Behavioral interventions--rationale, measurement, and effectiveness.

Effective STD and HIV prevention requires synergism of individual-based prevention behaviors and societal/structural supports that will promote and maintain these behaviors. We should also expect the unexpected. STD rates in gay men have risen after effective prevention of HIV/STD in gay men and effective antiretroviral therapy. New drugs of abuse, such as methamphetamine ("crystal meth"), have induced risky sexual behaviors in gay and heterosexual communities. Economic dislocation in Eastern Europe has resulted in trafficking of commercial sex workers to Europe, the Mideast, and Asia, all with the potential for STD and HIV spread. James Curran, formerly director of the HIV epidemiology and prevention effort at the CDC, has written: It is ironic that the two clearest examples of large-scale success in HIV prevention-reduction in HIV transmission in gay men in the United States and national declines in HIV incidence in Thailand-arise in societies/communities known in their own way for sexual openness....the openness in both communities provided the environment to make the powerful revolutionary changes needed. In Africa, the powerful voice of President Museveni of Uganda has also encouraged candor about sexual risk-taking and facilitated that nation's encouraging early success in reducing HIV prevalence...Unfortunately, most of the world remains unable or unwilling to deal frankly and consistently with sexuality despite the considerable risks of HIV infection in many communities. There is a worldwide sexual hangup hampering HIV prevention efforts.