The best available strategies for preventing the transmission of HIV aim to modify behaviors that place persons at risk for infection and transmission. However, there is considerable debate among HIV researchers, public health practitioners, policy-makers, and writers in the popular press about the appropriate audience for behavioral interventions. A major topic of debate concerns whether behavioral interventions should target individuals who are at the greatest risk for infection or a broader range of individuals within a general population [1–14].
Targeting concentrates intervention efforts on persons for whom HIV/AIDS prevalence or incidence rates are high, and for whom the prevalence of HIV risk behaviors is high, such as men who have sex with men (MSM), injecting drug users (IDU), or the sex partners of HIV-seropositive persons or those at high risk for infection. Interventions should match the social, cultural, linguistic, psychological, developmental, and behavioral characteristics of the risk group of interest. General population approaches disseminate an intervention among persons who have differing levels of risk or whose risk for infection is unknown. General population interventions are directed at groups defined by geographic or demographic characteristics rather than by a high prevalence of HIV infection or risk behaviors. Examples include public information campaigns and HIV education programs for school students.
The purpose of this article is to review the justifications for where to focus HIV prevention interventions. We propose the need for and will begin to formulate a comprehensive strategy that combines approaches for delivering HIV prevention interventions. References have been selected to illustrate our points rather than to provide a comprehensive review of the literature on HIV prevention. Although we specifically address HIV, many of the points apply to interventions to prevent the transmission of sexually transmitted diseases (STD); STD prevention, in turn, may also be associated with HIV prevention [15–17].
Political, social, economic, and ethical perspectives
The ongoing debate about the value of targeted compared with general population interventions reflects opinion and reasoned argument, and is concerned with controversies about the political, social, economic, and ethical implications of each type of intervention. It is reasonable to argue that targeting focuses resources on those with the highest potential for infection in order to maximize the chances of success in reducing high-risk behaviors and lowering the incidence of infection. On the other hand, targeting may fail to identify or influence the behavior of persons who are at some level of risk but who may not identify themselves with the targeted group. General population interventions will reach large numbers of people with differing levels of risk for infection and may prevent HIV from becoming a major threat in lower risk populations. However, general population approaches may fail to address the specific needs and characteristics of individuals, and therefore fail to influence the behaviors that put those individuals at risk of acquiring or transmitting HIV.
The debate about the targeting of HIV interventions was stimulated by a report of the US National Research Council, published in 1993 . Although the report may have been misinterpreted [2,11,18] many saw it as supporting the targeting of persons with the greatest risk of transmitting or being infected with HIV. In response, HIV specialists expressed support for and concern about targeting interventions. The concerns were, (i) that emphasizing targeting will cause HIV to be treated as a local rather than a national problem; (ii) that those at risk will be marginalized, stereotyped, and stigmatized; (iii) that emphasizing subgroups of society may lead to denial of risk by the broader public; (iv) that targeted approaches may lead to the loss of financial and other support for HIV prevention if those at risk are perceived as being on the margins of society; and (v) that low-risk but sexually active persons will not hear the prevention message [2,7,11,18]. The controversy about targeting has also raised ethical issues. Because effective interventions must be appropriate for the targeted group, health officials may seem to condone the values and behaviors of those in the targeted group . In the United States, where laws restrict the possession of syringes for use by IDU , the distribution by public health personnel of bleach for cleaning needles might be perceived as health officials' acceptance of drug use. At the same time, disregarding the specific needs of those at risk for HIV has sometimes had unfortunate consequences: the failure of prevention policies to address the imbalance of power between women and men has helped to put some women at risk for infection [19,21]. Targeting may also impede preventive efforts: some African Americans are concerned that targeting their communities will lead to further blaming and stigmatization by whites and will foster racist attitudes by whites concerning the drug use and sexual behavior of African Americans [22–24]. Finally, targeted interventions require costly formative research and labor-intensive intervention strategies; their costs may preclude large-scale efforts.
