The ABC’s of HIV/AIDS Intervention Programs - Laura Pinheiro

Since the beginning of the global AIDS epidemic, nearly 30 years ago, it is estimated that 60 million people have become infected with this virus and approximately 25 million have died from it (UNAIDS 3). In the U.S, some control over this epidemic has been gained, and currently, about 1% of the country’s population is living with HIV/AIDS even though about 56,300 Americans continue to become infected each year (CDC). Despite the U.S’s ability to decrease domestic HIV incidence, the global alarm for this epidemic has not subsided. In 2008, there were estimated to be 2.7 million new HIV infections and 2 million HIV related deaths in the world (UNAIDS 2). According to the UNAIDS 2009 report, there are up to 36 million people currently living with HIV and 67% of those reside in Sub-Saharan Africa, home to 91% of all new infections among children (UNAIDS 3). Since Sub-Saharan Africa is an area of large concern relating to this epidemic, there have been several initiatives aimed by national governments and international organizations to help those countries combat HIV/AIDS. Among these, is former President George W. Bush’s public health intervention, the President’s Emergency Plan for AIDS Relief (PEPFAR).

The original PEPFAR was launched in 2003 as part of the United States Leadership Against Global HIV/AIDS, Tuberculosis and Malaria Act (AVERT 1). The Act approved $48 billion to go towards fighting these three diseases: $39 billion towards HIV/AIDS, $4 billion for tuberculosis and $5 billion for malaria (AVERT 1). Under PEPFAR, the money would be allocated over 5 years where 55% went to treatment of those living with HIV/AIDS (ART therapy), 15% to palliative care (care to alleviate symptoms and improve quality of life to those diseased), 20% to HIV/AIDS prevention, and finally, 10% of the money would go to aiding children made orphans because of HIV/AIDS (ALERT 1). The US Global AIDS coordinator, Dr. Mark Dybul, is responsible for coordinating PEPFAR initiatives (ALERT 1). Although there are fifteen “focus” countries (mainly Sub-Saharan African countries among them, but Vietnam is also included), PEPFAR technically refers to, “any HIV/AIDS expenditures and activities that the US government provides to all countries outside of the U.S.” (ALERT 1) An example of a, “non-focus country PEPFAR expenditure is the substantial funding that is being provided for HIV/AIDS work in India.” (ALERT 1) The HIV/AIDS prevention intervention compromises 20% of PEPFAR and is often referred to, as the “ABC’s” meaning abstinence until marriage, be faithful and condom use. While this ABC approach has merits and is a valiant attempt towards combating the HIV/AIDS epidemic, it is also made up of various flaws, hindering it from having the impacts on this global issue that it set out to make. This paper will attempt to illustrate some of the major flaws in the ABC approach from a social and behavioral science perspective and to suggest some changes that could be made in order to increase the effectiveness of this intervention.

The first major flaw in the PEPAR initiative and particularly ABC approach is that it spends an inordinate amount of prevention funding (33%) on promoting abstinence only (ALERT 1). It is true that the only 100% effective way to prevent sexual HIV transmission is not having sexual intercourse with an HIV-infected person, and therefore, abstaining from sexual intercourse, would eliminate the risk of sexually contracting HIV. This idea is flawed, however, because it assumes that people make the decision to engage in sexual intercourse entirely rationally and that is frequently not the case. The Health Relief Model assumes that every health decision is a balancing act where an individual weighs perceived susceptibility to a disease with the perceived severity of the disease and they then make a planned, rational decision based on weighing these two factors (Edberg). Theoretically, a person should weigh the idea that if they engage in sexual intercourse at all, they will increase their risk of contracting HIV and that if they do contract HIV they are likely to become very sick from this disease and eventually die as there is no cure. However, due to optimistic bias, that is, the idea that individuals understand the actual, absolute risk of their behavior, but they perceive their personal risk being much lower, people may not always follow through with their initial intentions stemming from the Health Relief Model (Weinstein). A person may be educated about the ways to sexually contract HIV, they may be fully aware that by abstaining they will eliminate the risk of sexually contracting the disease, they may even have the intention to abstain in order to prevent infection, but when they meet someone that they love and are sexually attracted to and want to have sex with, they may think that their personal chance of contracting the disease is not really as great. Therefore, focusing such a large portion of an intervention to combat the growing HIV/AIDS epidemic on abstinence only is severely flawed, as it treats individuals as completely rational and levelheaded, when in reality, people are frequently governed by their emotions and desires. Rather than telling people not to engage in sexual intercourse, which may also induce psychological reactance, the theory that, “when people think that a freedom is threatened, they experience reactance, a motivational state aimed at restoring the threatened freedom,” more funds should be allocated to educating people on ways to protect themselves when having sex (Silvia, 409). Being more realistic about people’s sexual behavior, especially those who are young, as well as framing the ways to protect oneself in a less restrictive manner, would truly improve the reduction of HIV/AIDS transmission.

