230 AIDS/HIV
programs targeted toward suspected high risk •groupsŽ of
IDUs, adolescents, and gay men; and (c) intensive risk re-
duction counseling through traditional clinical and educa-
tional channels. Beginning in 1987, this strategy has been
subject to a continuous process of both qualitative and quan-
titative evaluation (Dubois-Arber et al., 1999). For example,
Dubois-Arber et al. (1997) reported that, although there had
been no changes in level of sexual activity, condom use with
a new steady partner increased between 1988 and 1994 from
40% to 64% among 17- to 30-year-olds, and from 57% to
72% among those aged 31 to 45. Systematic condom use
with casual partners increased from 8% to 56% between
1987 and 1994 among 17- to 30-year-olds, and from 22% to
42% between 1989 and 1994 among those aged 31 to 45. As
one would hope, condom use was higher among those with
multiple partners. Based on these ongoing evaluations, rec-
ommendations have been formulated by investigators, and
used by policymakers. Dubois-Arber et al. (1999) note that
the cost of such evaluation is low relative to the amount of
information provided, and that this project has also con-
tributed to the development of a culture of evaluation in
Switzerland.
Upstream approaches have much to recommend them, and
often involve integration of downstream and midstream ap-
proaches. Thus, far, they have been most successful in
smaller countries.
SECONDARY PREVENTION
Thus far, we have considered the progress that has been made
in the development of primary prevention interventions to
reduce the transmission of new HIV infections. We now
consider the contributions of health psychology research in
the area of HIV secondary prevention. In the present context,
secondary prevention refers broadly to interventions de-
signed to reduce adverse health, behavioral, and psychologi-
cal outcomes among men and women living with HIV
disease. Treatment gains brought about by the availability of
highly-active antiretroviral therapies (HAART) have
renewed hope for many persons living with HIV/AIDS.
However, many do not experience lasting bene“ts from
HAART, and those who do respond face many long-term
stressors and behavioral demands. The availability of
improved treatments raises a number of new priorities for
health psychologists in their work with persons living with
HIV. After providing an overview of recent advances in HIV
medical care, we focus on three critical issues in secondary
prevention: (a) coping and psychological intervention needs
among people living with HIV, (b) adherence to complex
drug regimens, and (c) sexual and drug use risk-reduction
needs among persons living with HIV.Historical and Psychosocial Context of HIV
Medical CareNearly 20 years have passed since the “rst cases of AIDS
were described in the scienti“c literature and HIV was found
to be the causal agent in AIDS (Barre-Sinoussi et al., 1983;
Gallo et al., 1984). Early in the epidemic, the only treatments
that were available were palliative efforts to forestall AIDS-
related opportunistic infections. Indeed, thousands of people
lost their lives well before a diagnostic test was available to
identify HIV infection. The early years of the epidemic were
characterized by an atmosphere of alarm, fear, and mistrust,
as many people sought to distance themselves from (and
often sought to blame) stigmatized groups of gay men,
Haitians, injection drug users, and hemophiliacs who were
identi“ed initially as carriers of a new and mysterious infec-
tious disease (Kobayashi, 1997). Those who developed AIDS
often died quickly and in isolation, leaving loved ones in a
state of fear and disbelief, mourning a sudden loss while wor-
rying that contact with the infected person may have infected
others with the disease. Meanwhile, with no understanding of
disease pathogenesis or transmission routes, the number of
new cases of HIV rose steadily.
In 1985, the ability to detect HIV antibodies represented a
crucial “rst step for the initiation of drug trials, and was of
obvious importance for prevention efforts. By con“rming
that many who were infected with HIV looked and felt •per-
fectly healthy,Ž HIV testing provided the early framework
for prevention work emphasizing the need for safer sex with
all partners of unknown serostatus. Further, HIV testing dis-
pelled the myth that HIV could be transmitted through casual
contact, allowing people to feel more comfortable interact-
ing, supporting, and providing treatment for those who were
infected. For many, however, the availability of HIV testing
raised more concerns and questions than it answered
(Kobayashi, 1997). The lack of treatment options, high levels
of stigma and discrimination associated with HIV, and
heightened anxiety associated with what was correctly per-
ceived as a virtual •death sentence,Ž led many at-risk men
and women to question the utility of HIV testing.
The “rst major treatment milestone came in 1987 when
the antiretroviral therapy zidovudine (AZT) became widely
available to persons living with HIV. Clinical trials demon-
strating that AZT treatment led to increased T-helper lym-
phocytes, reduced frequency of opportunistic infections, and
prolonged survival time (Fischl et al., 1987) provided some
cause for optimism. However, for most patients, long-term