The justifications for general population approaches are that most persons are potentially at some risk for infection, and should be helped to avoid infection [2,3,11,25,26]. Interventions for the general population can be implemented quickly and provide a standard message to very large numbers of people. These interventions also help to maintain public awareness of HIV and provide an environment that prepares those at highest risk to accept interventions to reduce their unsafe behaviors. However, general population interventions may also take a ‘scattershot approach’  rather than focusing on groups for which the prevalence of infection is highest. Recently in Europe and the United States, some homosexual groups have expressed concern that focusing resources on the broad population will divert resources from prevention among homosexual men (anonymous reviewer, personal communication, 1997). General population interventions may cause persons to overestimate their risks of infection or to underestimate their risks if their experience fails to confirm their fears . These interventions may diffuse resources so that they are not adequate for the groups at highest risk . In an effort to be acceptable to all perspectives in society, general population approaches may fail to name specific risky behaviors and thus fail to provide information about how to reduce these behaviors. A criticism of federally funded general information campaigns in the United States is that they were not explicit about specific risk behaviors or condom use ; by comparison, media programs in Switzerland and France [28,29] marketed condoms explicitly.
The controversy about where to focus interventions is likely to continue and to have broad implications for health policy. In 1997, private foundations that fund prevention programs are expected to give targeting the highest priority . An important question is whether targeted interventions will reach all or most persons who are vulnerable for infection.
In the following sections, the evidence for targeted and general population interventions has been summarized. We have drawn on the literature that describes mathematical models to predict the course of the epidemic, the epidemiology of HIV, research assessing the effectiveness of various intervention strategies, and some of the methodologies for influencing individual behavior through individual and social change.
Theoretical approaches to targeted and general population interventions
Mathematical models of HIV transmission predict the circumstances under which persons who engage in high-risk sexual behaviors or drug use are more likely to transmit or acquire HIV. Anderson's model for the reproduction rate of HIV infection predicts rapid transmission when infected individuals engage in risky behaviors and change partners at a high rate, assuming that their potential partners are not already infected and that they do not select partners randomly . When the prevalence of infection in a group is high, non-infected persons who engage in high-risk behaviors are particularly at risk for infection. Models of HIV transmission have borrowed the central concept of core groups from the epidemiology of STD [31–33]. Core groups are characterized by a disproportionately large number of infections within a small subgroup of individuals. The concept led to the development of targeted interventions for reducing STD, although the effectiveness of these targeted interventions alone for preventing STD has been variable . The research on STD prevention in core groups provides an important precedent for targeting HIV interventions.
General population interventions
Mathematical models provide a basis for the use of general population interventions. Using existing demographic and epidemiologic data from countries in sub-Saharan Africa, Rowley and Anderson  used mathematical modeling to predict the impact of several possible prevention approaches on the future prevalence of HIV. They compared two hypothetical interventions: one intervention would target only those aged 15–20 years, and the other would be directed at all sexually active persons. The authors concluded that over the same period of time, the intervention directed at the broader population group would lead to a lower prevalence of infection than the intervention targeting the smaller but higher risk group of young adults.
General population interventions are also justified depending on the extent of the epidemic. Early in an epidemic, when the prevalence of infection is low and epidemiologists have not yet identified those at risk, general population interventions may be the most effective way of reaching persons at risk [30,35]. General population interventions may also be appropriate when infection is widespread, as in parts of Africa and Asia [36,37], because risk is not confined to specific groups and the potential for infection is high.
