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Medical Anthropology: Cross-Cultural Studies in Health and Illness Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/gmea20
Introduction. Rethinking HIV prevention: Critical assessments of the content and delivery of AIDS risk‐reduction messages Ralph Bolton
a b c
& Merrill Singer
d e
a
Professor of Anthropology , Pomona College , Claremont, CA, 91711 b
Chair of the AIDS and Anthropology Research Group , Society for Medical Anthropology c
Member of the AIDS and Anthropology Task Force , American Anthropological Association d
Deputy Director of the Hispanic Health Council , 98 Cedar Street, Hartford, CT, 06106 e
Chairperson of the American Anthropological Association Task Force on AIDS Published online: 12 May 2010.
To cite this article: Ralph Bolton & Merrill Singer (1992) Introduction. Rethinking HIV prevention: Critical assessments of the content and delivery of AIDS risk‐reduction messages, Medical Anthropology: Cross-Cultural Studies in Health and Illness, 14:2-4, 139-143, DOI: 10.1080/01459740.1992.9966071 To link to this article: http://dx.doi.org/10.1080/01459740.1992.9966071
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses,
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This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/ terms-and-conditions
Medical Anthropology, Vol. 14, pp. 139-143 Reprints available directly from the publisher Photocopying permitted by license only
©1992 Gordon and Breach Science Publishers S.A. Printed in the United States of America
Downloaded by [Memorial University of Newfoundland] at 05:00 29 January 2015
Introduction. Rethinking HIV Prevention: Critical Assessments of the Content and Delivery of AIDS Risk-Reduction Messages Ralph Bolton and Merrill Singer Key words: AIDS prevention, HIV, AIDS education, medical anthropology
In 1989, Medical Anthropology became the first journal in the field to devote an entire issue to anthropological research on the AIDS pandemic. As Lawrence S. Greene, the Editor-in-Chief, pointed out in a prefatory note at that time, "we anticipate further issues on this timely subject in the future." Indeed, even before that issue appeared, at the annual meeting of the Society for Applied Anthropology in Santa Fe, New Mexico in April of that year, the co-editors of the present issue met with Greene to begin to plan future special issues of the journal on the AIDS crisis. In our discussion we observed that despite growing involvement of anthropologists in AIDS research, too little attention was being focused directly on the critical task of improving the design of educational efforts aimed at stopping the transmission of HIV. As a result, we resolved to pull together an issue devoted to the topic of HIV prevention. Anthropological research on AIDS encompasses a broad spectrum of inquiry (Bolton, Lewis, and Orozco 1991), and the results of these investigations have deepened our understanding of many dimensions of the epidemic. Such studies include: symbolic analyses of AIDS discourse; surveys of adolescent attitudes toward sexuality and AIDS, the response of health-care personnel toward AIDS patients, and general population knowledge, attitudes, and risk behaviors; ethnographies of drug using populations; discussions of ethical and methodological issues in AIDS research; experimental evaluation of the effectiveness of culturally specific AIDS prevention programs; and societal responses to the epidemic. All of these approaches have yielded important data and contributed valuable insights which should inform our efforts to cope more successfully with the AIDS crisis. Nonetheless, we sense that much of our collected effort is too far removed from RALPH BOLTON IS Professor of Anthropology at Pomona College, Claremont, CA 91711. He is Chair of the AIDS and Anthropology Research Group (an affiliate of the Society for Medical Anthropology) and a member of the AIDS and Anthropology Task Force of the American Anthropological Association. His current work focuses on cognitive mapping of the domain of sexuality and on the structure of sexual encounters. MERRILL SINGER is Deputy Director of the Hispanic Health Council, 98 Cedar Street, Hartford, CT 06106. He is Chairperson of the American Anthropological Association Task Force on AIDS and is the Principal Investigator on Project COPE, A National AIDS Demonstration Research Project (NADR) funded by the National Institute on Drug Abuse.
