(This draft was later published in Sexual Interactions and HIV Risk, Taylor & Francis, 1997.


Marking Time in Frameworks Explaining Sexual Behavior & Risk of HIV Infection
Mitchell Cohen, INSERM U263, Paris & HIV Center, New York
Michael Hubert, Facultés Universitaries Saint-Louis, Brussels


I. INTRODUCTION.........................................................................................................................1
A. Time and the AIDS Epidemic.............................................................................................................................1
B. Time and HIV/AIDS Prevention.........................................................................................................................3
II. TIME: SOCIETY AND COMMUNITY..................................................................................4
A. Inter-generation cultural transmission of norms.................................................................................................4
B. Intra-generation transmission of current trends and styles.................................................................................7
C. Stages of the HIV epidemic.................................................................................................................................9
III. TIME: THE INDIVIDUAL....................................................................................................12
A. The time frame for expected outcomes.............................................................................................................13
B. Sequence of developmental stages....................................................................................................................14
1. Stages of decision making...........................................................................................................................14
2. Life cycle stages...........................................................................................................................................15
IV. TIME: PARTNERS INTERACTION...................................................................................16
A. Social Norms, Attribution and Coorientation of Partners & Peers..................................................................16
V. DISCUSSION AND CONCLUSIONS....................................................................................17
Marking Time in Frameworks Explaining Sexual Behavior & Risk of HIV Infection
Mitchell Cohen, INSERM U263, Paris and HIV Center, Columbia University, New York
Michael Hubert, Facultés Universitaries Saint-Louis, Brussels


Many communities
in the world are battling an AIDS epidemic where sexual intercourse is a
major mode of transmission. Until a vaccine is developed, one goal of HIV/AIDS prevention
programs is to reducing the future impact of AIDS by influencing present sexual behavior.
Identifying those factors which are related to the adoption and maintenance of safer sex is one
goal of HIV/AIDS prevention research. Once identified, HIV/AIDS prevention programs can
develop interventions with individuals, partners and communities that emphasize those factors
related to behavior change.

The purposes of this paper are first to make explicit the place of time in determining factors
related to sexual behavior change and, second, to suggest ways in which interventions can be
more effective by taking into account time.

A. Time and the AIDS Epidemic

An epidemic occurs over time. In some instances, like the common cold, the virus is diffused
throughout the population at risk over a few months, with those who contract the virus showing
the symptoms of fever and running noses within a week or two. Within a community, the
HIV/AIDs epidemic is much longer and severe, with nearly 100% of those infected with HIV
dying of AIDS. The 5 to 10 year time lag between infection with HIV and the manifestation of
AIDS means that a community can be highly infected before symptoms appear and the health
care system acknowledges the severity of the problem.

In Figure 1, the solid line A represent an HIV epidemic curve for a community in Europe with an
existing prevention program. From this curve it can be inferred that a combination of viral
saturation in the community and change in behavior between 1982 and 1984 resulted in a decline
in HIV infection incidence, but there was an increase in unsafe behavior between 1989 and 1990
causing an increase in incidence.

"Community" is used throughout the text to refer to populations bound by some common self-identifying
geographic and psychosocial trait. While HIV/AIDS prevention programs are often planned at a national level the most
effective programs speak to the needs of specific communities effected by the epidemic.

The goal of HIV prevention programs is to change the severity of the HIV infection in a
community and/or to shorten the time and scope of the epidemic. For example, in the same
community, if an HIV prevention program were more successful it might produce an epidemic
curve like the dashed line B in Figure 1, reflecting a reduced yearly incidence of HIV, but an
equally long epidemic. Everything else being equal, the sustained lower incidence level suggests
a more rapid and consistent adoption of safer behaviors by many, but not all, of the at risk
subpopulations. Several questions are suggested:

•What types of behavioral changes cause the increase in incidence to slow?
•What types of behavioral changes cause the incidence to continue among certain
subpopulations at a lower but sustained level?
•Why was behavior change sustained by some but not everyone?

Another set of interventions in the community might produce an epidemic curve like the one
represented by the dotted line C, which shows a rapid increase, then a very rapid drop in HIV
incidence without a subsequent increase in infection during the tail. Everything else being equal,



that scenario suggests a somewhat faster spread of HIV, but then a very rapid and sustained
response by virtually all members of the population at risk. This curve begs the questions:

•What behaviors caused the epidemic to explode between 1980 and 1983?
•Did the virus saturate the community or was there a dramatic behavior change causing the
plummeting decline in HIV incidence?
•Why did virtually everyone in the community sustain the behavior change?

Given that there is no vaccine to prevent HIV infection, both scenarios depend upon changing
current social patterns and behaviors and sustaining the practice of safer sex in the community.
The next section suggests that in explaining the factors related to change time is a key factor.

B. Time and HIV/AIDS Prevention

Sexual intercourse occurs between partners at a particular moment in time. While one
explanation of why partners engage in "unsafe" sexual intercourse
is "the heat of the moment",
few would suggest that sexual behavior can be understood by only investigating that instant in
time where partners engage in sex. Many theories hypothesize that sexual behavior depends
upon the cultural norms, individual information processing, and partner interactions that precede
a particular sexual act. In almost all theories time is a crucial component -- yet the role of time is
often unstated.

Keeping an eye on time assists in determining what types of intervention are likely to result in a
decrease in unsafe sexual behavior and a corresponding decrease in HIV incidence. Table 1
displays the different perspectives of time for various levels of intervention.

"Unsafe sex" in this text refers to sex without a condomwhere the HIV status of the partner is not known for certain
or one partner is seropositive.


