Introduction
It has been thirty-two years since the
HIV was discovered in the United States, and twenty-six years since President
Ronald Reagan first publicly said the word “AIDS.” Since the beginning of
the AIDS epidemic in the 1980s, over a half a million people have died in the
U.S.--roughly equivalent to the entire population of Las Vegas. [1] While
dramatic gains in biomedicine and public health have succeeded in slowing the
spread of the epidemic, significant challenges remain. On average, over 50,000
Americans are infected with HIV each year, or one every nine and a half
minutes. [2]
After nearly three decades without a
cohesive, comprehensive national strategy in the U.S., the Obama administration
unveiled the first National AIDS Strategy in July of 2010. Two of the central
goals of the strategy are lowering the number of annual new infections by 25%,
and reducing HIV transmission by 30%. Intravenous drug users (IDUs) have been
identified as “vulnerable populations” since the onset of the HIV epidemic,
with intravenous drug use recognized as a direct route of transmission of the
virus. In light of the Obama administration’s goals, IDUs have been identified
as the “face” of the HIV epidemic and continue to be disproportionately
impacted by the epidemic today, accounting for 9% of all new HIV infections in
the US in 2009. [3]
Approaches to HIV Prevention among Intravenous Drug Users
One of the key ways in which public
health responded to high rates of HIV among IDUs was through the introduction
of structural interventions such as needle exchange and syringe access
programs. However, beyond these structural interventions, behavioral
interventions aimed at reducing risk behaviors associated with HIV transmission
have long played a critical role in the fight against HIV. With biomedical
solutions, such as an HIV vaccine, still in the distant future, behavioral
interventions continue to be an integral part of prevention efforts with active
substance users.
Many of these interventions are founded
in cognitive-behavioral theory, which seeks to change risk behavior at the
individual level. While general prevention efforts with active drug users have
succeeded in drastically lowering rates of HIV transmission among IDUs, these individual level interventions have inherent, severe
limitations in effectively preventing new HIV infections among IDU populations
[4]. The vast majority of these behavioral interventions are grounded in the
underlying assumption that if individuals increase knowledge of their risks,
and are adequately “motivated,” then they will take action to change their
risky behavior. These theories do not address the macro-social and
structural constructs of injection drug use such as poverty, violence, and a
multitude of other societal and fundamental factors. While research supports the claim that these behavioral
interventions, at least in the short term, increase knowledge of risk and
inspire changes in attitudes, there is a lack of evidence and research that
shows these modalities as effective in reducing the number of new HIV
infections. [5]
One of the most widely implemented
behavioral interventions, used with both injection and non-injection drug
users, is Safety Counts. This intervention aims to reduce high-risk drug
use and sexual behaviors, and is founded in cognitive-behavioral theory.
Comprising seven core sessions, held over the course of four months, Safety
Counts incorporates both group and individual level behavioral health
interventions.
The seven core components of Safety
Counts consist of two group sessions, one or more individual counseling
sessions, two or more social events, and two or more follow up contacts. A
behavioral health counselor facilitates group sessions, in which individuals
share personal accounts of risk reduction stories. The Stages of Change Model
(Prochaska) serves as the structural foundation for both the group and
individual level sessions, with participants assessing their own readiness to
change risky behavior, and then identifying personal behavior goals. In
following sessions, participants share personal stories of how they have
successfully implemented risk reduction in their own lives. By listening to how
peers have overcome barriers to behavior change, and by understanding how these
changes led to ultimately desirable outcomes, individuals in Safety Counts develop
their own belief in their individual ability to modify unhealthy behaviors.
With an end goal of long-term
behavioral change in all participants, Safety Counts relies on the
Health Belief Model, Social Cognitive Theory, and the Transtheoretical Model as
its foundation. [21] While there is evidence that interventions based in these
theories and models achieve short-term changes in behavior, there is no
evidentiary basis upon which Safety Counts can claim that
their participants will achieve successful behavior modification in the long-term.
[13]
Critique 1: Health Belief Model/Health Promotion
One of the theories on which Safety
Counts relies is the Health Belief Model (Rosenstock), which involves a
balancing act between a patient’s perceived benefits of a behavior versus their
perceived costs. The Health Belief Model relies on an individual’s perceived
personal threat in order to alter behavior. [22] Safety Counts, in
confluence with the Health Belief Model, assumes that with increased knowledge
of the risks and dangers of their behavior, IDUs will rationally modify their
behavior in order to avoid HIV infection and transmission.
