Journal of Primary Prevention 9 (1&2) Fall/Winter 1988.

Women and AIDS P r e v e n t i o n

JOANNE E. MANTELL, STEVEN P. SCHINKE and SHEILA H. AKABAS

A B S T R A C T : Many women are unaware of their potential risk of becoming infected with the human immunodeficiency virus (HIV), the virus presumed to cause AIDS. Other women are confused about what prophylactic measures to adopt to lower their susceptibility to infection. Moreover, the needs of women who do not inject drugs have been largely ignored in media and public information campaigns. Rising rates of AIDS infection among women underscore the need for targeted prevention efforts. In this paper, the risks of the spectrum of HIV-related disease, i.e., HIV seropositive, lymphadenopathy syndrome, AIDS-related complex or full-blown AIDS, for women are de- scribed. Methods of disease transmission, prevention means, and issues and barriers to adopting practices for reducing risk of exposure to and transmis- sion of the human immunodeficiency virus are reviewed. Finally, practice, research and policy initiatives for AIDS prevention are offered.

A commonly held myth is that Acquired Immunodeficiency S:~ndrome (AIDS) is a disease of gay men and drug addicts. In reality, AIDS is the leading cause of death among women aged 25-34 years in New York City (Kristal, New York City Department of Health, 1986). AIDS may ult imately become the primary cause of death among all women of childbearing age. Moreover, women are the primary source of human immunodeficiency virus (HIV) infection among newborns. Rising rates of HIV infection among women underscore the need for targeted prevention efforts. Prevention researchers and practitioners lack scientific guidelines based on established epidemiologic evidence for appropriately studying and serving the needs of women at risk for AIDS. Several questions are posed to guide thinking about planning and implementation of AIDS prevention programs for women.

This paper begins by describing the risk of HIV infection and related disease among women. HIV infection produces a spectrum of responses, which range from HIV seropositivity (infection but clinic- ally asymptomatic), persistent generalized lymphadenopathy (en- largement of lymph nodes), other AIDS-related complex (ARC)

Repr in t r e q u e s t s to: J o a n n e E. Mante l l , MS, MSPH, PhD. , Gay Men ' s H e a l t h Cris is , Box 274, 132 W e s t 24 th Street , New York, NY 10011.

18 © 1988 Gay Men's Health Crisis

J o a n n e E. Mante l l et al. 19

illnesses and symptoms (isolated cytopenias, viral infections, oral hairy leukoplakia, fever, night sweats, weight loss), to full-blown AIDS. The natural history of the disease is such that people with asymptomatic infection or ARC may not necessarily progress to developing frank AIDS. After discussing methods of HIV transmis- sion, AIDS prevention modalities and issues and barriers to adopting practices for reducing AIDS risks among women are presented: what types of heal th information should be disseminated, by what commu- nication media, to what target audiences? The paper closes with an agenda for AIDS prevention in practice, research and policy, with part icular attention to the questions of what obstacles are present to assuring that women act in a self-protective way in response to the AIDS health information, and how these obstacles can be overcome.

Risk of AIDS

The risks of women being infected with the human immunodeficiency virus (HIV) are drawing increased attention (Kinnier, 1986; Potter & Pritchard, 1986). Women have different absolute and relative risks than men for many diseases and disabilities and AIDS is no excep- tion. Of the more than 47,000 adult/adolescent cases of AIDS reported to the Centers for Disease Control (CDC) in the United States as of November 23, 1987, seven percent have occurred among women (CDC, 1987; Guinan & Hardy, 1987). Cases of women with AIDS have been reported in 43 states, the District of Columbia, three terri- tories and more than 70 countries (CDC, 1986). In the United States, 72% of the female cases are in Florida, New Jersey and New York. In New York City, the incidence of AIDS in women aged 2 5 - 4 4 years has risen from 0.7/100,000 in 1981 to 28/100,000 in 1986 (Chiasson, Fleisher, Walker, Petrus & Miller, 1987). In Europe, females have accounted for nine percent of all AIDS cases (World Heal th Organiza- tion [WHO], 1985). In central Africa and Haiti, however, AIDS strikes nearly equally among men and women (Kreiss, Koech, Plummer, Holmes, Lightfoote, Piot et al., 1986). Antibody test results from United States mili tary service applicants suggest that the infec- tion rate among women may be comparable to that among men. Between October 1985 through March 1986, the crude male:female seroprevalence ratio of applicants was 2.69 to 1; and in the six counties in the United States with the highest infection rates, the ratio was 1.21:1, which comes close to the 1:1 sex ratio observed in

20 Journal of Primary Prevention

Haiti and Central Africa (Burke, et al., 1987). Since 1983, the abso- lute number of women with AIDS in the United States has increased (Morgan & Curran, 1986), but the constant proportion of female AIDS cases to all AIDS cases has remained unchanged (Guinan & Hardy, 1987).