Inter-generation cultural transmission of norms
Intra-generation transmission of current trends and styles
Stages of the HIV epidemic
INDIVIDUAL The time frame for expected outcomes
Sequence of developmental stages
Decision making
Life cycle
INTERPERSONAL Sequence of interactions between peers and partners
Sequence of relational stages

From the society and community level, sexual behavior is viewed from three perspectives: 1) as
a consequence of cultural or traditional values passed from one generation to the next, 2) as a
consequence of intra-generational events, and 3) as a consequence of the different stages of the
HIV epidemic. From the individual level, sexual behavior is viewed from another two
perspectives: 1) as the result of estimating outcomes based on "rational" decision making and 2)
as the consequence of progressing through (a) stages of decision making and (b) life cycle
phases. From the interpersonal-interactive level, sexual behavior is viewed from two
perspectives: 1) in terms of sequencing of interactions between peers and partners and 2) as an
effect of stages in a relationship.


A. Inter-generation cultural transmission of norms

When designing an HIV/AIDS prevention program directed at modifying sexual behavior, a
frequent bit of advice is "be culturally sensitive." This is short-hand for the recognition that
sexual intercourse is often best understood within the context of traditions and customs -- the
transfer of norms from one generation to the next. Clearly, there are vast differences in the way
sex and sexuality is treated in different societies and, within those larger societies, different
communities, and there are significant differences in the frequency and meaning of sexual
intercourse between different social, religious, and ethnic populations. Time, in this context,
represents an intergenerational consistency of sexual patterns and behavior.

One of the strongest traditional values held by many communities is the high status associated
with procreation. Often the positive status conveyed by offspring -- potent, powerful, vigorous,

fertile, etc. -- is much greater than that conveyed by fidelity to a single partner. In these instances
the function of sexual intercourse is primarily procreation. Where the status of men and women
rest on their ability to produce offspring, the advice to use a condom or practice safer sex is
likely to be ignored. Even for those women who are HIV positive, the cultural value of raising
children is often much higher than the threat of perinatal infection or the perception of infertility.
For example, in many communities in Africa, infertility often means the loss of a husband or the
inability to attract a spouse and isolation from the community (AIW, 93; Lallemant, 92).

In contrast, some communities have adopted a norm where pleasure seeking becomes the central
function of sexual intercourse. As societies become more urbanized and children are viewed as
more an economic burden than economic asset, there is evidence of a desire for smaller families.
Also as child mortality decreases the necessity of large families to assure that the lineage
continues is reduced. Increasing rates of abortion in some countries in Europe, for example,
(CAN WE PRODUCE A CHART?) is one indication of a lower desire to have large families.
Another symptom of the change in norms to sex-for- pleasure is an increase in sex work in urban
areas in developed and developing countries. The cultural messages conveyed by the media
emphasize sex ( ) and, as the demand for sexual pleasure increases, sex work becomes a major
source of income for many who cannot find employment elsewhere or who find the pay higher
than in other areas of work. From an HIV prevention perspective, those communities which have
a norm of sexual intercourse for pleasure rather than procreation, would be more receptive to
adopting safer sex.

The diversity of cultural traditions has been documented in Africa, and it has been shown that a
number of cultural differences effect the spread of HIV. In some Central African societies men
traditionally prefer women having a dry vagina during intercourse. This leaves women more
susceptible to lacerations which facilitate transmission of HIV (Carrier et al. ?). In some tribes in
Western Africa, the tradition of the brother-in-laws `adopting' the wife of a deceased brother and
consummating the adoption with sexual intercourse is particularly likely to increase the spread of
HIV because many of the husbands' deaths are now due to AIDS (Caldwell, 89). In Rwanda,
Taylor (90) found that there was a high value placed on the exchange of semen, and this value
greatly limited the use of condoms, despite high awareness that they reduce the risk of AIDS.
Other cultures also place a high value on the exchange of fluids while having intercourse ( ).

In many communities cultural norms often reflect religious values. For example, some
community members object to the use of condoms because their religion prohibits the use of
contraceptives. In one instance, in Tanzania, the understanding of this cultural constraint by
those establishing HIV/AIDS prevention programs led to a redefinition of condom use by the
Muslim clergy from contraception to a method of disease prevention. In that context the
religious leaders could encourage their congregation to use condoms. For orthodox Catholics the
Pope's directive against artificial methods of contraception and his advocacy of procreation,
creates a conflict between disease prevention and loyalty to the church. For those with strong
religious ties, this creates a significant barrier to adopting condoms.

Different cultural values related to homosexuality can greatly effect the effectiveness of HIV

prevention programs. Because of the high probability of transmission of the virus though
unprotected anal intercourse, several HIV/AIDS prevention programs are directed toward
homosexual populations. Some of the first HIV prevention programs were designed by relatively
self-contained gay communities, defined by their own social and communication networks
(Abramson, et al 90; Connell, Stall...). Even within gay communities there are diverse norms.
Pollak in France ( ) and Kelly ( ) in the US suggest that rural gay men are different in their
behavior and attitudes than urban gay men. In part, the success of HIV/AIDS prevention
programs has been the exploitation of those networks to diffuse prevention messages.

These gay communities are, however, a fairly new phenomena of the twentieth century.
Homosexual behavior has a much longer tradition. For example, in the Kalepom Island, New
Guinea, homosexual behavior is part of a rite of passage where younger men are initiated with
the seamen of older men (Gray, 92). In this instance there may be little threat of HIV
transmission because the virus has not been introduced to that culture.

In Latin and South America, homosexuality is practiced in a broader context of a larger sexual
repertoire which includes bisexuality and frequently the insertive partner is not viewed as "gay".
This "machismo" behavior co-exists with exclusively homosexual and transvestite subcultures
(Parker et al., 91 [bisexual book]). When groups migrate from one country to another many
sexual customs continue. Carrier, 71 and Parker 91 show that the homosexuality of African- and
Mexican-American men differ considerably from that of Anglo-American men, and other studies
of ethnic populations have shown that there are notable differences in sexual behavior between
ethnic groups within the same country (...). In developing HIV prevention programs directed at
homosexual behavior, these differences in subculture should be considered.

