Final Paper
Solving AIDS in Palo Alto, CA
Palo Alto is home to Stanford University in the heart of Silicon Valley and is located 35 miles south of San Francisco. Although it is just a few miles away from the epicenter of the Acquired Immune Deficiency Syndrome (AIDS) epidemic, its location allows it to engage in some of the newest and most innovative AIDS research in the country. In the first paper, it was shown that Palo Alto does not have a significant problem concerning AIDS. As of December 31, 2006, Palo Alto had a total of 117 cumulative AIDS cases, giving it an AIDS rate of 199 per 100,000, putting it below both Santa Clara County’s rate of 202 per 100,000 and the national rate of 339 cases per 100,000 (See Santa Clara Data and Tables). As 56 percent of Santa Clara’s cases have resulted in death, it is likely many of the numbers are due to the original outbreak of the disease and that few cases are due to a large current problem (See Santa Clara Data and Tables). In Santa Clara County, 90 percent of the total AIDS cases have been men, which emphasizes the prevalence of the disease within gay communities, thus deeming problems like Intravenous Drug Use unlikely causes of the disease in this location. Men who have Sex with Men (MSM), on the other hand, is the mode of transmission which accounts for the incidence of AIDS in 68 percent of the county’s cases (See Santa Clara Data and Tables). When looking at prevention methods for Palo Alto, ways to reduce risk of transmission between MSM must be given top priority.
As MSM is the most evident problem with AIDS in Palo Alto, the second paper focused identifying correlations between the AIDS rate and factors associated with homosexual lifestyles. The strongest correlation found in Santa Clara County was between the AIDS rate per 100,000 and the Percent of Unmarried-Partner Households, which had a correlation coefficient equal to +0.731 (See Maps and Correlations). Another significant correlation was between the AIDS rate per 100,000 and the Percent of Male-Householder and Male-Partner Households, which had a correlation coefficient equal to +0.695 (p < .05) (See Maps and Correlations). These correlations identified a strong relationship between the AIDS rate and homosexual lifestyles. The AIDS rate per 100,000 did not correlate strongly with the Percent of Population that is Black or African American with a correlation factor equal to +0.46, Median Income with a correlation factor equal to -0.516, or the Percent of the Population that is Hispanic with a correlation factor equal to -0.097 (p < .05) (See Graphs and Data/Table 1). Due to weak correlations, the main problem with AIDS in Santa Clara County deals neither with poverty, nor race issues. Rather, the main issue that demands the attention of public health officials is MSM transmission.
Despite the fact that MSM risk and transmission of Human Immunodeficiency Virus (HIV), a precursor to AIDS, has declined since the initial outbreak of the disease in the early 1980s, many studies show that, in recent years, the risk and transmission have risen slightly again. According to findings from California focus groups, sentiments of an increase of risky tendencies began in 1996 when highly active antiretroviral therapies (HAART) was introduced and began to enhance and prolong the lives of HIV/AIDS patients (Morin et al. 2003). The focus groups found that, “participants perceived that HIV risk-taking has increased because (1) HIV is not the threat it once was due to more effective therapies, (2) MSM communicate less about HIV, and social support for being safe has decreased, and (3) community norms have shifted such that unsafe sex is now more acceptable,” (Morin et al. p. 353, 2003). The rise is risky behavior has important consequences for homosexual communities. Resulting changes in social norms and a decline in social support regarding HIV/AIDS could facilitate the spread of the disease even further. Another factor that influences the sexual practices of MSM is the communication of viral load—homosexual men often discuss and use the information to decide which activities to engage in (Guzman et al. 2006). Given the rise in MSM risk-taking behavior in recent years, social norms and discussion of sexual practices may be subject to further influences that could increase the transmission of HIV/AIDS.
Goal of Intervention:
Thus, the goal in the prevention of HIV transmission in Palo Alto is to reduce risk-taking behavior in MSM communities by changing social norms and practices by group level person-to-person intervention. Specifically, the solution to the AIDS epidemic in Palo Alto should involve internet-based chat room intervention, encouraging HIV testing, which will promote healthy sexual practices, such as increased condom use, reduced unprotected anal sex and fewer sexual partners.
Use of Internet-Chat Rooms for meeting sexual partners:
Since the beginning of the epidemic, many aspects of the AIDS epidemic have changed, including the locations where homosexual men meet sexual partners. In the 1980s many men met each other in bathhouses. Now, many studies have found that Internet websites are becoming increasingly popular among MSM in the absence of formal meeting places. According to AIDS Alert, “MSM increasingly are meeting men in Internet chat-rooms where they schedule what are called “real-time: sexual encounters or hook-ups. The relatively new venue for meeting sexual partners works nearly as fast as a meeting at a bar or bathhouse,” (AIDS Alert). The concern with the increasing use of gay chat-rooms is the lack of discourse about safe sexual practices. As the Internet is becoming a large venue for meeting sexual partners, it is important that healthy social norms are supported. Some websites, dedicated to “barebacking,” the act of engaging in unprotected anal sex, promote unsafe behavior (Morin et al. 2003). According to the findings of California focus groups, “unsafe sex has become a viable and acceptable option in the community and safer sex is no longer the only norm. The use of the Internet to find sexual partners has certainly contributed to this shift,” (Morin et al. p. 357, 2003). Society-wide tendencies and practices among MSM are difficult to change, but something such as the Internet may provide an ideal arena for reshaping the culture’s behavior.