Seven thousand adults in the United States are expected to develop AIDS through heterosexual transmission by 1991. Heterosexual women are four times more likely to contract AIDS through hetero- sexual transmission than heterosexual men (Guinan & Hardy, 1987). The proportion of women with AIDS as a result of heterosexual contact with a person at risk for AIDS increased from 12% to 26% between 1982-86 (Guinan & Hardy, 1987), and by September 1987, jumped to thir ty percent. Some of this increase is due to improved case reporting over time and the expanded case definition of AIDS. Of the 1.5 million people who may be infected with HIV, of whom 105,000 are women, an estimated 30% will develop frank AIDS within five years, and 50% within seven years. By 1991, between 8.3% to 11.6% of all AIDS cases are expected to occur among women (Morgan & Curran, 1986). Increasing numbers of children are born infected with HIV as a result of maternal infection. Not all babies born to mothers with HIV infection, however, will be infected, and if infection should occur, symptoms usually develop by the time the child is six months old (Shannon & Ammaan, 1985). As of November 23, 1987, 682 children less than 13 years of age were afflicted with AIDS (CDC, 1987), and by 1991, 3,000 pediatric AIDS cases are ex- pected (Institute of Medicine, 1986).

The risks of HIV infection, ARC and AIDS are not distributed equally among all groups of women (CDC, 1985). The greatest propor- tion of AIDS cases occurs among black and Hispanic women (Bake- man, et al., 1986). Among all women with AIDS, blacks account for 51% and Hispanics account for 21%. Among black and Hispanic women, the cumulative incidence of AIDS is ten times higher than that of white women (CDC, 1986). About 90% of all children who acquired AIDS through perinatal transmission are black or Hispanic (CDC, 1986). Behavioral factors rather than demographic descriptors increase levels of risk of exposure to and transmission of HIV (Deuchar, 1984; DeVita, et al., 1985; Jemmet & Locke, 1984; Joseph, 1986).

The age distribution of women with AIDS differs from that of men. One-third of all female cases occur in women between the ages of 20 to 29 years (CDC, 1986). In contrast, 20% of the men with AIDS are

J o a n n e E. Mante l l et al. 21

in the 20-29-year age group. Seventy-nine percent of all female cases have occurred among women of childbearing age, between the ages of 13-39 (Guinan & Hardy, 1987). Moreover, some preliminary evi- dence suggests that there is a longer lag time between asymptomatic infection and development of clinical manifestations of disease among younger women and men than their older counterparts (Schultz, 1987).

Intravenous (IV) drug use is the primary source of HIV infection among women in the United States. Fifty-two percent of all women who contract AIDS are former or current intravenous drug users (IVDUs). HIV-infected women who use drugs have drug-related medical problems, such as endocarditis, cellulitis, and sexually- t ransmit ted diseases (STDs), that may suppress their bodies' immune systems, and hence, ability to fight off repeated bouts of opportunistic infections. In general, drug-dependent women are reported to experi- ence more medical problems and higher levels of stress than their male counterparts (Mondanaro, 1987).

Twenty-one percent of the female cases are reported to be a result of heterosexual contact with an infected person with AIDS, and six percent by heterosexual transmission, i.e., persons who were born in countries where heterosexual transmission has a major role (Guinan & Hardy, 1987). Of the women who acquired AIDS through hetero- sexual contact with a person at risk for AIDS, 67% were sex partners of IV drug users while 16% were sex partners of men who have sex

w i t h men (Guinan & Hardy, 1987). In New York City, contact with a male IV drug user accounted for 84% of the cases of heterosexual transmission among women with AIDS (Chiasson, Fleisher, Walker, Petrus, & Miller, 1987). Padian (1987) has shown tha t HIV sero- prevalence among female sex partners of infected men is a function of the risk group of the index case (male partner); specifically, female sex partners of hemophiliacs, men infected as a result of transfusions and bisexual men have lower rates of infection than sex partners of IV drug users, Hait ians and Africans. A recent epidemiologic study has shown that 42% of the female partners of male IV drug users were seropositive compared to 22% who were sex partners of infected bisexual men (Padian, Marquis, Francis, Anderson, Rutherford, O'Malley, & Winkelstein, 1987). Several hypotheses have been offered to account for this greater infectivity and susceptibility, including more frequent sexual activity and the prevalence of co- factors (Padian, 1987).

Another ten percent of all women have contracted AIDS as a result

22 Journal of Primary Prevention

of blood transfusions. The prevalence of HIV infection among female sex partners of hemophiliacs is increasing (Goedart, Eyster, & Big- gar, 1987). Between ten percent to 13% of the female sex partners of hemophiliacs have been found to be infected (CDC, 1987). The re- maining 11% of women with AIDS have no known risk factors.