Downloaded by [Memorial University of Newfoundland] at 05:00 29 January 2015
U0I12] R. Bolton, M. Singer the needs and concerns of the men and women who are on the front lines of the battle to halt the transmission of HIV, those who design and implement on-theground programs of intervention intended to reduce high-risk behaviors. As anthropologists, we must raise the question of how we can help them to make their efforts more effective. We are all aware of the serious financial constraints faced by community organizations engaged in HIV prevention. These budgetary considerations make it all the more imperative for prevention activists to be as effective as possible. Since 1989 biomédical research has produced therapeutic improvements which promise to extend the lives of those who are infected, and candidate vaccines that may eventually prevent infection from occurring are in various stages of development. Still, no biomédical fix is in sight and there are no guarantees that such a solution to AIDS will be forthcoming in the long run, let alone in the near future. Moreover, even if a vaccine or effective treatment were available, it is far from certain that they would be widely distributed and equally available to all populations, social classes, and subgroups across the globe. The prevention of new infections through education, therefore, must remain as one of our highest priorities. By training most anthropologists are not equipped to make serious contributions to potential biomédical solutions to the epidemic, but because of our expertise in social and cultural processes, we are singularly prepared to make major contributions to educational approaches to HIV prevention. After all, HIV prevention is first and foremost a problem in culture change. While the goal of prevention efforts is to reduce risk-taking by individuals, the processes whereby that goal is accomplished are necessarily social and they occur within specific cultural contexts. Although the papers in this volume deal with HIV prevention in enormously different target populations, all of them emphasize the importance of basing prevention programs on a thorough comprehension of the social and cultural systems of the people for whom the program is intended. Bolton's paper offers a critical assessment of the role of promiscuity in the epidemic and of a prevention strategy which attempts to reduce HIV transmission by advising people to reduce the number of their sexual partners. This strategy, he argues, is derived from moralistic approaches to AIDS which ignore sexual values and behavioral realities and exemplifies the unwarranted application of epidemiologic concepts and findings to the design of prevention programs. The unintended consequence of the partner-reduction message has been to reduce the salience of safe-sex messages, thereby compromising their effectiveness. His analysis suggests that at least in sex-positive subcultures the outcome of this strategy has been to increase rather than decrease HIV transmission. Bolton recommends the elimination of references to multiple partners as a risk factor in AIDS prevention messages. In her paper, Schoepf describes the action-research in which she has been involved in Zaire, one of the epicenters of the AIDS pandemic in Africa. She points to the need to de-medicalize AIDS prevention and to develop community-based interpersonal methods of AIDS education which empower people to make riskreduction behavioral changes. The case study reported in this paper demonstrates the important point that while cultural knowledge is essential in designing prevention programs, cultural explanations for the failure of prevention programs must
Downloaded by [Memorial University of Newfoundland] at 05:00 29 January 2015
Rethinking HIV Prevention 131/141 not be accepted at face value. Schoepf and her associates in Zaire found that although cultural impediments to the use of condoms do exist, traditional beliefs and values did not stand as insurmountable obstacles to promoting condom use. By enlisting traditional healers in AIDS prevention, Schoepf and her African colleagues were able to induce a process of cosmological reinterpretation which made condoms more culturally acceptable. The safer-sex approach to risk-reduction has proven to be highly effective in promoting behavioral changes in the domain of sexuality, especially among gay men in Europe and the U.S. Instead of focussing on the dangers of sexuality, this approach emphasizes the positive values of sexual pleasure and the importance of empowering individuals and communities to make changes in their sexual practices which simultaneously reduce the risk of HIV transmission and enhance sexual fulfillment. In their paper, Taylor and Lourea describe a dynamic model which can