By the end of 2003, an estimated 40 million people throughout the world were living with HIV/AIDS (United Nations Program on AIDS/HIV [UNAIDS], 2004a). With the highest incidence rate in any one single year since the commencement of the pandemic, 5million people worldwide become newly HIV infected in 2003 (UNAIDS, 2004b). This increasing rate of HIV/AIDS infection is a critical public health crisis and highlights the need to continually advocate for the reduction of HIV risk behaviors. Since an effective vaccine or cure for HIV/AIDS infection has not been invented yet, developing effective intervention programs to prevent or reduce the risk of becoming HIV/AIDS infected is extremely important.
Nurses, with an obligatory role in providing quality health care for all, are cooperating with other professional disciplines and contributing to the prevention of HIV/AIDS infection. Studies to date have identified that unprotected sexual intercourse, having multiple sexual partners, and injection drug uses are the main risk behaviors for HIV transmission. Sexual contact is the major exposure to the HIV transmission in most reported AIDS-infected cases. Therefore, HIV risk behaviors generally imply sexual activities in which the likelihood of having HIV infection is increased. Unsafe sexual behavior, risky sexual behavior, or sexual risk-taking behaviors are the terms commonly and widely used by scientists and researchers to represent sexual activity that increases the risk of getting sexually transmitted diseases, including HIV/ AIDS infection, or becoming pregnant. Since the tragedy of the HIV/AIDS epidemic is spreading gravely, these terms in most studies specifically refer to HIV/AIDS-related sexual behavior.
Many psychosocial, biological, and sociologic circumstances or cofactors have been recognized as impacting the likelihood of HIV risks as well. The personal factors, including age, gender, race, developmental stage, early age of initiation of intercourse, HIV/AIDS-related sexual knowledge, sexual identity, self-esteem, self-efficacy, alcohol uses, and the use of illicit drugs, are associated with HIV infection-related risks. Interpersonal factors such as discussing safe sex with sexual partners and asking sexual partners about his/her sexual history may also be correlated with reduced risk of HIV infection. Environmental factors, such as social economic status, peer, school, family, and gender role, cultural norms, religious beliefs, and social isolation, were also found to influence the likelihood of becoming HIV infected.
Many behavioral contributors that increase or decrease the risk of HIV infection have been explored and identified; however, the contextual risk factors and their casual relationships with HIV risk behaviors are still not well understood. This limited understanding is an obstacle for developing effective interventions to prevent or reduce HIV risk-associated behaviors. Several health behavior theories, such as Social Cognitive Theory (Bandura, 1994), Health Belief Model (Rosenstock, 1974), and the Theory of Reasoned Action (Fishbein & Ajzen, 1975), have suggested possible mechanisms and been popularly employed in the understanding and prevention of HIV-related risk behaviors. Most of the cognitive-behavioral interventions that stem from these theories report effectiveness in reducing risk of HIV infection. Strong evidences have shown that human’s cognitive functions, such as self-efficacy, uniquely contribute to the rationale of the safer sexual behaviors, and especially in the domain of condom use. For example, a cross-sectional survey tested the social cognitive-based model for condom use in a randomly selected sample of 1,380 participants with ages 18 to 25 years who were single and reported initiation of sexual intercourse (DiIorio, Dudley, Soet, Watkins, &Maibach, 2001). Self-efficacy was found to be directly related to condom-use behaviors and indirectly through its effect on outcome expectancies.
Thousands of experts have contributed to research in this field since the beginning of the HIV epidemic. Research related to HIV risk behaviors has significantly moved toward interventional studies. Ongoing research is also being conducted on the contextual factors that increase HIV risk behaviors. Successful programs for reducing HIV risk related sexual behaviors are targeted toward different populations (e.g., based on race/ethnicity, sexual orientation, drug use). When examining the effectiveness of an intervention, measurement issues regarding the indications of the HIV risk behaviors are especially important. Because of its complex nature, HIV risk behaviors are measured variously by researchers in terms of content and form. In most of the existing correlational studies, HIV risk behaviors were measure dusing “relative frequency” data collected through Likert scales or “count data” which provided the accurate number of behavioral events used in interventional studies (2003).The “condom use” measure is the most frequently used indicator for HIV risk behaviors in many related behavioral studies. Many interventional programs also focus on improving the constant condom use. Besides the single item or several questions asked to measure risk behaviors, a small number of questionnaires for measuring HIV risk-related sexual behaviors are also available, such as the Safe Sex Behavior Questionnaire (SSBQ) (DiIorioet al., 1992).
Research is urgently needed to involve women and young people, especially adolescents, because these groups have increasingly high HIV risks (UNAIDS, 2004b). It is important to track emerging behavioral risks to identify the settings, subpopulations, or areas at particular risk for HIV infection so that preventive interventions can take these factors into consideration. For example, drug users, men who have sex with men, homeless people, HIV-positive individuals, and people affected with psychiatric disorders have diverse potential risks and disparate abilities to reduce their HIV risk-related behaviors.
Moreover, intervening factors of HIV risk behaviors, such as culture, race, age, and gender among the target populations as mentioned earlier in this section, should be identified and considered in order to design effective HIV prevention programs.
To understand and evaluate the maintenance of behavior change for reducing the risk of HIV infection, longitudinal and multi-variate studies are necessary to detect causal relationships and the changing patterns of HIV risk behaviors. Moreover, methodological issues, including criterion measures, validity of self-report risk behaviors, comparability and generalizability of studies, need special consideration. Future nursing studies in this field are encouraged to include biological markers that can bolster the validity of the studies, because risk behaviors and factors are complex and not easily measured. It is expected that future studies on the effectiveness of prevention programs and change of HIV risk behaviors utilize randomized controlled trial designs, as these are the most powerful designs for intervention studies. Meta-analysis research that integrates the results from various individual HIV risk-behavioral studies is also needed to provide multi perspective views for future direction of nursing practice. Developing a specific HIV risk-behavioral reduction theory from the nursing perspective may be useful and efficacious for nurses to apply to the reduction of HIV risk behaviors.
Effective interventions that prevent or reduce HIV risk behaviors must be disseminated to successfully contain the HIV/AIDS epidemic. Bridges between research, practice, and policy, as well as with other disciplines, must be built. This includes releasing research findings to the public and translating them into community-based practices.