1. Understanding HIV/Aids Issues Affecting Employees Personally

Major Behavioral Risks

Research to date has identified the key risk behaviours for HIV transmission to be unprotected anal and vaginal intercourse, having multiple sex partners, and using nonsterile drug injection equipment. Although there are some documented cases of transmission through oral-genital sexual contact, methodological issues make it difficult to precisely determine risk. At the present time, oral-genital sexual contact is considered to be a somewhat less risky behaviour for contracting HIV than anal or vaginal intercourse.

Contexts That Influence Risk

Important social and biological contexts and cofactors increase or decrease the likelihood of risk behaviours. A major contextual influence is the prevalence of HIV itself in the local population, which greatly influences the impact of any risky behaviour.

Other contextual influences include:

• Individual factors such as age and developmental stage;
• Early initiation of sexual behaviour;
• Sexual identity;
• Self-esteem;
• Untreated sexually transmitted diseases;
• Use of alcohol, and use of other drugs;
• Interpersonal factors such as sex with a partner of unknown HIV status;
• Partner commitment, and negotiation of safe sex;
• Social norms and values such as cultural and religious beliefs, gender role norms, and social inclusion versus marginalization of gay men, ethnic minorities, people of colour, sex workers, women, and drug users;
• And political, economic, and health policy factors such as laws and regulations, employment opportunities, poverty, sexism, racism, homophobia, and the availability of basic public health tools for protective behaviour, such as condoms and sterile injection equipment.

Although many of the behavioural risk factors are quite well known, the contextual risk factors are only beginning to be understood. For example, intervention programs with younger gay men need to address the fact that some of them consider HIV to be a threat mainly to older men. Negotiation about safe sex practices is much more difficult for women in populations where there are cultural barriers to doing so. Programs targeting sex workers have been highly efficacious in other countries, but in this country would encounter cultural and political barriers. The impact of poverty on seeking treatment for sexually transmitted diseases is much greater in countries without access to universal medical care. These contextual factors combine in dynamic ways to increase behavioural risk.

Means of Identifying Behaviors and Contexts

Behavioural risks have been identified by combining data from epidemiological studies and data from studies of homosexual and heterosexual couples with only one HIV-positive partner. Ongoing measurement of biomedical transmission factors will continue to be important as the epidemic changes. Because contextual factors are more numerous and more difficult to measure than biomedical factors, a wide variety of methods have been used to identify and measure them, including qualitative, ethnographic, and observational techniques. This work is multidisciplinary and requires ongoing consultation with local community groups. Contextual information is essential for designing tailored interventions that respond to the needs and preferences of people in particular communities. In addition, if a particular intervention is not effective for some participants, this information could guide the development of the next generation of interventions.