary

and middle schools, as well as in high school.

As gains in knowledge and attitudes acquired

through educational programs appear to

decline with time, there is a need to reinforce

AIDS prevention messages. As adolescents

advance through the school system, new, ageappropriate messages could be introduced.

Programs may be more effective if

adolescents, themselves, play a major role in

the educational program and accept some responsibility for the effectiveness of the programs (41 ). When many student leaders

openly and consistently express norms against
36 ● How Effective Is AIDS Education?

risk-taking behavior, school-wide norms may

change. Another reason to implement AIDS

education programs early is that those students who are most likely to live in high-risk

areas and to engage in risk-taking behaviors

are also more likely to drop out of school.

Nationally, about 25 percent of young people

drop out of school before high school graduation ( 112), and the percentages are much

higher in communities where AIDS is likely

to be more prevalent.

In addition to school drop-outs, other

high-risk adolescents may not be reached

through school-based AIDS educational interventions. Teen runaways, teens engaged in

prostitution, and youths in juvenile detentions

programs will need to be reached through

community-wide strategies. One suggested

approach is to train and utilize indigenous

community members and groups to serve as

AIDS educational resources and as community

outreach workers (62). The CDC is funding

several projects to reach out-of-school youth

through the National Programs for School

Health Education to Prevent the Spread of

AIDS (SHEPSA). For example, the National

Coalition of Hispanic Health and Human

Services Organizations will provide agencies

serving out-of-school Hispanic youth with

educational materials (see appendix B).

Shelters for the homeless may be an important site for AIDS educational activities as

many of them serve the estimated 1 to 1.25

million minors that annually run away from

home. Characteristics of runaway and homeless youth vary in different locals but many

appear to be at high risk for AIDS. One New

York City-based study found 85 percent to

be sexually active, 10 percent engaged in

prostitution, and 5 percent using IV drugs.

Anecdotal data from Los Angeles suggest that

as many as 35 percent of runaway youth

there have been thrown out of their homes

because of homosexuality (200). AIDS information for street youth and incarcerated

juveniles must be simple, explicit, and direct.

As many of these youth are learning disabled

or have other problems with reading, verbal

educational approaches are preferable (153).

The National Institute of Mental Health is

funding evaluations of AIDS prevention activities implemented for adolescents who seek

services at runaway shelters or at agencies

serving homosexual youth (see appendix B).
How Effective Is AIDS Education? ● 37

>

0 1
38 ● How Effective Is AIDS Education?

C

>

w

c

.

!5

w

c

o

al

u

wI

1
How Effective Is AIDS Education? ● 39

v

o

L

c

al

L

0

u

. - 0

03

l..

m a

m

aJ

i

x v

U

. .

m

N

u
40 ● How Effective Is AIDS Education?

--

c

9

0
How Effective Is AIDS Education? ● 41

—. . .

- -

c

0

L

o Lb

O(I3

W)

Q

3

o
Table 2-2.--Effectiveness of Educational Interventions Targeted to Attendees of Sexually Transmitted Disease Clinics l

--Page 4

Study population/

Author Educational Intervention(s) / Sample Size/ Results/

goal Outcome measure(s) Study design Year(s) data collected c Comnents

Tucker, Reduce gonorrheal

1977 reinfection among

STD clinic

attendees.

US DHHS, 1. Encourage

CDC, Div. gonorrhea patients

STD, 1978 to notify th e

sexual contact

the need for

examination.

2. Improve cl

return rates.

r

o f

n i c

Interventions :

Counseling patients to avoid

sex with untreated sex

partners, and to use condoms

to avoid reinfection.

Outcome measures:

Sexual activity as reported in

an interview.

Interventions :

Three interventions were

studied :

1. Pamphlet, counseling,

dispensing of partner referral

cards;

2. Counseling plus request for

names of sexual contacts for

clinic followup ;

3. Minimal control interview

plus dispensing of partner

referral cards .

Outcome measures:

Number of gonorrhea positive

cases per index case.

RCT. Study population:

STD clinic patients with firs t

infection who were at least a g e

16. Those returning to the

clinic with a reinfectio n

within 4 months were

interviewed and randomly

assigned to an intervention or

control group. Those not

returning within 4 months were

contacted for followup. 78% of

participants were black.

Of 500 male participants, 73

(14.6 percent) returned to

clinic reinfected within 4

months. Among those not

returning but followed up, 30%

were reinfected. 18X of study

participants were lost to

followup.

Years data collected:

1975-77

RCT. Study Population:

Male and female gonorrhea

patients seen in a STD clinic

in Miami, Florida.

Sample size:

c

1,898 gonorrhea patients. 94X

male.

Years data collected:

Unknown

Results:

Men in the experimental group

experienced the S a M e rate of

reinfection as those in the

control group (21X).

c ommment:

Sociodemographic

characteristics associated

with recidivism include age

and race.

Results:

Groups 1 and 3 (use of partner

referral cards) each yielded

0.36 gonorrhea positive sexual

contacts per index case .

Group 2 yielded 0.6 per index

case.

comment:

Although clinic followup

yielded more diagnosed

partners per index case, the

costs were 3-4 times the cost

of patient-initiated followup

up.

Abbreviations: RCT = randomized controlled trial; STD = sexually transmitted disease

IEducational interventions pertain to STDS other than AIDSSoURCE: Office of Technology Assessment, 1988, based on a contractor document by Stephen MargoLis, lThe Effectiveness of Educational and Related Efforts

among Attendees of PubLic CLinics for Sexualiy Transmitted Diseases, U prepared for the Office of Technology Assessment, Washington, DC, March 1988
Tale 2-3. --E ffec of AIDS of Sexuality Eckatimal tires Targeted to Adolescents Interven

Study population/

Author Educational Interventions )/ Sample Size/ Results /

goa l Outcome measure(s) Study* design Year(s) data collected Comnents

Dawson, 1986

DiClement et

al. , 1987

Study assessed the

impact of

sex/contraceptiv e

education on

initiation o f

sexual activity ,

use of birth

control, and

pregnancy.

Increase student’ s

knowledge of

AIDS/STD

transmission and

prevention.

Intervention :

NA

Outcome measure:

Reported initiation o f

sexual activity, use of

birth control and pregnanc y

at interview .

Intervention :

3-hour AIDS program.

Outcome measure:

Performance on knowledge

test .

Cross-sectional

survey.

Multivariat e

logit analysi s

used to study the

relationshi p

between sexualit y

education and

Outcomes of

interest whil e

controlling fo r

sociodemographic

characteristics .

Pretest-posttes t

design.

Comparisono f

changes in

knowledge of

● xposed vs.

control group.

Study population :

Women aged 15 to 19.

Sample size:

1,888 women were surveyed.

Year data collected:

Study is based the 1982

National Survey of Famil y

Growth.

Study population :

Students attending San

Francisco middle and high

schools.

Sample size:

366 students in intervention

group;

273 in control

Year data COI

1986

group.

ectd :

Results:

Sexuality education may be

related to initiation of se x

for 14 year olds, but no t

for older teens. Sexuality

education was positivel y

related to use of birth

control during first coitu s

and with ever having used

birth control but was no t

related to current use.

Sexuality education was not

significantly related t o

pregnancy.

Comment:

For cases in which sexuality

education and initiation o f

sex occurred in the same

year, the teqxmai mber o f

events could not be

determined. The analysis

controlled for region, race,

income, parents’ tiation,

number of parents lived with

at age 14, religiou s

practices, and urbanicity.

Results:

Intervention group should

statistically significan t

improvement in knowledge

scores (scores increased

from 31.4 to 36.0 out of a

total of 46) as ccqxmd t o

no significant change f o r

the control group.

The proportion of students

knowing that using condoms

helps prevent AIDS increased

from 70% to 87%.

Comment:

The posttest was

administered immediatel y

after the intervention .

Program was successful in

dispelling misconception s

about casual contact.
44 ● How Effective Is AIDS Education?

m
How Effective Is AIDS Education? ● 45

o

o

>

. -

.

0

.-

c

o

W

c

al

>

ta l

$

L

g

ii
46 . How Effective Is AIDS Education?

c

*

v)

(u

c

0

L

o

-c

. .

n
How Effective Is AIDS Education? ● 47

w

Q

L

m

L

0

.-

w

>
3. EDUCATION FOR THE GENERAL POPULATION

THE GENERAL POPULATION

AND RISK BEHAVIORS

The general U.S. population consists of

people at varying risk of HIV infection.

Some take part in behaviors that put them at

high risk, such as sharing IV drug equipment

or engaging in certain sexual practices with

people who may be infected. The vast majority of the U.S. population, however, are

most likely at little or no risk, because they

do not practice risky behaviors or because

they live in areas that so far have had low

rates of HIV infection.

Since there is little validated information

about the sexual behavior of U.S. adults,

estimates of people at risk have relied on

Kinsey’s study from the 1940s and on extrapolations from the size of groups that have

so far accounted for most AIDS cases.

Estimates of men who have homosexual contact range from 5-10 million, of people with

any IV drug use about 1.1 million, and of

people with hemophilia about 15,000 (185)

for a total of about 6.5-11.5 million people in

1987. Of course, not all homosexual men or

even all IV drug users are at high risk; only

those who engage in certain behaviors risk

HIV infection (see chapter 2 and appendix

A). Adding heterosexuals at risk from infected partners, infants at risk from infected

mothers, and people who received blood

transfusions before HIV screening began

would increase the total number at risk by an

unknown amount. But people in these latter

categories would have to equal the highest

estimates of the other groups for the total at

high risk to reach even 10 percent of the 240

million U.S. population.

Although no studies have tested a random sample of the U.S. population for HIV

infection, the results of screening certain

groups suggest that less than 1 percent of the

general population, including high-risk and

low-risk people, is infected with HIV (see

table 3-1) (185). From 1985 to 1987, HIV

infection among first-time blood donors

averaged 0.043 percent and among applicants

for military service 0.15 percent. Since the

Red Cross and the military--and the applicants themselves--attempt to exclude

people with high-risk behavior beforehand,

these results most likely underestimate the actual prevalence of HIV infection. Similarly,

the rate for residential Job Corps entrants and

selected hospital patients, 0.33 percent and

0.32 percent respectively, may underestimate

infection because the Job Corps does not accept active IV drug addicts and the hospital

study excluded infectious disease and cancer

patients.

HIV testing has shown consistent patterns

across geographical area, age, sex, race, and

ethnicity (185). Like AIDS cases, HIV

antibody prevalence is much higher in urban

than in rural areas and in the East coast, Gulf

coast, and California than in other regions.

The age distribution of seroprevalence also

follows that of AIDS cases, with the highest

rates among people in their 20s and early 30s,

a pattern that follows sexual activity and IV

drug use. Although males have higher rates

of AIDS and HIV infection than females, the

male-to-female ratio is much lower for HIV

infection than the 13-to-l relationship for

AIDS cases (see table 3-l). Infected men

outnumber infected women by about 5 to 1

among military applicants and blood donors,

but figures approach 1 to 1 in major cities.

Without more systematic sampling and study,

it is not clear whether differences between

HIV infection rates and AIDS cases reflect

changes in the underlying pattern of infection, differences between males and females

in progression from infection to disease, or

self-exclusion by high-risk men from military

application and blood donation.

49
50 ● How Effective Is AIDS Education?

. .

0

. .

o

. .

0

z

. .

N

(m

o

a
How Effective Is AIDS Education? ● 51

More rigorous studies are also needed to

determine the evolution of viral transmission

by race. Although blacks and Hispanics have

about 3 times the rate of AIDS cases, the

black rate of HIV infection is almost 7 times

higher among military recruits and more than

11 times higher among blood donors.

The Department of Health and Human

Services through various agencies is undertaking several surveys to obtain information on the prevalence of HIV. The National

Center for Health Statistics (NCHS) is planning a national survey of seroprevalence that

would draw on a random sample of U.S.

households (21 7). The Centers for Disease

Control (CDC) is expanding its testing of

patients’ blood samples to 40 hospitals across

the country and is exploring similar surveillance through diagnostic laboratories and

family physicians (185). In collaboration with

the National Institutes of Health and State

and local health departments, the CDC is also

supporting the use of blood tests that are now

routinely performed on newborns to gauge

the seroprevalence of childbearing women

throughout the United States (see chapter 2

on heterosexual adults).

PUBLIC KNOWLEDGE AND

ATTITUDES TOWARDS AIDS

Virtually every adult in the United States

is aware of AIDS. By August 1987, more

than 99 percent had heard of AIDS (50), a

significant increase from the 77-91 percent in

1983 ( 18). Also by 1987, only 2-5 percent

did not know that a person could contract the

AIDS virus by sharing needles for drug use

with a person with AIDS or by sexual intercourse with an infected person (see table 3-

2).

Despite these accurate perceptions about

known routes of HIV transmission, however,

a substantial body of inaccurate knowledge

remains about exposures that do not pose a

threat (see table 3-2). In 1987, only 18-26

percent knew that a person can definitely not

become infected by donating blood, perhaps

because people did not realize that a new,

sterile needle is used for each donor. Mis -

concept ions also pertained to infection

through routine activities; for example, 21-38

percent thought infection is likely from

working near someone with AIDS, from using

public toilets, or from insects. Although

there were differences by age or sex, blacks

were significantly more likely than whites to

hold these misconceptions. Regarding prevention, 93-94 percent knew that celibacy

and a monogamous relationship between two

uninfected people were effective, but only 82

percent thought using a condom and 15 percent thought using a sperm icicle were at all

effective (50).

A synthesis of public opinion polls from

1983 through 19861 found little change in erroneous perceptions about AIDS transmission

through non-invasive means (18). An apparent exception was that people were less likely

in 1986 to believe that a person could catch

AIDS by working in the same office.

During 1985 and 1986, only a small portion of the general population (5-20 percent)

reported changing personal behavior to avoid

AIDS exposure, and most of the changes

noted were ineffective, such as avoiding

water fountains and other public places,

avoiding contact with homosexuals, and

avoiding restaurants ( 18). In 1986, half of

the 7 percent who reported changing sexual

behavior said they were using condoms more

frequently. Surveys in 1987 reported higher

percentages had made some personal change

(37-43 percent), and more of these mentioned

taking effective approaches to avoid AIDS.

No increase occurred in the percent claiming

to have altered their sexual behavior or in the

percent using condoms.

1 The 32 polls included were national in scope, surveyed

adult men and women, and surveyed between 611 and

2,405 people. Differences in factors such as design and

sampling procedure may render the results not strictly

comparable across polls.The validity of the results is improved, however, if more than one poll found the same

pattern of results, a situation that occurred frequently.
52 ● How Effective Is AIDS Education?

m

m

,-< m ,+ ,-4 .+ -+

ITI 01

m

o U1 < m @a h

.-l!-i.-+ m.’+

. . .

. . .

. .

h

.

.

30

c

.,

,..

.

.

.

.

.4

. .+ Al

-g

n

“-

x 92
How Effective Is AIDS Education? ● 53

\

0

CO O-Y O) Q.-I

rJd(Nr4,-4

‘m NIDQulm

N4Nr4

(0. 7.+

. .

. .

. .

. .

.

. ,,.

.,.

,..

.

. .

.,.

. . .

. .

.<

<$

.4X .LIJd

al

..+

n

4

0

c

-+

o

J

3

0

2

d

-c

:

al

+-l

In

4 .+ ,.c

:

E

:

.L

U2
54 ● How Effective Is AIDS Education?

D

!+

c1

. . .

. .

. . .

. . .

. . .

.,.

. . .

. . . :5

h@

. . .

. . .

.@.!+

..0

.-4

u)

m

0 .

,9./.

. . .

. .

.

.

h

.

. . al

.4

. . al

co

:

o

IA c

Li

3

0

0

ad

mm

-x

,.,

w a

o

<“

L.
HOW Effective IS AIDS Education? ● 55

.24J

al

L4

.2

3

o40)olo-lo)N

C’4C4 (--J

a

c

.+

d)

c

!+

w

3

f-i

rn

n

z

.

-s

u-)

o

4-I

-(

Ln

co

o-l

NO)W!+ N- Y .-+

,-il-)mj~

..4

0

M

al

N

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

4

Oal

L+h

00

NE

. . . . . .

CJ
56 ● How Effective Is AIDS Education?