Cultural biases about homosexuality may also effect prevention. For example, many health
educators believe that only homosexuals engage in anal intercourse. Yet, in many communities
anal intercourse is practiced between heterosexuals and it functions as a form of birth control,
sexual pleasure, and rite of passage. Due to this bias, some communities have adopted the
practice of anal sex as a way of preventing AIDS because prevention messages have mentioned
only unprotected vaginal intercourse as risky sexual behavior.

A general message, in addition to "cultural sensitivity", is, where possible and ethical, to
integrate and adapt HIV prevention programs within existing cultural norms so that they
complementary. This is generally more effective that establishing counter-cultural or entirely
new habits into a community. There are, however, times when HIV prevention carry an agenda
of empowering different at-risk groups, such as women, even in cultures where this is not the
norm. The strategy recognizes that empowering women to take greater control in sexual
decisions and ending sexual abuse to women will serve a to limit the spread of AIDS. For both
men and women, this strategy involved a complex program of changing norms as well as sexual

B. Intra-generation transmission of current trends and styles

Current trends and events are often a countervailing force to long held traditional norms. Every
new generation is confronted with unique circumstances and crisis that have an impact on their
sexual behavior. For the generation defining their sexuality in the late 1960s and early 1970s in
Western developed nations the wide diffusion of the contraceptive pill and the wide use of
antibiotics to cure sexually transmitted diseases permitted the valorization of "free love" with
multiple sexual partners, "open marriage" and other "counter-cultural" sexual experimentation.

The same generation saw the marked liberalization of policies in North America and Western
Europe of laws prohibiting gay men from meeting in public places. The increased sexual
networking in saunas and venues for sexual intercourse in the 70's and early 80's where seen as
evidence of a more open self-proclamation of gay identity. An unfortunate side effect was that
these venues provided the perfect environment for the spread of HIV.

The adoption of new lifestyles can also increase the risk of AIDS. For example the rise in recent
years of large intravenous drug use populations (IDUs) has caused a tremendous increase in HIV
infection because of the efficient transmission of HIV through shared needles or solutions and
the exploitation of sex to earn money or barter for drugs. The illicit drug industry was greatly
expanded during the cold war as a way to finance clandestine political and military opposition in
the South East Mediterranean, southeast and northeast Asia and South America. Drug suppliers
found a ready market in both the urban ghettos of developed countries and among the large
middle class "baby boom" generation in their late teens and early 20s. Over the past few decades
drug producers and cartels have become an industry in their own right offering substantial
economic benefits to those engaged in the drug trade, including distributors in low income areas
who have no other economic opportunities. On the deamnd side, for those addicted to drugs,
there is substantial documentation about the link between sex for drugs through commercial sex
work or more direct barter agreements ( ). While drug treatment programs and needle
exchange programs have proven effective in decreasing the spread of HIV infection ( ),
programs which provide alternative economic and social opportunities for those involved in the
drug trade are part of the longer term solution.

Wars, famine and poverty are crisis which produce migration patterns where families are
uprooted from their traditional support groups and sexual norms often change. Epidemics of
STDs, including AIDS, often follow military campaigns where there is a lively market for
commercial sex workers and, in many instances, where soldiers have raped and abused women.
Neguma (92) tells how the border conflict between Tanzania and Uganda produced the key
situational factors for the rapid spread of HIV: the available money from the highly mobil
soldiers, truckers and black market entrepreneurs created a great demand for sexual partners. The
active sexual networks, combined with great mobility and the introduction of the virus led to the
rapid and wide spread transmission of HIV in Eastern Africa.

Following the disintegration of the Soviet Union, The widespread migration patterns in Europe
and the numerous civil wars throughout Eastern Europe and the former Soviet Republics are, in

many ways, analogous to the experiences of Eastern Africa and are likely to provide fertile
ground for the rapid spread of HIV. Young women migrating to urban centers find that sex work
is the only means of survival, and in most situations the immediate needs of shelter and food far
exceed the threat of HIV and AIDS. Drug use is spreading, as drug entrepreneurs find it easier to
cross borders and demand is rising in southern and eastern europe.

One expression of liberty in Eastern Europe is the liberalization of laws forbidding
homosexuality. In these communities information about HIV and AIDS has been weak and
greater sexual activity has accompanied new found freedom ( ). A dramatic increase in HIV
infection is highly probable unless major intervention programs are begun. It would be tragic to
allow HIV to become widespread in these emerging gay communities given that knowledge
exists to mount effective prevention programs targeting gay communities. Never-the-less, the
many higher priorities of those governments, lack of experience with community based
organizations (CBOs), and poor economic conditions, are likely to mean the rapid spread of HIV

For the current generation the AIDS epidemic is a crisis that has caused changes in traditional
sexual behavior. In many countries in Africa, for example, there is a trend where mature men are
seeking intercourse with very young women because they fear contracting AIDS from the older
partners they have traditionally sought. Because many of the men are already infected, the
undesired result is a rising epidemic among very young women, but there is little doubt that the
motivation for this new behavior was a desire by men to avoid infection.

The media, both mass and interpersonal channels, create an environment where persons respond
to the AIDS crisis. Evidence from hotlines throughout the developed countries indicate that
major news stories and major HIV/AIDS prevention campaigns, such as the death of movie star
Rock Hudson from AIDS, the HIV infection of sports superstar Magic J ohnson, or the tainted
blood supply in France, spark public concern and response ( ). While increasing public
awareness is often the goal of public HIV/AIDS prevention programs, public response and
subsequent actions are not always positive or in the best interest of public health. For example
the stereotyping by the media of drug users and gays as those mostly effected by HIV led to
continued high risk sexual behavior by other at-risk populations and provided a convenient
rationalization -- "I'm not one of those". At the other extreme, the highly awarded Grim Reaper
campaign in Australia caused an overwhelming response by the pubic to get tested; but the risk
portrayed to the general public far exceeded the actual danger of the epidemic and thus lost
credibility and may have been, in the end, counter productive to promoting change toward safer
sex ( ).