The second major PEPFAR flaw is its failure to recognize societal constructs and inequalities in the countries it is attempting to aid. In many of these Sub-Saharan Africa “focus” countries that PEPFAR aims to target, sexual abuse such as rape is a major issue, and a frequent mechanism in which women become infected with this terrible disease. The Theory of Gender and Power discusses how through the sexual division of power, women can be more susceptible to HIV infection due to inequalities: “As the power inequity between men and women increases and favors men, women’s sexual choices and behavior may be constrained, thereby increasing their risk for HIV.” (Wingwood, 564) Women may have the desire to be abstinent in order to protect themselves, but when they are raped or sexually abused, that choice and decision is taken away from them. The abstinence only component of the ABC approach is not tailored towards the societies of the Sub-Saharan African nations who devalue women and do not view men and women as equal members of society, reflecting yet another flaw in this intervention. An intervention that focuses more of its efforts on educating women about the disease, that teach them ways that they can protect themselves (vaginal microbicide gels, females condoms) would be more effective than simply encouraging them to abstain, when often that choice is not even in their power to make. In a region that harbors 67% of the current HIV infections, an intervention that better recognizes and comprehends societal constructs is likely to prove more beneficial in the attempt to reduce HIV/AIDS incidence. By ignoring societal constructs and gender-power roles between women and men, the PEPFAR intervention is not an effective public health intervention to combat the HIV/AIDS epidemic.

A third major flaw in PEPFAR is the “B” in the ABC approach: be faithful. President Bush’s Emergency Plan promotes being faithful by, “supporting counseling, peer education, and community-based interventions to address social norms that increase vulnerability to HIV, such as the acceptance of men having multiple sexual partners outside of marriage, cross-generational sex, and transactional sex.” (State) Being faithful is an individual-level behavior that is very difficult for an intervention to monitor, promote or control. Like the abstinence component, the being faithful component is unrealistic in regards to an individual’s behavior. While a person may have every intention of being faithful and to honor their commitment to their sexual partner, emotions and passion may intervene. The construct of marriage, for instance, may make people feel constricted and unable to exercise their freedoms, and in turn, due to psychological reactance previously described, they choose to stray from their marriage and pursue other sexual partners. There are many complex issues surrounding people’s decisions to not be faithful to their sexual partners: they do not feel satisfied in their relationship, they are sexually attracted to another person, they are unable to control themselves, they do not feel that being faithful is important…etc. It is impossible to approach the control or modification of this individual behavior from an angle that will target every person or even the majority of people because the reasons why people are not faithful vary immensely. For instance, the Theory of Reasoned Action stipulates that individuals balance individual decisions with outcome expectancies such as their personal attitude towards a behavior with subjective norms such as what do other people think about the behavior and how they will you be perceived by engaging in this behavior. (Edberg). While this model is more realistic than the Health Relief Model in that in takes into account societal influences on an individual’s choices, it still cannot explain individuals’ behaviors regarding being faithful. Cheating on a partner or committing adultery in a marriage is considered a terrible thing to do in nearly every society. A woman who commits adultery in some Islamic countries can even be stoned to death for her behavior. Why then, do people continue to betray their sexual partners? This behavior is not a simple one to explain and relying on it in order to combat the HIV/AIDS epidemic is foolish. Simply encouraging people to be faithful in their sexual relationships does not suffice and will not make a considerable impact in reducing the spread of HIV/AIDS as infidelity is not a rational, planned behavior.

The promotion of being faithful is yet another example of PEPFAR’s second major flaw of failing to account for societal constructs of the Sub-Saharan African countries, specifically gender inequality. For instance, in Botswana, the country with the second highest HIV prevalence, 25%, and a life expectancy below 40 years, the number of women living with HIV compared to men is more than twice as great (UNAIDS, 2). Botswana relies on PEPFAR’s aid more than any other foreign contribution to help fight the overwhelming HIV/AIDS epidemic (AVERT, 2). PEPFAR’s ABC policy focuses primarily on male-controlled forms of prevention, and this does not appear to address the overarching percentage of females infected with the disease. In a country where women are barely educated and are marginalized, by not employing HIV/AIDS prevention methods that empower females (who are at a higher risk of sexually contracting the disease), PEPFAR is not proving an effective intervention. According to the Theory of Gender and Power, “women are biologically more likely to become infected if they are exposed to a sexually transmitted pathogen,” so, “biologically, women are at a higher risk for HIV.” (Wingwood, 580) In terms of the “be faithful” approach, if a husband or boyfriend is not faithful to his partner, she may become infected by no fault of her own. A female may not even be aware that her partner was not faithful, and even if she is aware, she may rely so heavily upon this male for financial support and food, that she is not able to do anything about his infidelity. Therefore, if a woman is faithful in her relationship, complying with the ABC approach, but her male partner is not, the woman’s risk of contracting HIV is not significantly reduced, meaning that PEPFAR is not achieving its goal. An intervention that accounts for these societal issues and gender-power inequalities would be much more effective and unfortunately, PEPFAR fails to do this.