be used by AIDS educators to generate safe-sex interventions that are sensitive to the individual, cultural, and social attributes of specific target audiences. Based on the authors' extensive experience in offering safe-sex workshops and other performances, this paper, which is unique in the prevention literature, offers valuable, detailed advice on how to design safer-sex interventions. While the first three papers in this volume are concerned solely with the sexual transmission of HIV, the paper by Singer, Jia, Schensul, Weeks, and Page examines HIV prevention among injection drug users (IDUs) for whom multiple transmission routes exist, thereby complicating the prevention process. The authors of this paper convincingly challenge the homogenous portrayal of IDUs commonly found in the media. By comparing the participants in their studies in Hartford, Connecticut and Miami, Florida, they reveal major differences in the beliefs and behavioral patterns of these two populations. Given these differences, they argue that to be effective prevention strategies must be grounded in an ethnographically holistic awareness of the local context. Their analysis underscores, too, the importance of providing in each setting multiple types of interventions, such as street outreach education, bleach distribution, drug treatment programs, and sterile needle exchange projects, among others. These authors have been engaged for a number of years in implementing and testing the efficacy of many of these strategies in reducing risk behavior and seroconversion among IDUs, their sex partners, noninjection cocaine users, and professional sex workers. Susser and González discuss their work on a prevention project carried out among homeless men living in a shelter in New York City. Given the enormous difficulties in survival confronted by the homeless, HIV prevention in this context presents special problems. The authors argue that in this setting to effect changes in risk behavior it is necessary first to initiate a process of re-evaluation and recreation of a sense of identity. Their innovative approach to prevention involved engaging these homeless men in the making of a video addressing HIV infection among shelter residents. In collectively writing a script for the video, the participants not only became better informed about AIDS, but they also generated valuable information on the drawbacks and possibilities of various prevention strategies. This action research triggered a response of group self-help. Fostering such responses, the authors note, should be a primary goal of anthropologists working on HIV prevention.
Downloaded by [Memorial University of Newfoundland] at 05:00 29 January 2015
142/[4] R. Bolton, M. Singer In the final paper, Bolton, Vincke, Mak, and Dennehy explore the connections between alcohol consumption and risky sex. In the prevention literature the conclusion that drinking increases sexual risk-taking appears to be firmly entrenched, and most prevention programs convey the message that sex and alcohol are a dangerous combination. The authors conclude that this claim rests on a shaky empirical foundation. In their research among Belgian gay men they failed to find significant relationships between alcohol variables and sexual risk-taking; moreover, their review of the scientific literature suggests that most studies of this hypothesis have failed to replicate the findings of the early research on this subject. They advance several hypotheses to account for this "vanishing" co-factor of risky sex, including the possibility that such a relationship may exist in limited sociocultural contexts. However, they argue that rethinking the alcohol message is essential and that it may be necessary to turn the former message upside down. By allowing alcohol to serve as an excuse for risky behavior, we may inadvertently encourage risk taking; by telling people that alcohol does not cause risky behavior, we may encourage them to take responsibility for their actions. The papers in this volume challenge some of the most basic assumptions in HIV prevention. They question conventional wisdom on fundamental issues. We hope that they will stimulate debate and research on how to improve the content and delivery of HIV prevention messages. Despite the diversity of settings represented in these papers, a common theme emerges: prevention works best when it promotes change through individual and community empowerment strategies informed by holistic understandings of the local context, when it acknowledges the positive contributions of local cultural values to the process of change, and when it incorporates an array of options that permit individuals to transform their lives in ways that enhance their physical, emotional,