Online Intervention:
As sexual partners meet each other on the internet, the promotion of safe ideas and creating safe sexual norms on the internet in the chat-rooms themselves, before sexual encounters occur, will likely lead to safer sex and risk reduction in practice. A study conducted by Scott D. Rhodes of the Department of Public Health Sciences at Wake Forest University School of Medicine, demonstrated the ease and effectiveness of an Internet chat-room intervention (Rhodes, 2004). In this study a gay male health educator from an AIDS service organization conducted HIV/AIDS prevention intervention in a chat-room online for a month. During his time in the chat-room he offered health information and risk reduction tips and allowed those who were interested to contact him. He spread awareness and information about the disease, encouraged HIV testing, informed chatters of available local resources, suggested risk reduction techniques, and helped to establish safe norms within the chat-room and the greater community (Rhodes, 2004). By identifying problems and providing information, the health educator was able to dispel rumors or inaccuracies he saw within the chat-rooms, and, since it was a local website, he was even able to connect with chatters and distribute condoms. Not only was the intervention itself successful, the fact that it was conducted on the Internet allowed the health educator to reach otherwise inaccessible risk groups, such as homosexuals who are not “out” (Rhodes, 2004). According to Rhodes, online intervention proves beneficial as it, “may reach MSM in the exact space and time in which they are looking for sex; prevention messages and negotiation skills are less likely to be forgotten during the short gap between intervention delivery and behavioral opportunity,” (Rhodes, p. 322, 2004). The ease with which MSM can learn safe practices through online intervention, rather than seeking out health services themselves, may enhance the effectiveness of Internet prevention intervention programs if they are implemented in Palo Alto.
An important factor of Internet chat-room intervention programs is the degree of anonymity involved in them. Some users of the chat-rooms may worry about others finding out about their sexuality or their interest in risk reduction, and may otherwise not seek help from professionals (Fields et al. 2006). The process of talking to a health educator in a chat-room appears much less intimidating and intrusive than visiting a health clinic or stepping inside a mobile AIDS clinic bus as in other methods of AIDS prevention. Thus, Internet-based prevention may reach a larger crowd than other prevention methods as it provides at least a small amount of information to the many who do not intentionally seek it or who do not believe they have a need great enough to step foot in a clinic.
For this reason, easy access to information is another benefit of Internet-based chat-room prevention programs. According to a questionnaire, administered by G. Bolding, accessed on two popular gay Internet sites in the United Kingdom, most homosexual men are interested in increased knowledge about health promotion (Bolding et al. 2004). The results of the questionnaire revealed that 75 percent of the men questioned believed Internet sites should allow health educators in chat-rooms, 78 percent said they would click on a banner to learn about sexual health, and 84 percent would listen to a health educator if they met one in a chat-room (Bolding et al. 2004). Thus, if people are interested in learning about risk reduction practices, the Internet is an easy way for both to provide and receive information.
Other than accessibility and anonymity, another reason for the success of Internet chat-room intervention is its design as a group-level person-to-person form of intervention. According to Herbst et al. in a systematic review of the “Effectiveness of Individual-, Group-, and Community-Level HIV Behavioral Risk-Reduction Interventions for Adult Men Who Have Sex With Men,” group-level intervention is intended to encourage discussion and change social norms by changing attitudes by providing information (Herbst et al. 2007). In the same review, the cumulative result of five group-level interventions was to increase the odds of using condoms during anal intercourse by 81 percent (Herbst et al. 2007). If implemented on a wide-scale in Palo Alto and the surrounding areas, Internet-based prevention, a group-level person-to-person form of intervention, may be able to negate the effects of the current rise in risky behavior by changing the social norms.
Emphasis on HIV testing:
The other main important aspect to online intervention programs is the ease with which health educators can advise sexual partners to get HIV tests. According to the Bolding questionnaire, only 54 percent of the men questioned had had an HIV test, yet 82 percent of them were using the Internet to look for a sexual partner (Bolding et al. 2004). Knowing one’s HIV status is vital to reducing the risk of transmission. According to Schwarcz et al., “detection of HIV early in the course of infection is necessary for effective prevention efforts to reduce HIV transmission and for improved care for HIV-infected persons,” (Schwarcz et al. 2007). In the same study, it was found that, in a large sample of HIV infected people, only 20 percent were infected within 6 months of being diagnosed (Schwarcz et al. 2007). It follows that the remaining 80 percent may have spread the virus carelessly, without using proper caution, for extended periods of time longer than 6 months.