The PEPFAR prevention of HIV/AIDS is an intervention that has very good intentions, but does not seem to be approaching the global epidemic, especially in Sub-Saharan Africa in the most effective way. The plan claims that, “Past and current prevention messages have often failed to achieve the widespread behavior change that is necessary to end the pandemic,” and, “prevention efforts are further hampered by the stigma surrounding HIV/AIDS and gender inequality that increases the vulnerability of women and girls,” but it does not seem to adequately address these issues (State). By promoting the ABC’s, which stress the unrealistic and often uncontrollable pillars of abstinence and being faithful, and then telling people to use condoms is proving not to be the best approach. Signs on Botswana highways advertise, “Avoiding AIDS is as easy as: ABSTAIN, BE FAITHFUL, condomise.” (ALERT 2) Indicating that the first two components are more important, but if all else fails, people should use condoms. This ad is confusing; as PEPFAR is not maintaining consistency with the messages it is relaying and is contradicting itself. In addition, the PEPFAR intervention does not take into account gender-power roles, specifically those that marginalize women and increase their susceptibility to acquiring HIV/AIDS. Societal constructs that incorporate these gender discrepancies and inequalities must be considered when developing an adequate and appropriate intervention that will achieve success in reducing HIV/AIDS transmission and controlling this global epidemic. An optimal intervention needs to be more realistic about individual (especially those who are young) behaviors and educate people about ways to protect themselves without prohibiting the risky behavior entirely. The intervention should not use an authoritative voice, which might invoke resistance. Furthermore, it should not attempt to rationally control a behavior that is so strongly affected by emotions and impulses. Finally, a more appropriate intervention that accounts for societal constructs, gender roles and inequalities, will be much more successful in combating the HIV/AIDS global epidemic plaguing 36 million individuals worldwide.

Although there is no intervention that will perfectly address all of the PEPFAR issues previously discussed, there are interventions that would improve upon some of the PEPFAR flaws and thus create more effective HIV/AIDS prevention policies. First, rather than taking the approach of “abstinence only”, an intervention that is more sexually comprehensive, and realistic, will better serve the needs of the population suffering from this epidemic. According to an article published about abstinence programs in the U.S, “Abstinence-only education has had little demonstrable impact on teenagers' sexual behaviors, despite significant policy and funding efforts.” (Harper) Since abstinence only programs have proved to fail in the past, a comprehensive sexual health education program should be instituted in these focus countries either at the local health clinics or perhaps through the schools. If people (especially when they are young) are able to become educated about the risks of sexually transmitted infections (STIs), and ways to prevent, test and treat for them, the general population will be better equipped to handle this epidemic. By sheltering people and telling them that the only way to avoid getting HIV is to avoid having sex, interventions are essentially handicapping individuals who decide to have sex, but still want to remain HIV-free. According to the American Psychological Association (Rotheram), “Only comprehensive sex education is effective in protecting adolescents from pregnancy and sexually transmitted illnesses.” (Rotheram) These comprehensive programs have proven that they work better in efforts to protect youth from contracting STIS and, “scientifically sound studies of abstinence only programs show an unintended consequence of unprotected sex,” so, “in this way, abstinence only programs increase the risk of these adolescents for sexually transmitted illnesses, including HIV/AIDS." (Rotheram) Therefore, it is essential for HIV/AIDS intervention programs to increase funding and emphasis on sexual health education as a means to decrease HIV/AIDS incidence. The cliché “knowledge is power” is quite applicable in this situation: without proper knowledge of risks, symptoms and treatments, people cannot adequately protect themselves. Perhaps if people understood the actual consequences of HIV/AIDS and other STIs they would be able to take precautions in order to prevent their own infection. Realistically, understanding the consequences may not make people more likely to necessarily abstain from sexual intercourse all together, but it hopes to make people more likely to choose their partners carefully, get tested more frequently and use condoms more often, thus reducing the overall rate of HIV infection.

Furthermore, when creating these sexual health education programs in the focus countries local people, not foreigners, should deliver the information about STIs. According to Paul Silvia, a way to deflect psychological reactance is to present information through, “interpersonal similarity.” (Silvia, 278) That is, people are less likely to have reactance to information that is relayed to them by people they feel similarities to and can identify with, therefore deflecting reactance (Silvia). According to this theory, if sexual health messages were delivered by white, English-speaking Americans in Uganda, a much higher level of resistance will be met than if these messages were delivered by an individual that grew up in one of the local villages and speaks the people’s language (Silvia). Taking steps towards creating an environment that the population will not resist these HIV/AIDS messages will prove essential to the acceptance of safer sexual practices and therefore the reduction of HIV/AIDS incidence.

The PEPFAR plan only promotes consistent condom use among “high-risk” populations, which they identify as, “prostitutes, sexually active discordant couples, and substance abusers, “ but assures that, “the general population receives a clear message that the best means of preventing HIV/AIDS is to avoid risk all together,” meaning abstinence (State). This approach is ignoring the fact that many people who are not deemed “high risk” are also interested in having sex and rather than simply authoritatively telling them that they should abstain to be protected, facilitating protection if they choose to have sex would be more effective. Free condom distribution needs to be much more widespread and targeted to all populations (not just ones PEPFAR deems “high risk”), as condoms are the biologically most effective way to prevent HIV-transmission if you engage in sexual activity. Rather than focusing PEPFAR efforts to encourage people to “be faithful” and isolating “consistent condom use” to high-risk populations, if condoms were readily dispensed for free, more people would use them. Brazil’s HIV/AIDS efforts are internationally recognized as successful and condom use is one of the largest pillars of their interventions (ALERT 3). During carnival of 2009, Brazil distributed, “65 million free prophylactics to partiers,” across the country (Daily News). According to Mariangele Simao, the director of the national HIV/AIDS program in Brazil, the country spends nearly $40 million each year buying condoms, making it, “the world's No. 1 government buyer.” (Daily News) Brazil has achieved great success with its HIV/AIDS campaign and, “the number of deaths from the disease has dropped by 80% in recent years in Brazil.” (Costa) In addition, Brazilian media campaigns encourage condom use with messages relayed by celebrities saying slogans like, “Show how you’ve grown up. This carnival, use condoms!” (ALERT 3) These messages not only use an idolized, well-liked voice to spread the word (which has been proven to make the message more appealing), but they also use a technique, which empowers the individual by emphasizing that by using condoms they are smart and exercising control. Brazil is interesting because it is a country, which has been well-developed areas, but the urban and rural slums are overwhelming. Brazil, like many of the target African focus countries, serves a large population of poor, uneducated people without the financial means to adequately prevent themselves from contracting HIV/AIDS. Therefore, the following Brazil’s intervention policies of widespread condom distribution and having popular celebrity figures encourage the responsible behavior might appeal to a large audience (especially the youth) and prove to be effective in these focus nations that PEPFAR aims to help.