Female prostitutes have been singled out as major vectors of HIV transmission. However, IV drug use rather than prostitution per se, is a primary risk factor for HIV infection among female prostitutes in the United States. Hal f of the prostitutes interviewed in a seven city survey indicated histories of IV drug use (CDC, 1987). The male partners of prostitutes who share needles and syringes place them- selves at risk for contracting HIV when they do not use condoms (CDC, 1987). HIV infection rates among female prostitutes vary nationwide. A recent seroprevalence survey of street prostitutes in seven cities (CDC, 1987) indicated that overall 12% were infected; women in northern New Jersey had the highest rate of infection (57%) while those in Miami had the second highest rate (18.7%). In the Miami area, seroprevalence was higher among street prostitutes in an inner city economically depressed area (41%) compared to women who provided escort services in a middle-class urban area (23%) and those referred for HIV screening from the county jail system (0%) (Fischl, Dickinson, Scott, Klimas, Fletcher & Parks, 1987). Less than five percent of the prostitutes surveyed in Los Angeles, Colorado Springs and Atlanta tested positive, and none of the women in Las Vegas were seropositive. As the seropositivity rates of the prostitutes mirror the proportion of women diagnosed with AIDS cumulat ively in these seven cities, their risk of acquiring AIDS is similar to those of other women in the targeted geographic areas (CDC, 1987). Seroprevalence was lower in women who used condoms regularly (Darrow, Cohen, French, Gill, Sikes, Witte, et al., 1987). Interestingly, prostitutes in San Francisco used condoms regularly with customers, but were less likely to use condoms during vaginal intercourse with a boyfriend or husband (Cohen, et al., 1987).

The seropositivity rate among Central African female prostitutes ranges from 55% to 80%, and among female prostitutes of the Ivory Coast, 32.8% were reported to be positive for HIV (Kreiss, et al., 1986; Clumeck, et al. 1985; Piot, Plummer, Rey, Ngugi, Rouzioux, Ndinya-Achola, et al., 1987). In Western Europe, rates have varied from zero to 88% (CDC, 1987). This high rate of seropositivity among prostitutes, coupled with predominant heterosexual transmission, suggests that prostitution may be a significant factor in t ransmitt ing

Joanne E. Mantell et al. 23

HIV in Africa. It has been suggested that genital circumcision and infibulation, which often causes bleeding during sexual intercourse, may increase the risk of HIV infection among women in Central Africa (Alexander, 1987). In addition, there is increasing evidence that sexually-transmitted diseases, which are common among Afri- can prostitutes~ may facilitate transmission of HIV. The use of unsterile needles in the t rea tment of sexually-transmitted diseases is also believed to play an instrumental role in the development of HIV infection among this group of women.

AIDS manifests itself differently in women than men. Women rarely develop Kaposi's sarcoma. Recent data suggest that women may take longer to develop clinical symptoms of ARC or AIDS after being infected with HIV (Padian, 1987). Moreover, convergent data show that women with AIDS are dying more rapidly than their male counterparts (Rothenberg, Woelfel, Stoneburner, Milberg, Parker & Truman, 1987; Gido & Gaunay, 1987). This gender differential in mortal i ty rates, and hence, survival, may be at tr ibuted to biological, social or psychological factors.

Methods of Transmiss ion

AIDS is a human retrovirus that is t ransmit ted by body fluids, in- cluding semen and blood. Transmission vehicles encompass intimate sexual contacts, sharing of contaminated needles and drug parapher- nalia and transfusion of contaminated blood or blood products. Verti- cal transmission occurs, either congenital or perinatal, from infected women, to the fetus or newborn infant during pregnancy, labor or delivery or shortly after birth, and possibly through breast feeding (Pahwa, et al., 1986; CDC, 1985; Ziegler, et al., 1985). The risk of perinatal transmission may vary by duration of infection, stage of infection and level of viremia in the mother. The rate of vertical HIV transmission from symptomless carriers, mechanism of vertical transmission and the stage of pregnancy which poses the highest risk for transmission are not well understood (Chiodo, 1986; Hopkins, 1986; Kelly, Hallett , Saeed, Morgan, Levinsky, & Strobel, 1987). Research is currently underway to distinguish among intrauterine, natal and post-natal transmission.

HIV infection can also be t ransmit ted to women who undergo artificial insemination with donor (AID) semen if the donor is sero- positive. Four women have been infected with HIV as a result of in-

24 Journal of Primary Prevention

fected semen through AID, but to date, no cases of AIDS have been reported (Stewart, et al., 1985). The virus has been isolated in the female genital tract, including cervical secretions and menstrual blood, as well (Vogt, et al., 1986, 1987; Wofsy, et al., 1986; Chase & Stipp, 1986).

The efficiency of female-to-male transmission of HIV infection in the United States has been disputed by some researchers (Redfield, et al., 1985; Schultz, et al., 1986; Haverkos & Edelman, 1985; CDC, 1985; Pearce, 1986; Calabrese & Gopalakrishna, 1986). Although experience with other sexually-transmitted diseases like gonorrhea and hepatitis B indicates bidirectional transmission, to date, female- to-male sexual transmission of HIV in the United States is far less common than male-to-female transmission. The reasons for these differences are not clear and require further elucidation. Recent data indicate a relationship between the number of episodes of unprotected sex and transmission, and the differential impact of unprotected anal and vaginal practices on risk of transmission. Padian, Marquis, Francis, and colleagues (1987) recently reported that 23% of 97 women, 57% of whom were sexual partners of bisexual men, became infected with HIV. After a single episode of unprotected sex with an infected partner, the odds for a woman to become infected were about 1 in 1,000. Seropositive women were 4.6 times more likely than seronegative women to have had more than 100 sexual contacts with an infected partner. For women who engaged in anal sex without a condom in addition to vaginal or oral intercourse, the rate was almost 2.3 times higher than for those who did not practice anal sex.