Rose  discussed the use of general population interventions for the prevention of chronic diseases such as heart disease. Interventions leading to improvements in diet will reduce heart disease, even for persons at greatest risk. Rose's rationale may have implications for HIV prevention. He reasoned that the number of cases of a disease will be greater when many people are exposed to a small risk than when a small number are exposed to a high risk; thus, interventions need to be disseminated broadly among persons at all levels of risk. Even if the prevalence of a disease is low, general population interventions may avert an increasing incidence of new cases. Reducing the overall prevalence of risk behaviors in a population can produce an associated reduction in the prevalence of risk behaviors among those at the highest levels of risk. In the HIV epidemic, if the frequency of risk behaviors (such as having multiple sex partners) in the broad population decreased, perhaps because of social norms that proscribe multiple partners, then the prevalence of risk and the incidence of new infection would also be reduced at the extreme high end of the population distribution of risk behaviors. The frequency distribution of risk behaviors would shift downward for the whole population. It is speculative to predict that broad changes in social norms will decrease the incidence of HIV infection, but there is some evidence that a shift towards reduced HIV risk behaviors by a group of people will influence the behaviors of those at highest risk. Kelly et al.  described a shift away from risky behaviors in a community of MSM after an intervention to strengthen community norms for safer sex.
Evidence supporting targeted and general population interventions
Surveillance of AIDS cases in the United States has established the association of HIV infection and AIDS with sexual behaviors and drug use. From July 1995 through June 1996, MSM accounted for 51% of AIDS cases, and IDU accounted for 23% of cases in men and 36% in women. In the same period, heterosexual contact accounted for 5% of cases in men and 40% of cases in women . HIV and AIDS disproportionately affect those who are poor. Globally, developing countries account for the greatest burden of disease [37,41]. According to a 1994 analysis, 77% of diagnosed AIDS cases in women in the United States were from those who were poor, African American or Hispanic, and who lived in inner cities . This finding underscores the association between socioeconomic inequities and vulnerability to HIV infection [43–45]. A high percentage of adolescents are at some risk for infection because they are sexually active . However, some young people such as runaway adolescents are particularly at risk because of sexual behaviors and drug use [47–49]. World-wide, although transmission is primarily through heterosexual sex [41,50], IDU [51–54] and prisoners  account for significant numbers of cases.
Several reviews report on interventions that target high-risk persons to reduce HIV infection [2,56–63]; the following studies are examples of this type of research. An intensive training intervention for African American adolescent men that included video presentations and participation in group exercises led to increased knowledge about HIV and decreases in reported risk behaviors at a 3-month follow-up . A series of 20 small-group sessions that emphasized HIV/AIDS information and fostered the development of skills for recognizing and avoiding risky situations led to increased use of condoms by runaway adolescents . A 12-week series of educational and skill-training sessions for small groups of MSM reduced high-risk practices by participants . Commercial sex workers (CSW) in Ghana served as health educators and distributed condoms to peers; the intervention led to increased and sustained condom use by the cohort. A needle-exchange program in Amsterdam helped to stabilize the prevalence of HIV among IDU . Note that few HIV intervention studies have achieved the rigor of randomized control trials [56,62], a standard that many community-level interventions probably cannot achieve. For this reason, it is difficult to compare interventions across studies. In addition, this literature is only beginning to provide the information on cost-effectiveness that would allow the comparison of interventions .
Methodologies for influencing the behavior of high-risk persons are emerging. Strategies have been developed for clinical practice [68,69] and for counseling and training in public health settings . Behavioral theory has provided intervention strategies that emphasize specific risk behaviors and their emotional, social, and environmental antecedents. Theories commonly used in HIV interventions include the Transtheoretical Model of Behavioral Change, the Theory of Reasoned Action, and others [71–77]. According to the Theory of Reasoned Action, intention to perform a targeted behavior is considered a major determinant of the performance of that behavior: the strength of a person's intention to use condoms predicts his or her condom use . The theory also entails specifying the variables that correlate with intention, such as attitudes about performing the target behavior or subjective interpretations of social norms concerning those behaviors. HIV prevention interventions are designed to strengthen the intentions to perform the targeted behavior by changing the individual attitudes or social norms that affect the intention.