Early testing and detection of HIV is key in preventing the spread of the virus to others unknowingly. When people know they have HIV, most feel some sort of responsibility not to pass it on to others (Wolitski et al. 2003), thus, early detection is essential to stopping the spread. Wolitski et al. conducted a survey that questioned HIV positive men’s feelings of responsibility. The results showed that, “most of the men in this study believed that they had at least some responsibility to protect their sex partners from HIV infection and have adopted risk-reduction practices in an effort to protect others,” (Wolitski et al. p. 370, 2003). Responsibility took the forms of feelings of personal responsibility, partners’ responsibility and shared responsibility. One participant described his feeling of personal responsibility not to pass on HIV as he said, “if you don’t [have safer sex], you are at a detrimental risk of endangering the person’s life to the point of death, and it’s like murder...I am a responsible person, and I have chosen this for myself and those that I am in contact with,” (Wolitski et al. p. 366, 2003). Many participants felt a feeling of personal responsibility not to pass HIV on to their partners, but also felt a broader sense of responsibility not to continue the spread of the disease to a larger population.
An important part of any Internet-based intervention program is the focus on emphasizing the need to get tested and encouraging the chat-room participants to do so. Although it may be more difficult to get people to be tested though an Internet-based program where the resources are not present in the clinic, chat-rooms may be able to encourage a larger number of people on a larger-scale and change the social norms in favor of getting tested. Given that not knowing one’s HIV status most likely spreads the disease which, if known, could be monitored and contained, it is the duty of health officials to encourage testing.
The main reason a public health official should encourage the implementation of Internet chat-room prevention and encourage HIV testing in Palo Alto is its cost effectiveness. For a single chat-room, which can provide access to hundreds of MSM looking for sexual encounters, the public health official need only hire one heath educator to share information about methods of risk reduction, benefits of HIV testing, and safe practices. While mandatory HIV testing would be ideal for containing the disease and stopping its spread, it is not economically feasible. Internet intervention, however, poses a promising alternative as it can identify those MSM most at risk and advise them personally to get tested at a much lower cost. If the health educator is successful in changing social norms in favor of risk reduction, safe sex and frequent testing, the city of Palo Alto will prevent the costs of many at-risk men from acquiring the disease, saving the city money in personal health and lost social utility costs, while only pending money on a few health educators.
While Palo Alto does not have a specific, easily targeted problem that causes AIDS in the city, the strong correlation between the AIDS rate and MSM tendencies, such as the Percent of Unmarried Partner Households and the Percent of Male-Householder and Male-Partner Households, suggests that an Internet chat-room intervention program would work well. The fact that Palo Alto is located in the heart of Silicon Valley serves to further the likelihood that MSM will be using Internet chat-rooms and will likely be receptive to risk reduction information. At a low cost, with many potential benefits, Internet intervention is a relatively easy solution to the AIDS problem in Palo Alto.
Works Cited
Bolding, G, et al. "Use of Gay Internet Sites and Views About Online Health Promotion Among Men Who Have Sex with Men." AIDS Care 16 (2004): 993-1001.
Fields, Sheldon D, et al. "Internet Chat Rooms: Connecting with a New Generation of Young Men of Color At Risk for HIV Infection Who Have Sex with Other Men." Journal of the Association of Nurses in AIDS Care 17 (2006): 53-60.
Grov, C, et al. "Barebacking Websites: Electronic Environments for Reducing or Inducing HIV Risk." AIDS Care 18 (2006): 990-997.
Guzman, R, et al. "Communicaion of HIV Viral Load to Guide Sexual Risk Decisions with Serodiscordant Partners Among San Francisco Men Who Have Sex with Men." AIDS Care 18 (2006): 983-989.
Herbst, Jeffrey H, et al. "The Effectiveness of Individual-, Group-, and Community-Level HIV Behavioral Risk-Reduction Interventions for Adult Men Who Have Sex with Men." American Journal of Preventive Medecine 32 (2007): 38-67.
Morin, Stephen F, et al. "Why HIV Infections Have Increased Among Men Who Have Sex with Men and What to Do About It: Findings From California Focus Groups." AIDS and Behavior 7 (2003): 353-362.
Rhodes, Scott D. "Hookups or Health Promotion? an Exploratory Study of a Chat Room-Based HIV Prevention Intervention for Men Who Have Sex with Men." AIDS Education and Prevention 16 (2004): 315-327.
Scheer, Susan, et al. "Effect of Highly Active Antiretroviral Therapy on Diagnoses of Sexually Transmitted Diseases in People with AIDS." The Lancet 357 (2001): 432-435.
Schwarcz, Sandra, et al. "Characteristics of Persons with Recently Acquired HIV Infection: Application of the Serologic Testing Algorithm for Recent HIV Seroconversion in 10 US Cities." Journal of Acquired Immune Deficiency Syndrom 44 (2007): 112-115.
"The Internet's Role as Modern Bathhouse is Being Scrubbed." AIDS Alert 18 (2003): 121-123.
Wolitiski, Richard J, et al. "Self Perceived Responsibility of HIV-Seropositive Men Who Have Sex with Men for PReventing HIV Transmission." AIDS and Behavior 7 (2003): 363-372.