Gaps in Knowledge and Need for Future Research

It is probably clear at this point that there are several glaring gaps in our knowledge of AIDS, and indeed of sexual behavior in general, that have direct bearing on the spread, especially the sexual spread, of HIV to and from women. Among the areas that need to be addressed are:

1. Research on the exact mechanism of transmission. If it were to be determined, for example, that the uterus rather than the vagina was the primary site of transmission, women could use barrier methods such as a diaphragm or contraceptive sponge for prevention. Currently, women must rely on a prevention technique—condoms—that is not under their own control.
2. Research on the sexual patterns of bisexual men to determine future risks of transmission to women through this population. In light of the high incidence of bisexual behavior in adult men found in all sexological research from the time of Kinsey to the present, and in the light of Padian et al.'s evidence regarding anal intercourse in female partners of these men, it is somewhat surprising that this transmission vector has not been more salient in the AIDS epidemic. Although there are theoretical explanations for this phenomenon, more research is needed to investigate the future potential of this mode as a source of transmission. Moreover, research is needed to investigate effective prevention techniques for bisexual men, most of whom do not self-identify as gay and may not be exposed to prevention messages promulgated within the gay community.
3. Research is needed to evaluate the efficacy of different prevention techniques targeted at women. Preliminary reports (J. Jackson, New Jersey Department of Health, personal communication, November 1987) suggest that information alone is not effective at behavior change, and field reports suggest strongly that techniques useful with gay men cannot be translated to women.
4. Closer analysis of data suggesting rather low efficiency of transmission, male to female, via vaginal intercourse. Some researchers have speculated that the research findings that point to this are actually an artifact of a phenomenon that has been labeled the "super-spreader" effect. That is, it may be that the semen of some infected males is highly effective at transmitting AIDS whereas other infected men are virtually incapable of transmitting HIV to their sexual partners. This phenomenon might be responsible for data that suggest that vaginal intercourse is a fairly inefficient mode of transmission, when in fact the real picture may be closer to "all or nothing"—some males transmit very easily, others not at all.
5. Research on the sexual and drug use habits of the urban nongay populations most affected at present. For example, we need to know more about the sexual patterns of male and female drug users, the needle use habits of occasional drug users versus addicts, and the likelihood of sexual contact across class and racial lines. These data can help us carefully target prevention messages as well as to predict the likelihood of future spread of AIDS to other segments of the heterosexual population.
6. Research on female-to-male transmission. Reports from some sources (e.g., the military) are highly suspect (Potterat, Phillips, & Muth, 1987). While some female-to-male transmission seems to occur, we must know much more to ascertain how prevalent it actually is, and in this area in particular we need researchers highly skilled in sexual interview techniques. Reports from the field (J. French, New Jersey Department of Health, personal communication, November, 1987; Wallace, 1987) cast particular doubt upon men who claim to have contracted AIDS from prostitutes but who may actually be concealing a bisexual background.
7. Development and testing of prevention strategies aimed at men. As long as the major prevention tool for women (condoms) remains in the hands of men, it is critical to reach men with prevention messages.

Recommendations for Prevention: Interim Strategies

In the absence of comprehensive data, we must nevertheless increase and improve prevention efforts aimed toward women. We have no research investigating the efficacy of prevention strategies for women, but some survey reports, such as that done by Joyce Jackson in New Jersey, suggest that women in the minority urban populations who are most at risk have a good deal of knowledge about how AIDS is spread but are nevertheless not practicing safer sex techniques (i.e., not utilizing condoms). Interestingly, the only women showing significant behavior change are prostitutes: the CDC Multi-Center Prostitute Study (Centers for Disease Control, 1987) showed that 78% of prostitutes insisted that their male customers use condoms. However, even the prostitute- who made customers use condoms did not use condoms during sex with their boyfriends or spouses.

Any prevention efforts targeted toward women must address the issue of why even women knowledgeable about AIDS do not use condoms for sex. The reasons are complex and probably not entirely clear, but they are bound up in sex role socialization and social class issues. To begin with, women in this culture are socialized to defer to men in the setting of limits for sex: men usually determine how, when, and how often sex will occur. For a woman to suggest condom use, she must first overcome her internal barrier to setting any sexual limits. Moreover, for women sex is less likely to fulfill a pleasure function than it is to fulfill more pragmatic functions. Among these is the role of sex as a barter exchange for the financial support of a male partner. A poor woman, in particular, often cannot afford to alienate the man who supports her and her children. Many urban poor minority women at risk report fears of abandonment or even physical assault if they suggest condom use, and these women cannot simply replace a recalcitrant partner with a more compliant one that easily. Related to this is the notion of relative risk and temporally close versus temporally distant risk: if a woman balances the risk of AIDS in the future against the immediate loss of food and shelter for her and her children, safer sex loses.

