Behavioral Aspects of AIDS

419 Pages·1990·50.269 MB·English

by  Daniel Defert (auth.), David G. Ostrow (eds.)

Behavioral Aspects
of AIDS
Behavioral Aspects
of AIDS
Edited by
David G. Ostrow
University of Michigan
Ann Arbor, Michigan
Springer Science+ Business Media, LLC
Library of Congress Cataloging-In-Publication Data
Behavioral aspects of AIDS I edited by David G. Ostrow.
p. em.
Includes bibliographical references.
Inc 1u des index.
ISBN 978·1·4757-9388-8 ISBN 978-1-4757-9386-4 (eBook)
DOI 10.1007/978-1-4757-9386-4
1. AIDS <Oiseasel--Psychologlcal aspects. 2. AIDS <Oiseasel
-Pevention. 3. AIDS <Oiseasel--Patients--Mental health services.
I. Ostrow, David G., 1947-
[0NLMo 1. Acquired Immunodeficiency Syndrome--psychology.
2. Behavior. 3. Delivery of Health Care. 4. Mental Disorders
-etiology. WD 308 B419l
RC607.A26B44 1990
616.97"92--dc20
ONLM/DLC
for Library of Congress 90-7242
CIP
© 1990 Springer Science+Business Media New York
Originally published by Plenum Publishing Corporation, New York in 1990
Softcover reprint of the hardcover 1st edition 1990
All rights reserved
No part of this book may be reproduced, stored in a retrieval system, or transmitted
in any form or by any means, electronic, mechanical, ·photocopying, microfilming,
recording, or otherwise, without written permission from the Publisher
Contributors
JAMES ASHE • Department of Neurology, The Johns Hopkins University School of
Medicine, Baltimore, Maryland 21205
J. HAMPTON ATKINSON Ill • Psychiatry Service, San Diego Veterans Administration
Medical Center, San Diego, California 92161; Department of Psychiatry, University
of California, San Diego School of Medicine, La Jolla, California 92093
JAY BAER • Department of Psychiatry, Tufts University School of Medicine, Boston,
Massachusetts 02111
T. PETER BRIDGE • Intramural Research Program, National Institute of Mental
Health, Bethesda, Maryland 20892
KATIE A. BUSCH • Department of Psychiatry, Rush-Presbyterian-St. Luke's Medical
Center, Chicago, Illinois 60612
LARRY L. BYE • Communication Technologies, San Francisco, California 94111
CAROLE A. CAMPBELL • Department of Sociology, California State University, Long
Beach, California 90840
DANIEL DEFEAT • AIDES Federation Nationale, Paris Cedex 75010, France
DON C. DES JARLAIS • Beth Israel Medical Center, New York, New York 10013;
Narcotic Drug and Research, Inc., New York, New York 10013
JAMES W. DILLEY • Department of Psychiatry, University of California, San Francis
co, California 94105; and University of California, San Francisco-AIDS Health
Project, San Francisco, California 94193-0884
FRANCISCO FERNANDEZ • St. Luke's Episcopal Hospital, Houston, Texas 77030;
Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine,
Houston, Texas 77030
SAMUEL R. FRIEDMAN • Narcotic and Drug Research, Inc., New York, New York
10013
GEORGE FULOP • Division of Behavioral Medicine and Consultation Psychiatry, De
partment of Psychiatry, Mount Sinai School of Medicine, New York, New York
10029
IGOR GRANT • Psychiatry Service, San Diego Veterans Administration Medical Cen
ter, San Diego, California 92161; Department of Psychiatry, University of Califor
nia, San Diego School of Medicine, La Jolla, California 92093
JOHN R. HESSELINK • Psychiatry Service, San Diego Veterans Administration Med
ical Center, San Diego, California 92161; Department of Radiology, University of
California, San Diego School of Medicine, La Jolla, California 92093
v
vi CONTRIBUTORS
LORING J. INGRAHAM • Intramural Research Program, National Institute of Mental
Health, Bethesda, Maryland 20892
DOUGLAS JABS • Department of Ophthalmology, The Johns Hopkins University
School of Medicine, Baltimore, Maryland 21205
ROBS W. JOHNSON • Fenway Community Health Center, Boston, Massachusetts
02115
JILL JOSEPH • Department of Epidemiology, University of Michigan School of Public
Health, Ann Arbor, Michigan 48109
CAROLINE J. KENNEDY • Psychiatry Service, San Diego Veterans Administration
Medical Center, San Diego, California 92161; Department of Medicine, University
of California, San Diego School of Medicine, La Jolla, California 92093
RAND E. LENHART • Formerly, Psychological Services, Cornell University, Ithaca,
New York 14853-4401
JOEL K. LEVY • Department of Psychiatry and Behavioral Sciences, Baylor College of
Medicine, Houston, Texas
SARZ MAXWELL • Department of Psychiatry, Rush-Presbyterian-St. Luke's Medical
Center, Chicago, Illinois 60612
JUSTIN C. McARTHUR • Department of Neurology, The Johns Hopkins University
School of Medicine, Baltimore, Maryland 21205
DAVID MILLER • Academic Department of Genitourinary Medicine, The Middlesex
Hospital Medical School, London WIN 8AA, England
DAVID G. OSTROW • Midwest AIDS Biobehavioral Research Center, Institute for