Figure 3-1. --U.S. Condom Sales,

1981-1987

Mill Ions of condoms

500 , I

I

4 0 0

3 0 0

200

100

0

1981

Source:

By

slightly

1982 1983 1984 1985 1986 1987

Yea r

U. S. Department of Health and Human Services,

Public Health Service, Food and Drug

Administration, unpublished data, silver Spring,

MD, March 1988.

contrast, changes in condom sales rose

during 1986 and doubled during 1987

(see figure 3-l). The most likely influence

during this period was the publication of the

Surgeon General’s Report on Acquired Immune

Deficiency Syndrome in October 1986 and

Surgeon General Koop’s repeated advice during 1987 to use condoms to prevent HIV infection. Of course, the number of condoms

sold or otherwise distributed may differ

greatly from the number used.

Black respondents have expressed a

greater sense of personal susceptibility than

whites (32 vs. 15 percent in 1987), perhaps

because a disproportionate number of people

with AIDS are black (18). Blacks were also

more likely than whites to report changing

their personal behavior, in both ineffective

ways, such as avoiding homosexuals, and effective ways, such as using a condom. A

greater sense of vulnerability and past behavior change suggest that a substantial portion

of blacks are concerned and ready to act if

given correct information and the appropriate

means to effect change.

Adults under age 35 were more likely

than older ones to state changes in their personal behavior and, specifically, in their sexual behavior because of AIDS (18). Higher

percentages of younger adults reported limiting sex to one partner and using condoms, as

well as undertaking ineffective behavior, such

as avoiding casual contacts with certain

people. But even among those age 18 to 24,

only 16 percent said that they had altered

their sexual behavior because of AIDS. Another poll limited to single young adults

found the younger adults most likely to have

increased the number of sexual partners in

recent years, but it is not clear what role

sampling and study design played in the apparently conflicting results.

In general, few differences were found

among respondents by gender or by marital

status (18). There were too few data on

Hispanics to permit separate analysis. Among

regions, Southerners were the least well informed and expressed the greatest desire for

more AIDS information. How threatened

people felt by AIDS seemed to conform to

the prevalence of AIDS in the area, with the

greatest susceptibility felt in the northeast.

The analysts of the poll data concluded

that as people’s perceptions of AIDS transmission became more accurate, fewer were

undertaking ineffective behavior to avoid infection. Moreover, decreases in misconceptions also paralleled declines in respondents’

support for government restrictions on people

with AIDS, such as quarantine or mandatory

testing. People presumably at greater risk--

blacks, young adults, and single people--

expressed more concern and reported more

behavior change. Consistent with theories of

health behavior, however, accurate or improved knowledge was not necessarily associated with effective changes in behavior.

GOALS OF AIDS EDUCATION

FOR THE GENERAL

POPULATION

The goals of AIDS education for the

general population fall into two main categories: promoting social cohesion and checking
How Effective Is AIDS Education? ● 57

transmission of the virus. Achieving both

goals entails correcting misapprehensions and

conveying accurate knowledge about HIV

transmission. By providing information on

viral transmission, educational activities can

make people aware of their risk status.

People at no risk can be encouraged to continue their current behavior and to support

those who are infected or sick. People at

high risk can be urged to seek additional information to determine whether they are infected and to change their risky behavior.

A substantial portion of the population

mistakenly believe that HIV may be transmitted by blood donation and by everyday

activities, without intimate contact. As indicated by survey results and anecdotal accounts, people with more accurate knowledge

are less anxious about interacting with people

who may be infected. By correcting inaccurate perceptions, one may therefore

reduce fear among uninfected people and

reduce discrimination against those infected

or at high risk. With an estimated 1 to 1.5

mill ion people already infected and viral

transmission continuing, individuals and institutions throughout the country will have to

deal for a decade or more with HIV infection

among adults and children. If stigmatizing

and discriminating against people with HIV

infections declined, both high-risk and lowrisk people might be more willing to take

part in surveys to collect data needed to plan

public health activities. Moreover, improving

knowledge is likely to increase compassion

for infected people and lead to mor e

responsible responses to problems. In addition to generating unnecessary fear and discrimination, misperceptions about HIV transmission appear to be impeding certain socially

desirable activities, such as blood donation,

and recreational activities, such as visiting

crowded places and eating in restaurants (18).

To achieve the other goal of AIDS education for the general population, reducing

HIV spread, requires stimulating people at

high-risk to alter their behavior. Based on

behavioral research, the lower perceived barriers (social disapproval, physical discomfort,

financial cost, general inconvenience), the

more likely people are to use preventive

measures (see appendix A). People are also

more likely to undertake preventive measures

if they feel at risk of HIV infection, realize

that preventive means are available, consider

these means effective, believe in their own

ability to use them, have the skills (social and

mechanical) to use them, and feel that the

preventive measures have social approval.

EDUCATIONAL INTERVENTIONS SPECIFIC TO AIDS

The results of public surveys indicate

that substantial AIDS education has taken

place and that learning is continuing to occur,

with people absorbing inaccurate as well as

accurate information. Much of this education

has apparently stemmed from the mass media.

Although these sources have successfully

raised public awareness of AIDS, their efforts

have lacked a specific message and an

organized plan. Some information from the

media may also be inaccurate. Several State

governments have undertaken public educational programs (98), but the most notable

formal effort in the United States is the U.S.

National Information/Education Campaign,

which is being implemented through the

CDC.

The effectiveness of these

and informal, is not clear, in

cause the program designs

themselves to evaluation.

receive information from

efforts, formal

large part behave not lent

Since people

many diverse

sources and are constantly expanding their

AIDS knowledge, judging the effectiveness of

a particular program requires separating the

effects of the program from the effects of

other factors. Research methods call for

comparing changes within a group tha t

received an intervention (the experimental

group) with changes within a comparable

group that did not (the control group).

Alternatively, researchers may evaluate different educational strategies by comparing
58 ● How Effective Is AIDS Education?

changes among groups that received different

interventions. Neither of these research designs has been applied to AIDS education for

the U.S. general population. This section

briefly describes the CDC campaign and

campaigns in other developed countries, some

of which have been evaluated.

The U.S. National Information/Education Campaign

Operating within the CDC since mid

1987, the National AIDS Information and Education Program is intended to add a national

dimension to reduce the incidence of AIDS

by changing personal behavior and the social

norms that influence that behavior ( 184).

The

o

0

0

0

0

campaign has five objectives (204):

to disseminate detailed factual information on AIDS transmission,

to clarify misconceptions and to reduce

fear,

to support ongoing State and local efforts,

to provide a supportive environment for

AIDS education and for people with

AIDS, and

to help to develop a national consensus

on AIDS education.

The program consists of seven com -

ponents: public service campaign, national

mailing, minority outreach, national AIDS

hotline, national AIDS clearinghouse, corporate outreach, and research.

The first phase of the public information

campaign began in the fall of 1987 with a

national media campaign concentrated in October. On October 1, the CDC distributed

public service announcements to the media:

38 for television, 8 for radio, and 6 for print

(204). A brochure prepared by the CDC was

also available upon request. During the fall

campaign, staff met with national and local

organizations, community leaders, and

volunteers; a total of 31 meetings with representatives of community-based organizations

were held in 28 cities, and 12 forums with

leaders of interested constituencies (such as

black Americans, Hispanic Americans, and

religious media) were conducted (184a).

In developing public service announcements for the fall 1987 campaign, the CDC

and Ogilvy & Mather, the public relations

firm that prepared the campaign, convened

several focus groups, but because of limited

time and funding, did not attempt to pilot

test the messages (204). Since the same messages were distributed throughout the country, comparisons could be made only about

people’s knowledge and behavior before and

after the fall campaign. Given the many

other sources from which people may gain

information on AIDS, this approach does not

permit one to isolate the effects of the CDC’S

efforts. Under contract to the CDC, Macro

Systems is in the process of studying how to

evaluate the CDC’S information/education efforts (204).

In August 1987, NCHS, as part of its

National Health Interview Survey, implemented a survey of AIDS knowledge that was

fielded monthly from August through December among a representative national

sample of the U.S. population

(50,51,52,53,217). These results identify

areas of accurate and inaccurate perceptions

and could guide future phases of the

campaign (see table 3-2). Although the survey has excluded questions on behavior related to HIV transmission, NCHS is exploring

the incorporation of behavioral questions into

a separate study (217).

Some measures of the campaign’s process

are available. Between September and October 1987, operator-assisted calls to the National AIDS Hotline more than doubled, from

about 20,000 to over 49,000 ( 146). This

change cannot be attributed solely to the

CDC campaign; since the number of lines increased from 11 to 44 on Oct. 1, 1987 (204),

the increased number of calls may have

reflected the improved capability of the system to handle callers rather than increased

interest among the U.S. population.
How Effective Is AIDS Education? •59

Operator-assisted calls to the hotline

continued to increase throughout the following three months; however, they exceeded

70,000 in January 1988, an amount considered peak capacity during key calling hours

(see figure 3-2)(204). Although television

broadcasters began to use the CDC’s public

service announcements in October, their use

in number and dollar value more than

doubled in November and continued to grow

in December. During the first four months

of the campaign, radio and television broadcasters on major networks and in the top 75

local markets aired public service announcements valued at about $6 million (figure 3-3)

(204). Radio and television networks donated

about 65 percent of this time, and about 55

percent of the announcements appeared during prime-time viewing hours. Use of the

announcements varied greatly by markets:

from October through January, Philadelphia

aired 209 spots valued at $175,000;

Washington, D.C. aired 12 spots valued at

$2,000; and Los Angeles used only 1 valued

at $75. Using data already collected, the

CDC could gain some insight into people’s

response to the public service announcements

by examining the relationship between the

number and dollar value of spots run in a local market and hotline calls from area codes

in that locality (204).

During the quarter including the October

campaign, AIDS information conveyed by the

media apparently fell (see figure 3-4).2

2 The Centera for Disease Control conducted a computer

search of NEXIS Library for stories pertaining to AIDS.

NEXIS contains approximately 150 journals, newspapers,

magazines, newsletters, wires, financial information, and

medical information within its library.

Figure 3-2.-Calls to the National AIDSa

Hotline, September 1987-January 1988

Total number of cal1s (thousands)

801

20

0

. . . . . . . . . . . . . . . . . . . . . . . . . . .

September October November December January

Month

aOperated assited cal1s

SOURCE: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, unpublished data, Atlanta, GA, May 11, 1988.
60 ● How Effective Is AIDS Education?

Figure 3-3. --CDC PSAs Aired on

Television, October 1887-January 1888a

Number Dollar value (thousands)

I

160 0

1000

t

0 -

2600

2000

1600

1000

600

0

October November December January

Month

aTop 76 markets

SOURCE: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease

Control, unpublished data, Atlanta, GA, May 11, 1988.

Figure 3-4.--News Media Coverage of AIDS a

Number of AIDS stories

2500

2000 -

1600 -

1000 -

500 - “

o

I 1 1

123412341234 123412341234 1

I 82

Quarter/Year

aBased on computer search of NEXIS

SOURCE: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease

Control, unpublished data, Atlanta, GA, April 1988.
How Effective Is AIDS Education? ● 61

The decline was especially striking because

it ended continuous increases from spring

1985 and did not appear to reflect seasonal

trends. Since the content of these stories has

not been analyzed, it is not known whether

this change bore any relationship to the AIDS

campaign and whether any change occurred

during this period in the portion of stories

with accurate vs. inaccurate information.

During the period from October 1987 to

March 1988, the highest number of stories on

AIDS appeared during the middle two weeks

of October (16).

Unlike the situation in countries that

have government stations, U.S. agencies

depend on decisions of private managers

about whether and when to schedule public

service announcements. This problem exemplifies the admonition that the effectiveness of an educational program depends not

only on its content, but also on its implementation (74,207). At a minimum, the message

must reach the intended audience to have an

effect. If the media are not airing public

service announcements at appropriate times or

with adequate frequency, the Government

could pay for the messages to be given at

specific times. Although paying commercial

rates is clearly more costly per message used,

if payment increases the audience receiving

the message, the cost per person reached may

be much lower and the entire program more

effective.

The CDC and the Surgeon General have

prepared a brochure that will be mailed starting the end of May 1988 to every U.S.

household. The brochure provides information about how HIV is and is not transmitted

and urges support for people with AIDS

(193a). During 1988, the campaign’s messages will emphasize women at risk, sexually

active adults, teenagers, and parents (194).

During June 1988, NCHS will include in

its National Health Interview Survey questions relating to the brochure and public service announcements. The survey will query

respondents about whether they are aware of

the public service announcements or the

brochure; whether they have read the

brochure; and how they used the information.

Questions also pertain to their knowledge of

AIDS and HIV, use of blood tests for HIV

antibody, risky behaviors, willingness to participate in a national seroprevalence study,

and trust in information from Federal public

health officials. This information will permit

policy makers to determine the extent to

which messages from the campaign are reaching the populace. In addition, people’s reactions to blood testing and their trust in Federal public health officials can guide approaches to conducting seroprevalence surveys

and to future information dissemination.

Campaigns in the United

Kingdom and Australia

In 1986, the government of the United

Kingdom began an AIDS advertisin g

campaign that is still continuing (25). The

aim of the campaign is to educate people

about the facts and myths of AIDS, to offer

advice and reassurance, and to influence the

climate of opinion so that ultimately people at

risk modify their behavior. The first year’s

campaign consisted of three phases: advertising in the national press; extensive television

and press editorial coverage plus low-level

press advertising; and a press, poster, and television campaign combined with editorial television and press coverage, a youth campaign,

and delivery of booklets to all households.

The government arranged for an evaluation of the first year’s campaign. Since the

campaign used the same approach throughout

the country, it was possible only to track

changes that occurred over time, but not to

isolate the effects of the campaign. On the

basis of baseline and subsequent surveys, over

the year adults who were aware of any recent

AIDS information or who had discussed AIDS

more than doubled (25). About 80 percent of

the general population and of youth recalled

the campaign’s advertisements, the highest of

any such campaign in Britain. Substantial

improvement occurred in people’s knowledge

about specific routes of HIV transmission and
62 ● How Effective Is AIDS Education?

the desirability of condom use, but only

slight declines in the misconception that

blood donation can transmit HIV. Surveys

found little attitudinal change toward people

with AIDS and little behavioral change in the

number of sexual partners or in condom use.

Consistent with previous trends, however,

homosexual behavior had continued to

change, with less unprotected anal intercourse

and fewer sex partners.

In 1987, the government of Australia

launched an educational program to provide

information to motivate the public to avoid

risky practices (170). The program consisted

of a television announcement, which

portrayed great danger; pamphlets distributed

to physicians, pharmacists, and health and social service agencies; advertisements on radio

and in print that were targeted to specific

groups; and a hotline for counseling.

The results of interviewing urban Australians before and during the campaign are

consistent with the campaign’s correcting

misconceptions about how HIV is transmitted,

such as through public toilets, but there was

no change in the belief that blood donation

posed a risk. Knowledge that condom use

decreases the risk of HIV infection started at

a high level (92 percent) and increased (to 95

percent). Men reported more routine condom

use after the campaign began, and 44 percent

of the population reported that the campaign

had changed their attitudes or behavior, with

higher figures among young adults and single

people.

OTHER PUBLIC EDUCATION

PROGRAMS

Several programs that have used mass

media to try to promote health-related behavioral change may provide lessons for AIDS

education. This section reviews experience

with programs that have been associated with

behavioral changes in three areas: cardiovascular risk reduction, smoking cessation, and

control of syphilis. Researchers attempting to

reduce cardiovascular risk have designed and

implemented well-designed studies that

permit analyzing the effectiveness of the programs undertaken. Programs to curtail smoking have gained some prominence, for their

successes as well as their failures. U.S. efforts to control syphilis may provide insights

into effective strategies for AIDS education,

since both are sexually transmitted diseases.

Some other programs have had less success in fostering behavioral change in three

other health-related areas: use of seat belts,

use of family planning techniques, and use of

alcohol and other drugs. In general, programs

in these areas have resulted in changes in

knowledge and attitudes, but not in behavior.

Several programs to increase voluntary seatbelt use in the United States and other countries have failed to achieve even modest success ( 1 03). An information program in

Sweden during the 1970s, however, did lead

to increased seat-belt use.