and material well-being. Prevention efforts fail when they revictimize and stigmatize those who do not accept messages incompatible with their basic values and needs, when they blame those whose behavior suggests recalcitrance or relapse from risk standards established by health "experts," when they are based on top-down rather than community-designed and implemented approaches, and when they are shaped by the moralistic and authoritarian models advocated by political, religious, and medical leaders whose agendas may be inimical to the best interests of the clients of many prevention programs. HIV prevention in the 1990s may be even more difficult than it was in the 1980s. We ignore at our peril the lessons of the first decade of the epidemic. As anthropologists we need to use our special vantage point to help rethink prevention. Fortunately, this process has begun. In October 1991, approximately 30 anthropologists who are actively involved in AIDS research, programming, and policy issues, gathered together in Atlanta, Georgia for a conference on AIDS and Anthropology in the United States. With the support and active participation of the Centers for Disease Control and many CDC staff, the conference served as a state-of-the-art review of anthropological contributions to AIDS prevention research and community AIDS education and empowerment efforts. It was evident at this conference, as well as at several smaller anthropological conferences on AIDS that took place at the University of Pennsylvania, Hunter College, the New School for Social Research, and at other sites during 1991, that anthropology demonstrates a number of notable strengths in responding to the AIDS crisis. Many of these strengths are
Downloaded by [Memorial University of Newfoundland] at 05:00 29 January 2015
Rethinking HIV Prevention [5]/143
displayed in the papers included in this collection. Moreover, the anthropological imprint can already be discerned in numerous AIDS prevention projects within the United States and across the globe. While the number of anthropologists directly involved in responding to the epidemic remains comparatively small, their impact has been felt to a far greater degree than in many areas of applied research and program/policy design. However, it is also clear that there is much work to be done and many gaps remain in anthropological AIDS understanding and involvement. During the Atlanta conference, for example, it was evident that we lack critical knowledge about issues like the sexual behavior and attitudes of many (if not all) populations; the culture of service providers and the effect of this culture on AIDS service provision; the role of social relations structured around class, gender and ethnicity on participation in risky behaviors; the means of effectively involving so-called hard-to-reach populations like the homeless, sex partners of FVDUs, and gay men from ethnic minority communities; the configuration of life history factors (e.g. child abuse, domestic violence) that generate and shape risk behaviors; the contributions of anthropological insight to secondary prevention and treatment; and the operational understanding of cultural and gender appropriateness in prevention programs. A similar range of issues could be developed for AIDS efforts in the Third World. Items like these constitute the agenda for AIDS and anthropology as we move into the second decade of the epidemic.
REFERENCES CITED Bolton, R., M. Lewis, and G. Orozco 1991 AIDS Literature for Anthropologists: A Working Bibliography. The Journal of Sex Research 28(2):307-346.
Medical Anthropology: Cross-Cultural Studies in Health and Illness Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/gmea20
Introduction. Rethinking HIV prevention: Critical assessments of the content and delivery of AIDS risk‐reduction messages Ralph Bolton
a b c
& Merrill Singer
d e
a
Professor of Anthropology , Pomona College , Claremont, CA, 91711 b
Chair of the AIDS and Anthropology Research Group , Society for Medical Anthropology c
Member of the AIDS and Anthropology Task Force , American Anthropological Association d
Deputy Director of the Hispanic Health Council , 98 Cedar Street, Hartford, CT, 06106 e
Chairperson of the American Anthropological Association Task Force on AIDS Published online: 12 May 2010.
To cite this article: Ralph Bolton & Merrill Singer (1992) Introduction. Rethinking HIV prevention: Critical assessments of the content and delivery of AIDS risk‐reduction messages, Medical Anthropology: Cross-Cultural Studies in Health and Illness, 14:2-4, 139-143, DOI: 10.1080/01459740.1992.9966071 To link to this article: http://dx.doi.org/10.1080/01459740.1992.9966071
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses,
actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content.