Finally, addressing the societal constructs of the particular nation that the HIV/AIDS intervention aims to target is absolutely essential to its success. If the intervention does not acknowledge that the particular country they are implementing a policy in may not value the same things or may not work in the same way, it will not be successful. Of course, molding to societal constructs will vary from country to country. For African nations, programs that target women specifically, such as educating them about the ways that they can protect themselves are instrumental. Women can use vaginal microbicide gels such as Tenofovir 12 hours prior to and 12 hours after sex in order to reduce the risk of HIV infections without their partners even knowing. According to the Caprisa Study done in South Africa, “Women who used the gel in more than 80% of their sex acts had a 54% reduction in HIV infections, a 38% reduction if they used it 50% to 80% of the times they had sex, and a 28% reduction if they used it in less than half of their sex acts.” (Keller) This gel can make a large impact on the fight to combat the HIV/AIDS epidemic. If women are able to use this gel independently of what their partners want, they will be protecting themselves from acquiring the HIV virus within the constraints of their society. It is not the job of PEPFAR or any other HIV/AIDS intervention program to change a different country’s societal constructs because this is a nearly impossible task. However, if foreign intervention programs work within the constructs of these societies in order to help empower and protect those most susceptible to infection, they will be more successful in their attempts to reduce HIV/AIDS. Gender inequality exists in these focus countries and although HIV/AIDS interventions will not eliminate this inequality, it can certainly work to lessen the severity of the impact it has on HIV/AIDS by empowering women and promoting prevention methods that give women rather than men more control.

A reformed HIV/AIDS intervention needs to be created in order to make a larger and better impact on the focus countries defined by PEPFAR. This new intervention should account for individual’s irrational, impulsive and unplanned behavior and societal constructs that fuel gender inequality. A HIV/AIDS intervention that increases sexual health education as a form to protect those who choose to be sexually active rather than simply promoting abstinence will be a more effective way to reduce the spread of the disease. Rather than telling couples to be faithful to one another, an ambition that is noble yet not frequently practical, realistic or controllable (especially by the partner being cheated on), the intervention should promote the widespread use of condoms. Instead of targeting only “high risk” populations with condom use, all populations: even those who are married and in relationships should be targeted in order to reduce the overall spread of the disease. Furthermore, understanding and working within societal constructs of a particular country will only augment the impact of the reformed intervention. Empowering women, often the victims of sexual abuse, rape, and gender inequality in these “focus” countries to protect themselves through female condoms and particularly vaginal microbicide gels, will allow the intervention to effectively impact more people in need. Through these intervention policy changes, plans like PEPFAR can hope to make more efficient use of the billions of dollars that they are spending and impact a much larger population of people afflicted with HIV/AIDS.

Final Paper Sources

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2. AVERT 2: "AVERTing HIV and AIDS." HIV & AIDS in Botswana. AVERTing HIV and AIDS, 2010. Web. 1 Dec 2010. .

3. AVERT 3: "AVERTing HIV and AIDS." HIV & AIDS in Brazil. AVERTing HIV and AIDS, 2010. Web. 1 Dec 2010. .

4. CDC: United States. HIV in the United States. , 2010. Web. 1 Dec 2010. .

5. Costa, Mariana. "Brazil's pioneering Aids programme." BBC News April 2009: 2 pag. Web. 1 Dec 2010. .

6. Daily News: "Brazil boosts condom handouts by 20M for Carnival." Daily News 13 Feb 2009: 2. Web. 1 Dec 2010. .

7. Edberg, Mark, “Chapter 4: Individual Health Behavior Theories,” Essentials of health Behavior: Social and Behavior Theory in Public Health, Sudbury, MA: Jones and Bartlett Publishers, 2007. Pp. 35-49.

8. Keller, Daniel. "Tenofovir Vaginal Gel First Microbicide to Prevent HIV, HSV Infections." Medscape Medical News (2010): 2. Web. 3 Dec 2010. .

9. Harper, CC. "Abstinence and teenagers: prevention counseling practices of health care providers serving high-risk patients in the United States." (2010): 125-32. Web. 3 Dec 2010. .

10. PEPFAR: United States. President's Emergency Plan for AIDS Relief (PEPFAR) Prevention. , 2003. Web. 1 Dec 2010. .

11. Rotheram, Mary Jane. Based on the Research, Comprehensive Sex Education Is More Effective at Stopping the Spread of HIV Infection, Says APA Committee. American Psychological Association, 23 Feb 2005. Web. 2 Dec 2010. .