The tension between long held norms and current pressures to change sexual behavior cause
many conflicts between generations and communities. To the extent that HIV/AIDS is perceived
as a serious, real and immediate threat by individuals and communities, sexual behavior change
is likely to be adopted. To the degree that safer sex is perceived of as "the other community's
problem" or a vehicle by one part of the community to suppress another part -- for example
viewing safer sex advice as a form of genocide by some African communities or as contraction

in personal freedom from some gay communities -- the result is likely to be the continuation of
long held sexual norms which provide a continued fertile ground for the spread of HIV.

C. Stages of the HIV epidemic

The unfolding of the HIV/AIDS epidemic itself may greatly effect sexual behavior. Time, in this
case, is the underlying dimension in the stages of the HIV epidemic. Cohen (92) describes four
stages of the HIV epidemic (Figure 2): The beginning stage of the HIV epidemic when the virus
is introduced, the peaking stage when the HIV epidemic has peaked in a particular community,
the declining stage, as the incidence of HIV infection declines and the tail stage where the
epidemic continues to infect the community at a relatively low level. The concept of time
underlying the stages of the epidemic is not calendar time, but rather time associated with the
progression of the epidemic in a community. Even within the same country, different
communities (as represented by neighborhoods, ethnic identification, sexual orientation, etc.)
may have different HIV epidemics.

Cohen ( ) suggests that different factors are related to changing to safer sex during different
stags of the epidemic, and communities could maximize their prevention efforts by designing
programs which emphasize those factors most related to change. Table 2 summarizes some of
the observed factors related to change and, in a community with a relatively stable population,
their varying relative effect over the different stages of the epidemic.
In the beginning stage of
the HIV epidemic, due to the time lag between HIV infection and manifestation of AIDS,
communities see few AIDS cases and there is little demand placed on families, partners, the
community or governments for prevention or health care services by those infected with HIV.
Ignorance of the epidemic is not usually the reason for lack of community and government
response. Due to the international response to AIDS from the World Health Organization and
international Nongovernmental organizations (NGOs), many communities in the early stages of
the epidemic are aware of HIV and of rising levels of infection. Governments, often with
international aid, act swiftly to insure the safety of blood supplies, but there is usually a far more
moderate response regarding prevention (AIW, 92).

This chart was developed as a result of a meta-analysis of the literature reported elsewhere (Cohen, 93).


Government response Low-Moderate Moderate High High
Self-Efficacy Moderate Moderate Moderate-Low Low
Community identity Moderate Moderate High High
Partner/peer pressure Moderate Moderate-high High High
Intimacy (negative relationship) Moderate Moderate High High
Aware of PWA/HIV+ Low High Moderate Low
Knowledge, attitudes & beliefs
about safer sex
Moderate Moderate Moderate-Low Low
Aware of serostatus Moderate-Low Moderate-Low Low Low

In some communities the lack of response during the initial stage is because other health
priorities and more clearly life-threatening diseases drain the resources of the public health
agencies. A second reason is the battle for the type of HIV prevention waged between the
"moralists" and the "pragmatists". Moralists advocate sexual abstinence, long term fidelity, and
legal punishment for perceived "abnormal" behavior, and pragmatists tend to offer risk-reduction
techniques such as condom use and nonpenetrative safer sex techniques (AIW, 92).

Government policy serves to facilitate or constrain behavior change. Policy leads to resources
and guidelines which permit access to information and services, and plays an important role
throughout the epidemic. Equally important, policy effects the rights of individuals, and there is
considerable evidence that those who fear being confined, isolated, or restricted in their access to
housing, insurance, and health care because of their HIV status are much less likely to seek
preventive advice and care ( ).

As shown in the first row in Table 2, by the time the epidemic is peaking, AIDS service
organizations (ASOs) that have been started are likely to receive government support for
expanded distribution of prevention and care services. During the declining stage, HIV
prevention programs are attempting to influence the more difficult-to-reach populations who are
less involved with community based organization, consequently government sponsored
programs tend to support the undeserved and unorganized populations in a community. By the
tail stage, maintenance of safer sex may be as difficult as its adoption, thus continued
programmatic and government support are highly related to maintaining safer sex.

The second row in Table 2 is based on the fact that, in many communities, the first individuals to

respond to the epidemic are those who have a strong sense of self-efficacy and who adopt safer
sex in response to their perceived risk. A subset of those individuals have a strong affiliation
with their community and start community based organization (CBOs) and AIDS service
organizations (ASOs) which often evolve into major HIV prevention and care organizations
(Cohen, 91a, O'Malley 92). During the initial period of the epidemic, the most effective response
comes from those CBOs which perceive a threat to their constituencies and design programs to
emphasize self efficacy. A tool used by many of these organizations is group discussions and
workshops, and evidence from San Francisco (Frutchey, 89) and other communities (de Vries,
Margo, et al. 88; Boer, Kok, et al., 91) is that group discussions and workshops serve to increase
self-efficacy through skills enhancement and thus promote change.

Over the stages of the epidemic, the impact of community organizations is likely to shift from
reinforcing self-efficacy to providing networks for peers and applying social pressure for change.
As these organizations grow they encourage a greater sense of community identification, and
they serve to contribute to peer networks where safer sex becomes the norm (Fisher, 88; Kippax
et al __). Consequently, as shown in rows three and four of Table 2, by the tail of the epidemic
programs emphasizing self-efficacy are relatively less effective (de Wit, Vroome, et al. 90b),
while those emphasizing community identification and partner/peer pressure are more likely to
promote change in behavior.