A study of 45 heterosexual partners of adults with AIDS in Florida, where the seroconversion rate for male spouses (42%) was similar to that for female spouses (38%), strengthens the case for efficient bidirectional heterosexual transmission (Fischl, Dickinson, Scott, Klimas, Fletcher, & Parks, 1987). In Africa and Haiti, bidirectional transmission is prevalent. There have been no definitive cases of female-to-female sexual transmission; a suspected but unsub- stantiated case, however, has been recently reported in a lesbian without any recognized risk factors (Marmor, Weiss, Lyden, Weiss, Saxinger, Spira, et al., 1986).

Prevention Strategies

Despite the federal government 's slow start and pervasive concern with traditionally taboo subjects such as homosexuality, premarital

Joanne E. Mantel l et al. 25

sex and illicit drug practices, the political climate appears to be shift- ing toward greater public information sharing. The Surgeon General Dr. C. Everett Koop's s tatement (1986) is evidence of this shift.

Many people, expecially our youth, are not receiving information that is vital to their future health and well-being because of our reticence in dealing with the subjects of sex, sexual practices and homosexuality. This silence must end. We can no longer afford to sidestep frank, open discussions about sexual practices.. . Every person can reduce the risk of exposure to the AIDS virus through preventive measures that are simple, straightforward, and effective. However, if people are to follow these recommended measures--to act responsibly to protect themselves and others--they must be informed about them . . . We have made some strides in dispelling rumors and educating the public, but until every adult and adolescent is informed and knowledgeable about this disease, our job of educating will not be done.

The Insti tute of Medicine (1986) has called for two billion dollars for coordinated public health education and research by 1991.

Publ ic Heal th Measures

The development of a vaccine to control the AIDS epidemic is not on the horizon. The key to curtailing the further spread of HIV infection and, therefore, AIDS, lies in the implementation of prevention and control measures. One aspect of primary prevention, general public heal th control measures, has been effective and should be main- tained. Examples of such prevention strategies include mandatory screening of the nation's blood supply and screening of blood and sperm bank donors.

HIV antibody testing is another general public health control measure, particularly relevant to women who are pregnant or con- templating pregnancy. The appropriate uses of such testing are widely debated. While test results cannot predict who will develop clinical disease, testing can be of medical utility. Testing is being increasingly used by private physicians as part of the care plan for high-risk patients and those with AIDS as well as in STD, pre-natal and tuberculosis clinics. Knowledge of a patient's antibody status can facilitate physician management of HIV-related disorders and en- hance patients' t rea tment options. For example, patients known to be infected but asymptomatic might be treated aggressively with aerosol pentamidine to prevent the onset of lethal opportunistic infections.

26 Journal of Primary Prevention

The administration of immuno-stimulating drugs such as ampligen to maintain the immune system intact may prolong survival of a pa- t ient with HIV infection. Knowledge of antibody status can also help detect tuberculosis in patients who are infected with HIV. For pregnant women, disclosure of antibody status may lead to better management of the pregnancy.

Testing must take place, however, only on a voluntary basis with informed consent, supportive psychological pre- and post-test counsel- ing, risk assessment and assurances of anonymity. Seropositive pregnant women are at increased risk for pregnancy complications, and among pregnant women with AIDS, there is an increased risk of perinatal mortal i ty (McDonald, 1986). A pregnant woman infected with HIV has about a 40%-50% chance of passing on the virus through the placenta to the fetus (Selwyn, Schoenbaum, Feingold, Mayers, DaVenny, Rogers, et al., 1987; Blanche, Rouzioux, Veber, LeDiest, Mayaux, & Griscelli, 1987; Nzilambi, Ryder, Beherts, Francis, Bayende, Nelson, et al., 1987). Some data suggest that the risk of AIDS or ARC is greater in infants if the mother has clinical symptoms of HIV infection (Mok, DeRossi, Ades, Giaquinto, Grosch- Worner, & Peckham, 1987). The risk associated with transplacental infection, however, is inconclusive as the number of children born to HIV-infected mothers being followed from delivery have been rela- tively small.

AIDS poses a threat to the reproductive rights of women. The CDC has recommended that women who are HIV seropositive consider postponing pregnancy until there are more scientific data about transmission of the virus from mother to child or the woman is no longer at risk for acquiring the virus. There is fear that the medical profession will exert powers of social control and usurp women's rights to self-determination, especially over those women least capable of fighting back. For example, a recent study revealed that women of color, the unmarried and non-English speaking women were most likely to be subjected to court-ordered fetal life-saving obstetrical procedures (Kolder, Gallagher, & Parsons, 1987). With respect to AIDS, some are concerned that involuntary sterilization of infected women will be proposed, while others believe that involun- tary HIV antibody testing of certain high-risk groups would more likely be set in motion (Newman, 1987). The U.S. Surgeon General has voiced opposition to the mandatory HIV antibody testing of pregnant women on the grounds that it might drive women most in need away from prenatal care (San Francisco Chronicle, 1987).