12. Silvia Paul, “Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance,” Basic and Applied Social Psychology, 27(3) 2005. Pp 2249-2258.

13. State: United States. Critical Interventions in the Focus Countries: Prevention. , 2003. Web. 1 Dec 2010. .

14. UNAIDS 1: "UNAIDS Report on the global AIDS epidemic 2010." UNAIDS. Web. 2 Dec 2010. .

15. UNAIDS 2: "UNAIDS Report on the global AIDS epidemic 2008." UNAIDS, Feb 2009. Web. 2 Dec 2010. .

16. UNAIDS 3: "UNAIDS Report on the global AIDS epidemic 2009." UNAIDS, Feb 2010. Web. 2 Dec 2010. .

17. Weinstein Neil, “Unrealistic Optimism About Future Life Event,” Journal of Personality and Social Psychology, 39(5) 1980. Pp 806-820.

18. Wingwood Gina, “Chapter 12: The Theory of Gender and Power: A Social Structural Theory for Guiding Public Health Interventions,” Emerging Theories in Health Promotion Practice and Research: Strategies for Improving Public Health, San Francisco, CA: John Wiley & Sons, Inc., 2002. Pp 313-346.

All is Not Well in the Southern Front: Southern Policies Fueling the Spread of HIV: Alex Wasserman

INTRODUCTION

It is not uncommon for individuals to associate an expanding HIV/AIDS epidemic with less industrialized societies. As Americans, many take comfort in and typically assume that the epidemic is largely regulated. With a prevalent sense of individual responsibility and government policies to aid in treatment, this is an ostensibly reasonable assumption. This may be the case in certain concentrated areas within the country, but upon consideration of some additional figures and the broad social structures that shape them, one would quickly be shaken from any false sense of comfort. The figures being referenced are those that highlight the rapidly accelerating rate at which HIV/AIDS is becoming prevalent in the Southern United States (1). The focus of much recent research has been the disparity in both incidence and prevalence in the South as compared to other regions of the country (1). Being of primary source of concern for those within the areas of public policy, law and public health, a wide variety of factors have naturally been named attributable for this increasing gap.

A sufficient exploration of these forces far exceeds the scope of this paper, thus its focus will center on faulty public policies to explain why the current approach to HIV/AIDS prevention in the Southern United States is a cause for much concern. Additionally, after a review of the social and political conditions under which this epidemic is flourishing in the South, one might forego any former sense of ease or complacency and question why there is not a more permeating impression of duty, or even outrage. The primary aim of this paper will thus be to highlight ways in which the approach to HIV/AIDS prevention in the South have been largely unsuccessful in mitigating a burgeoning epidemic. This will be accomplished by examining the dire effects that lack of sex education have had within the nation’s southern states. It will also be instrumental to explore the policies, both at the state and federal level, that have aided in fueling the issue (1). It is critical to examine these policies because it is under this federal and state-level activity that ineffective educational models such as “Abstinence Only” models are permitted to continue. The failure to acknowledge the problem at a policy level will likely result in the same at the school level. Finally, an end goal of this paper will be to consider the South’s current conditions in an attempt to prompt alternative ideas in adopting new approaches to epidemic.

CONTEXT: HIV/AIDS AND THE SOUTH

An endemic disease, the risk of HIV/AIDS is often discounted in the United States. It’s prevalence, however, is much more pervasive than many perceive it to be, currently affecting more than 1.1 million Americans. Its incidence also need not be neglected at a rate of 56,000 new infections every year. These staggering figures become increasingly shocking as one explores the way in which they are distributed throughout the country. The Southern United States bears a disproportionate amount of the burden. Just over a third of the national population lives in this region; however, approximately half of Americans living with HIV/AIDS lives in the South. The same principle applies to minority exposure to the disease. African Americans make up just under a third of the population in several southern states; yet, they comprise nearly three-fourths of those with HIV in the region. Similar data is available on the prevalence among Latinos living in southern states (2).

Not only are individuals living in the South exhibiting more cases, but those living with HIV/AIDS in the South are significantly more likely to die of AIDS than those living in other regions of the country. To contextualize this disparity, it is useful to highlight the fact that the South is somewhat of a epidemiological anomaly. Typically, as the death rates of a disease remain steady, the prevalence diminishes (3). As a result of its spiking incidence rate, however, the region sticks out as an exception to the rule. The South currently has the highest rates of new infections, the highest AIDS-specific mortality rate, and the largest number of individuals living with HIV/AIDS (2).