The fifth row of the table indicates that programs which address a need for intimacy increases in
importance over time. The need for intimacy remains high throughout the epidemic and is a
leading cause of engaging in unsafe sex ( ). By the tail of the epidemic, those who maintain
unsafe sex are the most difficult to reach and are very likely to say that intimacy with their
partners is a main motivation in engaging in unprotected sex. Peer and partner pressure for safer
sex are main counter pressures to this personal need of intimacy expressed through unprotected
sexual behavior.

The final three rows in the table represent HIV/AIDS interventions that convey primarily
information particularly awareness, attitudes, and beliefs about HIV and AIDS, persons with
AIDS (PWAs) or who are HIV positive, and one's own serostatus. Mostly during the initial
stages of the HIV epidemic, information heightens anxiety and leads to the adoption of safer sex
or a desire for information seeking which may then lead to safer sex. Thus information is likely
to have a marked impact during the initial stages of the epidemic. For others, safer sex is not the
only way to reduce anxiety. Cognitive defense mechanisms often produce rationalizations which
reduce perceived risk or lead to 'tuning out' undesired messages. Still others may welcome
participation in a 'risky' situation. Finally, some may become fatalistic and continue with unsafe
sex with full knowledge of the risk. For any community, information about unsafe sex seems to
more-or-less reach a saturation level by the tail of the epidemic. However, during the declining
and tail stages continued unsafe sex is related to negative attitudes about condoms and
misperceptions about the efficacy of different preventive methods ( ).

Many working in AIDS prevention feel that the main motivator for sexual behavior change will
be the personal awareness of someone infected with HIV or dying of AIDS. Studies indicate that,

at the peaking stage awareness of a friend or partner with AIDS or who is HIV positive is likely
to have a relatively larger impact on behavior change as it underlines personal vulnerability to
HIV infection ( ). However, it is clearly false that the change to safer sex is simply a function of
people becoming aware of persons with AIDS or seropositive status. There is ample evidence
showing that many persons who are aware of persons with AIDS (PWAs) and HIV positive
persons continue unsafe practices. While some of these unprotected practices may be a conscious
decision among partners of the same HIV status, the recent increase in HIV incidence within gay
communities in several Western urban centers indicates that simply knowing someone is
insufficient motivation for maintaining safer sex.

Knowledge of serostatus is no magic bullet for AIDS prevention. A prevention strategy
undertaken by many communities is to advocate HIV testing and counselling. Although there is
considerable evidence that knowledge of serostatus, particularly combined with counselling, can
increase the rate of change, it seems to make little difference in adopting safer sex at the tail of
the epidemic. While the availability of early treatment for HIV positive persons may lead to a
continued emphasis on providing anonymous testing, there is no evidence to suggest that
knowledge of HIV status will lead to a substantial increase in the adoption of safer sex.

In general, the trend over the epidemic reflects a diminishing impact of information and a
heightening of factors such as peer, partner and community pressure toward safer sex increase.
Programs that increase partner and peer pressure are likely to be strongly related to adopting
safer sex. Group sessions, safer sex workshops, participation in CBOs and other forms of
interactive programs are likely to continue to be effective because they rely on peer pressure and
support to encourage and sustain safer sexual behavior.


Several theories of sexual behavior have, as their root, the idea that an individuals, over time, try
to optimize their outcomes. From this "cognitive" perspective, sexual behavior, the outcome, is
equal to an assessment of the the risk of AIDS and some combination of knowledge, attitudes
and beliefs. For example, an equation might look like:

Condom use = Perceived risk of AIDS + level of awareness about access to condoms + sum of
the personal belief about efficacy of condoms + sum of the attitudes about condoms + beliefs
about others' use of condoms + Skill with using condoms.

A frequently cited theory in AIDS prevention research is the Health Belief Model (HBM) and
there has been considerable research directed toward the goal of proving or disproving it
(Robert, et. al. .., Pollak ?.;Porter et al ?; ). Like other optimization models, it suggest that
individuals will optimize their long term outcome by making a rational choice to adopt safer sex
-- once they understand that: 1) they are susceptible to the HIV infection, 2) HIV infection leads
to the fatal disease AIDS, 3) through safer sex HIV can be avoided, and 4) that they have the
resources to adopt safer sex.

Once all the essential components are discovered, and the correct weights attributed, the goal of
prevention programs, according to cognitive theorists, would be to emphasize those factors that
explain the greatest amount of adopting safer sex. Notably, for these theories to be relevant,
sexual behavior must be under the control of the individual -- a condition that often is not met
among those populations at risk for HIV.

A. The time frame for expected outcomes

From the perspective of time, an essential part of cognitive theories is the clarification of
competing needs for the individual and their proximity, in calendar time, to the individual.
Perhaps the main reasons researchers find generally poor support for the model is that, unlike
other diseases, the 10 to 12 year time lag between behavior which lead to infection and
manifestation of AIDS many be outside the typical frame of action. Other considerations about
physical appearance, approval of others, economic survival, and need for intimacy frequently
take precedence over a long term and uncertain outcome of unprotected sex. For example an
individual might ask him- or her- self what is more important...

- My health in ten years or falling in love tonight?
- Using a condom to protect my health or not raising suspicions about infidelity?
- The chance of getting AIDS or feeding my family?
- The change of getting AIDS or being made fun of by my peers?

Even if the HBM were to work as suggested by their authors and individuals were motivated by
the possibility of contracting HIV and AIDS, it has proven extremely difficult for individuals to
correctly perceive their susceptibility and the severity of the AIDS ( ) and/or admit that the long
term consequence of infection leads to fatal disease.

