When Public Health Dean Michael Merson began discussing AIDS prevention with colleagues at Yale several years ago, it occurred to him that prevention research had to follow the path of the epidemic. A disease that had already mobilized the gay community, AIDS was becoming an ever-increasing threat to the poor, minorities, women and injecting drug users. The four projects that ultimately became the focus of the Center for interdisciplinary Research on AIDS are concentrating on those at-risk groups.
CIRA stands out for its interdisciplinary approach, bringing together physicians, psychologists, anthropologists, lawyers, statisticians and others to work toward the common goal of preventing AIDS. “If you really want to have effective prevention measures,” Dr. Merson says, “you need the skills of all those people.”
Convincing the most vulnerable to avoid risky sexual activity is the task of Peter Salovey, Ph.D., a Yale psychologist who with colleague John D. Mayer developed the theory of emotional intelligence popularized in a recent book by author Daniel Goleman.
“Clearly our traditional AIDS messages aren't reaching certain people,” says Dr. Salovey, professor of psychology and of epidemiology and public health. “The field has done a lot of work on delivering educational messages to people about HIV and safer sex, but they have not paid attention to the nature of those messages.”
Dr. Salovey, who is also the co-director of CIRA, is conducting a study based on prospect theory, which proposes that both negative- and positive-framed messages can work in different situations. For example, Dr. Salovey theorizes that accentuating the negative works best for detection behavior: If you don't get a blood test, you won't find out you are sick and get the treatment you need. Positive messages, he believes, will work best for prevention behaviors: Wear a condom and you'll stay healthy.
His study, which comprises three experiments, will compare the effects of four videos about detection measures, including HIV-testing, and prevention behaviors, such as condom use. Each experiment will follow about 500 poor Latina and African-American women recruited at community health centers in New Haven to determine whether positive- or negative-framed videos work best and whether participants take HIV tests, abstain from risky sex or use condoms as a result.
High-risk drug sites
Anthropologists and outreach workers in Hartford want to find out whether there are rules of conduct in places where people use drugs—crack houses, shooting galleries and abandoned buildings. “Can we make use of the fact that there are rules to establish other rules for AIDS prevention?” asks Margaret R. Weeks, Ph.D., associate director of the Institute for Community Research and director of this project. The Hispanic Health Council in Hartford is also working on the project. The institute and the council are each providing an anthropologist and an outreach worker to probe drug networks in the city. Could people who control drug sites distribute clean needles or discourage needle sharing? The research will take place over three years at 16 sites where people use drugs. “Typically we go with them to the site to see how they are using drugs and what goes on there,” says D. Scott Wilson, Ph.D., one of the anthropologists working on the study.
Benefits of needle exchange
A related project will track the spread of benefits from needle exchange programs. Studies have shown that needle exchanges slow the spread of HIV and hepatitis B, draw drug users into treatment programs and serve as a vehicle to disseminate information about AIDS. The researchers want to determine how deeply those benefits penetrate into communities of drug users.
“We already know the people who use the exchange benefit from it,” says Robert Heimer, Ph.D., associate professor of epidemiology. “There's no question about that. The question is, 'Is this benefit available only to people who come and exchange needles directly?' ” Using color-banded syringes that will be distributed to 150 injecting drug users in Hartford, 150 in Oakland and 240 in Chicago, they'll track usage patterns over four years. They plan to follow a total of 5 million needles from index participants in exchanges to a second level of drug users who don't participate but know people who do. They will continue to track the needles to see whether they penetrate a third level of drug users who neither use the exchange directly nor know anyone who does.
Dr. Heimer and Edward H. Kaplan, Ph.D., professor of management sciences and of public health, previously concluded that New Haven's needle exchange program reduced the rate of new infections by a third. In one of the first federally funded studies of needle exchanges, they logged when and where needles were distributed, who received them, when and where they were returned and who returned them. They then checked the used syringes for HIV. They found that a needle's street life dropped from about two weeks to a few days and that usage dropped from an average of eight to 12 times per needle to between one and five times. The study also showed lower percentages of syringes with blood from HIV-infected people and hepatitis B-infected people. Dr. Heimer's research has shown that the virus can survive in a syringe for up to a month, depending on how much blood is in the syringe and how much of the virus is present in the blood.
“What is left to do,” he says, “is to determine who benefits and who doesn't from needle exchange programs, to determine where operations can be improved to maximize their impact, and to create enhanced needle exchange programs that target people who are at highest risk.”
Pregnancy and disease
Jeannette R. Ickovics, Ph.D., is examining how adolescent relationships bear on pregnancy, risky sexual behavior and sexually transmitted diseases. Her study focuses on 600 girls ranging in age from 14 to 19, half of whom will be pregnant. “I think the question, particularly for adolescents, is whether or not pregnancy is by choice, by chance or by coercion,” says Dr. Ickovics, assistant professor of epidemiology and psychology. “The very behavior that put them at risk for pregnancy—unprotected intercourse—also puts them at risk for sexually transmitted diseases.”
She plans to recruit the subjects of her study at hospitals or health centers in Hartford, Bridgeport and New Haven. Dr. Ickovics said she will ask how many sexual partners they've had, how often they have sex and whether the sex was protected.
“Past behavior is the best predictor for future behavior,” Dr. Ickovics says. The study will follow the teens over two years to determine whether those who are pregnant become pregnant again and whether others become pregnant for the first time.
“We certainly hope to use the information to develop interventions that will limit and reduce the risk of adolescent women for both pregnancy and sexually transmitted diseases.”