J o a n n e E. Mante l l et al. 27

For women, the barrier to testing may be great, as a diagnosis of HIV infection is identified with promiscuity, homosexuality and substance abuse (Norwood, 1986). Women in high-risk groups should be counseled about the meaning of the test, risk of infection to the newborn and risk of disease to themselves to help them make in- formed choices about pregnancy. For pregnant women who test seropositive, counseling needs to center around decision making and the option of pregnancy termination. Women who choose not to have an abortion may require referral to high-risk prenatal clinics and psychosocial support services.

At the other end of the continuum are young women who are not yet sexually active. Preventive intervention efforts aimed at these women should begin in but not be limited to public and private schools. Additional venues for AIDS prevention among young women include neighborhood and community centers, housing projects and churches. Because of its particular appeal to young people, popular media of radio, television, motion pictures, and magazines should be incorporated into prevention campaigns. Parental and family based approaches to AIDS prevention can also be viable and effective.

To reduce their exposure to HIV, uninfected women need preven- tive intervention facts. On a community and political level, public morali ty and values may restrict the focus and content of writ ten educational materials and media messages about AIDS to the public. Materials targeted to the issues and dangers unique to women need to be developed within the context of public perceptions concerning sexually-explicit messages and information on the illegal behavior involved in intravenous drug abuse. Prevention programs should also have a counseling component to dispel myths surrounding AIDS and decrease public anxiety about its contagiousness.

Lifestyle and Individual Behavioral Practices

Lifestyle practices are the strongest predictors of risk exposure for HIV infection. Clinicians and researchers interested in AIDS preven- tion can profitably apply the concept of risk levels to guide lifestyle intervention efforts to help people reduce high-risk AIDS practices. Women are not homogeneous with respect to how they meet men nor how they practice sexual behaviors. Women who have sex exclusively with men and those who have sex with men and women are likely to have overlapping concerns about AIDS prophylaxis. But women who

28 Journal of Primary Prevention

have sex exclusively with women are at lowest risk for HIV infection and have different needs. Nevertheless, women who identify as lesbi- ans may have been heterosexually active with gay and bisexual men in the past and therefore may be at risk (Schneider, 1986). Because only a small group of lesbians have acquired AIDS as a result of IV drug use or sex with an infected man, it is difficult to generalize about their comparative risk of HIV infection.

High-risk lifestyles may include having sex in exchange for money or drugs, having unprotected sex with multiple partners, having unprotected sexual contact with bisexual men, IV drug users, or other men at increased risk for HIV infection, or sharing dirty needles or "works." Prevention of IV drug abuse transmission is essential as it is a major conduit for spreading the epidemic to the pediatric and adult nondrug-using heterosexual populations. Sexual contact with part- ners with unknown drug and sexual histories elevates women's risk for HIV infection. Monogamous relationships, or in their absence, regular use of condoms, and curtai lment of substance abuse consti- tute individual AIDS preventive behaviors.

Heterosexuals are being urged to follow the lead of gay men and practice safer sex. Prophylactics presently offer the best hope of controlling sexual transmission of AIDS. A recent laboratory study has shown that the AIDS virus cannot pass through latex condom membranes (Conant, et al., 1986). While condoms are not foolproof, the use of nonoxynol-9, a water-based spermicide, in conjunction with condoms, is believed to add a layer of protection against HIV infiltra- tion (Kelly & St. Lawrence, 1987; Scesney, Gantz, & Sullivan, 1987). Statistically significant differences in seropositivity rates among prosti tutes in Zaire who used condoms with partners (none of eight) compared to those who used such protection less frequently (26 of 77) also demonstrate support for the efficacy of condoms in reducing HIV transmission through sexual intercourse (Mann, et. al., 1987). One caveat is in order, however. While condoms should minimize the risk of spreading HIV, they do not guarantee absolute protection. A ten percent failure rate of condoms in preventing pregnancy has been frequently cited to support the latter, but it remains unknown whether such failure is due to misuse or nonuse (Gruson, 1987). Women need instruction and behavioral rehearsal to ensure proper condom use.

"The day of the condom has returned," Dr. Stephen Joseph, New York City's Heal th Commissioner, has recently noted (Eckholm, 1986). Indeed, from 1980 to 1986, sales for condoms rose from $182

Joanne E. Mantell et al. 29

million to a projected $338 million this year. Between 35% to 50% of the est imated 800 million condoms sold per year are purchased by women (Lipman, 1986; Kantrowitz, 1986). Condom manufacturers are market ing condoms to appeal to women, and pharmacies are placing them alongside feminine hygiene products (Greenfield, 1986). Vending machines that sell condoms are being placed in restaurants, bars and college campuses (Weisberg, 1987). With the mounting condom promotion campaigns, both health professionals and the condom industry must be careful not to oversell the commodity of condoms as an HIV prophylaxis.

