Sexual self-defense versus the liaison dangereuse: a strategy for AIDS prevention in the '90s

Abstract

The present public health strategy to encourage the adoption of "safe sex" practices to contain the AIDS epidemic in America is incomplete. Current policy is responsive to and appropriate for control of homosexual, but not heterosexual transmission. Powerful societal forces restrict a woman's perception of risk. Consequently, the adoption of safe sex (condom use/insistence on use) by women at risk has not matched safe sex practice by homosexual men. Predictably, pattern two (heterosexual, maternal-fetal) HIV transmission is now rapidly increasing in the United States, particularly among minority women. In anticipation of an intensified pattern two subepidemic, AIDS containment policy should be reoriented to develop the role of women in AIDS prevention. An initiative, termed "sexual self-defense" (SSD), combines the technology of double-barrier (female irrespective of male) protection with a "universal precautions" approach to long-term sexual risk management. The initiative addresses both per-contact infectiousness and new partner acquisition, the principal determinants of HIV spread. As a female-targeted strategy, SSD is a timely supplement to existing programs, consistent with the direction of contemporary women's movements in the United States. A "street smart" approach, SSD bridges ethnic and socioeconomic individual differences. As a unifying philosophy of risk management in health promotion, SSD may avert the threatened fragmentation of AIDS control from existing programs of sexually transmitted disease control and teenage pregnancy prevention.

PIP: Current efforts to control the spread of AIDS in the US are lacking for a variety of reasons. Pattern 1 male homosexual transmission has seen a significant drop because of education and prevention campaigns within the gay community. Pattern 2 heterosexual/maternal-fetal transmission has seen a significant increase because of a lack of effective programs to directly address this particular subepidemic. The AIDS deaths for women 15-44 have increased 75% over 3 years. Neonatal infection rates of 1.0-2.4% are common in metropolitan hospitals. The best method of serving this need is the sexual self-defense(SSD) concept. This program incorporates changing heterosexual women's attitudes an perceptions about risk, and changing their behavior so that they universally use double barrier protection for all sexual activity. Double barrier protection includes condoms and spermicides like nonoxynol-9. The biggest obstacle has been a failure by women to see their risk factor properly. Another problem has been the Bush administration's failure to properly frame the problem. The Presidential Commission on The Human Immunodeficiency Virus lists hemophiliacs over bisexuals an IV drug users as risk groups. Studies has shown that 50% of HIV-infected women attending family planning clinics do not associate their sexual behavior with high risk. Thus voluntary testing for HIV could be missing 50% of the infected women because they do not consider themselves at risk and thus do not get tested. Another problem stems from the fact that condom use is very low in primary relationships. Men may use condoms when they see prostitutes, but will not use them with their girlfriend. This behavior exemplifies the misperception of risk. Just as the defensive driving program got people to drive safely, SSD must get people to have sex safely. It is the responsibility of the government to educate the people about SSD, just as the surgeon general educated people about the risks of smoking in 1964.