These figures can be explained by a number of factors. The most prominent for the purposes of this paper, however, shall be the interplay between a lack of comprehensive sex education in southern schools and a slew of other counterproductive public policies. These policies have been instrumental in shaping the broad social structures that have entrenched so many Southerners in poverty and a more select group in their incapacity to obtain proper treatment. The argument of this paper is thus that the common approach in southern states, i.e., Abstinence Only curricula, has proven to be particularly ineffective and socially irresponsible in a region that is becoming increasingly rattled in disease. Though both of these factors are significant determinants of disease, neither one is the single source to address (2). Policies may be reformed, but the grander social forces need to be addressed by utilizing an alternative behavioral model in school teaching. Similarly, incidence of new disease may decrease with education reform, but if public policy inherently discriminates against groups of people, stigma will remain and undermine any efforts at prevention and treatment. Social change may either manifest itself through a bottom-up approach, i.e., through grassroots efforts, or through a top-down approach. This latter method has the ability to occur due to the specific effects that policy can potentially have on society. Over time, policies have the propensity to cause social norms to shift, thereby altering people’s behavior and the social structures around them. The exploration of public policy thus is an important part of Social Expectations Theory (4). As policies are passed, public opinion changes on a large scale, having an impact on social norms. In the case of HIV/AIDS, there are several policies currently in place that shroud the disease in stigma and denial. An essential component of reconstructing the current approach to HIV/AIDS prevention is thus to consider these policies, to be discussed below, so that access to treatment may improve and stigma may be absolved. When this is achieved and social norms are transformed, the widespread reluctance towards proper prevention education may potentially be diminished.

In order to emphasize the need to reform this approach to HIV/AIDS prevention, it is helpful to review the policies that are shaping the conditions within these states. There exist the policies that are faulty simply in their lack of funding or inappropriate standards (5). Then, there exist policies that are not rooted in scientific fact and therefore aid in the stigmatization of those living with HIV/AIDS (1). Both kinds of policies are necessary parts of the battle in improving the current approach to prevention, and both will be discussed below.

CRITIQUE ARGUMENT 1- CRIMINALIZATION OF HIV TRANSMISSION

As the prevalence of HIV/AIDS has increased, the means required to provide treatment have followed suit. The assistance procured in providing that treatment has been lacking, however (5). Instead, there are a number of policies in place, at both the state and national level, that serve to perpetuate a norm of HIV infection as worthy of shame. This process proves to be counterproductive in efforts towards prevention. Additionally, these approaches to containing the spread of HIV/AIDS undermine the ideas behind Social Expectations Theory. This theory asserts that you can change all of society by shifting the current social norms (4). The passage below will attempt to illustrate how current approaches to HIV/AIDS prevention could be more effective had they taken into consideration the far-reaching implications of Social Expectations Theory.

One current approach the prevent at prevention at the policy level is the criminalization of HIV. Under this policy, individuals who are aware of their HIV status and consequently transmit the disease to someone else can be sanctioned. However, no amendment is included in this policy to specify that transmission must be intentional (2). It is not even required for the transmission to have actually occurred. All that is required is a lack of disclosure to one’s sexual partner. Though this latter component is a crucial aspect to consider, the remainder of the policy poses serious threat to prevention efforts. If individuals fear criminalization, the likelihood of testing for HIV is greatly reduced, thereby undermining large scale screening efforts (2). Thinking on a broader scale, this trend of assigning “guilty” parties in this epidemic simply perpetuate stigma and downplay the importance of education. This form of criminalization has been prominent in southern states, such as Tennessee, Georgia, and Texas, proving to be a major threat to larger proportions of the southern population (2).

The social effects of HIV criminalization follow the principles of Social Expectations Theory. Laws punishing individuals for transmitting HIV, intentionally or unintentionally, foster a norm of fear and shame surrounding the disease. As a result, individuals who may have otherwise sought testing to determine their health status are significantly less likely to do so because the social structure in which they are embedded permeates a culture of punishment. The prevalent social norms deter individuals from adopting healthy behaviors (4). Thus, the criminalization of HIV transmission follows the Social Expectations Theory, but in a manner that is destructive, rather than conducive of HIV/AIDS prevention.

CRITIQUE ARGUMENT 2- OPPOSITION TO SYRINGE EXCHANGE PROGRAMS

A second faulty approach to HIV/AIDS prevention manifests itself in the current struggle with syringe exchange programs (SEPs). SEPs operate in a collaborative effort to to both prevent intravenous transmission by providing clean needles, as well as to connect drug users with services that make up a more comprehensive program. Individuals participating in these programs are often tested for HIV and other diseases, as well as connected to drug dependence treatment programs (2). Given that intravenous drug users make up a substantial portion of people living with HIV/AIDS in many southern states, i.e. 21% of infected individuals in Louisiana, SEPs serve as an ideal and innovative tool in prevention. Through this holistic process of providing clean needles and referral services, SEPs are notable in that they “meet people where they are” (2). They acknowledge the current needs of their beneficiaries and progress from there by providing the appropriate assistance. In the case of SEPs, individuals are not condemned for their behavior; instead, they are led onto a healthier track and provided with resources to gradually resume control. This approach has been praised for its effectiveness by such health-oriented organizations as Human Rights Watch and the Centers for Disease Control and Prevention (6).

One reason for this praise is the striking parallel that these programs run with the behavioral model, the Transtheoretical Model. This model asserts that individuals seeking to improve health behaviors progress gradually along a series of stages in a fairly structured order (7). SEPs, like many drug treatment programs, bear the same structure presented in the Transtheoretical Model. There are clear advantages to this model; namely, that it allows interventions to assess where an individual is in the process of adopting a particular health behavior and thus determine their readiness for next steps. Based on this determination, the specific intervention used may vary. A primary tenet of the model is that the process is gradual, rather than instantaneous, in that it entails a progressive change in the individual’s thought process (7).

