Over the course of the AIDS epidemic, behavioral scientists have sought to apply theoretical constructs to explain risk behaviors associated with HIV transmission and to develop interventions leading to behavior change. One of the oldest cognitive behavioral theories is the health belief model. According to this theory, individuals are more likely to change a given behavior if they believe that such behavior increases their risk for a certain condition and if they believe that this condition will form a serious threat to their health or well-being. In addition, they are also more likely to make behavioral adjustments if they believe that behavioral change will reduce susceptibility to the condition or its severity and that the perceived benefits of changing behavior outweigh potential negative effects.1 The health belief model has been used as a theoretical framework for a variety of health behavioral interventions, including breast self-examination, seatbelt use, exercise, nutrition, smoking cessation, and making visits to physicians for health checkups.1 It is interesting, therefore, that during the era of greatest activity in the development of theory-based behavioral interventions to prevent transmission and acquisition of HIV infection (roughly between 1985 and 1995), there did not seem to be much interest in using the health belief model as a guiding theoretical construct. A major reason for this seems to be that at the time there appeared to be an apparent lack of association between perceived risks of exposure to HIV (or of getting AIDS) and the likelihood of taking actions to prevent HIV transmission.2 In defense of the health belief model, however, it could be argued that the main behavioral effects as predicted by the model had already occurred when spontaneous, grass-roots prevention actions had taken place in the early phases of the epidemic, i.e., long before behavioral scientists became seriously involved in the development and implementation of theory-driven behavioral interventions. When they did, high-risk populations (the targets for such interventions) had been depleted of those individuals for whom the mere perception of risk and seriousness of disease had been sufficient to remove themselves from the risk pool. The size of this effect should not be underestimated. Behavioral change among men who have sex with men (MSM), particularly reductions in number of partners and episodes of unprotected anal intercourse, was significant across the United States and Europe in the early phases of the epidemic, as witnessed by dramatic declines in the incidence of gonorrhea and syphilis in this population. For example, among MSM visiting the Denver Public Health sexually transmitted infections (STI) clinic, cases of gonorrhea plummeted from 1809 cases in 1982 to 90 cases in 1988 (a 95% decrease), while primary and secondary syphilis cases fell from 138 to 20 (an 85% decrease).3
As the remaining at-risk populations appeared to be less sensitive to prevention messages targeting risk perceptions, behavioral scientists sought to apply other theoretical models to guide the development of interventions, including psychological constructs focusing on self-efficacy or the importance of attitudes and perceived social norms, as well as sociological models such as diffusion of innovation and peer-leader models.4 Still, it could be argued that these interventions continued to “work” against the backdrop of perceived susceptibility and threats to health, providing the extra push needed to accomplish risk reductions that others had already achieved by just pondering the risks alone.
The Revenge of the Health Belief Model
The study by van der Snoek et al.5 in this issue of Sexually Transmitted Diseases provides further evidence for the continued, or perhaps renewed, importance of the health belief model for HIV and STI prevention, albeit “in reverse.” The data provided in this paper strongly suggest that the perception of a reduced threat of HIV/AIDS since the introduction of highly active antiretroviral therapy (HAART) was related to incident STD and HIV among a cohort of MSM in Rotterdam. Previously published studies had already suggested a link between “HAART optimism” (or “AIDS optimism”) and resurgent risk behaviors among MSM, but these studies relied on self-reported behaviors.6,7 The strength of the paper by van der Snoek et al. is that it provides biomedical evidence for this association.
