prevention programs

[Guest guest]

Prevention Programs (Alayne, Alice, and Lori de Ravello). From 7-09.

Congratulations on providing this kind of information (Sex Transm Infect

2003; 79:197-201). Its directness is welcome but members of the list-serve

may find the reading a little difficult. May I offer comments on this

information as " ammunition. "

First, the excerpt (part of a full article) does not identify the

populations beyond characterization as " risk " populations. Specifically,

the sampled population was persons with STDs and their sex partners. As

list-serve members recognize from other discussions, culturally appropriate

and culturally responsive work best. It thus remains for clinic or program

staff to develop skills and approaches to work with clients who " present "

(have a problem, seek services), or those who do not " present " but may be

receptive to harm reduction messages in the course of community outreach or

any context in which these topics can be approached with sensitivity, and

the information can be disseminated, responsibly and appropriately.

Second, the abstract (from the except) identifies what has long been a

contention among those who work with harm reduction: Is risk a matter of

reducing partner multiplicity or the selective elimination of high-risk

partners? These are separate issues that may overlap. They are linked to

sometimes personal philosophies of morality and how we view concepts such

as monogamy, promiscuity and prescribed sex roles. Note how the excerpt

identifies as a concern, " concurrent relations " (those happening at the

same time), that may be normative after " sexual debut " (one's first sexual

experience). Concurrent activity could " telescope " (concentrate) risk but

not necessarily to a greater extent than short-term " successive relations "

(end one, before starting another). The excerpt goes further than most

published materials to examine factors that affect people as they seek to

identify in their own manner, or fail to identify owing to incomplete

communication, a likelihood that a partner poses a risk, if contact is

initiated or a relationship develops that may include sexual activity, as

well as the possibility of drug activity. Although it concludes that better

communication will increase the likelihood of one's taking precautions and

using barrier protection (euphemism for condom use), at times the excerpt

leaves open the possibility that improved awareness of one's partner

through communication will provide a set of criteria by which someone may

selectively choose no protection over protection.

Third, the discussion of " agreement " in matters of communication introduces

the concept of concordance. Agreement in communication should not be

confused with efforts to measure it statistically (separate meanings of

concordance), nor should these two terms be confused with " concordant " /

" discordant " as a means to classify couple composition. At one point, the

excerpt mentions " serodiscordant heterosexual couples. " Here discordance

refers to couples where one partner is HIV-positive (seropositive) and one

is HIV-negative (seronegative), versus a couple where both partners are the

same serostatus ( " serosorting " ). Or one has an STD, one doesn't. Or it may

refer to a couple where one partner uses illicit substances and one doesn't

(discordance by use and non-use; also discordance by preference for drugs

of different administration modes, i.e., injection versus non-injection). A

little thought on these differences in couple composition (the study

limited itself to heterosexual couples) will suggest the challenges that

face not only individual partners in their communication for activity

selection, but service providers wishing to communicate appropriate and

effective risk reduction messages.

I am pleased these issues were brought forward. There is work to be done to

develop programs and " contact scripts " prior to services that incorporate

these issues; identify local programs that can fill-in where clinic or

program competencies are minimal or lacking, as well as share information

on programs that have successfully worked out how issues such as these are

effectively handled in ways and by approaches that are culturally

appropriate and culturally responsive.

V Bletzer