In spite of the proven effectiveness of SEPs in particular regions of the country, there remain a set of laws and restrictions in the Southern United States that regulate the distribution of clean needles. Though larger concentrations of SEPs can be found in other regions of the country, they are few and far between in the southern states. This is largely due to the state laws that prohibit the sale or prescription of syringes for the injection of illegal substances (2). This policy undermines the Transthereotical Model’s approach in meeting people where they are. The current approach of outlawing the use of syringes for illegal substances suggests to individuals struggling with addiction that if they cannot immediately quit their behaviors, then they cannot be helped. This mindset has not had much proven success in other public health interventions, and this instance is no exception. The strict prohibition of providing clean syringes assumes that there is but a standard script to use in helping an individual overcome addiction. SEPs bear a striking parallel to the theory in that it assumes that individuals respond more or less successfully to different forms of intervention, depending on where they are in the process of dropping their addiction.

CRITIQUE ARGUMENT 3- EMPHASIS ON ABSTINENCE ONLY EDUCATION

A third manner in which southern states are fueling the HIV epidemic is through its widespread lack of access to sex and HIV/AIDS education in school. Although the South is certainly not the only area of the country experiencing some degree of reluctance to this standard, the escalating number of HIV cases indicate that there must be larger cultural structures in place making this reluctance more permeating. It is startling to consider the education policies that are currently in place in many of these states. While no state is required to emphasize the use of contraceptives, many states expect that it at least be addressed in school curricula. In a hand full of Southern states, however, no such expectation exists. Rather, several states require an emphasis on abstinence before marriage (2).

This lack of education does not take place within a vacuum, however. Both the Kaiser Foundation and the Centers for Disease Control and Prevention have published data indicating that among all cases of HIV/AIDS in the United States, a majority of recent infections has been among individuals in their teenage and young adult years (8). Southern states make up a largely disproportionate number of states with the highest number of teen pregnancies (2). These and other data indicate that an unavoidable portion youth in the South is indeed sexually active, despite many hopes or notions to the contrary. With the data indicating such a high percentage of youth engaging in sexual activity at a young age, any policy or law aimed at shielding them from any sort of cautionary information can be deemed socially irresponsible.

By using biased and misleading information, abstinence-only curricula heavily rely on the use of scare tactics to instill the belief that sex outside of marriage is immoral, thus making anyone who partakes immoral (9). Leaving students with a sense of ambiguity, this method perpetuates an association of sex with fear and shame. Actual harm comes into play as well, in that adolescents and young adults are barred from attaining vital, potentially life-saving information about sexual health (10).

Through this kind of curriculum, it not uncommon for students to be conditioned into associating abstinent individuals with honesty and prospects of success, as compared to viewing sexually active individuals as lacking good moral character (11). People who have premarital sex are thus perceived to be less desirable and are then impressed with a sense of shame. This concept runs parallel to the basic tenets of Labeling Theory (12). The implications of this theory are vast, in that individuals are influenced by the terms used to classify them. Additionally, the way they treat others is influenced by the labels ascribed to them. In the abstinence-only curriculum, adolescents may be introduced to negative labels of their sexually active peers that powerfully impact both groups’ behaviors, performance and even physiological factors. A variety of devastating emotional consequences including heartbreak, loneliness and feelings of regret place a heavy burden on the young adult population due to these programs (11). This approach inherently communicates a degree of loss in self-respect for individuals who participate in premarital sex, every time a sexual activity is initiated. These aforementioned emotional consequences are largely rooted in the teaching that adolescents who are or who will become sexually active, that they are worth less than their abstinent counterparts. For those few individuals who remain abstinent until marriage are left without any tools in which to communicate with their partners about sexual matters.

An additional, more apparent consequence of abstinence-only programs providing inaccurate information about sexually transmitted disease prevention or by completely eradicating information about prevention as a whole, is adolescents growing up with impeded abilities to make healthy sexual decisions (9). In order to prevent the spread of disease, adolescents must be educated on how to avoid them, learn how to recognize any possible symptoms and be encouraged to seek regular testing and medical attention without being fearful.

PROPOSED INTERVENTION 1- CHANGING SOCIAL NORMS

One proposal to fight these faulty approaches to HIV/AIDS approaches is to address the criminalization of HIV transmission. In order to attack the consequences of this policy, it is necessary to utilize its underpinning social theory; that is, Social Expectations Theory, or the theory that you can change all of society by changing the social norms pervading it (4). In the case of HIV criminalization, the social norm being perpetuated is that HIV transmission is an act of shame and moral deficit. As a result, sexually active individuals in states with criminalization laws become fearful of testing their HIV status (2). An alternative approach to address HIV prevention in these states would be change the norm by perhaps airing television advertisements about the importance of testing for HIV and other sexually transmitted diseases. These advertisements could come in the form of commercials showing couples getting tested together. The commercials could use certain dialogue to paint the situation in a way that purveys it as an experience of emotional closeness and growth between a couple. A second possible method would be secure agreements with television networks or program writers to incorporate HIV testing into the story lines of their programs. Television programs viewed by teenagers and young adults largely consist of story lines centered around of plot of romance, leaving much room to seamlessly integrate a situation where one or more characters gets tested. It would, of course, be ideal for the decision to get tested to be portrayed as a natural and obvious course of action for the character. Additionally, the situation should be portrayed in a positive light, perhaps by having the character testing negative and feeling relieved.