While providing women with the evidence that supports condom use is essential, women may also require social skills training to enable them to negotiate any kind of safer sex practice with partners. Skills training also needs to be directed toward helping women overcome any embarassment they may have in asking a new male par tner about his sexual practices (Clark, et al., 1986). With these skills, women may feel empowered and begin to question their part- ners about their drug and sexual histories. Unfortunately, informa- tion about current partners ' backgrounds may be futile in protecting women who have been exposed to the HIV in the past, particularly with a five to seven year incubation period between exposure and emergence of clinical manifestations of disease. With respect to lovemaking, heterosexual women must learn new sexual repertoires that incorporate condom use.

Because many women have not perceived themselves at risk for AIDS as well as other sexually-transmitted diseases, the notion of telling adult women and teenagers to carry condoms may not be well received. Moreover denial of personal risk may override the taking of self-protective measures. Behavioral training which emphasizes the value of personal and moral responsibilities for practicing pr imary prevention of AIDS is essential for instilling a sense of personal control and self-efficacy.

Cultural barriers may impede the adoption of condom use. For instance, women may believe that condoms remove the spontaneity from sexual activity. Condoms may also be. perceived as threatening to men. We must recognize that teaching women how to make be- havioral changes may incite domestic violence. Latino gender roles make it difficult for Latinas to suggest having protected sex with a par tner (Worth & Rodriguez, 1987). Condoms may be seen as inter- fering with desired reproductive goals, and thus dissonant with the cultural ideals of virility and womanhood. Moreover, unmarr ied

30 Journal of Primary Prevention

Latina women who carry around condoms or insist that they be used may be seen as having "been around" or "loose" by their sexual partners and therefore, unattractive. Protection for women requires a change in the behavior of men. As such, a male partner's support may serve as an essential catalyst for safer sexual practices.

Religious beliefs and economic constraints may also limit the use of condoms. Strong and persistent advocacy efforts interpreting the pub- lic's "right to know" how to protect themselves from exposure to the AIDS virus will be necessary in many communities. The Roman Catholic Archdiocese of Los Angeles, for example, prohibited AIDS prevention activities that condone condom use for Hispanic parish audiences (The New York Times, 1986). Media campaigns which at tempt to legitimate condom use for AIDS prophylaxis have already been censored. Many television stations throughout the country have refused to air public service announcements that urge condom use for birth control or HIV prophylaxis. The manufacturing firm, Ansell America, has had difficulty promoting the use of its product, Life- s ty les condoms, with the ad "I enjoy sex, but I'm not ready to die for it" (Rigg, 1986) in the mainstream media.

Sexually active women who are sex partners of men with histories of IV drug use or having sex with other men and women who share needles and syringes are at risk for acquiring and transmitt ing HIV infection, and thus are priority targets for preventive interventions. The nondrug-using female sex partner of a male IV drug user who is unaware of her partner 's drug use history and other women who unknowingly have sex with infected men represent a population with hidden risk for acquiring HIV infection (Mondanaro, 1987).

Prevention of AIDS requires behavior changes around IV drug use as well. The prevention and t reatment of IV drug use are extremely complex, and beyond the scope of this paper. The shortage of drug t reatment program slots, particularly in New York City, however, adds to the difficulty of targeting AIDS prevention initiatives toward women who use drugs or are sex partners of IV drug users. To reduce the spread of AIDS, behavioral changes among drug users are neces- sary (Joseph, 1986). Obviously, the first target of prevention should be preventing IV drug use. On a policy level, through the legislative process, states could make clean needles and syringes widely avail- able. Failing that, women should not share dirty needles and drug paraphernalia. The low income and educational levels and sexual oppression of women IV drug users struggling with economic and psychological survival, however, may cloud their perceptions of the salience of AIDS prevention.

Joanne E. Mantell et al. 31

In all instances, women should avoid having unprotected sex with IV drug-using men. Similarly, women who use drugs should protect their sexual partners. Unfortunately, drug-dependent women may be reluctant to change their sexual practices with established partners out of fear of rejection (Mondonaro, 1987). Behavioral science re- search on smoking, obesity and hypertension demonstrates that change in lifestyle is a complex process. Different barriers can deter actual and/or sustained behavioral change. Information alone is clearly a necessary, but insufficient prevention strategy to change behavior. Commitment requires overcoming the usual denial charac- teristic of many groups that knowingly pursue self-destructive behav- ior. Commitment also requires overcoming cultural forces that cause women to feel unable or unwilling to assert their right to control their lives. Moveover, a supportive social network may be useful in promoting and maintaining behavioral change.