Mass media programs to promote the use

of family planning techniques have had

limited success in changing people’s behavior

(173). It was notable that television messages

increased awareness most and that people

generally reacted favorably to the advertisements. Advertisements in the print media,

however, had little effect.

During the early 1970s, several educational efforts were undertaken to discourage

drug abuse, particularly among adolescents

and young adults (103). In one program, the

Advertising Council, working with the National Institute of Mental Health, developed

public service announcements to combat drug

use. The announcements were consistently

aired outside prime-time hours, did not expose target groups to specific messages, failed

to take account of social networks and

sources of information credible to drug users,

and may have erred in containing strong fear

messages (103). There is a consensus that efforts during the 1970s failed to influence

drug use, whether among youth or adult

women. Programs specifically focused on al-
How Effective Is AIDS Education? ● 63

cohol use produced little or no change in behavior, although awareness of alcoholism increased (103).

Instead of indicating that mass media approaches cannot change behavior in this area,

campaigns that did not achieve an effect may

exemplify only approaches that were poorly

designed or implemented (74,207). At least

one program to curtail alcohol use and driving produced attitudinal changes (103). AS

Wallack emphasizes, programs that address

the community as well as the individual are

more likely to succeed, and efforts to curtail

drunk driving are occurring in an environment where media advertising and television

programs promote unsafe practices (209,137).

Certain characteristics of HIV infection

described above that make behavior change

and its evaluation difficult apply to some of

these other public health programs. In all

cases, ongoing media attention and public interest impede- isolating the

ular educational program.

Cardiovascular Risk

effect of a partic -

Reduction

Perhaps the best designed studies of interventions that use mass media come from

programs to reduce the risk of cardiovascular

disease among entire communities. Comparing changes in three similar communities,

Stanford researchers found that over a 3-year

period during the early 1970s, risk of cardiovascular disease 3 fell and remained significantly lower in the two communities that

had received educational interventions (69).

Mass media alone successfully promoted behavior, particularly nutritional behavior, to

lower cardiovascular risk about 25 percent.

Combining mass media with face-to-face instruction achieved even greater changes

(about a 30-percent reduction), largely because of a greater reduction in smoking. In

addition to providing information and at3 The researchers measured cardiovascular risk by means

of a composite score that incorporated factors such as

plasma cholesterol, systolic blood pressure, relative weight,

age, and sex.

tempting to affect attitudes and motivation,

mass media materials were developed to teach

specific skills and to reflect the characteristics

of the target audiences (121). With greater

use of health professionals and less use of

media, a project in Finland during the same

period achieved comparable

(69).

The Stanford researchers

sustained community-based

achieve behavior change for

risk reduction

concluded that

education can

risk reduction,

but the optimal mix of approaches to conduct

an education program has yet to be defined.

Research is continuing in five larger communities, with the addition of youth education, and interim results support the effectiveness of the educational interventions

(121). Projects are also underway in other

States (Rhode Island, Minnesota, Pennsylvania) and other European countries (Switzerland, Germany, Portugal, Italy, and Yugoslavia) (103).

Although this body of research supports

the effectiveness of community-based programs using mass media, cardiovascular risk

reduction differs from reducing HIV transmission in certain ways that may well influence the success of educational programs

(103). Because cardiovascular disease is so

much more prevalent than AIDS, people are

more likely to know someone like themselves

who has had cardiovascular disease and hence

may be more likely to feel susceptible to the

disease. In addition, behaviors linked to cardiovascular risk, such as diet, smoking, and

exercise, are easier to discuss and acknowledge publicly than behaviors associated with

HIV infection, which relate to sexual behavior, IV drug use, and reproduction. Finally,

for several years the social environment has

been supporting changes in behavior to

reduce cardiovascular risk. Similar social

support may be building for changes in drug

use. There is no such consensus in the

United States about sexual behavior, however,

and messages in the media and in society

generally regarding sexual behavior often

conflict with behavior to reduce the risk of

HIV infection.
64 ● How Effective Is AIDS Education?

Reduction of Smoking

Over the past generation, U.S. social

norms regarding smoking have changed

dramatically. Although the role of mass

media and anti-smoking campaigns in this

development is not clear, a review of 40 programs involving the mass media concluded

that large-scale campaigns not only improved

people’s awareness, knowledge, and motivation, but also reduced smoking prevalence

(75). Since few studies incorporated comparison groups that received no intervention,

the review compared the effects of different

programs, with the results from face-to-face

clinics as the ultimate (highest) standard for

success and the results from a self-help program of the American Lung Association as a

lower, more reasonable standard by which to

judge mass media programs.

In the late 1960s, an advertisin g

campaign using the Fairness Doctrine was

undertaken to counter advertisements that

promoted smoking. The results suggest that

public service announcements can be effective. That successful campaign included

the following features: widespread dissemination (reach); high frequency, including

some during prime-time broadcast hours (frequency); endurance, in this case three years

(duration); and variations in the message.

The high frequency probably reduced the opportunity for the audience to avoid the message, and presentation of opposing views (the

tobacco industry’s vs. health agencies’) probably increased discussion of the issue.

Intensive media campaigns in the United

States and other developed countries have

lowered the prevalence of smoking as much

as good self-help manuals, such as those of

the American Lung Association; both approaches have led people to quit smoking at

twice the rate of the smoking population

without such programs (75). Adding cornmunity activities, in turn, appears to double

the effectiveness of media programs alone.

Self-help clinics that are broadcast on television or radio are about as effective as selfhelp manuals. Combining media self-help

clinics with printed material raised their effectiveness, and adding group discussion

raised it even more. None of the interventions that used mass media reduced and

maintained smoking prevalence as well as

face-to-face clinics. Mass media interventions, however, would be more cost effective

than face-to-face clinics if, as Flay suggested, mass media approaches can reach and

change the behavior of more people for the

same or lower cost (75).

Control of Syphilis

During World War I, 13 percent of the

men drafted in the United States were infected with either syphilis or gonorrhea (24).

Although a diagnostic test could detect

syphilitic infection, the main treatment, a

drug containing arsenic, was toxic and necessitated prolonged administration.

The campaign undertaken by the military

against venereal disease centered on promotion of sexual abstinence and repression of

prostitution (24). Posters, films, and other

material warned soldiers about the health

risks of prostitutes, and more than 20,000

women were quarantined. Although the efficacy of condoms in preventing syphilis was

recognized, the military did not provide them

to the troops because it was feared that such

a step would encourage sexual relations. Instead, soldiers were required to undergo disinfectant treatment after sexual exposure.

Moreover, soldiers who contracted a sexually

transmitted disease lost their pay and were

subject to court-martial (23). Despite these

measures, rates of syphilis remained high

during the war.

During the late 1930s, State and Federal

governments developed programs to detect

and treat syphilis in its early stages (24).

Diagnostic facilities and clinics increased, and

States began to require applicants for marriage licenses to be tested for syphilis, despite

the recognition that intercourse before marriage was common. Although premarital testing became compulsory in most States, 25
How Effective Is AIDS Education? ● 65

percent of the people who tested positive

were actually uninfected, but still underwent

treatment. By 1978, only about 1 percent of

all tests positive for syphilis were conducted

as part of premarital testing.

During World War II, the military not

only undertook an educational program, but

also provided condoms and sought to treat

soldiers rapidly without punishing them (24).

Rates of syphilis infection fell during the

early 1940s, a decline that accelerated with

the introduction of penicillin from late 1943

(23). Even with the availability of effective

treatment, however, the disease has persisted

and has begun to increase in prevalence during the past decade.

Like syphilis during the early part of this

century, AIDS has raised issues of sexual behavior about which there are diverse and

conflicting views in U.S. society. Also

similar are the populace’ widespread fear of

contagion and its stigmatization of infected

and sick people (24), mainly people from

groups historically subjected to discrimination. The experience with syphilis indicates

that intensive education and provision of

condoms during World War II protected

soldiers from infection, but that attempts

during World War I to prevent infection

through abstinence, fear, and appeals to

morality were not successful (24).

CONCLUSIONS

What is known specifically about AIDS

education and generally about public health

campaigns indicates the considerable capability of the mass media. In only a few years,

the general population has gained a great deal

of knowledge about AIDS, most of it through

television ( 103). Furthermore, studies of

other public health campaigns have shown

that education through the mass media can

change people’s health-related beliefs and behavior to a limited extent. It is also clear

that an educational program increases its ef -

festiveness by combining use of mass media

with interpersonal communication and by

helping people develop skills to implement

their new beliefs and motivations, through

mass media or supplementary approaches (74).

The media set an agenda for society; their

coverage can heighten public awareness of an

issue such as AIDS and stimulate people to

ponder and discuss it (208). The media can

provide factual information that reduces misconceptions and fear about HIV transmission

and that alerts people with risky behaviors to

their susceptibility and directs them to more

detailed information. The media can also

legitimize efforts and attitudes to reduce the

stigma associated with HIV infection and to

prevent further spread of HIV.

Although past experience indicates that

public health campaigns directed to the general population can achieve change, it is not

clear why some programs have been more effective than others (74). Which elements and

combinations of elements are responsible for

successful campaigns is the subject of continuing research, for example, in the area of

cardiovascular risk reduction. To identify

successful program elements requires that

programs be designed to isolate the effect of

different elements and that evaluations be

conducted. Such an approach could be applied to AIDS education programs. For example, in cooperation with States and

localities, the CDC could systematically vary

the content or dissemination of messages

within a State or across States. Surveys before and after the interventions, perhaps as

part of NCHS’ current AIDS surveys, could

evaluate their relative effectiveness. These

insights could then be used to increase the

effectiveness of subsequent phases of the

campaign.

A necessary condition for effective education is that the message reach the intended

audience, a precondition that depends on the

number of messages, when and how they are

presented, and the duration of the campaign.

Relying on public service announcements increases uncertainty about this aspect of a

campaign, because media managers rather
66 ● How Effective Is AIDS Education?

than campaign organizers control the frequency, timing, and duration of the message.

Although the anti-smoking campaign illustrates that public service announcements

can effectively disseminate information, legal

requirements related to the Fairness Doctrine

underlay media use of that advertising. Existing data on the CDC’s fall campaign and

data that NCHS plans to collect about the national mailing can be analyzed to gain insight

into the audience reached by these messages.

For some aspects of AIDS education, notably

condom use, commercial interests coincide

with public health concerns and can help

communicate certain messages to prevent HIV

infection (103).

One aspect of reaching the intended

audience for AIDS education entails tailoring

the content and dissemination of messages so

that they reach people at high risk. That

AIDS has disproportionately affected blacks

and Hispanics argues for special measures to

reach them. Television may offer particular

opportunities. Blacks, Hispanics, and people

from lower socioeconomic groups have

generally recalled better those messages

delivered through television (1 19,178).

Audiovisual media are especially important

means of reaching minorities, since minorities

have been more likely to obtain health information through these sources than through

print media (22). Reaching people from different ethnic backgrounds may also require

the development of messages that are sensitive to the language and culture of specific

communities. In many of its activities, the

CDC’s national information and education

program has undertaken special efforts for

minorities. Few studies, however, have

evaluated programs of AIDS education for

minorities in the general population or with

risky behaviors (see chapter 2).

Finally, but very importantly, one must

consider the environmental context of AIDS

education (208). Like any public health

problem, HIV transmission and its prevention

depend not only on individual behavior but

also on community norms and social policies.

As noted earlier, the tone of mass media

coverage can improve individual and social

attitudes towards HIV infection and support

preventive behavior and compassion .

Relevant messages, however, pertain to more

than specific matters regarding AIDS. U.S.

society, advertising, and television programming exploit sexual insecurity (208). To support behavior consistent with reducing HIV

transmission, the media and advertisers could

alter their depiction of sexual behavior, as

they did for smoking and are doing for alcohol use. Messages from mass media also

have the potential to generate greater demand

for certain services, such as drug treatment

and HIV testing.

Since there have been few public service

announcements about AIDS over the course

of the epidemic, people must have been acquiring information from other aspects of the

media. Greater insights into the role that

news and entertainment media have played in

shaping public perceptions and behavior

about AIDS might help to guide future

policies regarding AIDS education.
Appendix A: RECOMMENDED BEHAVIOR CHANGES AND

PRINCIPLES OF HEALTH-RELATED BEHAVIOR

In response to the AIDS epidemic, the

Centers for Disease Control (CDC) and other

public health officials have developed recommendations to reduce further HIV transmission. Researchers at the CDC and elsewhere

have revised these guidelines as knowledge of

HIV and its epidemiology have progressed.

As background to the discussion of AIDS educational programs, this appendix briefly

presents the major recommendations that

have been made. Also relevant as background for AIDS education are general principles of health-related behavior that have

been developed for other educational programs. The points that seem most relevant to

AIDS education are summarized in the second

section of this appendix.

RECOMMENDED BEHAVIOR

CHANGES

Knowledge of how HIV is transmitted

and studies of how people have become infected have identified behavior that increases

and decreases the chance of infection. In

general, one prevents HIV infection by

avoiding contact with infected blood and

other bodily fluids, especially semen and

vaginal fluid. These actions prevent an

uninfected person from contracting the infection and prevent the virus from spreading

from an infected to an uninfected person. A

goal of AIDS education is to prevent HIV

transmission by promoting the adoption of

these preventive behaviors:

Sexual behavior:

o Reduce the number of sex partners that

may be at high risk of HIV infection

(48,88). Least risky is monogamy with

one faithful partner or abstinence.

Reducing the number of partners and

contacts and knowing their sexual his0

0

0

0

0

tory will lower but not eliminate the risk

of viral transmission.

Use condoms with a spermicide effective

against HIV throughout sexual relations,

unless both partners are known to be

uninfected (70). The use of condoms

appears to reduce but not eliminate viral

transmission (88).

Avoid anal intercourse, because subsequent trauma and bleeding may facilitate transmission of the virus (48).

Avoid anal-oral and oral-genital contact

(48).

Seek testing to determine infection status

if one is at risk of infection because of

past behavior (181). This advice applies

particularly to women who may become

pregnant. Part of a testing program

entails counseling about positive and

negative results and preventive behavior.

Use only sterilized instruments for skin

piercing, such as ear-piercing, tattooing,

and acupuncture (18 1,221 ).

Intravenous drug use:

o Seek treatment for drug use so that IV

injection is reduced or eliminated.

o Do not share needles or other equipment

that may have residues of infected blood

(181).

o Clean any shared needles or other equipment with bleach to kill the virus.

Blood transfusions:

o

0

Do not donate blood if one has clinical

or laboratory evidence of HIV infection,

Do not donate blood if one is at high

risk of HIV infection because of any of

the following: a man who has had sex

with another man since 1977; a person

who is or has been an intravenous drug

user; a person who emigrated since 1977

from a country where heterosexual activity seems to play a major role in

67
68 ● How Effective Is AIDS Education?

HIV transmission; a person wit h

hemophilia who has received clotting

factor concentrates; a person who has

engaged in prostitution since 1977; and a

person who has been the sexual partner

of an infected person or a person in any

of the above high- risk categories

(179,181,198,199).

In addition to suggesting behavior to

prevent HIV transmission, studies of the

AIDS epidemic have identified behaviors that

have not been associated with infection. Another goal of AIDS education is to relieve

anxiety among people at low or no risk by

conveying information about behaviors that

have

o

0

0

not transmitted the virus:

People have not become infected

through casual contact, including routine

activities connected with sharing a

household or workplace with people

with HIV infection (180).

People cannot become infected by

donating blood, because new sterile

equipment is used for each donor (176).

There is no evidence that insects spread

HIV infection (174).

THEORETICAL BASES FOR

AIDS HEALTH EDUCATION

Social scientists seeking to explain and

modify individuals’ voluntary health behavior

have increasingly broadened their perspectives from individuals to encompass the social

environment. Models run the gamut from

those linking behavior with individual attitudes and beliefs to those explaining the diffusion of innovations, those incorporating the

influence of social networks, and those based

on marketing principles. Although no unified

theory exists to guide a specific program of

health education, several behavioral models

contain elements relevant to the changes that

are needed to check HIV transmission and to

reduce anxiety and discrimination.

o

0

0

0

0

0

0

0

0

The more individuals perceive that they

are at risk of contracting a condition,

the more likely they are to engage in

behavior to prevent it (101).

An even stronger factor in explaining

preventive health behavior are the barriers that people perceive, such as

physical, economic and psychological

costs (14, 101 ).