Ethnographic methods provide the information needed to tailor interventions to the social, cultural, psychological, developmental, and behavioral characteristics of the targeted persons or groups. Maticka-Tyndale et al.  assessed the HIV-related knowledge, attitudes, and beliefs of women residing in 12 villages in Thailand and used this information to develop appropriate interventions targeting CSW and IDU. The AIDS Community Demonstration Projects of the US Centers for Disease Control and Prevention (CDC), used formative data to specify risky behaviors and behavioral determinants among high-risk groups in order to develop role-model stories that served as interventions for targeted individuals [72,80]. A similar approach was used in CDC's Women and Infants Demonstration Project . Methods typically used for studying culturally-based behaviors can also help in targeting interventions at persons who are difficult to reach. In some regions of the United States, African American adolescent women are at much higher risk for infection than their white counterparts, but their risk characteristics are under-studied and poorly understood. Interventions targeting these women can be developed to address their unique needs and characteristics in terms of sex-role socialization, family responsibilities, racial identity, and communication styles [82,83].
General population interventions
Behavioral surveillance data support the importance of general population interventions because they reveal that many persons are at some level of risk. Many adults have multiple sex partners but do not engage in behaviors such as same-sex contact or injecting drug use that would place them in the highest risk categories for HIV; that is, they are at low-but-not-zero risk of infection . Survey findings indicate that 2.7% of a nationally representative sample of adults in the United States have had sex with five or more partners in 1 year and that 3.6% have had sex with a stranger ; as many as 31% of adults have had more than one sexual partner in the preceding 5 years ; and as many as 50% of men and 38% of women have had extramarital sex at least once in their lifetimes . According to random household surveys, 2.1% of adults in Britain and 2.4% of adults in France have had sex with five or more partners in 1 year . Surveys of US adolescents have estimated that 50% are sexually active; they are thus at some risk if they engage in unsafe sex [46,87–89].
General population interventions are also needed for at-risk persons who are difficult to distinguish and thus may be difficult to reach through interventions. Bisexual men, who may be at high risk for infection, are difficult to reach through interventions for homosexual men, because they may not openly identify themselves with this group. This is particularly true of MSM of color, whose risk for HIV is higher than that of whites . Women who are unaware that they may be at risk because of the risk behavior of their partners are also difficult to distinguish. In a survey of single, inner-city women, approximately 85% considered themselves at no or low risk for HIV infection because they had a single male partner at the time. These women had poor knowledge about HIV transmission, tended not to use condoms, and did not believe their partners put them at risk, even though few limited their partners to persons they knew to be seronegative . These groups might be missed by targeted interventions but might be reached through general population approaches.
Various studies have documented the impact of interventions directed at the general public in changing knowledge and attitudes, as well as behaviors related to HIV and AIDS. Twenty-one to 59% of study participants who were shown a news program that included public service announcements from the ‘American Responds to AIDS’ campaign could correctly recall the announcements 1–3 days later . Analysis of data from the population-based National Health Interview Survey in the United States revealed that parents who had received an AIDS informational brochure from a health-care provider were significantly more likely than those who had not received a brochure to discuss AIDS with their 10–17-year-olds . Large-scale AIDS educational campaigns in six cities in Mexico and France were associated with safer sex practices [29,94]. A household-based educational campaign in Nicaragua led to increased knowledge about HIV prevention and small increases in condom use by women . The Swiss AIDS prevention strategy included a national media campaign promoting condom use, safer sex practices, the use of clean injecting equipment by IDU, and social support for infected persons. Evaluators reported that public acceptance of the Swiss campaign was high and that the intervention was associated with increased sales of condoms and self-reports of increased condom use [28,52,96].