Roles for P r o f e s s i o n a l s

Health behavior research suggests that behavioral change will occur only when the individual is presented with acceptable alternatives to the deleterious practices. Low-risk sexual alternatives include hugging, petting, mutual masturbation, fantasy-sharing, frottage (body rubbing) and erotic massage. Women who have multiple sexual encounters with men may pursue this lifestyle, like gay men, out of need for physical intimacy and tension-reduction (Conant, et al., 1986). For IV drug users, the substitute for drug use may be enroll- ment in a methadone maintenance program. Thus, AIDS prevention programs for women need to recommend low-risk practices palatable to the target audience.

All these efforts require an informed provider community. AIDS prevention requires education of human service professionals who are in contact with women in the natural environment. These settings include well-baby clinics, sexually-transmitted disease clinics, Women, Infant and Children (WIC) programs, public health clinics, family planning and prenatal clinics, workplace employee assistance programs, homes for runaways and the homeless, rape crisis centers, the courts and prisons. Heretofore, many of these professional had not initiated discussion of sexual and drug practices as part of their inter- action with patients/clients. With the threat of AIDS looming, they need to take responsibility for conveying information to their clients.

Priority targeting and tailoring of education to different segments

32 Journal of Primary Prevention

of the population are essential for effective planning of educational strategies and for appropriate content of health messages and risk- reduction recommendations. Understanding the varied barriers to behavioral change includes understanding and responding to specific groups of women. Such a campaign should at tempt to reach all women before they become sexually active, and throughout the life span. School, workplaces, supermarkets, churches and other norma- tive life space settings are the obvious sites for such a campaign. Men certainly cannot be neglected as an essential link in the HIV trans- mission chain. Targeting efforts directed toward men can take the form of public health, individual, and mass media campaigns. These efforts, in turn, can nonexclusively help men reduce their risk and their partners ' risk for HIV infection.

The high prevalence of HIV infection among women of color un- derscores the need for a multiethnic and class approach to risk-reduc- tion. The materials developed should be culturally and class-sensitive. Information should be disseminated through appropriate channels, both health provider sites and public venues. The significance of churches and indigenous leaders in minority communities makes it essential tha t they be included in any outreach efforts. Clearly, increased funds are needed for health education. Failure of govern- ment to allocate adequate funds for risk-reduction education and research impedes health professionals' ability to provide prevention services to the general public and individuals who practice high-risk behaviors.

Discuss ion

The impact of the AIDS epidemic on women raises a number of criti- cal issues for preventive intervention practice, research and policy. From a practice vantage, a concerted drive to develop preventive counseling programs for women is required. Feminist organizations, heal th professionals, business groups and community groups need to assume a catalytic role and encourage health and social service agencies to provide basic psychosocial support and preventive inter- vention services. Without such advocacy and public support, women's ownership of risk for AIDS will continue to be denied. Public inter- vention for AIDS prevention advocacy entails pressuring private and governmental human service providers to effect changes in policies and resource allocation specific to women's issues.

Research on the impact of AIDS on women is needed. Little is

Joanne E. Mantell et al. 33

known about the prevalence of high-risk behaviors among heterosex- ual women who do not use IV drugs or other substances. The number of women with multiple heterosexual partners and bisexual male partners is unknown. Similarly, other than seroprevalence studies of mili tary recruits and applicants, prostitutes, and high-risk heterosex- ual women (Cohen, et al., 1986; Burke, et al., 1987), the extent of HIV infection in women is not well documented. Thus, longitudinal seroprevalence cohort studies of women are warranted. In the fall of 1987, the CDC launched a series of blind seroprevalence studies throughout the country. Recent data from one New York City Depart- ment of Heal th anonymous al ternate HIV counseling and test site indicated that 40% of the people tested were women considered to be at low risk as none were found to be seropositive (Sullivan, 1987).

Little is known about the impact of HIV antibody testing on the behavior of women. In fact, there is uncertainty as to whether knowl- edge of test results, pre-post-test counseling per se, or the additive/in- teractive effects of counseling plus knowledge of test outcome produce behavioral change. Moreover, the quality of counseling interventions has not been empirically examined. Thus, the benefits of counseling and HIV antibody screening in effecting behavioral change among women demand thorough investigation.

Presently, no consensus exists regarding safer sex guidelines for women. This consensus can only be reached through sound scientific research. That research, in turn, ought to distinguish the AIDS prevention needs of women from those of men. For example, the efficacy of latex dams in blocking transmission of HIV among women needs to be tested. The prophylactic ability of latex condoms should not be used to justify the HIV blocking effect of latex dams. More- over, we should not assume that behavioral change strategies proven successful with gay men will be effective for women.

Without sufficient financial .support for prevention services and research from the governmental and private sectors, the AIDS epi- demic will continue. Were it to escalate, this epidemic could threaten not only individuals but also society, ul t imately leading to significant costs and suffering.

To prevent the unchecked spread of HIV infection among women, the following recommendations are offered:

1. AIDS prevention efforts must be stepped up for women, especially women of color, because of the disproportionate number of cases among blacks and Hispanics.

2. AIDS risk-reduction messages need to be culturally and class-

34 Journal of Primary Prevention

sensitive, presented in the appropriate language and geared to the reading level of the target audience. These messages should be direct and refrain from moral proselytization.