However, the Health Belief Model in
inherently flawed in its reliance on this assumption of rationality. It has
been shown that people will do irrational, extreme things to prevent experiencing
loss. Once a person owns something, whether it is something physical or
intangible like a habit or behavior, that person will value it very highly and
won’t let it go. As humans, behavior is a part of who we are, so asking IDUs to
change their health behaviors based solely on assumed rationality is asking
them to willingly give up a part of themselves.
Along with the flawed assumption of
rationality, the Health Belief Model does not take into account
behavior-modifying influences that surround IDUs. Behaviors are deeply
influenced by environmental, social, and cultural factors; improvement in
knowledge is not necessarily concurrent with a positive change in an
individual’s behavior. Perceived risk of HIV acquisition, and even knowledge of
the severity of the disease, is often not enough to override competing
priorities and interests. For example, there are habits, rituals and
expectations within IDU subculture that at times include social expectations
around needle sharing. Regardless of increased knowledge, social norms within
IDU networks may cause a drug user to fear consequences among his or her peers
upon refusal to share injection equipment. [12]
Critique #2: Social Cognitive Theory
Another key tenet of the Safety
Counts intervention model is based in Social Cognitive Theory, which is
built upon two concepts: self-efficacy and social modeling. By determining the
beliefs that an individual has about their own ability to affect situations and
be successful, and coupling that self-efficacy with models of good behavior to
imitate, Social Cognitive Theory seeks to address both individual behaviors and
the impact of societal factors on an individual. One key aspect of this theory
is social modeling. The assumption behind modeling is that people act by observing
the behavior around them, and model the behaviors they see. Therefore, Social
Cognitive Theory is not solely reliant on assumed rationality.
However, Social Cognitive Theory does
not account for the fact that relapse into risky behaviors is an impulsive
decision. Also missing from the theory is the acknowledgement of ‘visceral
factors’ [20], such as thirst, hunger, sexual desire, or cravings, and how
these factors mitigate the regulation of behavior. In addition to the critical
oversight of these two factors, it is important to note that they are
inextricably linked; impulsivity increases as these visceral factors intensify.
So for IDUs, as withdrawal, trauma, and other emotional crises increase, so
also increases the likelihood of relapse. The more intense withdrawal becomes
for an IDU, regardless of the level of self-efficacy or modeled behavior
modifications, the more apt the IDU is to use a borrowed needle, or engage in
other high-risk behaviors.
Social Cognitive Theory is severely
limited by the assumption that changes in an individual’s environment
automatically changes behavior. For example, in the case of Safety Counts,
the environment that the intervention is changing is limited to a loosely
affiliated group of participants involved in the intervention. The modification
does not extend to personal networks, close interpersonal ties, and other
important elements of IDUs’ lives. [9]
In order for an intervention based in
Social Cognitive Theory to be effective, it must be based in the reality of the
IDUs it serves. The inherent artificiality of the groups within Safety
Counts automatically limits the intervention’s effectiveness, because
changes, triggers, and other factors from the individuals’ environment are
completely unaccounted for.
Critique #3: Transtheoretical Model
While Safety Counts is
theoretically based in both Social Cognitive Theory and Health Belief Model
Theory, the group and individual level sessions are modeled on the Stages of
Change, also known as the Transtheoretical Model. The Transtheoretical Model
(TTM) is based on the assumption that behavioral change does not occur in a
moment, but is an ongoing, cyclical process. [21]
The TTM is grounded in the belief
that every individual moves through six stages in order to achieve change:
precontemplation, contemplation, preparation, action, maintenance, and
termination. The TTM is not a theory in and of itself, and different behavioral
theories and intervention strategies are most effective at each stage in moving
an individual through the model. In the TTM, several cognitive, affective, and
evaluative processes are applied to progress individuals through the stages of
change; these processes range from increasing awareness to rewarding positive
behavior and from committing to change to substituting healthy behaviors for
unhealthy ones.
While the TTM is one of the most
dominant models of behavior change in healthcare, and it is the model upon
which Safety Counts is based, it has serious limitations when it comes
to working with IDU populations, and affecting long-term behavioral change in
general. The first major issue with the TTM is a lack of consistency and
transparency within the model itself. [3]There is no determined timeline for
how long an individual should take in each stage; neither is there a timeline
for how long an individual should remain in each stage of change. In addition,
there is no standardization among assessments used to determine which stage an
individual should be assigned to, and these assignments are often arbitrary.