On a more methodological level, the assumption of cause and effect is another criticism of the
Health Belief Model (Moatti et al). They suggests that knowledge attitudes and beliefs are as
much a consequence of behavior as the cause of behavior; he notes that correlational analysis
used to prove the theory may actually represent rationalizations for behavior.

Still another criticism of the HBM is that it does not account for cultural values. Porter et al ( )
notes that the operationalization of the model "does not measure cultural variables, which we
expect to influence behavior, and has very few questions relating to social structure, except for
standard demographic questions." In answer to that criticism, cognitive theorist note that
regardless of "external" factors, the final decision to act is a product of the individual's
perception of the environmental information and thus is a product of attitudes and beliefs, and
the HBM does include perceptions of "external barriers".

Bandura's social cognitive theory (SCT) ( ) is other cognitive model and differs from the HBM
by adding the component of self-efficacy and suggesting that the individual's perceived ability
that he or she can successfully execute safer sexual practices is a major factor in adopting safer
sex. While the SCT allows for a person to be motivated to change their sexual behavior because

of the realization of long term consequences of risk behavior, in the short term the SCT
recognizes that peers and partners play an important role because they allow an individual to
learn through observation and modelling. Consequently sexual behavior change can be explained
as a short term imitation of behavior as well as a more distant calculated way to avoid AIDS. The
application for HIV prevention is that programs should be designed to empower individuals by
providing the skills and mind-set to control their own behavior.

B. Sequence of developmental stages

Most cognitive models place their emphasis on some assessment of outcomes by an individual.
In the area of HIV/AIDS research the distant negative outcome of AIDS is what motivates
persons to change their behavior. While static cognitive theories suggest similar outcomes given
the same knowledge, attitudes and beliefs, developmental theories focus on sequential changes in
the psychological structure of the individual which would cause him or her to interpret
information differently.

1. Stages of decision making

Catania's ( ) AIDS Risk Reduction Model (ARRM) introduces the importance of stages of
decision making in adopting safer sex. The ARRM starts with the same criteria as most other
cognitive models, that individuals perceive the risk of HIV infection based on their sexual
behavior. From that point it diverges from static models by emphasizing three stages of decision
making rather than the estimation of static levels of knowledge, attitudes and beliefs. The three
stages are: 1) labeling high risk behaviors as problematic, 2) making a committment to changing
high risk behaviors, and 3) seeking and enacting info seeking and obtaining remedies. The three
stages are shown in Table 3.

Catina et al ( ) does not speculate on the individual variation in the time it takes individuals to
move through the stages, nor does he believe these stages are universal. However, he does
suggest that HIV prevention programs can facilitate the passage form one stage of adopting safer
sex to the next by motivating action by introducing moderate levels of anxiety, developing
external motivation such a public health programs, and encouraging social networks to provide
support for safer sex.


Labeling Susceptibility, Transmission knowledge,
aversive emotions, social factors
Risk assessment for becoming HIV+
Committment Aversive emotions, Perceptions of
enjoyment, risk reduction, self-efficacy,
social factors
Intention to engage in safer sex in "x"
Enactment Aversive emotions, Sexual
communication, help-seeking, social
Practicing safer sex.

2. Life cycle stages

Another developmental sequence is suggested by Peto et al ( ). She suggests that individuals
pass through life cycle stages as they mature and that unsafe sex and risk of HIV is more likely
during some stages than others. The stages include: 1) discovery of sexuality and love; 2)
searching for a way of life and partner; 3) stabilization of a relationship; 4) deterioration of a
relationship, and 5) the life a person who wishes to live without a primary relationship. This
model focuses on psychological and developmental attributes over time rather than on
information processing and optimization of outcomes suggested by most cognitive models.

Life cycle models have received some empirical support in the domains of personal growth ( )
and religion ( ), but the suggested stages have not been tested in the realm of HIV/AIDS.
Hypothetically, during the discovery stage, knowledge and self-efficacy to engage is safer sex
are likely to be relatively low. Individuals engaged at this early stage have a biological drive to
experience sex and often a cultural expectation to find "love". Both of these drives place
individuals at risk because they are more vulnerable to their partners' wishes and less interested
in the probability of contracting AIDS.

As the individual enters the second stage of searching for a partner, many continue to be at high
risk. As stable relations become a possibility, suggesting the use of a condom may be seen as a
sign of lack of trust, an indication of fidelity, or an obstacle to love. Ideally, if the environment
were supportive, safer sex would be part of the negotiation about becoming sexually involved.
Unfortunately this is rarely the case, and the desire to search for a partner may require unsafe sex
as a statement of trust and love.

During the third stage of a stable relationship the individual probably has the lowest risk of
becoming HIV positive because the number of partners is limited and there is less sexual
experimentation. Some risk continues because, while a person may be monogamous, past
partners may have infected one of the partners. Also it is not uncommon for at least one partner

to have sexual relations outside their primary relationship. Research has shown ( ) that
unprotected sex in stable relationships is very likely to occur before the latency period of HIV is
passed or before the partners determine their serostatus and do not engage in any continued risky
activities. In cultures permitting multiple marriages or which place a value on multiple partners,
this stage may continue to have substantial risk of contracting HIV.

As relationships dissolve and one or both partners re-enter the sexual marketplace, there is again
a high risk. There is some indication ( ) that although most of these partners are knowledgeable
about HIV and AIDS, the habits of unprotected sex practiced in the relationship are difficult to
break and the lack of familiarity with condoms and other types of safer sex leave those re-
entering the sexual market more likely to have unsafe sex.

The notion that an individual passes through defined temporal stages require research to test the
various hypotheses. If they are true, then prevention programs can identify the individuals or
groups likely to be in one stage or another and target messages to influence the sexual behavior
associated with each stage.