These and other interventions would likely prove to be very effective in this case by portraying awareness of one’s HIV status as a responsible and necessary course of action. Ideally, this would have a gradual effect on social norms, leaving an increasing number of people taking responsibility for their health and knowing their HIV status” (4). The current approach used by some states of criminalizing the transmission of HIV is an effective method aimed at prevention. This is a method that is short-sighted and attempts a simplistic solution at prevention. Instead of punishing individuals for their behaviors, people should be encouraged to assume control and an active role in their health.

PROPOSED INTERVENTION 2- MEETING PEOPLE WHERE THEY ARE

A second necessary approach is to drift away from the current restriction of providing clean syringes in certain states. Currently, drug users that use syringes to inject substances into their body are risking using contaminated needles because they have no means of attaining clean ones, facilitating the spread of disease. Lawmakers that set restrictions on needle distributions are doing so with the underlying belief that drug users are as such because of a lack of discipline and irresponsibility and need to abruptly quit their behaviors. This is, again, a simplistic view of a legitimate medical and psychological problem. Successful efforts need to be geared to assist individuals at various stages in the process of quitting, thereby utilizing the Transtheoretical Model (7). This can be done by lobbying for policy reform that will lift restrictions on physicians’ abilities to provide safe needles. Justification for such legislation includes that it is socially responsible and has the long term potential to improve the public’s health, as well as to cut costs in HIV/AIDS-related health care. If physicians, from hospital emergency rooms or community health centers, could provide clean needles and simultaneously connect individuals to treatment programs for drug addiction, southern states would be on the path to a sustainable project in gradual reduction of HIV incidence. This use of the Transtheoretical Model is sensitive to the varied needs of a large population and encompasses a wide range of interventions people, depending how much progress they have made in ceasing, or considering to cease, illegal drug use (7).

PROPOSED INTERVENTION 3- COMPREHENSIVE SAFE SEX EDUCATION

Finally, a third way to address the increasing incidence of HIV in the Southern United States would be to address the lack of sex education and STD prevention curricula in schools. Many schools, in an attempt to discourage sexual activity, inadvertently instill in students a stigma attached to sex. This stigma, by extension, aids to form a negative label on sexual active students (12). A possible approach to reverse this trend would be to require that school place a strong emphasis on safe sex, and not simply address it while placed an emphasis on abstinence before marriage. Shifting the norm from viewing sex as mysterious and shameful to a topic around which teenagers can engage in meaningful dialogue would hopefully have the effect of lifting the label off of sexually active individuals (4). As a result, individuals would have more accessible information on safe sexual activity.

CONCLUSION

The threat of HIV/AIDS is not a peripheral issue to this country’s youth. However, various policies persist in the South and other regions of the country that pose a serious threat to the AIDS response. Criminalization of HIV transmission, restrictions on syringe exchange programs, and lack of access to safe sex information are but a few examples of such challenges. These attempts at prevention the spread of the HIV/AIDS have only worked to fuel the epidemic, as evidenced by the disproportionate number of cases in the South. Various social theories can be used to examine as to why these interventions have been unsuccessful. If policymakers are to make an impact in their goal of prevention, they will need to reconsider the theories underlying their interventions. Ensuring that injection drug users and various segments of our nation’s youth are empowered to access comprehensive and appropriate packages of HIV prevention, treatment, and support services is essential to the fight against HIV/AIDS.

REFERENCES

1. Human Rights Watch. Southern Policies Fuel HIV Epidemic: Outdated Approaches, Ineffective Strategies, Punitive Laws at Nation’s HIV Epicenter. 26 November 2010. New York. http://www.hrw.org/en/news/2010/11/26/us-southern-policies-fuel-hiv-epidemic

2.Human Rights Watch. Southern Exposure: Human Rights and HIV in the Southern United States. Human Rights Watch. November 2010.

3.Aschengrau, A.; Seage, G. Essentials of Epidemiology in Public Health. Jones & Barlett Learning. June 2007.

4.Siegel, M. “Group Level Models”. Boston University School of Public Health, Lecture Notes. 28 October 2010.

5. United States General Accounting Office. Ryan White Care Act of 1990: Opportunities to Enhance Funding Equity. November 1995.

6.Human Rights Watch. Injecting Reason: Human Rights and HIV Prevention for Drug Users. New York. September 2003. http://www.hrw.org/en/node/12269/section/1

7.Siegel, M. “Traditional Individual Level Models.” Boston University School of Public Health, Lecture Notes. 7 October 2010.

8.Kaiser Family Foundation. HIV/AIDS Policy Fact Sheet. September 2009.

9.Kay, J.; Jackson, A. “How Abstinence-Only Programs Harm Women and Girls”. Sexuality and Family Rights Legal Momentum, Advancing Women’s Rights. 2008.

10. Kornman, A. “A Critique of the Abstinence-Only Approach: A Consideration of Adolescent Decisional Development and Democratic Sexual Citizenship”. University of Pittsburgh. 2008.

11. Harding, D. “Take Action for Comprehensive Sex Ed Tomorrow!” 8 February 2010. http://www.progressohio.org/page/community/post/daveharding/CXzH

12. Siegel, M. “Labeling & Stigma Theory”. Boston University School of Public Health. 2 December 2010.