Social Research; Department of Psychiatry, University of Michigan School of Medi
cine, Ann Arbor, Michigan 48109
MICHAEL W. ROSS • Albion Street AIDS Centre, The Sydney Hospital, Surry Hills,
NSW 2010, Australia
CAITLIN C. RYAN • AIDS Policy Center, Intergovernmental Health Policy Project,
George Washington University, Washington, D.C. 20007
RITCH C. SAVIN-WILLIAMS • Department of Human Development and Family Stud
ies, Cornell University, Ithaca, New York 14853-4401
BERTRAM SCHAFFNER • William Alanson White Institute of Psychoanalysis and
Psychology, New York, New York 10023
JAMES J. STRAIN • Mount Sinai Medical Center, New York, New York 10029-6577
JEFF STRYKER • Department of Public Health Policy and Administration, University
of Michigan, School of Public Health, Ann Arbor, Michigan 48109-2029
MICHAEL TRAUGOTT • Center for Political Studies, Institute for Social Research,
University of Michigan, Ann Arbor, Michigan 48106
JOYCELYN SUE WOODS • Narcotic Drug Research, Inc., New York, New York
10013
DOOLEY WORTH • Montefiore Medical Center and Department of Epidemiology and
Social Medicine, The Women's Center, Bronx, New York 10467
Preface
As we enter the last decade of the twentieth century, the AIDS epidemic looms ever larger
and threatening. The specter of upwards of a million deaths in the United States and
perhaps many millions worldwide from a sexually transmitted virus shakes our belief in
modem medical science, while challenging the foundations of democratic society. Almost
ten years into the epidemic, and with an enormous body of basic science research on the
Human Immunodeficiency Virus (HIV), we still do not know why AIDS emerged when it
did or how to stop its spread. A very humbling experience for scientists, clinicians, public
health experts, politicians, and the general public.
Yet there are signs that a well coordinated multidisciplinary research program can
conquer the epidemic and, perhaps, provide the basis for preventing future epidemics.
The HIV family of viruses is now better understood, both in terms of structure and
function, than any other virus. Genetically engineered peptides and nucleic acids are
being tested as specific treatments or vaccines against HIV infection/disease. Most prom
ising are the strides which have been made in understanding those aspects of human
behavior which have contributed to the spread of HIV infection and which must be
substantially modified if AIDS is to be controlled and eventually eradicated. The basis of
that understanding has roots in a diverse set of disciplines which have converged in the
work presented in this book. Psychiatry, epidemiology, sociology, anthropology, and the
neurosciences have all contributed individually and in combination to the behavioral
understanding of AIDS. This is perhaps a new and unique approach to the understanding
and control of an infectious disease, at least in the twentieth century.
The emergence of the behavioral approach to understanding AIDS has its roots in
several earlier periods of study, epitomized by studies of the sexual transmission of
hepatitis B in the 1970s and earlier work on the ethnography of intravenous drug use.
Each of those, in turn, was facilitated by social changes which demystified and permitted
the study of previously "hidden" populations. And each contributed to the development
of biological therapies-opiate antagonists for heroin addiction and a vaccine against
hepatitis B. Whether or not we are on the verge of similar biological breakthroughs in the
treatment or prevention of HIV infection is debatable. What is clear is that the future
course of the AIDS epidemic is being shaped by human behavior and increasingly by
interventions which seek to modify behavior.
The individual chapters in this book summarize the available behavioral information,
describe its application to clinical problems, and, to a varying extent, discuss the research
challenges which lie ahead. It is hoped that taken as a whole they contribute to our under
standing of HIV infection and disease more than do the individual parts. In any rapidly
growing field, new developments make books obsolete even before they appear. While all
of the contributors to this volume have had the opportunity to update their chapters just
prior to publication, there are undoubtedly gaps in information which editing and updating
vii
viii PREFACE
cannot fill. There is no way that this collection can be totally comprehensive in such an
expanding field, where new areas of research and intervention appear daily. Several
chapters are devoted to providing information and guidance for persons working in the
field of AIDS so that they can be aware of the clinicaL ethical, and public health policy
implications of new behavioral research findings as they emerge.