Without a standardized set of criteria to determine an individual’s stage of change
and without a timeline for an individual’s planned rate of change, the TTM
becomes an organized form of guesswork for healthcare intervention providers.
[3] Alongside
its lack of accountability, standardization, and validation, the TTM also fails
in its core assumption of rationality. Much like Social Cognitive Theory, the
TTM’s design is rooted in the belief that an individual will make and follow
coherent and logical steps in their decision-making and behavioral processes.
An inherent flaw in the TTM is its failure to address the social and
environmental contexts in which individuals make behavioral decisions. IDUs,
like all individuals, have a variety of environmental factors that influence
behavior on a daily basis. [3,11]The TTM disregards these factors, and claims
that the process for behavioral change is uniform across all individuals.
Drug use is a complex behavioral
issue, stemming from a multitude of environmental, mental, physiological, and
emotional concerns. Applying generic, arbitrary stages of change to complex
behavior such as drug use [3] is ineffective and problematic. Multiple
researchers have emphasized that with complex behavioral challenges, such as drug
use, a more objective assessment of an individual’s behavior is essential for
effective intervention.
Recommendations
The majority of
behavioral interventions used in vulnerable populations are implemented exclusively
at the individual level, and are thus only able to address one small part of a
complex epidemic, fundamentally undermining HIV prevention efforts. Without
addressing macro-level factors, interventions that are solely psycho-socially
based cannot have a lasting impact on behavior change, neither at the
individual nor community level. [14]
An IDU’s behavior,
and consequent behavior change, does not happen in a vacuum. Rather, there are
interactive and dynamic relationships between the individual, and
socio-economic, cultural and structural factors that surround him or her. [13] Safety
Counts is a commonly used intervention with IDU populations, and its
efficacy is hampered by the narrow lens through which it views and approaches
behavior change. Although the intervention utilizes both group level and
individual level activities, the community change that Safety Counts
advocates is limited to the artificial community of the program participants.
[19]
The creation of an
artificial, temporal “peer network” in these group sessions is problematic, as
participants are likely to have few ties or relationships outside the scope of
the intervention itself. Since a central tenet of Social Cognitive Theory is to
utilize social influence to reinforce behavior change, these group level
sessions do not achieve this goal. Once the intervention is over, participants
return to their own communities and reintegrate into their own social networks,
where the norms and values may be different or even counteractive to the
behavior changes learned in the Safety Counts intervention.
In order to
effectively address the HIV epidemic, interventions must address both the
individual and community levels. While individual-level interventions have been
shown to produce short-term belief, attitude, and behavior changes, there is no
evidence showing that they have any long-term effect. Social Network Theory
posits that individuals are dynamically and fluidly a part of many different
networks and groups, such as peers, co-workers, family members, and social
circles. If individuals are to maintain long-term behavior change,
community-level interventions must be implemented in order to change the norms
and values of individuals’ social networks. [5]
By influencing
positive change in participants’ social networks, Safety Counts could
also address its intrinsic issues that stem from the use of Health Behavior
Models. Because individual-based Health Behavior Models are founded in the
assumed rationality that increased knowledge leads to behavior change, Safety
Counts could mitigate the negative influences of the complex social and
environmental factors surrounding IDUs by implementing broad, community-based
interventions.
Adapting Social
Cognitive Theory to a broader community-based intervention model will address
several inherent flaws in Safety Counts’ theoretical framework. However,
the program’s design basis on the TTM remains a fundamental flaw. Multiple
researchers argue in favor of a more objective assessment system for the
complex behavioral issues that accompany IDUs. By adopting more uniform,
objective, and standardized criteria for assessing participants’ needs and
projected timeline, Safety Counts would be more effective in attending
to individual’s needs.
There are several
CDC AIDS Community Demonstration Projects that have yielded promising results
with the kind of community-based interventions that Safety Counts needs
in order to be more effective Rather than applying social modeling theory to
artificial groups of unrelated intervention participants, instead Safety
Counts should adequately invest in capacity building and training for these
individuals, in order to build cohorts of peer educators. These peer educators
then can be sent out into the community to both live as role models of and
advocate for reducing risky behaviors. With a growing cadre of influential peer
educators, Safety Counts could begin to change the norms of the IDU
social networks and affect lasting behavior change.
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