Also important are the perceived benefits or effectiveness of the intervention

(101). Receptive attitudes towards an

intervention can be promoted by stressing potential benefits, such as peace of

mind from using condoms (165).

Exposing people to cues about the

availability of a health procedure and

encouragement to use it has been associated with greater subsequent use (14).

After individuals have decided to adopt

certain health behavior, they require the

skills, both social and mechanical, to

carry out the new behavior (85).

Rehearsing or practicing the desired behavior can help to convey the required

skills (1 1,160).

Individuals’ perceptions of the social approval or disapproval accorded to

specific actions influence their behavior

(5). Support and approval from friends,

community, and society at large reinforce people’s intention to change their

behavior (11 ,85).

The stronger individuals’ beliefs in their

ability to undertake or maintain a

health-related behavior (self-efficacy),

the more likely they are to undertake

that behavior (1 1).

Using fear as punishment to weaken unhealthy behavior is unlikely to produce

the desired effect. The use of fear is

most likely to be effective if the desired

behavior is reinforced by a reduction in

the level of fear (102). This approach

entails offsetting fear-arousing information by presenting people actions or

skills that they can use to lower their

risk (165).

People are more likely to act on information if they perceive the source as
How Effective Is AIDS Education? ● 69

credible, a belief that relates to the expertise and trustworthiness of the source

material (14a, 144, 165). To be credible,

messages must acknowledge the beliefs

and values of the target audience. Prevention messages also gain credibility if

they clearly acknowledge the disadvantages of the intervention ( 165).

Health messages conveyed in the course

of a patient’s treatment acquire a medical imprimatur that may increase their

credibility y. By contrast, if people feel

castigated, they are likely to distrust the

bearers of the information and to ignore

the message.

o Evidence that behavior may change attitudes supports examining the possibility

of altering behavior through structural

interventions (1 4). The inconsistency

between alterations in attitudes and behaviors undercuts using attitude change

to measure behavior change (207).

o People learn by modeling their behavior

on that of others with whom they

identify. Opinion leaders and peer

counselors can serve as role models (11).

Several factors pose particular barriers to

persuading people to alter the behaviors that

transmit HIV. Although perhaps not unique

to AIDS or HIV infection, these factors do

make behavior change difficult to achieve.

First, the behaviors that are responsible

for HIV transmission and that people are

called upon to change relate to sexual,

reproductive, and addictive activities. Since

these activities in turn have profound

psychological, physical, and social implications, people may face great distress in

changing these behaviors. These are sensitive

areas, often considered more appropriate for

private decisionmaking than public policy

(1 5). Nor is there a consensus on social

values in these areas, especially regarding

sexual it y and reproduction . Thi s

heterogeneity hinders the coalescing of public

opinion behind certain educational strategies

and reduces social support to reinforce

desired behavior change in individuals.

In addition, AIDS and HIV infection are

highly stigmatized conditions (15). Perhaps

this situation stems from the fact that most

AIDS cases have been concentrated among

groups considered marginal and discriminated

against by society, namely homosexuals and

IV drug users and more recently, prostitutes

and prisoners. Even racial and ethni c

prejudice may play a role in furthering the

stigmatization of people with AIDS. The fact

that blacks and Hispanics have a disproportionate share of AIDS cases may reinforce existing racial and ethic prejudice.

People who are infected or even suspected or

being infected may face being ostracized by

their families and friends, losing their jobs,

having difficulty finding housing or selling

their houses, and even obtaining medical care.

Such discrimination poses a powerful barrier

discouraging people with high-risk behaviors

from determining whether they are infected

and sharing this information with others.

Also impeding behavior change are the

threat of what is known and the uncertainty

of what is not known about HIV infection

and AIDS (15). Since a high percentage of

infected people have developed serious

illnesses and died, those who acknowledge

being infected face the prospect of an increasingly debilitating disease likely to end in

dependence and death. Unlike most other

sexually transmitted diseases, and certainly

fatal ones, medicine so far can offer no cure,

only palliation and perhaps postponement of

the worst symptoms. Scientists have made

phenomenal strides in only seven years in

identifying the cause of AIDS and the mechanisms for viral transmission. Knowledge

is constantly evolving, however, and much

uncertainty remains. Both infected and

uninfected people are being called on to make

behavioral changes for life. The immediate

benefits to be gained from changing behavior

may be limited, especially for people who are

already infected. Yet over time, eliminating

risky behavior offers infected people the opportunity to protect their loved ones and offers uninfected people the enormous benefit

of remaining uninfected.
Appendix B: AIDS EDUCATION FUNDED BY

THE FEDERAL GOVERNMENT

71
72 ● How Effective Is AIDS Education?

I

G

a
How Effective Is AIDS Education? ● 73

. .

o

m

:

In

u
Table B-1.--AIDS EducaLlon Prosr- Euuded by ALcoIJoL, Drug Abuse, and PkmLal tlealt.h A&inist.rat. ion ( ADAMIA) (Continued), Hay 1986

Name of program/ Organ lzat~on/ I-’I(JJ ect,

cont,ract/grant contact. AmounL period Description Evaluative component

Center for

AIDS

PreventIon

St.udles/Edward

Morale s

Center for

AIDS

Prevention

Studies/Jemes

Sorenson

Center for

AIDS

Prevention

St,udles/Jwnes

Sorensen

Center for

AIDS

PreventIon

Services/l)avld

Gibson

S2.4

million

for the

total

center

grant.

S2.4

million

for the

entire

center

grant.

S2.4

million

for the

tot.dl

center

grant.

S2.4

million

for Lhe

total

center

grdnL.

9/1/86

through

2/90

9/1/86

through

8/31/91

9/1/86

through

8/31/91

9/1/87

through

8/31/91

Title: AIDS Prevention Through Coaxnun ity

Action Networks for Blacks aud Hispanics.

Target groups: 60 black and 60 Hispanic

coamunity leaders from O~klmd and San

Francisco. interventions: workshops VS.

mon~hly newsletters. Subjects randomly

assi~ned to either of two groups.

Title: AIDS Prevention w~th Drug Abusers

Completing Residential Treatment. Tar8et

Uroups: 114 seronegative IVDUS enrolled in

outpatient phases of residential treatment

in Walden House in San Francisco.

Interventions: SubJects WILL be involved in

a randomized clinical trial where 57 will

receive a 10-hour risk reduction training

workshop and 57 will receive a packet of

educational materials.

Title: Methadone Maintenance Impact on

Sharing of Body ?’luids by SeroposiLlve Drug

Abusers. Target groupa: Seropositive IVDUa

enrolled in a treatment. program at Substance

Abuse Services. Interventions: assigned

randomly to standardized treatment pro8ram

(abstinence-orietlt.ed focus) compared to

public-health-oriented treatment (focus on

divertln.g seropositives from sharins

needles).

Title: Clinic-Based Outreach to IV Dru8

Users and Sexual Partners. Target groups:

180 stironegative IVDUS in heroin

detoxification at San Francisco General

Hospital, 180 “comnunity” drug users

recruiLed with vouchers, and 180 female

sexual partners of IVDUS who do nok inject

drugs. Interventions: Members wiAl be

randomly assigned to a counseling/probLemsolving condition or an information only

control condition. Antibody t.estlng will

also be done.

N.A.

Subjects will be interviewed before the

workshop, after the workshop, and at 6

and 12 montha after the intervention to

asseaa knowledge about AIDS, riak

behaviors, and exposure to HIV.

Pre-meaaures will be taken at admission

to program and post-measures will be

taken at 3- and 12-month followup.

Will look at knowledge about riskreductlon, acceptance of risk-reduction

guidelines, self-reported risk

behaviors, perceived AIDS threat, and

conxnunication skills. Antibody sLatus

wiLl serve as a behavioral measure.

9
How Effective Is AIDS Education? ● 75

a

I

I z

z z

I
76 ● How Effective Is AIDS Education?

.4 0 .

c

4

c

0 0
How Effective Is AIDS Education? ● 77

<

4

d

&l

d

c

o

c

o

4

$ 1
78 ● How Effective Is AIDS Education?

d

4

0

4J

c

o

0

.

d

e \
How Effective Is AIDS Education ● 7 9

,

I

I

I

I

d

6

J

IA. . d

0

&

au

w

o

4

IA

Jz

K %’N ‘D 30 )

\!4\

0s0

-d0
80 ● How Effective Is AIDS Education?

c

o
How Effective Is AIDS Education? ● 81

A

- 2’ (.4 moo) \l-l\

O.co .+44

m
82 ● How Effective Is AIDS Education?

1

o

1

c

0
How Effective Is AIDS Education? ● 83

>

c-0

m

0

0
84 ● How Effective Is AIDS Education?

\
How Effective Is AIDS Education? ● 85

a

>

\

G

o

<

z“

w

8’

m @- ‘a

a
86 ● How Effective Is AIDS Education?

>.

g m

m

,J

@ E

ln\
How Effective Is AIDS Education? ● 87

4

a

A

c

o

u

a

zs

4

z’

-4

z“
n88 ● How Effective Is AIDS Education?

c

o

4

0 0

\

c

o

d

6

a

c

c

a
$.

3’

m

How Effective Is AIDS Education? Q 89

\

g

.

4

u

.AA.

-i

c ,6

w

!4

a

c

a

-.4

a“

z

4

. .
90 ● How Effective Is AIDS Education?

o

(n

r-

(0

(n
How Effective Is AIDS Education? ● 91

m -4

ij

a

c403

o

m

o

0

4.) 0

c

3

.!

\

c

o4

c

o

4
92 ● How Effective Is AIDS Education?

Q

.9

c

4

a

a!

O(U

4-4

ul

ml

m

a

m

w

o

. 1A

ul
How Effective Is AIDS Education? ● 93

c

0

a-c

Inn c

o
Table B-2.--AIDS Education Program Funded by the Centers for Disease Control (CDC), 1988 (Continued)

Name of program/ Organization/ ProJect

contract/grant contact Amount period Description Evaluative component

Nassau County,N.A.

New

York/Robert

Levin

Houston, $226,000

Texas/Elaine for FY88

McParlain

Began

9/1/87

with 5

months

duration.

Continued

ation

grants

available

each

year

for a

possible

project

period

of 5

years.

9/1/87

throuuh

8/31/88

Up to SIX new $5 million 3 to 5

projects In years

FY38/Stuart.

Berman (CDC)

Target group:women at high risk for HIV Will evaluate how well women at risk

infection who attend medical clinics, are identified and whether are not they

planned parenthood clinics, and drug abuse are using effective contraception.

treatment. Interventions:identify women Will determine if women are using more

who are not affiliated with the health care effectiv a contraception after the

system and ascertain their knowledge, intervention.

attitudes,intentions about HIV infection

and pregnancy through surveys,

questionnaires, and interviews. From this

information, develop effective methods of

contraceptive practices and determine

reasons why HIV + women still want to become

pregnant in order to target educational

efforts.

Target group;women at high risk for HIV

infection attending local health

departments, STD clinics, family planning

clinics,and perinatal clinics.

Interventions;identify women who are not

affiliated with the health care system and

ascertain their knowledge, attitudes,

intentions about HIV infection and pregnancy

through surveys, questionnaires, and

interviews.From this information, develop

effective methods of contraceptive practices

and determine reasons why HIV + women still

want to become pregnant in order to target

educational efforts.

Applications are due July 15, 1988 for new

projects. MILL tar~et women at high risk

for HIV infection

Will evaluate how well women at risk

are idenified and whether are not they

are using effective contraception.

Will determine if women are using more

effective contraception after the

intervention.

•
How Effective Is AIDS Education? ● 95
.

n

4

j

96 ● How Effective Is AIDS Education?

\

G

o

4
How Effective Is AIDS Education? . 97

c

.nm

a

a

260>4’s

-(

4.)

uoa

co0

a

c

o

c

o

I

m

n

<

.
98 ● How Effective IS AIDS Education?

c0

u

m“ .

. .

\

c

o

w

o
How Effective Is AIDS Education? ● 99

I I

-0

fw Q

o

c

o

al u-i

I

a)

Inm

a)

u) >0

d

-0

c.

mmal

.O1

Em

I

I . . . .

,,

1

I u

<

z’ z

Ov

z

\

I
100 ● How Effective Is AIDS Education?

m

c

Q

500

l-la

.n

m W

.

Cll o

u

\

0

. . .2 -

c

.-l

a)

d

n

2

u-la

U.cn

-(u >3$ 4NW

@N’Y

rn; a
How Effective IS AIDS Education? ● 101

I

.

d

0.

Id- i
Table B->. --AIDS Education Programs Funded by Health Resources and Services Administration (HRSA), MAY 1988

a

Name of program/ Organization/ Project

contract/g r aII contac t L Amount period Descriptio n Evaluative componen t

Bureau of tl~t.emal and Child Health and Resources Development :

Pediatric AID S

Demonstratio n

Grant s

b

Regionalize d

Family Stress

and Risk

Reductio n

Team s

c d

Demonstra t

grant, .

d e

.

Privat e $4.43 5

entitles, non- mllllon,

profit an d FY8 8

profit/Joh n

Hutching s

(HRSA )

Nationa l $6. 3

Hemophili a millio n

Foundation / f o r

Sharon Barrett upcomin g

(HRSA ) F Y

(Suppl e

-

ment to

origina l

grants. )

Nationa l $200,000

Hemophili a tota l

Foundation /

Sharon Barret t

(HRSA )

1 to 3

year s

Con -

tinuou s

funding .

AID S

suppl e

-

ment s

bega n

In

1985 .

7/1/8 8

throug h

6/30/8 9

10 to 20 grants will be awarded to private Will be written in grant proposals. In

entitlesnonprofit. and for profit, which , applications read, thus far, the type

develop strategies and models for the care of evaluation that will be done

of children with AIDS. 47 applications have includes counting the number of

been received all education components ar education programs e and the number of

included . people in the audience receiving the

educationSome grantees comment tha . t

they are not sure how to conduc t

evaluation for this new grant.

Target grouphemophiliac communit : y Currentlyno formal evaluation, but ,

(hemophilia, spouse, and family). Eac will develop an evaluation tool in the h

hemophiliac diagnostic and treatment center future Outcome data are being .

offers different educational intervention collected s(i.e., activities an d

to the target group (i.e. , one-on-one strategies going on in the field).

counselinggroup , sessions, dissemination o f

pamphlets dealing with teenagers and sexua l

intimacy, women questions most often , aske d

about AIDS and hemophilia) The Nationa . l

Hemophilia Foundation also operates as a

clearinghouse for AIDS-related materials .

Demonstration funds will be made availabl Will be written in grant proposals. e

to 10 chapters within the National

Hemophilia Foundation to develop outreac h

strategies/models for culturally divers e

populations with hemophilia .

a Table includes only those program components targeted to the general population, homosexual/bisexual men, intravenous drug u

sexually transmitted disease clinic attendees and school-age youth .

b AIDS Record“Over , $24 million Available from Health Resources services Administration for Three New Programs,” AIDS Record 2(8/9)

April 8, 1988

c 

HRSA IS offering LIIIS ~ra[it 111 conJunctlorl with the CellLers for Disease col~trol,

d Barrett, S.,

Center for Infectious Diseases.

Director ot Hwnophllla Program, ofi~ce of Materndl arid Cl]lld tiedlL}l, Bureau of Maternal and Child Health and Resources

Developmetlt, Health Resources a[d Services Admlnlstr~t,lon, Publlc Health Service U.S. Department of Health and Human Services, ,

Ruckv~lle, MD, personal comrrur)lcdtlo[), M~y 12, 1!388.

e U S. Depart.menL of Heal~ll al~d Human Services, Publlc Health Service Health , Re>ources atld Services Admln~stration, Bureau of Mdternal drld

Child Healt_.h and Resources Development., Abstracts of Active Proqects FY 1988, (U.S. GPO: 1988-209-524),

SOURCE. Ofilc.e of TeLl)nulogy Assessment, 1988.
Table B-6.--AIDS Education Program Funded by the National Institutes of Health, May 1988 a

—

Name of Program/ Organ ization/ projec t

con t r a c t/g rant con tact Amount period Description Evaluative component

National Cancer Institute (NCI):b

HIV in New NCI/Maryan n $22,000, 1984 NCI IS collaborating with the New Jersey

Jersey Drug Roper, John FY88 (part through State Department of Health in Implementing

Abusers Hartinger attri- FY88 an AIDS intervention targeted to IVDUs.