A. Social Norms, Attribution and Coorientation of Partners & Peers

Several theories suggest that behavior is the result of an interaction between peers and partners.
Virtually every study that has measured the impact of partner and peer interaction has found it
significantly related to sexual behavior (Valdiserri, 89; Weisman, 89, MacDonald, et al., 90,
Catina, et al,90, Hunt & Davies, 91, Kelly, et al., 91). Several theories suggest the reasons why
partners and peers have such a strong influence. Each, however, require a sequence of
interactions and an expectation of an outcome.

Unlike the long term negative outcome of contracting AIDS, the positive and almost immediate
outcome of social acceptance and the gratification of pleasing others or the equally immediate
negative outcomes of social rejection and isolation may be powerful reasons to engage in unsafe
sex or adopt safer sex. The immediate reward of social acceptance is the underpinning of many
behavior modification programs, where peer pressure and public commitment are used to change
strong habitual (or addictive) behavior, and peer support is used to reinforce change (Hergenhan,

Partners and peers can also be role models. After personal experience, the most powerful stimuli
often come from social groups, peers and sexual partners, rather than stemming from personal
awareness of information (Rikert, et al, 91; Bandura, 77; Rosentock, Strecher, et al., 88).

Theories, such as Heider's (58) balance theory, would predict that behavior would continue in an
unaltered manner until it is challenged, for example by a disagreement between peers or partners.
There is clear evidence that the best predictor of unsafe sex is the previous practice of unsafe sex
(McCusker, Stoddard, et al. 89b,; Martin, 86; Connell, Crawford, et al., 89). From Heider's

perspective this would be an "understood" behavior between two partners, and, unless there was
a disagreement causing imbalance, the status quo behavior would be likely to continue. Once
there was disagreement, the partner with the greatest influence would be likely to persuade or
coerce the other into safe or unsafe sex.

Attribution theory (Heider, 58; Fisk, Taylor, et al. 84, Memon, 91) and Social Interaction Theory
(Friedman, Levine, et al. 86; McGuire, 91) suggest that behavior can be explained in terms of
one partner's perception or expectation of the other. For example, if one partner believes the
other would be offended by condom use, condoms would not be used -- regardless of the
partner's actual belief. The power of partners is suggested from many studies that indicate that
more unsafe sex occurs within a primary relationship than between men who are not in a primary
relationship or between men who also have sex outside their primary relationship (Bye, 87;
McCusker, Zapka, et al., 89b; Martin, Dean, et al, 89; Connell, Crawford, et al., 88a).

A key motivation for behavior for these theories is an expectation by one of the partners that the
other expects safe or unsafe sex, or it may reflect one partner's expected reaction to the other
partner about the use of safer sex. For example, one partner may believe that the other partner
would interpret using a condom as admitting to infidelity or lack of trust. In relationships, this
perspective suggests the importance of clarifying expectations with a partner and, in some
instances, negotiating safer sex before unsafe practices become the default behavior.

B. Relational Stages

Another interpersonal interpretation of sexual behavior hypothesizes that different sexual
behaviors are related to stages of a relationship. Petro et al ( ) suggests three stages: 1)
seduction, 2) familiarity, 3) denouncement. During each of these stages the type of relationship
and the experience of each partner in practicing safer sex is likely to effect the practice of safer


To understand the reasons an individual and partners adopt safer sex their past, present and
(expected) future have to be examined. As times passes the context and meaning of sex changes
for the community, an individual and partners.

At the community level, sexual behavior is often less the result of a collective rational decision
based on the potential danger of contracting AIDS, than the outcome of past customs and
traditions about the rites of passage to adulthood and childbearing. What is clear from the past
decade is that the advice to have protected sex runs counter to powerful traditional values placed
on fertility and procreation, the demands of the church, and the exchange of seamen.
Incorporating traditional values and customs and habits is often a key to developing successful
HIV prevention programs. An essential part of a HIV prevention program is understanding the
value that is associated with insertive intercourse in a community and determining if other means

of safer sex can be substituted and fulfill the same cultural needs.

A major barrier in HIV/AIDS prevention is overcoming traditional discriminatory views rooted
in religious traditions. Bolstered by the incorrect labeling of the epidemic as isolated among gay,
prostitutes and intravenous drug users, "moralists" have used AIDS as a symbol of the
consequences of a "deviant" life style (using as a referent a normal monogamous, heterosexual,
child bearing couple). The unsubstantiated, but often cited, argument that condoms promotion
encourages promiscuity is rooted in these types of beliefs. The persistent belief shown in surveys
that people assume they are not at risk because they are not homosexual, a drug user, a
prostitutes or a client of a prostitute confirms the resonance "moralist" theme has with many
communities. Moralists use current trends in more open homosexuality, rising drug use and
public sex work as evidence of decaying moral core and suggest that AIDS is some form or
restitution for immoral behavior. Many public health officials do not refute the argument that
HIV is concentrated in so-called deviant populations, but they argue that HIV will spread from
prostitutes, drug users and bisexuals to the general population and therefore must be arrested
before the spread of HIV to "innocent victims".

Countering this "moralist" perspective is a "human rights" perspective which believes that all
persons have a right to health services including HIV prevention and care. The human rights
advocates emphasize the changing trends in society as evidence of a failing public health system.
They observe the rising rate of teenage pregnancies and STD's who must, therefore, be targeted
for HIV/AIDS prevention. Sex work is understood as a symptom of a society that offers few
other economic incentives particularly to many women who have migrated to urban settings and,
therefore sex workers should be given the information and resources to avoid HIV infection.
Drug use is viewed as a symptom of poverty and, while viewed as harmful, IDUs have a right to
treatment and clean needles to reduce their risk to HIV. Gay and bisexual lifestyles are viewed as
a legitimate alternative to heterosexual relationships and therefore should be provided the tools
to limit HIV infection.