Because most youth are enrolled in school, school health education can also be classified as a general population intervention. AIDS and HIV information is provided to most school students in the United States: in 1994, 86% of schools had courses covering HIV prevention [97,98]. Kirby and associates reviewed school-based interventions in the United States [98,99] and concluded that, despite methodological weaknesses in the research, some educational programs help to reduce the risky behaviors of school students: 3 months after a six-session curriculum that included information on HIV and the teaching of skills to avoid infection, high school students showed increased knowledge of HIV and reported fewer HIV risk behaviors than those in a control group . A 15-session health education program that included role playing to help high school students build skills for avoiding risky situations led to delayed initiation of sexual activity and reduced rates of unprotected sex among sexually active students .
Some effective targeted HIV interventions could be adapted for broader populations. Researchers delivered a knowledge and skill-building intervention to 157 African American adolescent men recruited from a school, a health clinic, and a sports club . The participants were not specifically selected because of high risk for infection. The intervention was designed to be culturally and developmentally appropriate for their demographic group. Compared with the members of a control group, participants demonstrated more knowledge about AIDS and more negative attitudes and intentions about engaging in risky sexual behaviors. Similar interventions could be developed and used broadly in school or community settings.
Social marketing provides methods for influencing broad population groups. The application of these techniques has grown both for general health promotion and HIV/AIDS prevention [101–108]. Social marketing draws upon an array of behavioral and social science theories and emphasizes the importance of orienting behavioral interventions and health education campaigns to fit the needs of the intended audience . Social marketing involves market or audience segmentation, a process of dividing a community or population into relatively homogeneous subgroups and then developing interventions tailored to each segment [101,105,107]. Typically, social marketers identify relevant segments on the basis of sociodemographic variables. They may further subdivide populations by using variables from census-tract databases . Segmentation promotes the efficient use of scarce resources by maximizing the effect of an intervention for the group of interest . Regardless of the method use to define segments, social marketers typically attempt to develop, pretest, implement, and evaluate interventions for each segment. In this way, social marketing techniques can be used to design general population interventions for the specific knowledge, beliefs, motivations, concerns, and barriers that influence the behaviors of persons in a segment of the population.
A comprehensive approach to HIV interventions
When a society includes persons at high risk as well as those at low-but-not-zero risk simultaneously and over time, a complex mix of interventions is needed. Theoretical and data-based evidence describes different patterns of disease transmission and suggests the need for a mix of targeted and general population interventions.
Anderson  predicted that transmission begins within risk groups as ‘a series of separate but interlinked epidemics’ before moving into the general population. Both types of interventions are appropriate at different points in the epidemic. That is, when individuals who are at risk cannot be distinguished, general population interventions are appropriate. Targeting is indicated when sexual mixing patterns are selective and those at risk can be distinguished. Later, if the epidemic moves into the general population, universal interventions are needed. Loytonen and Arbona  modeled the HIV epidemic in Puerto Rico and found that transmission was random at the beginning of the epidemic, became established in limited urban areas as the number of cases grew, and then spread across all cities and into rural areas later in the epidemic.
Anderson and associates have differentiated the impact of assortative and disassortative mixing patterns on transmission. If individuals engage in unprotected sex or drug use within a limited subgroup (assortative mixing), transmission will occur within that group but will not spread beyond the group. However, if individuals mix disassortatively (outside their group), the disease will spread [109,110]. A social network analysis of HIV transmission in Colorado Springs revealed a number of isolated core groups that included the sexual and needle-sharing contacts of HIV-infected persons, but surveillance revealed low rates of transmission in the community as a whole [111,112]. However, in a community in Iceland, disassortative mixing spread HIV extensively . Communities and countries may show various mixing patterns within and between subgroups simultaneously and over time [50,114]. Simultaneous targeted and general population interventions may be directed at different groups in a population, depending on prevalence rates and risk behaviors. In most areas of the world, HIV is an established disease and new groups of vulnerable individuals continue to emerge; a comprehensive approach is needed that includes both types of interventions.