(Intermural butable to Intervention:Information dissemination

project) education) about HIV transmission, risky behavior, and

other AIDS facts.

National Heart, Lung, and Blood Institute (NHLBI):c d

Blood Donor University of $94,000, 1984 Target group:high school students in 29

Recruitment Washington/ FY88 through blood centers.Interventions:(1)

Among High Irwin Sarason 1988 Informational approach (i.e., 3 l-hour

School Student s sessions,audiovisual presentation), (2)

motivational approach (i.e., 3 l-hour

sessions,role playing,social skills,

questionnaires) ,and (3) combination of the

two.

Psychosocial New York Blood $436,000,1985 Target group:HIV positive blood donors.

Support for Center/Johanna FY88 through Interventions:Subjects are divided into a

Anti-HI V Pindyck 1989 control group,a group receiving individual

Positive Donors counseling,and a group receiving individual

as well as peer counseling.

National Institute on Aging (NIA):e

AIDS Age Brief NIA/Virginia Approxi- In the Age briefs are disseminated regularly by

Morgan mately planNIA; typically 530,000 copies of each brief

$17,000 to ning are distributed.The AIDS Age Brief will be

print and stages.a 2 to 3 page fact sheet and will deal with

dissemin- Release transmission of HIV in the elderly. It will

ate a probab- be disseminated to the press, major

typical ly May organizations dealing with the elderly,

age brief. 1988. minority organizations, physicians, grocery

stores, etc.

Program impact will be determined, in

part, through seroepidem~ologic surveys

conducted yearly and incidence of

seroconversion.Preliminary results

suggest increased knowledge levels in

the exposed group.

Will evaluate knowledge gained under

the 3 approaches and determine who

donates and why.Will measure the

number students volunteering to donate

and their HIV blood status.Thus far ,

intervention 1 seems more effective

with students already Interested i n

donating, 2 seems more effective with

students who have not thought about

donating,and 3 seems more effective

with all students.

Pre- and post-test data are being

collected. A Longitudinal analysis is

being conducted as well as clinical

followup to determine the progression

of the disease.

None. Age Briefs are reviewed every

few years.
Table B-6.--AIDS EducaLitn Program Funded by the National Institutes of Health, May 198 8

a

—

con tact Evaluative component

$22,000, 1984 NCI IS collaborating with the New Jersey

Jersey Drug Roper, John FY88 (part through State Department of Health in Implementing

Abusers Hartinger attri- FY88 an AIDS intervention targeted to IVDUs.

(Intermural butable to Intervention:Information dissemination

project) education) about HIV transmission, risky behavior, and

other AIDS facts.

National Heart, Lung, and Blood Institute (NHLBI):c d

Blood Donor University of $94,000, 1984 Target group:high school students in 29

Recruitment Washington/ FY88 through blood centers.Interventions:(1)

Among High Irwin Sarason 1988 Informational approach (i.e., 3 l-hour

School Student s sessions,audiovisual presentation), (2)

motivational approach (i.e., 3 l-hour

sessions, role playing, social skills,

questionnaires) , and (3) combination of the

two.

Psychosocial New York Blood $436,000, 1985 TargeL group: HIV positive blood donors.

Support for Center/Johanna FY88 through Interventions: Subjects are divided into a

Anti-HI V Pindyck 1989 control group, a group receiving individual

Positive Donors counseling, and a group receiving individual

as well as peer counseling.

National Institute on Aging (NIA):e

AIDS Age Brief NIA/Virginia Approxi- In the Age briefs are disseminated regularly by

Morgan mately plan- NIA; typically 530,000 copies of each brief

$17,000 to ning are distributed. The AIDS Age Brief will be

print and stages. a 2 to 3 page fact sheet and will deal with

dissemin- Release transmission of HIV in the elderly. It will

ate a probab- be disseminated to the press, major

typical ly May organizations dealing with the elderly,

age brief. 1988. minority organizations, physicians, grocery

stores, etc.

Program impact will be determined, in

part, through seroepidemiologic surveys

conducted yearly and incidence of

seroconversion.Preliminary results

suggest increased knowledge levels in

the exposed group.

Will evaluate knowledge gained under

the 3 approaches and determine who

donates and why.Will measure the

number students volunteering to donate

and their HIV blood status.Thus far ,

intervention 1 seems more effective

with students already Interested in

donating, 2 seems more effective with

students who have not thought about

donating, and 3 seems more effective

with all students.

Pre- and post-test data are being

collected. A Longitudinal analysis is

being conducted as well as clinical

followup to determine the progression

of the disease.

None. Age Briefs are reviewed every

few years.
Table B-6.--AIDS Education Programs Funded by the National Institutes of Health, Hay 1988 (Continued)

a

b

c

d

e

Table includes only program components targeted Lo the general population, homosexual/bisexual men, IVDUs, sexually transmitted diseas e

clinic attendees,and school-age youth.

Cushing, M.,Budget Analyst, National Cancer Institute, National Institutes of Health, Public Health Service, U.S. Department of Health

and Human Services, Bethesda, MD, personal communication, April 15, 1988.

McCurdy, P.,Spec~al Assistant for Clinlcal Hematology, Division of Blood Diseases and Resources, National Heart, Lung, and Blood

Institute, National Institutes of Health, Publlc Health Service, U.S. Department of Health and Human Services, Bethesda, MD, personal

communication, April 15, 1988.

Czarra, A.,Chief, Program Planning and Prevention Branch, National Heart, Lung, and Blood Institute, National Institutes of Health,

Public Health Service, U.S. Department of Health and Human Services, Bethesda, MD, personal conznunication, May 17, 1988.

Morgan, V.,Writer/Editor, Information Office, National Institute on Aging, National Institutes of Health, Public Health Service, U.S.

Department of Health and Human Services, Bethesda, MD, personal communication, April 15, 1988.

SOURCE: Office of Technology Assessment, 1988.
Table B-7.--AIDS Education Programs Funded by Lhe Office of the Assistant Secretary for Health, fldy 198 8

a

——— .

Name of progrm/ Org~nlzat.loll/

cu[ltracL/grant, Contact moun t

Office of Minority Health (ml):

Minorit y NOt yet Total of

Community Health determined/$400,000

Coalitio n Henry Montes

Demonstratio n (OMH)

Project s

b c

Minority AID S Not yet

Education / determined /

Prevention Grant Jacqueline

Program bc Bowles (OMH)

Model Program Office of

Assessment.c

Minority

Health/

Jacquellne

Bowles

Training

package b c

Office of

Minority

Health/

Jacqueline

Bowles

Total of

$700,000

$100,000

to

$150,000

Project

period Description Evaluative component

—

ProJect Grant was announced In March. There will be

period: a tC)tdl of 8 grant,s awdrded to cornnutllty

2 years COdlltlOIIS to develop programs to prOmOte

healthy behavior wlt.hln mlnorlty

conrnnunltles . Two of these grants will be

~warded Lo corrMmKIllLy COdlltlOIIS providin g

AIDS education tdrget.ed to bldcks and to

Hlspanlcs. Both gral]ts will be up t o

$200,000 (glvell up flo[lt) for a 2 year

proJect period.

Project Sollcltation for this grant w1ll be

period: announced In Holy. Fifteen to 20 grants will

3 be awarded by September 30 to minority

years. comnunity based organizations and national

Funds mlnorlty organizations wh~ch conduct HIV

for 2nd lnfect~on education and risk-reduction

dnd 3rd programs; the dwiirds. w1ll range from $20,()()0

ytidr to $75,000.

colltlll-

~enL on

dvallabillty

of

funds.

In Will evaluate HIV r~sk-reduction and

plan- educatlon programs throu~hout the country

nlng that targeL minority comnun~t~es and

to conduct stages ldentlfy essential components of successful

thi s programs.

program

Not yet, In Will develop HIV l[lfecLlon ~nformat.lon

determined plan- guldellnes and mdteLlals that mlllorlty

nlng organlzdtlons cdn use to IIILt,late

stages lnfOrIK)dtlOn dlld risk-reduction actlvltles

wlthln their conmmltles.

Grantees will write EValutio n

components in their grant proposals.

Grantees will also complete an outcome

evaluation at the end of the project

period.

Grantees will write evaluation

components in their grant proposals.

Grantees will also complete outcome and

process evaluations at the end of the

3rd project year.

This project is an

risk-reduction and

Not yet determined.

evaluation of HIV

education programs.
Table B-7.--AIDS Education Program Funded by the Office of the Assistant. Secretary for Health, May 1988 (Continued)

a Table Includes only those program components target,ed to the general population, homosexual/bisexual men, Intravenous drug users,

sexually transmitted d~sease cllnlc aLt.endees, and school-age yout,}i.

b Montes, H. ,Associate Director for External Pro~rams, OffIce of Mlnorlty HealthOffice , of the Assistant Secretary for He.alt.h, U.S.

Department of Health and Human Services, Washington, D.C., personal corrmunlcat.ion, March 18, 1988.

c Bowles, J. ,Senior Science Advisor and AIDS Program Coordinator, Office of Mlnorlty HealthOffice of the Assistant Secretary for Health, ,

U.S. Department of Health and Human Services, Washington, D.C., persondl ccmnun~catlon, April 11, 1988, and May 7, 1988.

SOURCE: OffIce of Technology Assessment, 1988.

9
108 ● How Effective Is AIDS Education?

Shirley A. Gross

Bayview Hunter’s Point Foundation

San Francisco, CA

Alice Horowitz

National Institute of Dental Research

Bethesda, MD

Joyce Jackson

New Jersey State Department of Health

Trenton, NJ

David Kanouse

The RAND Corporation

Santa Monica, CA

Jeffrey Kelly

University of Mississippi Medical Center

Jackson, Miss.

Lloyd Kolbe

Centers for Disease Control

Atlanta, GA

Bryan Keith Lindsey

Centers for Disease Control

Atlanta, GA

Nathan Maccoby

Stanford University School of

Medicine

Stanford, CA

Joanne Mantell

AIDS Behavioral Research Program

Gay Men’s Health Crisis

William McAuliffe

Cambridge Hospital

Cambridge, MA

Paul R. McCurdy

National Heart, Lung, and Blood

Institute

Bethesda, MD

Diane McMenamin

Health Resources and Services Administration

Rockville, MD

Florence Meltzer

Office of Population Affairs

Washington, D.C.

Heather Miller

National Academy of Sciences

Institute of Medicine

Washington, D.C.

Stephen N. Morin

University of California, San Francisco

San Francisco, CA

Lincoln Moses

Stanford University

Stanford, CA

Andrew Moss

University of California, San Francisco

San Francisco, CA

Matthew Murguia

U.S. Conference of Mayors

Washington, D.C.

Kevin O’Reilly

Centers for Disease Control

Atlanta, GA

David Ostrow

University of Michigan

Ann Arbor, Mich.

Guy Parcel

University of Texas,

Health Science Center at Houston

Houston, TX

Roy Pickens

National Institute on Drug Abuse

Rockville, MD

Penelope Pine

Health Care Financing Administration

Washington, D.C.

Steve Rabin

Ogilvy and Mather Public Affairs

Washington, D.C.

Stephen Schultz

New York City Department of Health

New York, NY

Beverly Schwartz

Centers for Disease Control

Atlanta, GA
How Effective Is AIDS Education? ● 109

Peter Selwyn Lawrence Wallack

Albert Einstein College of Medicine University of California

Bronx, NY

Melissa Shepard

Centers for Disease

Atlanta, GA

Laurie Sherman

Centers for Disease

Atlanta, GA

Mildred Solomon

Solomon Associates

Sudbury, MA

Ron Stall

Rutgers University

School of Public Health

Berkeley, CA

Control John Walters

U.S. Department of Education

Washington, D.C.

Control Kenneth Warner

University of Michigan

School of Public Health

Ann Arbor, Mich.

John Watters

Urban Health Study

San Francisco, CA

New Brunswick, NJ Robin Weiss

Institute of Medicine

Michael Stoto National Academy of

National Academy of Sciences Washington, D.C.

Institute of Medicine

Washington, D.C. Gloria Weissman

Ellen Stover

National Institute of Mental Health

Rockville, MD

Charles Turner

National Academy of Sciences

Institute of Medicine

Washinton, D.C.

Paula Van Ness

Centers for Disease Control

Atlanta, GA

Sciences

National Institute on Drug Abuse

Rockville, MD

Ronald Wilson

National Center for Health Statistics

Hyattsville, MD

William Winkenwerder

Health Care Financing Administration

Washington, D.C.

William Yarber

Indiana University

Bloomington, IN

Thomas Vernon

Colorado Department of Health

Denver, CO
110 ● How Effective Is AIDS Education?

Workshop Participants, January 7, 1988

Zili Amsel Lloyd Kolbe

National Institute on Drug Abuse Centers for Disease Control

Rockville, MD Atlanta, GA

Thomas J. Coates

University of California,

School of Medicine

San Francisco, CA

Don Des Jarlais

State of New York Division

of Substance Abuse Services

New York, NY

Jill G. Joseph

University of Michigan

Ann Arbor, MI

Franklyn Judson

Denver Department of Public Health

Denver, CO

Douglas Kirby

Center for Population Options

Washington, DC

Stephen Margolis

Margolis and Associates

Atlanta, GA

Kevin O’Reilly

Centers for Disease Control

Atlanta, GA

Lawrence Wallack

University of California

School of Public Health

Berkeley, CA

Milton Weinstein

Harvard School of Public Health

Boston, MA

William Yarber

Indiana University

Bloomington, IN
REFERENCES

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

Adrien, A., “A Campaign to Promote Safe Sexual Practices in the Montreal Homosexual

Population-Quebec,” Canada Diseases Weekly Report 13:9-12, 1987, as cited by Coates,

Stall,

AIDS

Phase

AIDS

1988.

AIDS

and Hoff, 1988.

Record, “Initial Results of Phase One AIDS Awareness Campaign Noted; Second

Planning Underway,” AIDS Record 2(1):7, Dec. 7, 1987.

Record, “Federal Research Funding Opportunities,” AIDS Record 2(8/9):20, April 8,

Record, “Over $24 million Available from Health Resources Services Administration

for Three New Programs,” AIDS Record 2(8/9):7, April 8, 1988.

Ajzen, 1., and Fish bein, M., Understanding Attitudes and Predicting Social Behavior (New

Jersey: Prentice-Hall, Inc., 1980), as cited in Janz and Becker, 1984.

Alexander, P., Co-director, COYOTE, personal communication, San Francisco, CA, April

1988.

Alkhateeb, W., Lukeroth, C. J., and Riggs, M., “A Comparison

Techniques Used in a Venereal Disease Clinic,” Public Health

1975, as cited in Margolis, 1988.

of Three Educational

Reports 90(2): 159-164,

Amsel, Z., Research Anthropologist, Clinical Medicine Branch, National Institute on Drug

Abuse, Alcohol, Drug Abuse, and Mental Health Administration, Public Health Service,

U.S. Department of Health and Human Services, Rockville, MD, personal communication,

April 12, 1988, and May 16, 1988.

Bachman J., Johnston L., and O’Malley, P., Monitoring the Future: Questionnaire

Responses from the Nation’s High School Seniors, 1986 (Ann Arbor, MI: Institute for

Social Research, 1987), as cited in Kirby, 1988.

Baker, T., Chief, Information Services, National AIDS Information/Education Program,

Centers for Disease Control, Public Health Service, U.S. Department of Health and Human

Services, Atlanta, GA, personal communication, April 21, 1988.

Bandura, A., “Self-Efficacy: Toward a Unifying Theory of Behavioral Change,” P.s~~chol

Rev 84:193, 1977, as cited in Janz and Becker, 1984 and Macro Systems, 1987.

Barrett, S., Director of Hemophilia Program, Office of Maternal and Child Health, Bureau

of Maternal and Child Health and Resources Development, Health Resources and Services

Administration, Public Health Service, U.S. Department of Health and Human Services,

Rockville, MD, personal communication, May 12, 1988.

Bates, R., Project Manager, Aspen Systems Corporation, Rockville, MD, personal

communication, May 6, 1988.