Downloaded by [Memorial University of Newfoundland] at 05:00 29 January 2015
This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/ terms-and-conditions
Medical Anthropology, Vol. 14, pp. 139-143 Reprints available directly from the publisher Photocopying permitted by license only
©1992 Gordon and Breach Science Publishers S.A. Printed in the United States of America
Downloaded by [Memorial University of Newfoundland] at 05:00 29 January 2015
Introduction. Rethinking HIV Prevention: Critical Assessments of the Content and Delivery of AIDS Risk-Reduction Messages Ralph Bolton and Merrill Singer Key words: AIDS prevention, HIV, AIDS education, medical anthropology
In 1989, Medical Anthropology became the first journal in the field to devote an entire issue to anthropological research on the AIDS pandemic. As Lawrence S. Greene, the Editor-in-Chief, pointed out in a prefatory note at that time, "we anticipate further issues on this timely subject in the future." Indeed, even before that issue appeared, at the annual meeting of the Society for Applied Anthropology in Santa Fe, New Mexico in April of that year, the co-editors of the present issue met with Greene to begin to plan future special issues of the journal on the AIDS crisis. In our discussion we observed that despite growing involvement of anthropologists in AIDS research, too little attention was being focused directly on the critical task of improving the design of educational efforts aimed at stopping the transmission of HIV. As a result, we resolved to pull together an issue devoted to the topic of HIV prevention. Anthropological research on AIDS encompasses a broad spectrum of inquiry (Bolton, Lewis, and Orozco 1991), and the results of these investigations have deepened our understanding of many dimensions of the epidemic. Such studies include: symbolic analyses of AIDS discourse; surveys of adolescent attitudes toward sexuality and AIDS, the response of health-care personnel toward AIDS patients, and general population knowledge, attitudes, and risk behaviors; ethnographies of drug using populations; discussions of ethical and methodological issues in AIDS research; experimental evaluation of the effectiveness of culturally specific AIDS prevention programs; and societal responses to the epidemic. All of these approaches have yielded important data and contributed valuable insights which should inform our efforts to cope more successfully with the AIDS crisis. Nonetheless, we sense that much of our collected effort is too far removed from RALPH BOLTON IS Professor of Anthropology at Pomona College, Claremont, CA 91711. He is Chair of the AIDS and Anthropology Research Group (an affiliate of the Society for Medical Anthropology) and a member of the AIDS and Anthropology Task Force of the American Anthropological Association. His current work focuses on cognitive mapping of the domain of sexuality and on the structure of sexual encounters. MERRILL SINGER is Deputy Director of the Hispanic Health Council, 98 Cedar Street, Hartford, CT 06106. He is Chairperson of the American Anthropological Association Task Force on AIDS and is the Principal Investigator on Project COPE, A National AIDS Demonstration Research Project (NADR) funded by the National Institute on Drug Abuse.
Downloaded by [Memorial University of Newfoundland] at 05:00 29 January 2015
U0I12] R. Bolton, M. Singer the needs and concerns of the men and women who are on the front lines of the battle to halt the transmission of HIV, those who design and implement on-theground programs of intervention intended to reduce high-risk behaviors. As anthropologists, we must raise the question of how we can help them to make their efforts more effective. We are all aware of the serious financial constraints faced by community organizations engaged in HIV prevention. These budgetary considerations make it all the more imperative for prevention activists to be as effective as possible. Since 1989 biomédical research has produced therapeutic improvements which promise to extend the lives of those who are infected, and candidate vaccines that may eventually prevent infection from occurring are in various stages of development. Still, no biomédical fix is in sight and there are no guarantees that such a solution to AIDS will be forthcoming in the long run, let alone in the near future. Moreover, even if a vaccine or effective treatment were available, it is far from certain that they would be widely distributed and equally available to all populations, social classes, and subgroups across the globe. The prevention of new infections through education, therefore, must remain as one of our highest priorities. By training most anthropologists are not equipped to make serious contributions to potential biomédical solutions to the epidemic, but because of our expertise in social and cultural processes, we are singularly prepared to make major contributions to educational approaches to HIV prevention. After all, HIV prevention is first and foremost a problem in culture change. While the goal of prevention efforts is to reduce risk-taking by individuals, the processes whereby that goal is accomplished are necessarily social and they occur within specific cultural contexts. Although the papers in this volume deal with HIV prevention in enormously different target populations, all