What is the role of the family in HIV prevention?

Why families?

Families have great influence over a person, and that influence can last a lifetime. Even people who are no longer or never were in touch with their family are influenced by their absence. One half of all persons with HIV became infected during adolescence or early adulthood (ages 15-24). Working with families as early as possible in children’s lives helps solidify healthy behaviors and relationships, thus preventing risk before it happens. HIV prevention has traditionally focused on the individual and not the family. Yet families can have both positive and negative impact on sexual and drug using behaviors that put a person at risk for HIV. Families are important determinants of adolescent sexual behavior, can affect men and women as they “come out” as gay and lesbian and can affect injection drug users (IDUs) as they gain and lose ties to family throughout the years. For this fact sheet, families are defined as the people you grew up with: fathers, mothers, uncles, aunts, cousins, grandparents or foster parents. Many families have strong ties with the community as well, making the community a strong influence. We will not be discussing families of choice, such as intimate social networks.

How do families affect risk behavior?

Families can help protect themselves and their children from risky sexual and drug using behaviors. Family connectedness and parent child communication are key for ensuring healthy behaviors.1 Likewise, when families are not connected and adolescents feel they can’t talk to the adults in their lives, there is a greater risk of unhealthy behavior. Adolescents who feel connected to their families and perceive their parents as caring are more likely to postpone their sexual debut, use contraception, have fewer pregnancies and fewer children.2,3 Two key aspects of parenting that are influential to adolescents are their beliefs that their parents know who they spend time with, and know where they are when they’re not at home or at school.1 In families with strong religious values and an emphasis on marriage and having children, young gay men can have a hard time coming out to their parents. Young men may fear that having a gay son could cause the family shame, or that they will disappoint their parents by not getting married and having children.4 This can lead to internalized shame and low self esteem which contribute to risky behavior. A child who grows up in a family where high stress, alcoholism, substance use and domestic violence are the norm, may repeat that behavior as an adult. Many alcohol and substance abusers have a family history of alcoholism and substance abuse and high levels of domestic violence. In addition, family members sometimes are the ones who give young people their first puff of marijuana, first taste of alcohol or first injection of drugs.5 Family childhood physical abuse, sexual abuse and neglect often lead to risky sexual behavior and drug use in adolescence and adulthood. One study of persons who left methadone maintenance found that 36% had experienced sexual abuse as a child, 60% physical abuse, 57% emotional abuse, 66% child physical neglect and 25% all four experiences. Persons with a history of childhood abuse reported more sexual partners and those with physical neglect were more likely to be HIV+.6

W hat puts families at risk?

Families that have problems often produce children who have problems. Stress, poverty, violence and substance abuse in families leads to less family cohesion, less communication and less tolerance. As a result, teens experience more abuse, neglect and risky drug use and sexual behavior. Neighborhoods with few job opportunities and high levels of drug use and violence have a negative impact on teenage sexual behavior.7 Work and feeling overworked can greatly affect family life. At every economic level, work-related stress negatively impacts family cohesion and communication. When parents have long work hours and feel burned out by their jobs, they don’t have enough time for themselves or their families.8

What’s being done?

The Collaborative HIV Prevention and Adolescent Mental Health Project is a family-based preventive intervention. The program is based on the needs of urban African American youth and their families living in neighborhoods with high HIV infection rates. It seeks to 1) address pre-adolescent behavior, 2) target specific child, parent, and family factors in preventing HIV risk exposure and 3) address high HIV infection rates through a family-based approach. The program offers multiple family groups, a pre-adolescent component, an adolescent component, and stresses the importance of community collaboration.9 Family to Family is a structural intervention that strengthens family functioning and the bonds that connect families to each other. Designed to address a broad range of social issues, the program seeks to increase family communication in a community with high rates of violence, drug abuse and HIV infection. The program uses family groups and life coping skills to address issues such as forgiveness, communication, responsibility, teamwork, family traditions, and household management.10 While many schools and community agencies have begun to offer risk reduction programs for gay/lesbian/bisexual/transgender (GLBT) youth, there are few programs to help GLBT children and their parents. Groups such as Parents, Families & Friends of Lesbians & Gays (PFLAG) offer support and education.11 In San Francisco, CA, a coalition of agencies serving Latino gay and bisexual men started a media campaign to address family cohesion. In their research they found that women were overwhelmingly identified as a source of support: mothers, sisters, aunts and cousins. The campaign “Families Change, Families Grow/Las Familias Cambian, Las Familias Crecen,” used posters showing a mother hugging her adult son’s boyfriend with the caption, “Mom got to know my boyfriend, now there’s a place for him too.” Keepin’ it R.E.A.L.!, a program for adolescents and their mothers, works to increase parental knowledge about HIV and sexuality issues and increase comfort discussing these issues with their children. The program gave mothers and teens a chance to interact and bond, as well as gave mothers a chance to communicate with each other. Women in the program were more likely to talk to their adolescents about sex. School classes that give homework assignments for students to talk to their parents about sexual topics can be effective. The assignments are required, and parents don’t have to go anywhere, but can talk to their children at home.