A major obstacle to prevention for women is our failure to convince men of the necessity to use condoms. Safer sex messages have been effective in the gay male community for a number of reasons, but among these is the fact that messages played more upon the desire to protect oneself than the altruistic desire to protect others. That is, gay men were told to use condoms because they risked AIDS from both insertive and receptive anal intercourse. Most heterosexual men have the (erroneous) impression that condoms are necessary only to protect their female partners, and thus we are relying solely upon an altruistic motive rather than addressing the motive of self-interest. This is doubly difficult because condom use often interferes with a rather rigid sexual repertoire among many heterosexuals, compared with the repertoire of substantial numbers of gay men. That is, many gay men have never been as focused upon anal intercourse as a sexual mode as heterosexuals are focused upon vaginal intercourse. Also, among drug users, we have obscured the real significance of sexual transmission by grouping those with multiple risk factors as "IV drug user" cases. In other words, a drug-abusing woman who contracts AIDS is presumed to have been infected through needle use, although she may indeed have been infected through sex.

Because we view all cases of AIDS among drug users as needle related, we underemphasize the role of sexual transmission to the very population we would like to change their sexual habits.

It has been particularly difficult for (mostly) white professionals in the health care field to reach minority populations in an effective way. These very groups of people often have grave mistrust of a white bureaucracy, often based on many years of negative experiences with hospitals, social service agencies, and the like. Hyacinth Foundation staff members, for example, often are asked to respond to questions from black audiences about whether AIDS itself is a plot by the United States government to eradicate blacks. Herb Samuels, prevention consultant for the New York City Health Department, says that Health Department employees are sometimes physically assaulted in minority communities.

A not insignificant factor in the failure of women (and male heterosexuals) to use condoms is that most AIDS prevention messages emphasize multiple sexual partners as the chief risk factor. To most of the population, this phrase translates as "promiscuity," and is extremely perjorative. This message has two unfortunate effects. First, it implies that only "promiscuous" people get AIDS, and that is one reason why women do not see themselves to be at risk if their sexual pattern has been serial monogamy with a small number of partners. Second, the "promiscuity" message means that if a woman asks her male partner to use a condom, she is implying either that he has been "immoral" or that she has been. If she implies that she has been "sexually loose" she risks rejection from her male partner; if she suggests that he may have been she risks his anger and outrage. Moreover, women have been socialized to emotionally protect their male partners. Joyce Jackson describes women who say that they cannot ask their partners to use condoms for fear of hurting their feelings; these women truly are prepared to die for love.

In the absence of better research, and despite the complexity of the problem, what, then, can we suggest as interim prevention strategies for women? We can do the following:

1. Provide free or low-cost legal clean needles to drug users; half of women with AIDS are still drug users.
2. Focus prevention on the group that needs it the most: inner-city minority women of child-bearing age. Use people indigenous to the community to deliver prevention messages.
3. Emphasize the risk from ongoing steady sexual partners rather than multiple partners. Emphasize the length of time the HIV virus has been around, so that women who have been in monogamous relationships for several years do not believe themselves to be safe. Let women know that it can take many exposures to one infected partner before infection takes place, so that women in steady relationships where safer sex has not been practiced do not feel that it is "too late" to start condom use. "It's never too late" is a better message.
4. Target the two highest risk behaviors—anal and vaginal intercourse—rather than a laundry list of "possibly safe/possibly unsafe" behaviors. The less we ask people to change, the more likely they will be to change.
5. Target heterosexual men, not just women.
6. Consider race, class, language (e.g., Spanish), and age factors in designing prevention strategies; consider the roles and functions sex plays in the lives of women.
7. Suggest two barrier methods—for example, condoms plus spermicides with nonoxynol-9, diaphragm, etc. Suggest that if a woman absolutely cannot get her man to use a condom, she at least can use a method she herself can control.

We must learn more about AIDS and women, indeed about all aspects of AIDS. But in the meantime, we can prevent thousands of unnecessary deaths if we simply act upon the existing knowledge we already have.