In the face of the maddening complexity of HIV-AIDS, RSPH researchers have found that simple things like relationships and community—maybe even love—are powerful tools in fighting one of the most devastating public health problems of our time. Jill, an African-American mother of four, longs for the strong community ties of her childhood. Her inner-city neighborhood began falling apart during her teen years. As drugs and violence took hold, established families moved out, and long-term residents began keeping to themselves and staying indoors. The community disintegrated, and the people lived in fear and isolation.

Claire Sterk, chair of the RSPH Department of Behavioral Sciences and Health Education (BSHE), has studied some of the most troubled residents of the inner city—drug users, prostitutes, and the homeless—for nearly two decades. She says their feelings of alienation and hopelessness contribute to self-destructive behaviors that cause HIV and other sexually transmitted diseases.

Her search for solutions led Sterk to establish the Health Intervention Project (HIP), a safehouse in “The Bluff,” one of Atlanta’s roughest neighborhoods. Here, women at risk for HIV—many, drug users and prostitutes—gather regularly to share cereal in the kitchen, watch videos, and cook dinner together. Counselors also offer HIV/AIDS prevention counseling and health information. Many women who completed the intervention program were deeply moved by the certificate they received at the end.

“I can’t tell you how powerful that was,” says Sterk. “Some had tears in their eyes. They said it was the first certificate they had ever received. And when they walk down the street now, they know each other from a context other than getting high together.”

This ancient strategy—becoming part of a communal group—may well be one of the best survival techniques society has to offer. While searching for ways to slash the spread of HIV/AIDS, social and behavioral scientists at RSPH have found that bolstering this sense of belonging can be a powerful intervention.

In an age of high-tech solutions to diseases, it is almost poetic that one of the best ways to prevent the infectious spread of this insidious virus, which has already killed more people than died in both World Wars, is to embrace the motto “United we stand. Divided we fall.” As public health journalist Laurie Garrett said in a lecture at Emory last year: “AIDS became a medicalized problem. This shifted the epidemic from one viewed as a collective disaster to one seen as an individual treatment paradigm. . . . Medicalizing public health problems can be disastrous.”

A capital investment
RSPH researchers have found that a lack of social connections results in high rates of sexually transmitted diseases, including AIDS. In a study presented in July at the 14th International AIDS Conference in Barcelona, David Holtgrave, professor of BSHE and director of the behavioral core of the Emory Center for AIDS Research, presented a groundbreaking study. He found that the amount of a state’s “social capital”—the trust, reciprocity, and cooperation among community members—is a much higher predictor of the rates of sexually transmitted diseases (STDs) than other measures, such as poverty and income disparity.

The concept of social capital was developed by Harvard sociologist Robert Putnam in his book Bowling Alone: The Collapse and Revival of American Community, which makes the case that Americans have become increasingly disconnected from family, friends, neighbors, and democratic structures. Social capital has plummeted, Putnam warns, impoverishing lives and communities. “We sign fewer petitions, belong to fewer organizations that meet, know our neighbors less, meet with friends less frequently, and socialize with our families less often,” Putnam writes. “We’re even bowling alone.” Putnam calculated each state’s social capital through a composite of 14 variables, including the number of civic organizations, voting rates, and how residents respond to statements like: “Most people can be trusted.”

After reading Bowling Alone, Emory researcher David Holtgrave was curious to see if there was a relationship between social capital and STD levels.

Social capital levels have already been correlated with public health variables like violence and mortality. But after reading Bowling Alone, Holtgrave was curious to see if there was a relationship between social capital and STD levels. By comparing Putnam’s state levels with CDC surveillance measures of syphilis, gonorrhea, chlamydia, and AIDS, he found social capital to be a significant predictor of each disease, as well as of risky sexual behaviors, such as early sexual experience and having multiple partners.

“That’s why small, community-based intervention groups work so well,” says Holtgrave. “They allow people not only to share information about how the virus is transmitted and what you can do to protect yourself, but friends and peers are also able to reinforce for each other that it’s important to protect yourself.” Also, with increased levels of social capital, Holtgrave says, risk behaviors go down and access to health services go up.

Taking on a goal as ambitious as raising a state’s or community’s social capital doesn’t come cheaply, admits Holtgrave, but the losses would be quickly recouped in reduced treatment costs for AIDS victims. A greatly expanded national HIV/AIDS prevention effort is essential, says Holtgrave, if the US government plans to fulfill its mandate of cutting the 40,000 new AIDS cases a year in half by 2005—and to protect the estimated 5 million Americans still at risk of HIV.

In a massive study published in the July 2002 issue of the American Journal of Preventive Medicine, Holtgrave outlines the need to spend millions more on domestic AIDS prevention: from an additional $817 million for brief interventions up to $1.85 billion for multi-session, small group interventions. Since the estimated lifetime cost of care and treatment for one HIV-positive individual is about $195,000, these initial investments would pay for themselves if just 5,000 to 12,000 new infections a year were prevented. Now, less than 7% of the HIV budget in the United States is spent on prevention measures.

Custom tailored
For RSPH researchers whose work focuses on small-group interventions, growing recognition of their effectiveness is welcome. But to have a lasting impact, they says, such sessions must be tailored to specific populations.

Husband-and-wife team Ralph DiClemente and Gina Wingood, for example, focus on reducing HIV-risk behavior in adolescents, especially African-American females, through small groups with peer facilitators.

“We contextualize the message,” says Wingood, associate professor of BSHE. “Our programs include an emphasis on ethnic pride, self-image, and self-awareness, as well as sexual health.”