Additional points support a comprehensive approach. Because transmission is slow in groups with low rates of risky behavior, targeted and general population interventions need to be maintained simultaneously. In addition, a comprehensive strategy would support interventions directed at groups in which the incidence rate of infection is increasing, even though the current prevalence of disease is not high.
Comprehensive prevention interventions include efforts at the level of the environment and social structures [2,41,115,116]. The literature describes local examples such as regulatory strategies to limit high-risk behaviors in gay bathhouses , policies supporting needle exchange [54,66,117], social policies to increase the economic power of women so that they can make safer choices about their sexual behavior , and strengthened approaches to STD prevention and control that will reduce the likelihood of HIV transmission . Structural level interventions would affect both targeted and broad population groups and provide an environment that would support protective behavior and enhance the effectiveness of prevention interventions. They are likely to produce prevention strategies that can be sustained over time by strengthening the abilities of communities to help individuals reduce risk behaviors.
Comprehensive efforts need to be maintained over time and tailored to the changing needs of a population [13,118]. Interventions are needed to appeal to new generations of persons at risk  and to respond to variations in surveillance data that reflect the prevalence of HIV and behavioral risk factors. New intervention strategies may begin with targeted groups and then be diffused to the population; media-based interventions found to be effective with a risk group may be adapted for wider distribution .
There are several current examples of comprehensive national strategies. The Swiss AIDS prevention strategy combines public education with interventions targeting IDU, prisoners, foreign prostitutes, foreign migrants, and health-care professionals . The 100% condom program in Thailand [119,120] targeted CSW by requiring them to use condoms with all clients. A mass education campaign raised public awareness about HIV and warned men to use condoms if they were clients of CSW. At a structural level, health personnel traced the contacts of men with STD to their CSW contacts and establishments, provided condoms and education to CSW contacts, and reported to the police the establishments that spread STD. The program was associated with dramatic increases in reported condom use by CSW and decreases in STD in men in Thailand . A process for planning comprehensive HIV prevention activities was recently initiated in the United States . The community planning process is conducted by committees of local planners who identify target groups and interventions tailored for the characteristics of each group. Community planners are also charged with developing community-level interventions and public information programs in order to change social norms and the practices of individuals in the population. The process emphasizes community participation in program planning, in the design of interventions, and in the development of capacity by communities for sustaining interventions .
Research and theory point to the need for HIV prevention interventions that are comprehensive and focus both on persons at greatest risk and on the general public. Different types of strategies will target high-risk MSM, IDU, and their partners, or increase the knowledge and prevention skills of sexually active adults and adolescents. A mix of strategies will match the needs of an evolving epidemic. There should be no controversy about whether HIV prevention interventions should targeted those at highest risk or be directed at general populations. Clearly, both approaches are needed.
A more pressing challenge is to determine how best to use and combine these intervention approaches. To do this, we need additional research to assess which interventions are effective and under what circumstances. This research will require that new methodologies are developed for evaluating the effectiveness of general population approaches. Feasibility and effectiveness studies are needed to help broaden the use of targeted interventions. Improved surveillance of HIV and associated risk behaviors is needed to enable us to respond to changes in disease incidence and to measure the impact of interventions. We need to examine the usefulness of mathematical models in helping us to anticipate the course of HIV. We also need to know more about the prevention of STD and how STD prevention interacts with HIV transmission in a variety of circumstances [15,16,122]. Studies of the cost-effectiveness of various approaches are beginning to emerge [123–126] and should be used to assist policymakers in comparing and selecting intervention strategies.
The work ahead is daunting. The dialogue must move beyond debate about the relative merits of targeted and general population interventions. Researchers and policy-makers must begin to articulate the optimal mix of approaches so that interventions will effectively address the challenges of an ever-changing HIV epidemic.
The authors thank S. Dooley, R. Kohmescher, S. Semaan, I. Thompson, G. West, and M. Willingham for their suggestions and review of this article, and M. Morgan for her editorial suggestions.
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