Becker, M. H., “Psychosocial Aspects of Health-Related Behavior,” Handbook of Medical

Sociology)), H.E. Freeman, S. Levine, and L,G. Reeder (eds.) (Englewood Cliffs, NJ:

Prentice-Hall, Inc., 1979).

111
112 ● How Effective Is AIDS Education?

14a,

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

Becker, M. H., Associate Dean, School of Public Health, University of Michigan, Ann

Arbor, MI, personal communication, December 1988.

Becker, M. H., and Joseph, J. G., “AIDS and Behavioral Change To Reduce Risk: A

Review,” Am J. Public Health 78(4):394-410, April 1988.

Berreth, D. A., Director, Office of Public Affairs, Centers for Disease Control, Public

Health Service, U.S. Department of Health and Human Services, Atlanta, GA, personal

communication, May 19, 1988.

Black, J. L., Dolan, M. P., DeFord, H. A., et al., “Sharing of Needles Among Users of

Intravenous Drugs,” letter to the editor, N. Eng. J. Med. 314(7):446-447, Feb. 13, 1986.

Blake, S. M., and Arkin, E. B., The American Red Cross AIDS Information Monitor: A

Summary of National Public Opinion Surveys on AIDS, 1983 through 1986 (Washington,

DC: American Red Cross, in press).

Booth, W., “The Long, Lost Survey on Sex,” Science 239:1084-85, March 4, 1988.

Botvin, G., “Substance Abuse Prevention Research: Recent Developments and Future

Directions,” J. of School Health 56(9), 1986, as cited in Kirby, 1988.

Bowen, S., Deputy Director, Center for Prevention Services, Centers for Disease Control,

Public Health Service, U.S. Department of Health and Human Services, Atlanta, GA,

personal communication, March 17, 1988, and May 11, 1988.

Bowles, J., Senior Science Advisor and AIDS Program Coordinator, Office of Minority

Health, Office of the Assistant Secretary for Health, U.S. Department of Health and

Human Services, Washington, DC, personal communication, April 11, 1988, and May 7,

1988.

Brandt, A. M., No Magic Bullet: A Social History of Venereal Disease in the United States

Since 1980 (New York: Oxford University Press, 1985).

Brandt, A. M., “The Syphilis Epidemic and Its Relation to AIDS,” Science 239(4838):375-

380, Jan. 22, 1988.

British Market Research Bureau Limited, “AIDS Advertising Campaign,” prepared for

Central Office of Information, London, July 1987.

Buning, E. C., Van Brussel, G. H. A., and Van Santen, G., “Amsterdam’s Drug Policy and

Its Implications for Controlling Needle Sharing,” Needle Sharing Among Intravenous Drug

Abusers: National and International Perspectives, R. Battjes and R. Pickens (eds.)

(Washington, DC: National Institute on Drug Abuse Monograph, in press), as cited in Des

Jarlais, 1988.

Cabaniss, N., Office of Population Affairs, Public Health Service, U.S. Department of

Health and Human Services, “Office of Population Affairs Program Instruction Series

OPA-87-4: AIDS Education, Counseling and Testing in Title X,” letter to Regional

Health Administrators Regions I-X, December 8, 1987.
How Effective Is AIDS Education? ● 113

28.

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

Cain, V., Sociologist, Center for Population Research, National Institute of Child Health

and Human Development, National Institutes of Health, Public Health Service, U.S.

Department of Health and Human Services, Bethesda, MD, personal communication, May

1988.

Casadonte, P., Des Jarlais, D. C., Smith, T., et al., “Psychological and Behavioral Impact of

Learning HTLV-III/LAV Antibody Test Results,” paper presented at the 11 International

Conference on AIDS, Paris, France, 1986, as cited in Des Jarlais, 1988.

Chaisson, M. A., Fleisher, E., Petrus, D., et al., “Epidemiologic Characteristics of Women

with AIDS in New York City,” paper prepared for the 111 International Conference on

AIDS, Washington, DC, June 1-5, 1987, as cited in Des Jarlais, 1988.

Chaisson, R. E., Moss, A. R., Onishi, R., et al., “Human Immunodeficiency Virus Infection

in Heterosexual Intravenous Drug users in San Francisco,” Am. J. Public Health 77(2): 169-

172, February 1987.

City and County of San Francisco, Department of Public Health, Perinatal and Pediatric

AIDS Advisory Committee, “Guidelines for Control of Perinatally Transmitted Human TLymphotropic Virus-Type 1ll/Lymphadenopathy -Associated Virus Infection and Care of

Infected Mothers, Infants, and Children, San Francisco Epidemiologic Bulletin, 2( Supp.

1):1 S-16S, 1986.

Clark S., Zabin L., and Hardy, J., “Sex, Contraception, and Parenthood,” Fare. P/an.

Perspectives 16(2), 1984, as cited in Kirby, 1988.

Coates, T. J., Associate Professor, University of California, San Francisco, CA, personal

communication, May 1988.

Coates, T. J., Catania, J. A., Dolcini, M. M., et al., “Changes in Sexual Behavior with the

Advent of the AIDS Epidemic,” report prepared for the Hudson Institute, New York, NY,

November 17, 1987.

Coates, T. J., McKusick, L., Kuno, R., et al., “Stress Management Training Reduces

Number of Sexual Partners but Does Not Enhance Immune Function in Men Infected with

Human Immunodeficiency Virus (HIV),” unpublished manuscript, University of

California, San Francisco, 1987, as cited in Coates, Stall, and Hoff, 1988.

Coates, T. J., Stall, R. D., and Hoff, C. C., “Changes in Sexual Behavior of Gay and

Bisexual Men Since the Beginning of the AIDS Epidemic,” contractor document prepared

for the Office of Technology Assessment, U.S. Congress, Washington, DC, March 1988.

Communication Technologies, Inc., “Designing an Effective AIDS Risk Reduction

Program for San Francisco: Results from the First Probability Sample of Multiple/HighRisk Partner Heterosexual Adults,” report prepared for the San Francisco AIDS

Foundation, San Francisco, CA, June 30, 1986.

Communication Technologies, Inc., “Designing an Effective AIDS Prevention Campaign

Strategy for San Francisco: Results From the Fourth Probability Sample of an Urban Gay

Male Community,” unpublished paper, San Francisco, CA, 1987.
114 ● How Effective Is AIDS Education?

40.

41.

42.

43.

44.

45.

46.

47.

48.

49.

50.

51.

Conlon, D., Public Health Advisor, Centers for Disease Control, Public Health Service,

U.S. Department of Health and Human Services, Atlanta, GA, personal communication,

April 13, 1988, and May 12, 1988.

Cooper, F., and Bye, L., “AIDS Educational Programs for Adolescents: Factors that

Impact Behavior Change,” Communication Technologies, San Francisco, CA, 1988, as cited

in Kirby, 1988.

Cox, C. P., Selwyn, P. A., Schoenbaum, E. E., et al., “Psychological and Behavioral

Consequences of HTLV-111/LAV Antibody Testing and Notification Among Intravenous

Drug Abusers in a Methadone Program in New York City,” paper presented at the II

International Conference on AIDS, Paris, France, 1986, as cited in Des Jarlais, 1988.

Curvy, M., Program Specialist, Division of Basic Sciences, National Institute of Mental

Health, Alcohol, Drug Abuse, and Mental Health Administration, Public Health Service,

U.S. Department of Health and Human Services, Rockville, MD, personal communication,

May 19, 1988.

Cushing, M., Budget Analyst, National Cancer Institute, National Institutes of Health,

Public Health Service, U.S. Department of Health and Human Services, Bethesda, MD,

personal communication, April 15, 1988.

Czarra, A., Chief, Program Planning and Prevention Branch, National Heart, Lung, and

Blood Institute, National Institutes of Health, Public Health Service, U.S. Department of

Health and Human Services, Bethesda, MD, personal communication, May 17, 1988.

Darrow, W. W., “Innovative Health Behavior: A Study of the Use, Acceptance, and UseEffectiveness of the Condom as a Venereal Disease Prophylactic,” unpublished doctoral

dissertation, Emory University, Atlanta, GA, 1973, as cited in Margolis, 1988.

Darrow, W. W., “Condom Use and Use-Effectiveness in High-Risk Populations,” Sexually

Transmitted Diseases (in press), 1987, as cited in Margolis, 1988.

Darrow, W. W., Echenberg, D. F., Jaffe, H. W., et al., “Risk Factors for Human

Immunodeficiency Virus (HIV) Infections in Homosexual Men,” Am J. PubZic Health

77(4):479-483, April 1987.

Dawson, D., “The Effects of Sex Education on Adolescent Behavior,” Fare. PZan.

Perspectives 18(4):162-170, 1986, as cited in Kirby, 1988.

Dawson, D. A., Cynamon, M., and Fitti, J. E., “AIDS Knowledge and Attitudes:

Provisional Data from the National Health Interview Survey: United States, August 1987,”

Advance Data From Vital and Health Statistics, DHHS Pub. No. (PHS) 88-1250, No. 146

(Hyattsville, MD: November 19, 1987).

Dawson, D. A., Cynamon, M., and Fitti, J. E., “AIDS Knowledge and Attitudes:

Provisional Data from the National Health Interview Survey: United States, September

1987,” Advance Data From VilaZ and Health Statistics, DHHS Pub. No. (PHS) 88-1250,

No. 148 (Hyattsville, MD: January 18, 1988).
How Effective Is AIDS Education? ● 115

52.

53.

54.

55.

56.

57.

58.

59.

60.

61.

62.

63.

Dawson, D. A., Cynamon, M., and Fitti, J. E., “AIDS Knowledge and Attitudes:

Provisional Data from the National Health Interview Survey: United States, October

1987,” Advance Data From Vital and Health Statistics, DHHS Pub. No. (PHS) 88-1250,

No. 150 (Hyattsville, MD: March 19, 1988).

Dawson, D. A., and Thornberry, O. T.,’’AIDS Knowledge and Attitudes: Provisional Data

from the National Health Interview Survey: United States, November 1987” Advance Data

From Vi/a/ and Health Statistics, DHHS Pub. No. (PHS) 88-1250, No. 151, (Hyattsville,

MD: March 16, 1988).

Deren, S., “A Description of Methadone Maintenance Patients and their Children,” New

York: New York State Division of Substance Abuse Services, 1985, as cited in Des Jarlais,

1988.

Des Jarlais, D. C., Coordinator for AIDS Research, New York Division of Substance Abuse

Services, New York, NY, personal communication, 1988.

Des Jarlais, D. C., “The Effectiveness of AIDS Educational Programs in Intravenous Drug

Users,” contractor document prepared for the Office of Technology Assessment, U.S.

Congress, Washington, DC, March 1988.

Des Jarlais, D. C., and Friedman, S. R., “Intravenous Cocaine, Crack, and HIV Infection,”

letter to the editor, JAMA 259(13): 1945-46, April 1, 1988.

Des Jarlais, D. C., Friedman, S. R., and Strug, D., “AIDS Among Intravenous Drug Users:

A Sociocultural Perspective, “ in The Social Dimensions of AIDS: Methods and Theor~), D.

Feldman and T. Johnson (eds.) (New York, NY: Praeger, 1986), as cited in Des Jarlais,

1988.

Des Jarlais, D. C., Chamberland, M. E., Yancovitz, S. R., et al., “Heterosexual Partners: A

Large Risk Group for AIDS,” Lancet 8415:1346-7, 1984, as cited in Des Jarlais, 1988.

DiClemente, R., Boyer, C., and Morales, E., “Minorities and AIDS: Knowledge, Attitudes

and Misconceptions Among Black and Latino Adolescents,” Am. J. PubZic Health 78(1):55-

57, January 1988.

DiClemente, R., Pies, C., Stoner, E., et al., “Prevention of Acquired Immunodeficiency

Syndrome Among Adolescents: Evaluation of the San Francisco Comprehensive AIDS

Risk-Reduction Education Program,” paper presented at the Third International

Conference on AIDS, Washington, DC, June 2, 1987.

DiClemente, R., Zorn, J., and Temoshok, L., “Adolescents and AIDS: A Survey of

Knowledge, Attitudes, and Beliefs About AIDS in San Francisco,” Am. J. Public Heallh

76(12):1443-1445, 1986.

Doll, L., Darrow, W. W., Jaffe, H., et al., “Self-Reported Changes in Sexual Behaviors in

Gay and Bisexual Men From the San Francisco City Clinic Cohort,” paper presented at the

III International Conference on AIDS, Washington, DC, June 5, 1987, as cited in Coates,

Stall, and Hoff, 1988.
116 ● How Effective Is AIDS Education?

64.

65.

66.

67.

68.

69.

70.

71.

72.

73.

74.

75.

76.

Duncan, C., Center for Health Promotion and Education, Office of School Health and

Special Projects, Centers for Disease Control, Public Health Service, U.S. Department of

Health and Human Services, Atlanta, GA, personal communication, March 15, 1988.

Duncan, W., National AIDS Information/Education Program, Centers for Disease Control,

Public Health Service, U.S. Department of Health and Human Services, Atlanta, GA,

personal communication, March 17, 1988.

Educational Development Center, Inc., “Sexually Transmitted Diseases: A Clinic-Based

Demonstration Project to Improve Patient Compliance,” paper prepared for the U.S.

Department of Health and Human Services, Public Health Service, Centers for Disease

Control, Division of Sexually Transmitted Disease, Atlanta, GA, 1986, as cited in

Margolis, 1988.

Ehrhardt, A., Director, HIV Center for Clinical and Behavioral Studies, New York, NY,

personal communication, May 6, 1988.

Ekstrand, M., and Coates, T., “Prevalence and Change in AIDS High Risk Behaviors

Among Gay and Bisexual Men,” unpublished paper to be presented at the IV International

Conference on AIDS, Stockholm, Sweden, June 1988.

Farquhar, J. W., Maccoby, N., and Solomon, D. S., “Community Applications of Behavioral

Medicine,” Handbook of Behavioral Medicine W.D. Gentry (cd.) (New York, NY: Guilford

Press, 1984).

Feldblum, P. J., and Fortney, J. A., “Condoms, Spermicides, and the Transmission of

Human Immunodeficiency Virus: A Review of the Literature,” Am. J. Public Health

78(1):52-54, January 1988.

Fineberg, H. V., “Education To Prevent AIDS: Prospects and Obstacles,” Science

239(4840):592-596, February 5, 1988.

Finkel, M., and Finkel, D., “Sexual and Contraceptive Knowledge, Attitudes and Behavior

of Male Adolescents,” Fare. Plan. Perspectives 7:256-260, November/December 1975, as

cited in Kirby, 1988.

Flay, B. R., HeaZth Psychology, 4(5), 1985, as cited in Kirby, 1988.

Flay, B. R., “Mass Media Linkages with School-Based Programs for Drug Abuse

Prevention,” J. SchooZ Health 56(9):402-406, November 1986.

Flay, B. R., “Mass Media and Smoking Cessation: A Critical Review,” Am. J. Public

Health 77(2):153-160, February 1987.

Flynn, N. M., Jain, S., Harper, S., et al., “Sharing of Paraphernalia in Intravenous Drug

Users (IVDU): Knowledge of AIDS is Incomplete and Doesn’t Affect Behavior,” paper

presented at the 111 International Conference on AIDS, Washington, DC, June 1987, as

cited in Des Jarlais, 1988.
How Effective Is AIDS Education? ● 117

-77.

78.

79.

80.

81.

82.

83.

84.

85.

86.

87.

88.

89.

90.

Forsman, I., Nurse Consultant, Bureau of Maternal and Child Health and Resources

Development, Office of Maternal and Child Health, Health Resources and Services

Administration, U.S. Department of Health and Human Services, Rockville, MD, personal

communication, May 12, 1988.

Fox, R., Ostrow, D., Valdiserri, R., et al., “Changes in Sexual Activities Among

Participants in the Multicenter AIDS Cohort Study,” paper presented at the III

International Conference on AIDS, Washington, DC, June 5, 1987.

Francis, D. P., and Chin, J., “The Prevention of Acquired Immunodeficiency Syndrome in

the United States,” JAMA 257(10):1 357-1366, March 13, 1987.

Freimuth, V., Edgar, T., and Hammond, S., “College Students’ Awareness and

Interpretation of the AIDS Risk,” Science, Technology and Human Values 12(3 & 4),

1987, as cited in Kirby, 1988.