In many instances the response to AIDS has been sparked by critical event. Sports stars and
movie stars confessing that they have HIV or have died of AIDS or major newspaper articles
about AIDS, has heightened public interest and demand for prevention. While increasing
awareness is generally beneficial, raising anxiety among the worried well often drains resources
away from these most in need of services. The main source of information has been the mass
media, and while the mass media have a large potential role in disseminating information, if the
past is a guide, they will rarely consistently cover AIDS during the initial stages of the epidemic,
and then only from a predominantly moral and medical perspective (Albert, 88; Herzlich &
Pierret, 89). In general HIV prevention recommendations have largely been the domain of
advertisements, brochures, billboard and other promotional rather than editorial aspects of the

From a community perspective, perhaps the most powerful stimulus for community action is
stages of the epidemic itself. However, the belief that the epidemic is self-regulating once
persons are aware of other with AIDS has proven not true, and there is evidence that continued

prevention in the tail of the epidemic is necessary to maintain the adoption of safer sexual
practices. In some ways it is unfortunate that the short term consequences of risky behavior is
not more severe as perhaps the greatest obstacle to prevention is having persons place priority on
the 10 to 12 year outcome of HIV infection.

While effective early action when the epidemic first appears in a community could minimize its
impact. Unfortunately, most communities and governments respond late in the HIV epidemic,
and given the time lag between HIV infection and AIDS, by the time AIDS becomes a public
health issue, the HIV epidemic is well established in the community.

Many HIV prevention programs provide information to individuals which allow them to make a
rational decision that today's unsafe sexual act has a good chance in resulting in a fatal disease,
AIDS, in 6 to 12 years in the future. Monogamy (although usually advocated without the
necessary condition os mutual fidelity over several years) and the practice of safer sex, usually
condoms, are advocated as the best means of prevention. Unfortunately, researchers have clearly
shown that information alone is not the key to behavior change, although the suggestion that it
has little influence is overstated.

For those prevention programs with a goal of conveying information, theory suggests that the
cognitive process is complex and that increasing awareness is relatively easy compared to
creating positive attitudes toward safer sex and the belief that safer sex recommendations are
credible. For programs based on the premise that persons will "rationally" process information,
HIV/AIDs prevention programs must create believable messages and redress misperceptions
about methods of safer sex; overstating the risk of HIV infection can be counterproductive
because persons will not find the information credible and will, therefore, ignore the advice. For
example, belief that there are high levels of condom failure should be countered with clear
information about the strong relationship between condom use and seronegativity and the
reasons for failure. Advice should be provided on the correct use of high quality condoms,
including the proper use of water-based lubricants. Once basic information is disseminated, HIV
prevention should focus on developing positive attitudes about safer sexual methods, including

Shortening the time frame from action would be another strategy to improve HIV prevention
programs. Emphasizing shorter term consequences of safer sex such as associating safer sex with
erotism, love, intimacy and concern for partners rather than only emphasizing protection from
the longer term consequence of AIDS may result in more persons adopting safer sex. Erotic
formats and safer sex workshops assist in creating and reinforcing positive attitudes about safer

Even where programs are successful in conveying clear messages about unsafe and safer sex, it
is wrong to believe that all those who continue to engage in unprotected anal intercourse do so
because they do not understand the possible outcomes. Many make "informed" decisions and
others engage in unsafe sexual practices because it fulfills more immediate needs, such as the
need for social approval or intimacy with one's partner. Among steady partners there is a need to

rethink the definition of unsafe sex. For example, "unsafe" sex is usually defined as any
unprotected intercourse. Yet unprotected intercourse among two persons with the same
serostatus in a steady relationship does not fuel the epidemic. Prevention programs should
provide the information that allows partners to make informed decisions about their sexual lives
instead of excluding unprotected intercourse under any circumstance. Admittedly a more
situational definition of unsafe sex places a good deal of faith in the honesty of the partner, but
there is ample evidence that partners are much more likely to have safer sex outside of their
steady relationship while continuing unsafe sex within the steady relationship. Partners should be
encouraged to explore the meaning of safer sex in their relationship and strategies have to be
defined which recognize that the need for intimacy is often more immediate and stronger than
protection from HIV.

From the individual perspective, the work by Catania et al ( ) suggests that the individuals are at
different stages of readiness to personalize HIV prevention messages. He suggests that different
strategies should be established to facilitate the knowledge of the outcomes, the committment to
the behavior change, or the actual adoption and maintenance of the behavior. Programs based on
a progression of developmental steps have shown success in pilot studies ( ).7

Another developmental approach is to direct programs at groups in different life cycle stages.
The work by Petro et al ( ) suggests that there are different risks for persons exploring sexuality
than those in stable relationships. (ADD HERE)

From the perspective of partner and peers, HIV/AIDS prevention is an outcome of the sequence
and types of interactions. Attribution theory suggests that barriers hindering the adoption of safer
sex include the perception by one partner that other partner will believe that safer sex is an
indication of infidelity or lack of trust. Consequently, the positive values of safer sex, such as
safer sex being a act of caring and intimacy, should be stressed. Interpersonal programs such as
the STOP AIDS Project and safer sex workshops may be particularly effective because they rely
on peer support and pressure. The longer term objective of HIV prevention programs should be
to create a social norm of safer sex. Once this is accomplished, the expected outcome in a
relationship will be safer sex, and the opportunity to have unsafe sex will be greatly reduced,
regardless of one's level of knowledge.

Finally relationships themselves go through stages and identifying what stage the relationship is
in may provide clues to the most effective HIV/AIDs prevention.

While by no means exhaustive, this last section demonstrates that taking account to time is a
necessary part of any HIV prevention program. Understanding how time is incorporated into
theories of behavior change and accounting for past values, current trends, and projected future
outcomes increases the chance that program can be designed which maximize the adoption of
safer sex and decrease the impact of the AIDS pandemic.