3. There should be concerted outreach activities to educate high-risk women about the prevention of perinatal HIV trans- mission.

4. A massive, extensive AIDS educational program starting at an early age in the grade school and continuing straight through high school and college is essential.

5. AIDS education should take place within the context of the natural life space of people, such as churches, community centers, schools, bars, movie theaters, business and industry, health care institutions, public venues (billboards, subways/ buses, supermarkets, bodegas and restaurants, record stores and restrooms, inserts in mailings of public utility bills, and recreational channels and events (radio, television, "foto- novelas" and other comic books, sports events, etc.)

6. Women who use drugs should be encouraged to seek treat- ment. This may require innovative strategies, such as the coupon system piloted in New Jersey (Jackson & Rotkiewicz, 1987), to facilitate and prioritize entry into t reatment pro- grams. At the same time, available t reatment slots in states, such as New York, must be greatly augmented.

7. AIDS risk-reduction programs for women who use IV drugs must address, modes of sexual transmission and high-risk sexual practices as well as those related to drugs.

8. People who are or who have been sexually active with anyone who has or might have HIV-related disease should take maximum precautions and use condoms whenever having vaginal, anal or oral intercourse.

9. For high-risk women, pre- and post-test counseling and volun- tary HIV antibody testing on an anonymous and confidential basis can serve as prevention tools. Infected women can learn to take measures to prevent the spread of HIV to their unborn children and sex partners, and for the uninfected, counseling must tap health values and motivations that will help these women remain virus-free.

10. Education abou t other sexually-transmitted diseases (STDs) and women's health issues should be incorporated into AIDS prevention initiatives. Many women at risk for HIV infection are also at risk for STDs, pelvic inflammatory disease and ectopic pregnancies.

Joanne E. Mantell etal. 35

11. Continuous inservice education related to the impact of AIDS on women, children and families needs to be targeted to all health and human service providers.

This agenda will be unacceptable to those who believe that "any health information developed by the Federal government that will be used for education should encourage responsible sexual behavior - - based on fidelity, commitment, and maturity, placing sexuality within the context of marriage" (Bowen, 1987). We might wish this to be an adequate control measure, but it is not. Its stress on sexual abstinence until marriage fails to recognize the realities of human sexual behavior and ignores the sexual practices of youth, sexually- active single, divorced and widowed heterosexuals and especially gay people (Gay Men's Health Crisis, 1987). In the face of an acute health care crisis, personal values and prejudices about celibacy and monog- amy need to be overriden by sound public health policy.

In sum, the issues of HIV infection and AIDS for women a re very different than those for men. In a field where scientific information is changing rapidly, professionals concerned with prevention must keep abreast of empirical research that may change the shape, context or content of AIDS prevention programs. Though data and scientific knowledge on HIV-spectrum disorders among women are emerging, new and aggressive prevention research, policy and practice are warranted. These efforts ought to address the health and sociobe- havioral problems of AIDS for women, their children and sexual partners. AIDS is not only a health concern, but a highly-charged ethical and political issue centered around demands for mandatory HIV testing, confidentiality, balancing protection of the public's health and individual rights and monopolization of scarce resources.

Women may create their own barriers to AIDS prevention inter- vention. If the birth of a second generation of people with HIV infec- tion is to be prevented, then we must awaken women and correct distorted perceptions of immunity to AIDS. The semblance of shy- ness, "machismo," good looks and nice family background of a partner should not be equated with a negative antibody test. In the midst of a major epidemic that may ult imately become the plague of the twenti- eth century, aggressive at tempts must be made to educate those potentially at risk and the general public about prevention of AIDS among women. In addition, voluntary serologic testing which in- cludes counseling and risk-assessment components is essential. Though likely to be an unpopular public policy by some, proactive encouragement of delayed childbearing among infected women or

36 Journal of Primary Prevention

women at high risk until more is known about vertical transmission may be in the best interest of protecting the public's health. At the same time, we must recognize that this solution may not be accept- able to those with conflicting cultural prescriptions of womenhood and fertility goals (Wofsy, 1987). In the absence of any fool-proof preventive measures, the exercise of responsible sexual and drug practices is the only option.

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Preparation of this paper was supported in part by grants from the Centers for Disease Control (Cooperative Agreement No. U62/CCU2C1065-01), National Cancer Institute (CA29640), National Institute on Drug Abuse (DA03277), and National Insti- tute of Disability and Rehabilitation Research (G008535120).

The authors warmly thank Mark Ketcham, David Blaustein, Mark Alexander and Ken Anderson for their assistance in preparing the many drafts of this manuscript. The authors also appreciate the contributions of Steven Bowen, M.D., M.P.H., Deputy Director for AIDS, Gary West, M.P.A., Assistant to the Deputy Director for AIDS, Center for Prevention Services, The Centers for Disease Control, and Stephen Schultz, M.D., Deputy Commissioner, Epidemiology and Prevention Services, New York City Department of Health, incorporated after their review of this manuscript.