French, J., Chief, Office of Data Analysis and Epidemiology, New Jersey Department of

Health, Trenton, NJ, personal communication to D. Des Jarlais, 1986, as cited in Des

Jarlais, 1988.

Friedman, S. R., Des Jarlais, D. C., Sotheran, J. L., “AIDS and Self-Organization Among

Intravenous Drug Users,” International J. Addictions 22:201 -220, 1987, as cited in Des

Jarlais, 1988.

Friedman, S. R., Sotheran, J. L., Abdul-Quader, A., et al., “The AIDS Epidemic Among

Blacks and Hispanics,” The Milbank Quarterly (in press).

Furstenberg, F., Moore, K., and Peterson, J., “Sex Education and Sexual Experience

Among Adolescents,” Am. J. PubZic HeaZth 75(1 1):1331 -1332, November 1985, as cited in

Kirby, 1988.

Green, L. W., Kreuter, M. W., Deeds, S. G., et al., Health Education Planning: A Diagnostic

Approach (Palo Alto, CA: May field Publ. Co., 1980).

Guinan, M. E., and Hardy, A., “Epidemiology of AIDS in Women in the United States:

1981 Through 1986,” JAMA 257(15):2039-2042, April 17, 1987.

Hagey, A., Senior Program Analyst for Health Promotion, Assistant Secretary of Defense

(Health Affairs), Department of Defense, Washington, DC, personal communication, May

4, 1988.

Hearst, N., and Hulley, S. B., “Preventing the Heterosexual Spread of AIDS,” JAMA

259(16):2428-2432, April 21, 1988.

Helgerson, S. D., Petersen, L. R., and the AIDS Education Study Group, “Acquired

Immunodeficiency Syndrome and Secondary School Students: Their Knowledge is Limited

and They Want to Learn More,” Pediatrics 81(3):350-355, March 1988.

Hessol, N. A., and Lemp, G., Staff Assistants, City and County of San Francisco Health

Department, San Francisco, CA, personal communication to C. Hoff, March 18, 1988, as

cited in Coates, Stall, and Hoff, 1988.
118 ● How Effective Is AIDS Education?

91.

92.

93.

94.

95.

96.

97.

98.

99.

100.

101.

102.

1030

104.

Hoch, L., “Attitude Change as a Result of Sex Education,” J. Res. Sci. Teach. 8:363-367,

1971, as cited in Kirby, 1988.

Hoff, R., Berardi, V. P., Weiblen, B. J., et al., “Seroprevalence of Human

Immunodeficiency Virus Among Childbearing Women,” N. Eng. J. Med. 318(9):525-530,

March 3, 1988.

Hofferth, S. L., and Hayes, C. D., Risking the Future: Adolescent Sexuality, Pregnancy,

and Childbearing, Volume 2 (Washington, DC: National Academy Press, 1987).

Hopkins, D. R., “Background Material” prepared for Keynote Address, National

Conference on AIDS in Minority Populations in the United States, Atlanta, GA, Aug. 8,

1987.

Hopkins, D. R., “Public Health Measures for Prevention and Control of AIDS,” PubZic

Health Reports 102(5):463-467, September-October 1987.

Howard, M., “Postponing Sexual Involvement Among Adolescents: An Alternative

Approach to Prevention of Sexually Transmitted Diseases,” J. Adolescent Heallh Care

6(4):271-77, July 1985.

Intergovernmental Health Policy Project, Slate Issues, PoZicies and Programs, vol. 1 of

State Issues, Policies and Programs (Washington, DC: U.S. Department of Health and

Human Services, Public Health Service, October 1987).

Intergovernmental Health Policy Project, Managing and Financing the Problem, vol. 2 of

State Issues, PoZicies and Programs (Washington, DC: U.S. Department of Health and

Human Services, Public Health Service, October 1987).

Jackson, J., and Rotkiewicz, L., “A Coupon Program: AIDS Education and Drug

Treatment,” paper presented at the III International Conference on AIDS, Washington, DC,

June 1987, as cited in Des Jarlais, 1988.

Jackson, M., Special Assistant to the Director of Public Affairs, Department

Washington, DC, personal communication, March 11, 1988.

Janz, N. K., and Becker, M. H., “The Health Belief Model: A Decade Later,”

Education Quarterly 11(1):1-47, Spring 1984.

of Education,

Health

Job, R. F. S., “Effective and Ineffective Use of Fear in Health Promotion Campaigns,” Am.

J. Public Health 78(2): 163-167, February 1978.

Joseph, J., “HIV Infection and the Effectiveness of Education for the General Population,”

contractor document prepared for the Office of Technology Assessment, U.S. Congress,

Washington, DC, March 1988.

Joseph, J. G., Montgomery, S., Kessler, R. C., et al., “Behavioral Risk Reduction in a

Cohort of Homosexual Men: Two Year Follow-up,” paper presented at the HI

International Conference on AIDS, Washington, DC, June 1987, as cited in Coates, Staff,

and Hoff, 1988.
How Effective Is AIDS Education? ● 119

105.

106.

107.

108.

109.

110.

111.

112.

113.

114.

115.

116.

117.

118.

Joseph, J., Montgomery, C., Kirscht, J., et al., “Perceived Risk of AIDS: Assessing the

Behavioral and Psychosocial Consequences in a Cohort of Gay Men,” J. AppZied

Psychology 17:231-250, 1987, as cited in Coates, Stall, and Hoff, 1988.

Judson, F. N., and Vernon, T. M., Jr., “The Impact of AIDS on State and Local Health

Departments: Issues and a Few Answers,” Am J. Public Health 78(4):387-93, April 1988.

Kegeles, S. M., Adler, N. E., and Irwin, C. E., Jr., “Sexually Active Adolescents and

Condoms: Changes Over One Year in Knowledge, Attitudes and Use,” Am J. Public

HeaZth 78(4):460-61, April 1988.

Kelly, J. A., St. Lawrence, J. S., Hood, H. V., et al., “Behavioral Interventions to Reduce

AIDS Risk Activities,” unpublished manuscript, University of Mississippi, Oxford, Miss.,

1987, as cited in Coates, Stall, and Hoff, 1988.

Kemp, V., Budget Analyst, National Institute of Mental Health, Alcohol, Drug Abuse, and

Mental Health Administration, Public Health Service, U.S. Department of Health and

Human Services, Rockville, MD, personal communication, May 19, 1988.

Kingsley, L. A., Kaslow, R., Rinaldo, C. R., et al., “Risk Factors for Seroconversion to

Human Immunodeficiency Virus Among Male Homosexuals,” Lancet 10:345-349, 1987, as

cited in Coates, Stall, and Hoff, 1988.

Kinsey, A. C., Pomeroy, W. B., Martin, C. R., Sexual Behavior in the Human Male

(Philadelphia, PA: WB Saunders, 1948), as cited in Coates, Stall, and Hoff, 1988.

Kirby, D., “The Effectiveness of Educational Programs To Help Prevent School-Age

Youth from Contracting AIDS: A Review of Relevant Research,” contractor document

prepared for the Office of Technology Assessment, U.S. Congress, Washington, DC,

March 1988.

Kirby, D., Sexuality Education: An Evaluation of Programs and Their Efjects (Santa

Cruz, CA: Network Publications, 1984).

Kirby, D., “Sexuality Education: A More Realistic View of Its Effects,” J. School Health

55(10), 1985, as cited in Kirby, 1988.

Kleinman, P. H., Friedman, S. R., Mauge, C. E., et al., “Beliefs and Behaviors Regarding

AIDS: A Survey of Street Intravenous Drug Users,” abstract in the III International

Conference on AIDS (Washington, DC: U.S. Department of Health and Human Services

and the World Health Organization, June 1987).

Kolbe, L., “Behavioral Epidemiology of AIDS: An Organizing Model,” paper presented at

the American Association for the Advancement of Science, Boston, MA, Feb. 14, 1988.

Kolbe, L., “The Application of Health Behavior Research: Health Education and Health

Promotion,” Health Behavior: Emerging Research Perspectives, D. Gochman (cd.),

(Plenum, forthcoming 1988).

Kroger, F., “Compliance Strategies in a Clinic for Treatment of Sexually Transmitted

Diseases,” Sex. Transm. Dis. 7(4):1 78-182, 1980, as cited in Margolis, 1988.
120 ● How Effective Is AIDS Education?

119.

120.

121.

122.

123.

124.

125.

126.

127.

128.

129.

130.

Lim, G., “Campaign Helped 28,000 Kick Habit,” Houston Post, June 12, 1986, as cited in

Joseph, 1988.

Loken, G., Director of Advocacy, Covenant House, New York, NY, personal

communication to D. Kirby, March 1987, as cited in Kirby, 1988.

Maccoby, N., “Communication and Health Education Research--potential Source for AIDS

Education for Women,” prepared for Workshop on Women and AIDS by the National

Institute of Mental Health and the National Institute of Drug Abuse, Bethesda, MD, Sept.

27-29, 1987.

Macro Systems, Inc. “Review of Media, Communication, and Evaluation Methodology

Literature,” paper prepared for the Centers for Disease Control, AIDS Information and

Education Program, Atlanta, GA, Oct. 30, 1987.

Margolis, S., “The Effectiveness of Educational and Related Efforts Among Attendees of

Public Clinics for Sexually Transmitted Diseases,” contractor document prepared for the

Office of Technology Assessment, U.S. Congress, Washington, DC, March 1988.

Marlink, R. G., Foss, B., Swift, R., et al., “High Rate of HTLV-111/LAV Exposure in

IVDA’S from a Small-Sized City and the Failure of Specialized Methadone Maintenance to

Prevent Further Drug Use,” abstract in the III International Conference on AIDS

(Washington, DC: U.S. Department of Health and Human Services and the World Health

Organization, June 1987).

Marlink, R. G., School of Public Health, Harvard University, Boston, MA, personal

communication, April 1988.

Marmor, M., Des Jarlais, D. C., Cohen, H., et al., “Risk Factors for Infection with Human

Immunodeficiency Virus Among Intravenous Drug Abusers in New York City,” AIDS

1:39-44, 1987, as cited in Des Jarlais, 1988.

Marsiglio, W., and Mott, F., “The Impact of Sex Education on Sexual Activity,

Contraceptive Use and Premarital Pregnancy Among American Teenagers,” Fare. P/an.

Perspectives 18(4):151-161, 1986, as cited in Kirby, 1988.

Martin, J. L., Associate Research Scientist, School of Public Health, Columbia University,

New York, NY, personal communication to T.J. Coates, December, 1987, as cited in

Coates, Staff, and Hoff, 1988.

Mason, J., “Centers for Disease Control AIDS Fact Sheet,” testimony presented at hearings

on Public Health Service Update on the AIDS Epidemic, conducted by the Subcommittee

on Health and the Environment, Committee on Energy and Commerce, House of

Representatives, U.S. Congress, Washington, DC, February 19, 1988.

Mazzuchi, J. F., Acting Deputy Assistant Secretary (Professional Affairs and Quality

Assurance), Office of the Assistant Secretary of Defense, Department of Defense,

Washington, DC, personal communication, May 6, 1988.
How Effective Is AIDS Education? ● 121

131.

132.

133.

134.

135.

136.

137.

138.

139.

140,

141.

142.

143.

McAuliffe, W. E., Doering, S., Breer, P., et al., “An Evaluation of Using Ex-Addict

Outreach Workers to Educate Intravenous Drug Users About AIDS Prevention,” abstract in

the ]]1 InlernationaZ Conference on AIDS (Washington, DC: U.S. Department of Health

and Human Services and the World Health Organization, June 1987).

McCurdy, P., Special Assistant for Clinical Hematology, Division of Blood Diseases and

Resources, National Heart, Lung, and Blood Institute, National Institutes of Health, Public

Health Service, U.S. Department of Health and Human Services, Bethesda, MD, personal

communication, April 15, 1988.

McCusker, J., Stoddard, A. M., Mayer, K. H., et al., “Effects of HIV Antibody Test

Knowledge on Subsequent Sexual Behaviors in a Cohort of Homosexually Active Men,”

Am J. Public Health 78(4):462-67, April 1988.

McGuire, W. J., “The Myth of Massive Media Impact: Savagings and Salvaging,” Public

Communication and Behavior, vol. 1 G. Constock (cd.) (Orlando, FL: Academic Press,

1986).

Meltzer, F., Program Analyst, Office of Population Affairs, Public Health Service, U.S.

Department of Health and Human Services, Washington, DC, personal communication,

April 1988.

Miller, L., and Downer, A., “Knowledge and Attitude Change in Adolescents Following

One Hour of AIDS Instruction,” presented at the 111 International Conference on AIDS,

Washington, DC, June 1987, as cited in Kirby, 1988.

Minkler, M., Wallack, L., and Madden, P., “Alcohol and Cigarette Advertising in Ms

Magazine,” J. Public Health Polic~) 8(2):164- 179, Summer 1987.

Montes, H., Associate Director for External Programs, Office of Minority Health, Office

of the Assistant Secretary for Health, U.S. Department of Health and Human Services,

Washington, DC, personal communication, March 18, 1988.

Moore, O., Administrative Analyst, Center for AIDS Prevention Studies, University of

California, San Francisco, CA, personal communication, May 19, 1988.

Morgan, V., Writer/Editor, Information Office, National Institute on Aging, National

Institutes of Health, Public Health Service, U.S. Department of Health and Human

Services, Bethesda, MD, personal communication, April 15, 1988.

Murguia, M., Assistant Executive Director, U.S. Conference of Mayors, Washington, DC,

personal communication, March 16, 1988.

Namerow, P., “Teenagers Perceived and Actual Probabilities of Pregnancy,” paper prepared

for the annual meeting of the American Public Health Association, Anaheim, CA, 1984,

as cited in Kirby, 1988.

National Academy of Sciences, National Research Council, Commission on Behavioral and

Social Sciences and Education, “Proposal for Support of a Committee on AIDS Research

and the Social and Behavioral Sciences,” proposal No. 88-025, Washington, DC, August

1987.
122 ● How Effective Is AIDS Education?

144.

145.

146.

147.

148.

149.

150.

151.

152.

1530

154.

155.

156.

157.

158.

159.

Nelkin, D., “AIDS and the Social Sciences: Review of Useful Knowledge and Research

Needs,” Reviews of Infectious Diseases 9(5):980-986, Sept. -Oct. 1987.

Oakley, K., Communication Technologies, San Francisco, CA, personal communication,

April 1988.

Ogilvy and Mather, Washington, DC, unpublished data, 1987.

Ogilvy and Mather, “AIDS Campaign Development Focus Group Research Report,”

Atlanta, GA, November 1987.

Oliva, G., and DiClemente, R. J., “A Survey of Risk Behaviors Associated with HIV

Transmission in a Family Panning Clinic Population in San Francisco,” abstract submitted

for presentation at the American Association of Public Health, November 13-17, 1988.

O’Reilly, Kevin, Research Anthropologist, Centers for Disease Control, Public Health

Service, U.S. Department of Health and Human Services, Atlanta, GA, personal

communication, September 30, 1987.

Polk, F., MACS data source, Johns Hopkins University, Department of Epidemiology,

Baltimore, MD, personal communication, May 1988.

Potterat, J. J., and Rothenberg, R., “The Case-Finding Effectiveness of a Self-Referral

System for Gonorrhea: A Preliminary Report,” Am. J. Public Health 67(2):174- 176, 1977,

as cited in Margolis, 1988.

Pratt, et al., “Understanding U.S. Fertility,” Population Bulletin 39(5), 1984, as cited in

Kirby, 1988.

Quackenbush, M., testimony before the Select Committee on Children, Youth, and

Families, House of Representatives, U.S. Congress, Washington, DC, February, 1987.

Remafedi, G., CDC AIDS Week/y, August, 3 1987, as cited in Coates, Stall, and Hoff,

1988.

Resnick, L., Veren, K., Salahuddin, S. Z., et al., “Stability and Inactivation of HTLVIH/LAV under Clinical and Laboratory Environments,” JAMA 255:1887-91, 1986.

Roos, L., Administrative Coordinator, Center for AIDS Prevention Studies, University of

California, San Francisco, CA, personal communication, May 19, 1988.

Rosenberg, M., testimony presented at hearings on Prevention and Educalion, conducted by

the Presidential Commission on the Human Immunodeficiency Virus Epidemic,”

Washington, DC, March 1, 1988, as cited in Margolis, 1988.