In their groundbreaking HIV prevention program SISTA (Sisters Informing Sisters About Topics on AIDS,) which DiClemente presented in Barcelona, and its offspring, SIHLE (Sisters Informing, Healing, Living, and Empowering), the girls learn about condom use and AIDS transmission. They also role-play and read poetry, such as Maya Angelou’s Phenomenal Woman.

Pretty women wonder where my secret lies.

I’m not cute or built to suit a fashion model’s size

But when I start to tell them,

They think I’m telling lies.

I say,

It’s in the reach of my arms,

The span of my hips,

The stride of my step,

The curl of my lips.

I’m a woman

Phenomenally,

Phenomenal woman,

That’s me.

Such gender- and culture-sensitive programs are effective, Wingood says, because they not only increase HIV-prevention skills, like condom use, but also result in positive changes in participants’ assertiveness, body image, and self-esteem. The girls, even years down the road, are better able to communicate their desires, manage interpersonal conflicts, and cope with outside pressures: all precursors to being able to take charge of one’s sexual health.

“Unfortunately, AIDS strikes many women during their young adult years—most women living with AIDS are between 20 and 44,” says Wingood, meaning that they probably acquired the virus while in their teens or early twenties.

A testament to its effectiveness is the fact that the CDC has adopted SISTA as a boxed kit—including manuals, a video, pre- and post-tests, poetry, games, and homework—for use by community organizations and social service agencies.

RSPH behavioral researchers Gina Wingood (front left) and Ralph DiClemente (front right) find small groups most effective for getting HIV prevention messages across.

DiClemente and Wingood’s work also indicates that weak relationships between parents and children can affect teens’ sexual risk taking. Their most recent studies have found that teens with less parental monitoring engage in more high-risk behaviors with sex, fighting, and drugs; that teen dating violence contributes to unhealthy sexual attitudes and behaviors, resulting in higher rates of sexually transmitted diseases and unplanned pregnancies; that adolescents who view X-rated movies exhibit more unhealthy sexual behaviors and attitudes about contraceptives; and that teenage girls who were pregnant or taking sexual health risks watched more violent, sexually demeaning TV programs.

“The more you can find out about the factors that predispose someone to a disease, the better you can inform and motivate them to do something to avoid it,” says DiClemente, Charles Howard Candler Professor of BSHE.

The power of a captive audience
In some communal settings—as varied as a college, an inner-city neighborhood, a group of commercial sex workers, or a prison—the proximity and relative cohesion of the group provide both increased risk for the spread of infectious diseases like HIV and opportunities to lower this risk.

Torrance Stephens, research assistant professor of BSHE, assisted in a condom distribution campaign among commercial sex workers in Lagos state, Nigeria, and was the recipient of a CFAR developmental award for his studies using hip-hop music as a prevention tool among students.

Lawrence Bryant, senior research coordinator for the behavioral core of CFAR, has studied the black church and its influence on African-American gay men in the era of AIDS. He also works with Second Sunday, an Atlanta group of African-American gay men who meet monthly to discuss health and relationship issues. He says that peer influence and group experience have enormous impacts on whether people engage in sexually risky behavior or take precautions. The alarming rise in new infections among young minority gay men can be seen as evidence, he says. “The younger generation has not experienced AIDS the way the older generation has—losing close friends every other day, seeing the disease manifest itself in its entirety. There’s not the same urgency to be safe as there was in the 1980s. It was fear that drove our behavior.

Lawrence Bryant works with Second Sunday, a monthly meeting of African American gay men in Atlanta.

Ronald Braithwaite, associate professor of BSHE and author of Prisons and AIDS: A Public Health Challenge, has studied and worked extensively with prison populations in America and South Africa, teaching inmates to counsel small groups of their peers about HIV and substance abuse prevention. “As soon as inmates are released, one of the first things they do is have sex, and they often go back to alcohol or drugs,” he says. “While they are inmates, they really are a captive population, so we have a unique opportunity.”

Ideally, he says, prevention efforts would include supplying inmates with condoms while they are incarcerated, a practice that is fairly routine in South Africa and very rare in the United States.

The will to change
When planning interventions that involve changing people’s behaviors, motivation is as important as skills training, says Sterk, who established HIP house only after asking women at risk what type of program would fit their needs. “Many of them said that AIDS was important, and scared them, but that they had so much going on in their lives that they couldn’t worry about it—they focused on just surviving,” she says.

Slowly, as the women gathered, talked among themselves, and spoke with counselors, they set out to reclaim control, although not always in ways public health workers might have envisioned.

“One woman decided she would smoke crack only with other women, so that she wouldn’t then have unsafe sex. That may not fit our traditional view of an intervention, but at least it took care of some of the risk,” Sterk says. “None of us, in our lives, are able to address all of our problems at once.”

Society’s collective motivation to combat AIDS is crucial as well, said RSPH Dean James Curran in a senior lecture at the Barcelona conference this past July.

Claire Sterk, Chair of the RSPH Department of Behavioral Sciences and Health Education

“In this era, we are often incapable of thinking about long-term solutions for anything. Since AIDS is a new disease, we remain optimistic that science will provide an easy solution for the epidemic. Ironically, in some ways, the HIV threat seems too new and urgent for us to consider the long-term implications of the epidemic and consider revolutionary change...HIV will continue to radically change communities. Successful efforts to combat the epidemic will demand revolutionary changes at the individual, community, national, and global levels.”

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