of them emphasize the importance of basing prevention programs on a thorough comprehension of the social and cultural systems of the people for whom the program is intended. Bolton's paper offers a critical assessment of the role of promiscuity in the epidemic and of a prevention strategy which attempts to reduce HIV transmission by advising people to reduce the number of their sexual partners. This strategy, he argues, is derived from moralistic approaches to AIDS which ignore sexual values and behavioral realities and exemplifies the unwarranted application of epidemiologic concepts and findings to the design of prevention programs. The unintended consequence of the partner-reduction message has been to reduce the salience of safe-sex messages, thereby compromising their effectiveness. His analysis suggests that at least in sex-positive subcultures the outcome of this strategy has been to increase rather than decrease HIV transmission. Bolton recommends the elimination of references to multiple partners as a risk factor in AIDS prevention messages. In her paper, Schoepf describes the action-research in which she has been involved in Zaire, one of the epicenters of the AIDS pandemic in Africa. She points to the need to de-medicalize AIDS prevention and to develop community-based interpersonal methods of AIDS education which empower people to make riskreduction behavioral changes. The case study reported in this paper demonstrates the important point that while cultural knowledge is essential in designing prevention programs, cultural explanations for the failure of prevention programs must
Downloaded by [Memorial University of Newfoundland] at 05:00 29 January 2015
Rethinking HIV Prevention 131/141 not be accepted at face value. Schoepf and her associates in Zaire found that although cultural impediments to the use of condoms do exist, traditional beliefs and values did not stand as insurmountable obstacles to promoting condom use. By enlisting traditional healers in AIDS prevention, Schoepf and her African colleagues were able to induce a process of cosmological reinterpretation which made condoms more culturally acceptable. The safer-sex approach to risk-reduction has proven to be highly effective in promoting behavioral changes in the domain of sexuality, especially among gay men in Europe and the U.S. Instead of focussing on the dangers of sexuality, this approach emphasizes the positive values of sexual pleasure and the importance of empowering individuals and communities to make changes in their sexual practices which simultaneously reduce the risk of HIV transmission and enhance sexual fulfillment. In their paper, Taylor and Lourea describe a dynamic model which can be used by AIDS educators to generate safe-sex interventions that are sensitive to the individual, cultural, and social attributes of specific target audiences. Based on the authors' extensive experience in offering safe-sex workshops and other performances, this paper, which is unique in the prevention literature, offers valuable, detailed advice on how to design safer-sex interventions. While the first three papers in this volume are concerned solely with the sexual transmission of HIV, the paper by Singer, Jia, Schensul, Weeks, and Page examines HIV prevention among injection drug users (IDUs) for whom multiple transmission routes exist, thereby complicating the prevention process. The authors of this paper convincingly challenge the homogenous portrayal of IDUs commonly found in the media. By comparing the participants in their studies in Hartford, Connecticut and Miami, Florida, they reveal major differences in the beliefs and behavioral patterns of these two populations. Given these differences, they argue that to be effective prevention strategies must be grounded in an ethnographically holistic awareness of the local context. Their analysis underscores, too, the importance of providing in each setting multiple types of interventions, such as street outreach education, bleach distribution, drug treatment programs, and sterile needle exchange projects, among others. These authors have been engaged for a number of years in implementing and testing the efficacy of many of these strategies in reducing risk behavior and seroconversion among IDUs, their sex partners, noninjection cocaine users, and professional sex workers. Susser and González discuss their work on a prevention project carried out among homeless men living in a shelter in New York City. Given the enormous difficulties in survival confronted by the homeless, HIV prevention in this context presents special problems. The authors argue that in this setting to effect changes in risk behavior it is necessary first to initiate a process of re-evaluation and recreation of a sense of identity. Their innovative approach to prevention involved engaging these homeless men in the making of a video addressing HIV infection among shelter residents. In collectively writing a script for the video, the participants not only became better informed about AIDS, but they also generated valuable information on the drawbacks and possibilities of various prevention strategies. This action research triggered a response of group self-help. Fostering such responses, the authors note, should be a primary goal of anthropologists working on HIV prevention.