Samuel, M. C., and Winkelstein, W., “Prevalence of Human Immunodeficiency Virus

Infection in Ethnic and Minority Homosexual/Bisexual Men,” letter to the editor, JAMA

257(14):1901-1902, April 10, 1987.

Samuel, M. C., and Winkelstein, W., “Does Syphilis Facilitate Sexual Acquisition of HIV?”

in reply to the editor, JAMA 258(4):473-474, July 24/31, 1987.
How Effective Is AIDS Education? ● 123

160.

161.

162.

163.

164.

165.

166.

167.

168.

169.

170.

171.

172.

Schinke, S., Blythe, B., and Gilchrest, L., “Cognitive-Behavioral Prevention of Adolescent

Pregnancy,” J. Counseling Psychology 28(5):451-454, 1981.

Schoenbaum, E. E., Selwyn, P. A., Klein, R. S., et al., “Prevalence of and Risk Factors

Associated with HTLV-111/LAV Antibodies Among Intravenous Drug Abusers in

Methadone Programs in New York City,” abstract in the II International Conference on

AIDS, 1986, as cited in Des Jarlais, 1988.

Schwartz, B., Information/Education Specialist, National AIDS Information/Education

Program, Centers for Disease Control, Public Health Service, U.S. Department of Health

and Human Services, Atlanta, GA, personal communication, April 20, 1988.

Shepard, M., Information/Education Specialist, National AIDS Information/Education

Program, Centers for Disease Control, Public Health Service, U.S. Department of Health

and Human Services, Atlanta, GA, personal communication, April 15, 1988.

Siegel, K., Mesagno, F. P., Chen, J. Y., et al., “Factors Distinguishing Homosexual Males

Practicing Safe and Risky Sex,” poster presented at the III International Conference on

AIDS, Washington, DC, June 2, 1987, as cited in Coates, Stall, and Hoff, 1988.

Solomon, M. Z., and DeJong, W., “Recent Sexually Transmitted Disease Prevention Efforts

and Their Implications for AIDS Health Education,” Health Education Quarterly 13(4):301 -

316, Winter 1986.

Stall, R., et al., “Alcohol and Drug Use During Sexual Activity and Compliance with Safe

Sex Guidelines for AIDS: The AIDS Behavioral Research Project,” HeaZth Education

Quarter/y 13:359-371, 1986, as cited in Joseph, 1988.

Stover, E., Deputy Director, Division of Basic Sciences, National Institute of Mental

Health, Alcohol, Drug Abuse, and Mental Health Administration, Public Health Service,

U.S. Department of Health and Human Services, Rockville, MD, personal communication,

April 18, 1988.

Strunin, L., and Hingson, R., “Acquired Immunodeficiency Syndrome and Adolescents:

Knowledge, Beliefs, Attitudes, and Behaviors,” Pediatrics 79(5):825-828, 1987.

Sutton, S. R., “Fear-Arousing Communications: A Critical Examination of Theory and

Research,” Social Psychology and Behavioral Medicine, J.R. Eiser (cd.) (Chichester: John

Wiley & Sons, Inc., 1982).

Taylor, W. T. L., “Market Research for Australia’s National AIDS Education Campaign,”

paper presented at the 111 International Conference on AIDS, Washington, DC, June 1987,

as cited in Joseph, 1988.

Tucker, C. W., “Gonorrhea Recidivism in Richland County, South Carolina,” prepared for

the U.S. Department of Health and Human Services, Centers for Disease Control, Atlanta,

GA, 1977, as cited in Margolis, 1988.

Uddin, D., Senior Policy Analyst for Medical Research, Office of the Assistant Secretary

for Defense (Health Affairs), Department of Defense, personal communication,

Washington, DC, May 16, 1988.
124 ● How Effective Is AIDS Education?

173.

174.

175.

176.

177.

178.

179.

180.

181.

182.

183.

184.

Udry, J. R., Clark, L. T., Chase, C. L., et al., “Can Mass Media Advertising Increase

Contraceptive Use?” Fare. Plan. Perspectives 4(3):37-44, July 1972.

U.S. Congress, Office of Technology Assessment, Do Insects Transmit AIDS? (Washington,

DC: U.S. Government Printing Office, 1987).

U.S. Department of Commerce, Bureau of the Census, Statistical Abstract of the United

States: 1987 (Washington, DC: U.S. Government Printing Office, 1986).

U.S. Department of Health and Human Services, Public Health Service, Surgeon General’s

Report on Acquired Immune Deficiency Syndrome (Washington, DC: U.S. Government

Printing Office, October 1986).

U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Health Administration, National Institute of Drug Abuse, “NIDA

Technical Review: Women and AIDS,” unpublished mimeo, Rockville, MD, 1988.

U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Health Administration, National Institute of Mental Health, Television

and Behavior: Ten Years of Scientific Progress and Implications for the Eighties, vol. 11,

D. Pearl, L. Bouthilet, and J. Lazar (eds.), DHHS Pub. No.(ADM) 82-1196 (Rockville,

MD: 1982).

U.S. Department of Health and Human Services, Public Health Service, Centers for

Disease Control, “Update: Revised Public Health Service Definition of Persons Who

Should Refrain from Donating Blood and Plasma-- United States,” MMWR 34:547-548, Sept.

6, 1985.

U.S. Department of Health and Human Services, Public Health Service, Centers for

Disease Control, “Summary: Recommendations for Preventing Transmission of Infection

with Human T-Lymphotropic Virus Type 1ll/Lymphadenopathy -Associated Virus in the

Workplace,” MiWWR 34(45):681-686, 691-695, Nov. 15, 1985.

U.S. Department of Health and Human Services, Public Health Service, Centers for

Disease Control, “Additional Recommendations to Reduce Sexual and Drug Abuse-Related

Transmission of Human T-Lymphotropic Virus Type 1ll/Lymphadenopathy -Associated

Virus,” MMVR 35(10):152-155, March 14, 1986.

U.S. Department of Health and Human Services, Public Health Service, Centers for

Disease Control, “Antibody to Human Immunodeficiency Virus in Female Prostitutes,”

MMWR 36(1 1):157- 161, March 27, 1987.

U.S. Department of Health and Human Services, Public Health Service, Centers for

Disease Control, “Public Health Service Guidelines for Counseling and Antibody Testing

to Prevent HIV Infection and AIDS,” MMWR 36(31):509-515, Aug. 14, 1987.

U.S. Department of Health and Human Services, Public Health Service, Centers for

Disease Control, “National AIDS Information Campaign: Overview,” Atlanta, GA, Sept. 15,

1987.

184a. U.S. Department of Health and Human Services, Public Health Service, Centers for

Disease Control, “National AIDS Information Campaign: Overview,” Atlanta, GA, no date.
How Effective Is AIDS Education? ● 125

185.

186.

186a.

187.

188.

189.

190.

191.

192.

193.

193a.

194.

195.

196.

U.S. Department of Health and Human Services, Public Health Service, Centers for

Disease Control, “Human Immunodeficiency Virus Infection in the United States: A

Review of Current Knowledge,” MMWR 36( S-6):1-48, Dec. 18, 1987.

U.S. Department of Health and Human Services, Public Health Service, Centers for

Disease Control, “Division of Sexually Transmitted Diseases and STD Laboratory Program

Annual Report 1987- 1988,” internal document, Atlanta, GA, December 1987.

U.S. Department of Health and Human Services, Public Health Service, Centers for

Disease Control, “Update: Serologic Testing for Antibody to Human Immunodeficiency

Virus,” MMWR 36(52):833-840, 845, January 8, 1988.

U.S. Department of Health and Human Services, Public Health Service, Centers for

Disease Control, “Guidelines for Effective School Health Education to Prevent the Spread

of AIDS,” MMWR 37( S-2):1 -14, Jan. 29, 1988.

U.S. Department of Health and Human Services, Public Health Service, Centers for

Disease Control, “Continuing Increase in Infectious Syphilis--United States,” MMWR

37(3):35-38, Jan. 29, 1988, as reported in American Medical Association, “Continuing

Increase in Infectious Syphilis-- United States,” JAMA 259(7):975-977, Feb. 19, 1988.

U.S. Department of Health and Human Services, Public Health Service, Centers for

Disease Control, “Condoms for Prevention of Sexually Transmitted Diseases,” MMWR

37(9):133-137, March 11, 1988.

U.S. Department

Disease Control,

U.S. Department

Disease Control,

U.S. Department

Disease Control,

U.S. Department

Disease Control,

U.S. Department

Disease Control,

U.S. Department

Disease Control,

U.S. Department

Disease Control,

U.S. Department

Disease Control,

of Health and Human Services, Public Health Service, Centers for

unpublished data, Atlanta, GA, March 31, 1988.

of Health and Human Services, Public Health Service, Centers for

unpublished data, Atlanta, GA, April 1988.

of Health and Human Services, Public Health Service, Centers for

AIDS Weekly Surveillance Report, May 2, 1988.

of Health and Human Services, Public Health Service, Centers for

unpublished data, Atlanta, GA, May 11, 1988.

of Health and Human Services, Public Health Service, Centers for

Understanding AIDS, May 1988.

of Health and Human Services, Public Health Service, Centers for

“Future of Campaign,” Atlanta, GA, no date.

of Health and Human Services, Public Health Service, Centers for

“Center for Prevention Services Annual Report,” January 1988.

of Health and Human Services, Public Health Service, Centers for

Division of Sexually Transmitted Diseases, “Miami Study,” unpublished

contractor rer)ort. 1978. as cited in Mar~olis. 1988.
126 ● How Effective Is AIDS Education?

197.

198.

199.

200.

201.

202.

203.

204.

205.

206.

207.

208.

U.S. Department of Health and Human Services, Public Health Service, Food and Drug

Administration, unpublished data, Silver Spring, MD, March 1988.

U.S. Department of Health and Human Services, Public Health Service, Food and Drug

Administration, Center for Drugs and Biologics, Office of Biologics Research and Review,

“Additional Recommendations for Reducing Further the Number of Units of Blood and

Plasma Donated for Transfusion or for Further Manufacture by Persons at Increased Risk

of HTLV-111/LAV Infection,” Rockville, MD, Oct. 30, 1986.

U.S. Department of Health and Human Services, Public Health Service, Food and Drug

Administration, Center for Drugs and Biologics, Office of Biologics Research and Review,

“Recommendations Concerning Persons at Increased Risk of HIV-1 and HIV-2 Infection,”

Bethesda, MD, April 6, 1988.

U.S. Department of Health and Human Services, Public Health Service, Health Resources

and Services Administration, “Runaway and Homeless Youth: What Do We Know About

Them and About HIV Infection?” unpublished internal briefing paper, Rockville, MD,

1988.

U.S. Department of Health and Human Services, Public Health Service, Health Resources

and Services Administration, Bureau of Maternal and Child Health and Resources

Development, Abstrac/s of Active Projects FY 1988, (Washington, DC: U.S. Government

Printing Office, 1988).

Valdiserri, R. O., Lyter, D., Callahan, C., et al., “Condom Use in a Cohort of Gay and

Bisexual Men,” paper presented at the 111 International Conference on AIDS, Washington,

DC, June 5, 1987, as cited in Coates, Staff, and Hoff, 1988.

Van den Hock, J. A. R., Coutinho, R. A., Van Zadelhoff, A. W., et al., “Prevalence,

Incidence and Risk Factors of HIV Infection Among Drug Users in Amsterdam,” abstract

in the 111 Interna/ionaZ Conference on AIDS (Washington, DC: U.S. Department of Health

and Human Services and the World Health Organization, June 1987), as cited in Des

Jarlais, 1988.

Van Ness, P., Director, National AIDS Information and Education Program, Centers for

Disease Control, Public Health Service, U.S. Department of Health and Human Services,

Atlanta, GA, personal communication, August 1987 and May 11, 1988.

Vincent, M., Clearie, A., and Schluchter, M., “Reducing Adolescent Pregnancy through

School and Community-Based Education,” JAMA 257(24):3382-3386, 1987.

Wallace, J. I., Christonikos, N., Mann, J., et al., “HIV Exposure in New York City

Streetwalkers (Prostitutes)” paper presented at the III International Conference on AIDS,

Washington, DC, June 4, 1987.

Wallack, L. M., “Assessing Effects of Mass Media Campaigns: An Alternative Perspective,”

Alcohol Health and Research World 17-29, Fall 1980.

Wallack, L., “The Role of Mass Media in Educating the Public About AIDS,” testimony

presented at hearings on Prevention and Education, conducted by the Presidential

Commission on the Human Immunodeficiency Virus Epidemic,” Washington, DC, March

2, 1988.
How Effective Is AIDS Education? ● 127

209.

210.

211.

212.

213.

214.

215.

216.

217.

218.

219.

220,

221,

Wallack, L., and Wallerstein, N., “Health Education and Prevention: Designing Community

Initiatives,” International Quarterly of Community Health Education 7(4):319-342, 1987.

Walters, J., Assistant to the Secretary, Department of Education, Washington, DC, personal

communication, April 8, 1988.

Watkins, J. D., Chairman, Presidential Commission on the Human Immunodeficiency Virus

Epidemic, “Chairman’s Recommendations,” report for the consideration of the Presidential

Commission on the Human Immunodeficiency Virus Epidemic, Washington, DC, February

29, 1988.

Watters, J. K., “Preventing Human Immunodeficiency Virus Contagion Among Intravenous

Drug Users: The Impact of Street-Based Education on Risk Behavior,” abstract in the 11/

In/ernationaZ Conference on AIDS (Washington, DC: U.S. Department of Health and

Human Services and the World Health Organization, June 1987).

Weissman, G., Public Health Service Analyst, National Institute on Drug Abuse, Alcohol,

Drug Abuse, and Mental Health Administration, Public Health Service, U.S. Department

of Health and Human Services, Rockville, MD, personal communication, March 15, 1988.

Williams, K., Program Analyst, National Information/Education Program, Centers for

Disease Control, Public Health Service, U.S. Department of Health and Human Services,

Atlanta, GA, personal communication, May 18, 1988.

Williams, L. S., “AIDS Risk Reduction: A Community Health Education Intervention for

Minority High Risk Group Members,” Health Education Quarterly 13:407-421, 1986, as

cited in Coates, Stall, and Hoff, 1988.

Willoughby, B., Schechter, M. T., Boyko, W. J., et al., “Sexual Practices and Condom Use in

a Cohort of Homosexual Men: Evidence of Differential Modification Between

Seropositive and Seronegative Men,” paper presented at the 111 International Conference on

AIDS, Washington, DC, June 1, 1987, as cited in Coates, Stall, and Hoff, 1988.

Wilson, R., Director, Division of Epidemiology and Health Promotion, Office of Analysis

and Epidemiology, National Center for Health Statistics, personal communication,

Hyattsville, MD, April 20, 1988.

Winkelstein, W., Professor, School of Public Health, University of California, Berkeley,

CA, personal communication, May 1988.

Winkelstein, W., Lyman, D. M., Padian, N., et al., “Sexual Practices and Risk of Infection

by the Human Immunodeficiency Virus,” JAMA 257:321 -325, 1987.

Winkelstein, W., Samuel, M., Padian, N., et al., “The San Francisco Men’s Health Study:

111. Reduction in Human Immunodeficiency Virus Transmission Among

Homosexual/Bisexual Men: 1982- 1986,” Am. J. Public Health 76(6):685-689, June 1987.

World Health Organization, Coun.selling in HIV Infection and Disease, Geneva,

Switzerland, January 1988.
128 ● How Effective Is AIDS Education?

222. Yarber, W., “Pilot Testing and Evaluation of the CDC-Sponsored STD Curriculum,”

prepared for the U.S. Department of Health and Human Services, Public Health Service,

Centers for Disease Control, Atlanta, GA, February 1986.

223. Zelnik, M., ‘Sexual Activity Among Adolescents: Perspectives of a Decade,” Premature

Adolescent Pregnancy and Parenthood, E.R. McAnarey (cd.) (New York, NY: Grune and

Stratton, 1983), as cited in Kirby, 1988.

224. Zelnik, M., and Kim, Y., “Sex Education and Its Association with Teenage Sexual

Activity, Pregnancy and Contraceptive Use,” J. School HeaZth 14(3):1 17-126, 1982, as

cited in Kirby, 1988.