Determining What Puts People At Risk for HIV Infection: CDC's Role in Prevention Research

Giving Communities the Tools They Need To Fight HIV

Knowing the who, what, when, where, why, and how of HIV infection risks is a prerequisite to developing effective prevention programs. (For information on CDC's surveillance systems, see "How Does CDC Track HIV Infection and AIDS?," at the CDC press office and through the National AIDS Clearinghouse database.) CDC conducts and sponsors surveillance, epidemiology and behavioral research to answer those questions and then gets the answers to communities, so they can develop and deliver effective local HIV prevention programming.

CDC's behavioral research activities range from large-scale, population-based tracking studies of sexual risk behaviors to targeted research investigating the internal and external determinants of risk behaviors among specific high-risk groups. Activities also include intervention evaluation to learn more about what works and how programs can be improved.

Biomedical research, including natural history research is also vital to evaluate promising prevention methods such as microbicides, the effect of STD treatment on HIV acquisition, and other biologic prevention tools. And CDC examines the integration of behavioral and biomedical solutions, conducting research into people's willingness and ability to adopt new prevention methods and how to increase their adoption.

CDC disseminates prevention research results to the scientific and academic communities; federal, state, and local public health infrastructure; and directly to community-based nongovernmental organizations (NGOs) serving populations at risk. CDC uses prevention research results to develope guidelines and public health policy. Additionally, HIV Prevention Community Planning groups are both a major recipient and a major distributor of prevention research findings and an integral part of the diffusion of innovative and effective prevention techniques across the U.S. (For more information on HIV Prevention Community Planning, see the companion fact sheet.) CDC also provides technical assistance to all these groups in applying research findings to HIV prevention programs.

CDC scientists will be presenting findings from CDC-sponsored prevention research in Vancouver. Following are highlights of research focused on specific populations:

Youth

Family Adolescent Risk Behavior and Communications Study

Half of all new HIV infections in the U.S. are thought to be among people under 25, and the majority of them are infected sexually. More information is needed about the range of adolescent sexual behavior to help develop interventions that are targeted to young people, work within the context of adolescent sexual behavior, and focus on individual, social, and community-level change.

• To better understand adolescent sexual behaviors and the impact of selected family, social, and cultural factors on those behaviors, CDC researchers collected information from approximately 1,000 mothers and their adolescents 14 to 16 years old recruited from public high schools in San Juan, Puerto Rico; Montgomery, Alabama; and Bronx, New York.

• The researchers learned that the traditional dichotomy between "sexually active" and "not sexually active" masks important behavioral intentions and sexual practices. Even adolescents who might traditionally be defined as not sexually active are engaging in or intend to engage in a range of sexual behaviors that could place them at risk for HIV infection, and these differences must be taken into account as HIV prevention programs are developed and implemented.

• The researchers also looked more closely at adolescent females in the study group and gathered information about age of first sexual partner, pregnancy history, and HIV risk behaviors. They found that girls whose first-time voluntary sexual partner was older (ranging from 3 to 21 years older) were significantly different than those whose first partner was the same age. Girls whose first partners were older had sex at an earlier age, were significantly less likely to use condoms, and were far more likely to report a history of pregnancy. Research has shown older sex partners present a greater risk for HIV transmission because they are more likely to have had multiple partners and to have had more varied sexual and drug use experiences. Power differences are greater between older and young partners, likely contributing to riskier behaviors young women report with older partners.

Women

The Prevention of HIV in Women and Infants Project

The Prevention of HIV in Women and Infants Demonstration Project (WIDP) is a community-level behavioral intervention research project underway in five sites across the United States to better understand the social and individual factors that influence women's behaviors regarding condom and contraceptive use, and thus understand how to best design and deliver community-wide interventions that advance women along the continuum of behavior change. The target population for this research is young women (age 15 to 34) at high risk for STD/HIV infection and unintended pregnancy.

• The project has shown that community mobilization can be fostered by using a consistent model for implementation, monitoring, and evaluation and that community involvement varies in time, intensity, and commitment throughout the life of an intervention. Additionally, community-level intervention efforts can be maximized by the use of "gatekeepers" and "stakeholders" as intervention change agents.

Women in Group Support

• The WINGS project is a three-site study funded through the Association of Schools of Public Health (ASPH) to evaluate the effectiveness of small-group interventions for women at high risk for acquiring HIV or other STDs. The six-session intervention focuses on skills-building to reduce risk behavior within the context of ongoing relationships. Structured groups are followed by drop-in sessions that serve as boosters to the behavioral change initiated in the first six sessions.

• The sites are recruiting women who are 18 years of age and older (or emancipated 17-year-olds) who are currently sexually active and have at least one risk factor for STD/HIV, but are HIV negative. Women will be recruited from a variety of sources including STD clinics, teen clinics, and correctional settings, and through projects targeting injecting drug users.

Research on Female-Controlled Prevention Methods

• The alarming rise in HIV infections and AIDS cases among women lends urgency to the search for female-controlled barrier methods -- both mechanical and chemical -- to prevent infections with HIV and other STDs, as well as unplanned pregnancy. CDC has a broad array of behavioral and biomedical research on female HIV/STD prevention methods. For example, behavioral researchers are examining the determinants of female condom use; the effectiveness of hierarchical prevention messages that place women within a framework of prevention choices, from safest (abstinence) to safer (using a condom with nonmain partners) to less safe (using spermicide); and how women communicate about sex and sexual risk reduction. Among the biomedical research being conducted are studies of HIV in cervicovaginal secretions; HIV infectivity by contraceptive method; clinical trials of microbicide-containing vaginal gel; and the efficacy of the female condom.