I am especially grateful to all of the contributors to this book, who took the time out
from their own research or clinical work to write their chapters. Most of the contributors
have also participated in several of the symposia, courses, and workshops on behavioral
aspects of AIDS which contributed to the conceptualization and organization of the book.
I have had the pleasure to work with several editors at Plenum, beginning with Hilary
Evans, who shepherded the first book on sexual behavior and sexually transmitted dis
eases, Homosexuality and STDs: Diagnosis, Treatment and Research, and began the
discussions which lead to the proposal for the current publication. Janice Stem was most
helpful in the difficult process of realizing the project, especially in helping to find the best
contributors for each chapter and support their efforts. And finally, Mr. Eliot Werner took
over the project for the final editing and production work. Many thanks to them and to all
the scientists and clinicians working to find better ways to stop this epidemic.
David G. Ostrow
Ann Arbor, Michigan
Contents
Introduction. A New Social Reformer: The Patient
Daniel Defert
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Modification of the Doctor-Patient Relationship. . . . . . . . . . . . . . . . . . . . . . . . . 2
Transformations in Hospital Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
The Sharing and Control of Medical Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . 4
Transformation of the Relationship between Society and the Disease . . . . . . . . . 5
FutureofCommunity Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Sociological Element . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Geographical Element . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Political Element. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
I. AIDS: CONTRIBUTIONS OF THE BEHAVIORAL SCIENCES
1. Psychiatric Aspects of AIDS: An Overview
David G. Ostrow
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
A Psychosocial Model of the Behavioral Consequences of AIDS . . . . . . . . . . . . 11
The Spectrum of AIDS-Related Psychiatric Illness . . . . . . . . . . . . . . . . . . . . . . . 13
A Biological Model of the Psychiatric Consequences of AIDS . . . . . . . . . . . . . . 13
The Virus of Fear Model. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2. Psychovenereology: Psychological Aspects of AIDS and Other Sexually
Transmissible Diseases
Michael W. Ross
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Psychological Variables Associated with Risk of STD Infection . . . . . . . . . . . . . 20
Personality and Attitudinal Variables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Psychological Concomitants of Partner Numbers. . . . . . . . . . . . . . . . . . . . . . . . . 25
Psychological Concomitants of Particular Sexual Practices . . . . . . . . . . . . . . . . . 26
Psychological Concomitants of Partner Anonymity and Places
of Sexual Contact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
The Psychology of STD Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Reactions of STD Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Medical Reactions to STD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Psychological Reactions to HIV Seropositivity . . . . . . . . . . . . . . . . . . . . . . . . 33
Illness Behaviors in STD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
ix
x CONTENTS
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
II. PREVENTION: HIV RISK REDUCTION
3. Educational Strategies for Prevention of Sexual Transmission of HIV
Robb W. Johnson, David G. Ostrow, and Jill Joseph
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
The Health Belief Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Knowledge.................................................... 44
Perception of Personal Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Perceived Effectiveness of Change and Response Efficacy . . . . . . . . . . . . . . . 45
Faith in Medical Technology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Sociodemographic Variables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Social Network Affiliation and Peer Norms... . . . . . . . . . . . . . . . . . . . . . . . . 47
Personality Factors and Cognitive Cues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Sexuallmpulse Control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Alcohol or Drug Use. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Summary..................................................... 50
Practical Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Setting Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
The Settings of the Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Role of the Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Tailoring Interventions to Target Audiences. . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Clarity, Simplicity, and Specificity of Messages . . . . . . . . . . . . . . . . . . . . . . . 62
Acknowledging and Dealing with Barriers to Change . . . . . . . . . . . . . . . . . . . 63
Evaluation Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Examples of Educationallnterventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Targeting Efficacy and Social Factors through Modeling . . . . . . . . . . . . . . . . . 66
Building Social Skills to Enhance Response Efficacy . . . . . . . . . . . . . . . . . . . 66
Targeting Perception of Risk with PWA Spokepersons . . . . . . . . . . . . . . . . . . 67
Norm-Setting through Social Networks and Opinion Leaders . . . . . . . . . . . . . 67
Social Marketing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Skill Building to Influence Cognitive Cues . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Interventions to Reinforce and Maintain Positive Changes . . . . . . . . . . . . . . . 69
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
4. AIDS Prevention among Gay and Lesbian Youth: Psychosocial Stress
and Health Care Intervention Guidelines
Ritch C. Savin-Williams and Rand E. Lenhart
Overview....................................................... 75
Psychosocial Stress, Adolescence, and AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Psychosocial Stresses for Lesbian and Gay Adolescents . . . . . . . . . . . . . . . . . . . 79
Homosexual Behavior and Gay Identity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80