Still, there has been considerable controversy over the relationship between HAART optimism and resurging risk behaviors among MSM. Some have outright rejected the existence of such an association,8 while others suggest that associations between optimism and high-risk behavior may exist but that these do not necessarily imply a causal relationship. In fact, individuals at high risk may “use” their optimistic beliefs as a post hoc rationalization for their actions.9 Even when accepting a causal relationship, the impact of HAART optimism at the population level has been considered to be quite small because many studies show that the majority of MSM are quite “realistic” where it pertains to the ongoing threat of HIV/AIDS and that only few men are optimistic.10 In my view, however, the opposition of the terms optimism and realism gauges the problem in an inappropriate semantic dichotomy. In many studies dealing with this issue, HAART optimism is not simply seen as a positive outlook on the progression of HIV disease in the presence of adequate treatment but is often contextualized as something naive and unrealistic. Clearly, the view that HAART is the cure for AIDS is not only optimistic, it is also wrong. At the same time, though, it is quite realistic to view HIV/AIDS as a more manageable condition compared to just 10 years ago. Indeed, it would be considered rather callous for a counselor or clinician not to tell his or her newly diagnosed HIV-infected patient that the diagnosis no longer carries an automatic death sentence and that life can be prolonged and its qualitatively improved with the use of HAART. The reality is that HIV infection is a less severe condition than it was 10 years ago. In addition, there is at least a scientific rationale for the perception that the reduction in HIV viral load through HAART will affect the likelihood of HIV transmission. It is hard to believe that these new realities have failed to affect public perceptions on a wide scale. One therefore wonders whether the studies that purport to investigate the relationship between changed perceptions and high-risk behaviors, and that show only small fractions of their populations to be “optimistic,” are measuring the right thing.
In conclusion, the downside of the remarkable pharmacological progress in the treatment of HIV infection has come at the price the health belief model has predicted and for which the van der Snoek et al.5 article provides further supporting evidence. The effects on prevention may be profound. In the post-HAART prevention landscape, we are not in Kansas anymore. We have to rethink our strategies and carefully evaluate how changed perceptions and beliefs have affected the effectiveness of our current interventions. We should start to refocus our education and prevention efforts with a rational approach to the persisting and resurgent risks for HIV transmission in the era of “HAART realism.”
1. Rosenstock I, Strecher V, Becker M. The health belief model and HIV risk behavior change. In: DiClemente R, Peterson J, eds. Preventing AIDS: Theories and Methods of Behavioral Interventions
. New York: Plenum Press; 1994.
2. Fishbein M, Guinan M. Behavioral science and public health: a necessary partnership for HIV prevention. Public Health Rep 1996;111(suppl):5–10.
3. Rietmeijer CA, Patnaik JL, Judson FN, Douglas JM Jr. Increases in gonorrhea and sexual risk behaviors among men who have sex with men: a 12-year trend analysis at the Denver Metro Health Clinic. Sex Transm Dis 2003;30:562–567.
4. DiClemente R, Peterson J. Preventing AIDS: Theories and Methods of Behavioral Interventions
. New York: Plenum; 1994.
5. van der Snoek E et al. Incidence of STDs and HIV infection related to perceived HIV/AIDS threat since HAART and PEP availability in men who have sex with men: the Dutch MSM-cohort study. Sex Transm Dis 2004;Current issue.
6. Van de Ven P, Rawstorne P, Nakamura T, Crawford J, Kippax S. HIV treatments optimism is associated with unprotected anal intercourse with regular and with casual partners among Australian gay and homosexually active men. Int J STD AIDS 2002;13:181–183.
7. Stolte IG, Dukers NH, Geskus RB, Coutinho RA, de Wit JB. Homosexual men change to risky sex when perceiving less threat of HIV/AIDS since availability of highly active antiretroviral therapy: a longitudinal study. AIDS 2004;18:303–309.
8. Elford J, Bolding G, Sherr L. High-risk sexual behaviour increases among London gay men between 1998 and 2001: what is the role of HIV optimism? AIDS 2002;16:1537–1544.
9. Huebner D, Rebchook G, Kegeles S. A longitudinal study of the associateion between treatment optimism and sexual risk behavior in adult gay and bisexual men. J Acquir Immun Defic Syndr 2004;37:1514–1519.
10. Elford J. HIV treatment optimism and high-risk sexual behaviour among gay men: the attributable population risk. AIDS 2004;16:2216–2217.