Downloaded by [Memorial University of Newfoundland] at 05:00 29 January 2015
142/[4] R. Bolton, M. Singer In the final paper, Bolton, Vincke, Mak, and Dennehy explore the connections between alcohol consumption and risky sex. In the prevention literature the conclusion that drinking increases sexual risk-taking appears to be firmly entrenched, and most prevention programs convey the message that sex and alcohol are a dangerous combination. The authors conclude that this claim rests on a shaky empirical foundation. In their research among Belgian gay men they failed to find significant relationships between alcohol variables and sexual risk-taking; moreover, their review of the scientific literature suggests that most studies of this hypothesis have failed to replicate the findings of the early research on this subject. They advance several hypotheses to account for this "vanishing" co-factor of risky sex, including the possibility that such a relationship may exist in limited sociocultural contexts. However, they argue that rethinking the alcohol message is essential and that it may be necessary to turn the former message upside down. By allowing alcohol to serve as an excuse for risky behavior, we may inadvertently encourage risk taking; by telling people that alcohol does not cause risky behavior, we may encourage them to take responsibility for their actions. The papers in this volume challenge some of the most basic assumptions in HIV prevention. They question conventional wisdom on fundamental issues. We hope that they will stimulate debate and research on how to improve the content and delivery of HIV prevention messages. Despite the diversity of settings represented in these papers, a common theme emerges: prevention works best when it promotes change through individual and community empowerment strategies informed by holistic understandings of the local context, when it acknowledges the positive contributions of local cultural values to the process of change, and when it incorporates an array of options that permit individuals to transform their lives in ways that enhance their physical, emotional,
and material well-being. Prevention efforts fail when they revictimize and stigmatize those who do not accept messages incompatible with their basic values and needs, when they blame those whose behavior suggests recalcitrance or relapse from risk standards established by health "experts," when they are based on top-down rather than community-designed and implemented approaches, and when they are shaped by the moralistic and authoritarian models advocated by political, religious, and medical leaders whose agendas may be inimical to the best interests of the clients of many prevention programs. HIV prevention in the 1990s may be even more difficult than it was in the 1980s. We ignore at our peril the lessons of the first decade of the epidemic. As anthropologists we need to use our special vantage point to help rethink prevention. Fortunately, this process has begun. In October 1991, approximately 30 anthropologists who are actively involved in AIDS research, programming, and policy issues, gathered together in Atlanta, Georgia for a conference on AIDS and Anthropology in the United States. With the support and active participation of the Centers for Disease Control and many CDC staff, the conference served as a state-of-the-art review of anthropological contributions to AIDS prevention research and community AIDS education and empowerment efforts. It was evident at this conference, as well as at several smaller anthropological conferences on AIDS that took place at the University of Pennsylvania, Hunter College, the New School for Social Research, and at other sites during 1991, that anthropology demonstrates a number of notable strengths in responding to the AIDS crisis. Many of these strengths are
Downloaded by [Memorial University of Newfoundland] at 05:00 29 January 2015
Rethinking HIV Prevention [5]/143
displayed in the papers included in this collection. Moreover, the anthropological imprint can already be discerned in numerous AIDS prevention projects within the United States and across the globe. While the number of anthropologists directly involved in responding to the epidemic remains comparatively small, their impact has been felt to a far greater degree than in many areas of applied research and program/policy design. However, it is also clear that there is much work to be done and many gaps remain in anthropological AIDS understanding and involvement. During the Atlanta conference, for example, it was evident that we lack critical knowledge about issues like the sexual behavior and attitudes of many (if not all) populations; the culture of service providers and the effect of this culture on AIDS service provision; the role of social relations structured around class, gender and ethnicity on participation in risky behaviors; the means of effectively involving so-called hard-to-reach populations like the homeless, sex partners of FVDUs, and gay men from ethnic minority communities; the configuration of life history factors (e.g. child abuse, domestic violence) that generate and shape risk behaviors; the contributions of anthropological insight to secondary prevention and treatment; and the operational understanding of cultural and gender appropriateness in prevention programs. A similar range of issues could be developed for AIDS efforts in the Third World. Items like these constitute the agenda for AIDS and anthropology as we move into the second decade of the epidemic.
REFERENCES CITED Bolton, R., M. Lewis, and G. Orozco 1991 AIDS Literature for Anthropologists: A Working Bibliography. The Journal of Sex Research 28(2):307-346.