Gay and Bisexual Men

Young Men's Survey

• The Young Men's Survey (YMS) is multi-stage probability survey of the prevalence and determinants of HIV and related risk behaviors among 15- to 22-year-old men who have sex with men (MSM) in six urban counties across the United States. Preliminary YMS data indicate that HIV prevalence is very high among these young MSM compared with general populations of U.S. youth. This high HIV prevalence and the co-existing prevalence of unprotected anal sex is alarming, and shows that prevention programs must intensify efforts to target and reach young MSM and to change their risk behavior.

The Young African-American Men's Study

• This 2-year formative study seeks to describe the social contexts in which young African-American men have sex with other men; to define social, cultural, and psychological influences on participation in risky sex; and to identify community partners and resources for the subsequent planning, delivery, and evaluation of a community-based HIV intervention for this population.

• Preliminary findings suggest several common themes: (1) the relevance of low self-esteem to risky sexual behavior; (2) the profound stigmatization of homosexuality in the black community; (3) the importance of the church in black communities and, by implication, in interventions designed with and for black communities; and (4) the prevalence of HIV/AIDS-specific myths among young MSM.

Injection Drug Users (IDUs)

Epidemiologic Studies of HIV Infection Among Drug Users

• Two studies are examining the prevalence, incidence, and risk factors for HIV infection among drug users: the Collaborative Injection Drug Users Study (CIDUS) and the Multicenter Study of Crack Cocaine and HIV Infection. CIDUS has enrolled more than 3,000 injection drug users in seven cities who were not in substance abuse treatment and is re-enrolling a majority in follow-up studies. The Crack Cocaine Study enrolled more than 2,000 street-recruited crack smokers and nonsmokers from the streets of inner-city communities and recruited about half of them for a follow-up study.

The Work Ahead

Prevention research will continue to play an integral role in the planning, implementing, and evaluating HIV prevention programs. CDC must continue to carry out behavioral research to better understand complex issues related to risk behaviors in diverse populations as a basis for developing behavioral interventions. As new biomedical HIV prevention tools are developed, innovative approaches will be necessary to evaluate the safety and efficacy of these tools and practical ways of implementing in diverse populations and circumstances. As HIV treatment options are refined, early knowledge of HIV status will become more and more important, and CDC will work to promote widespread testing and access to treatment. CDC will continue to provide technical assistance, facilitate partnerships at the local level and involve representatives of affected communities in all areas of HIV prevention research..

Prevention Research Presentations in Vancouver

Case-Control Study of HIV Seroconversion in Health Care Workers after Percutaneous Exposure to HIV-infected Blood, Implications for Postexposure Management, David Bell.

Five-Year Trends in HIV Risk Behaviors Among Youth, Janet L. Collins (oral)

The AIDS Community Demonstration Projects: A Successful Multi-Site Community-Level Behavioral Intervention, Martin Fishbein.

Condom Carrying and its Relationship to Condom Use Among High Risk Populations, Carolyn Guenther-Gray.

Tuberculosis (TB) Transmission among AIDS Patients in Puerto Rico, Karen A. Hennessey.

Rapid Decline In Sexually Transmitted Disease Prevalence Among Brothel-based Sex Workers In La Paz, Bolivia: The Experience Of Proyecto Contra Sida, 1992-1995, William C. Levine.

Adolescent Sexual Experience: A New Typology, Kim S. Miller.

Depressive Symptoms and Coping Strategies Among HIV-infected and HIV-Uninfected Women in Four Urban Centers, Jan Moore.

Genetic Diversity of HIV-1 in Thailand, 1994-5, Shambavi Subbarao.

Heterogeneity of Heterosexual Transmission: The Role of Other STDs, Judith Wasserheit.

Poster

The Impact of Street Outreach for HIV Prevention in Five High Risk Populations, John Anderson.

Evaluating School-Based HIV/AIDS Education Efforts: A Systematic Approach to Improving Program Quality, Stephen W. Banspach.

Randomized Controlled Trial of Intensive Group Counseling to Reduce Risk Behaviors in High-Risk STD Clinic Patients, Bernard Branson.

Is Prevention Research Reaching Front Line Prevention Programs?: A Descriptive Study from San Francisco, Amy DeGroff.

A Pilot Study of Risk Behaviors and Condom Use among Incarcerated Adolescents, USA, Juarlyn Gaiter.

Association of Penicillin Mass Treatment Program with Sexually Transmitted Diseases among Female Sex Workers in Indonesia, M. Riduan Joesoef.

Incidence Trends in AIDS-related Opportunistic Illnesses in Men Who Have Sex with Men and Injecting Drug Users, Jeffrey L. Jones.

Focus Group Themes that will Shape Participatory Social Marketing Interventions in Five Cities, May Kennedy.

Additional Sources of Care for STD Clinic Patients: Implications for HIV/STD Prevention

Efforts, Jean M. Lawrence.

HIV Prevalence, Risk Factors, and Predictors of Unprotected Sex Among Homeless and Runaway Youth in Four U.S. Communities, Duncan MacKellar.

Access to Sterile Needles in the Collaborative Injection Drug Users Studies (CIDUS), Edgar Monterroso.

Initiation of Sexual Intercourse: Ages and Trends, Ellen Sogolow.

HIV Prevention Programs for Gay and Bisexual Men of Color: A National Initiative, Laurence Tate.

HIV and Risk Behavior Prevalence Among Young Men who Have Sex with Men Sampled in Six Urban Counties in the U.S.A., Linda Valleroy.

HIV Prevention Programs: A Decade of American Experience, Gary West.

High Prevalence of Abnormal Vaginal Flora And Bacterial Vaginosis in Women With or at Risk For HIV Infection, Dora Warren.

Research to Classroom: Selecting and Disseminating Educational Programs that Reduce HIV Risk Behaviors Among Adolescents, Susan Wooley.