What still needs to be done?

Families need support to increase communication and build strong bonds as early as possible. Many HIV prevention programs acknowledge that families play a large role in determining risk behavior, but few programs offer interventions for families. In addition to supporting persons who are already engaged in risky behaviors, programs should support family members so that risk behavior doesn’t have cause to start. To establish open communication and solidify family bonds, special care must be taken to encourage gay and lesbian youth to talk about their sexuality, especially in families with strong values regarding the importance of marriage and bearing children. Gays and lesbians are prohibited by law from marrying, may not wish to have children and are often prohibited from adopting children. Community institutions such as churches and schools can work with prevention programs to educate their members and instill tolerance and acceptance of diverse sexual identities. Too often, communities hardest hit by drug use, crime and poverty also have the highest rates of HIV and the lowest rates of family and community support. However, negative outside influences can often be overcome with the help of a strong family. Family strengthening programs, parenting centers and hotlines are needed. Well monitored recreational activities and community centers are also necessary so that parents can know their children will be safe when not at home.

Says who?

1. DiClemente RJ, Wingood GM, Crosby R, et al. Parental monitoring: Association with adolescents’ risk behaviors. Pediatrics. 2001;107:1363-1368. 2. Resnick MD, Bearman PS, Blum RW, et al. Protecting adolescents from harm: Findings from the National Longitudinal Study on Adolescent Health. Journal of the American Medical Association. 1997; 278:823-32. 3. Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy, Washington, DC: National Campaign to Prevent Teen Pregnancy, 2001. 4. Newman BS, Muzzonigro PG. The effects of traditional family values on the coming out process of gay male adolescents. Adolescence.1993;28:213-216. 5. Hampton RL, Senatore V, Gullotta TP, editors. Substance abuse, family violence and child welfare. Thousand Oaks, CA: Sage Publications; 1998. 6. Kang SY, Deren S, Goldstein MF. Relationships between childhood abuse and neglect experience and HIV risk behaviors among methadone treatment drop-outs. Child Abuse and Neglect. 2002;26:1275-1289. 7. Averett SL, Rees D, Argys LM. The impact of government policies and neighborhood characteristics on teenage sexual activity and contraceptive use.American Journal of Public Health. 2002; 92:1773-1778. 8. Gallinsky, E. Ask the children: A breakthrough study that reveals how to succeed at work and parenting. Quill Publications. 2000. 9. Madison SM, McKay MM, Paikoff R, et al. Basic research and community collaboration: Necessary ingredients for the development of a family-based HIV prevention program. AIDS Education and Prevention. 2000;12:281. 10. Fullilove RE, Green L, Fullilove MT. The Family to Family program: A structural intervention with implications for the prevention of HIV/AIDS and other community epidemics. AIDS. 2000;14S1:S63-S67. 11. PFLAG. 12. Freedman B. Great HIV prevention campaigns are not just born. CAPS Exchange. 2000. 13. DiIorio C, Resnicow K, Dudley WN, et al. Social cognitive factors associated with mother-adolescent communication about sex. Health Communications.2000;5:41-51. 14. Kirby D, Miller BC. Interventions designed to promote parent-teen communication about sexuality. New Directions for Child and Adolescent Development. 2002;97:93-110. Prepared by Lesley Green*, Bob Fullilove*, Pamela DeCarlo** *Community Research Group, Columbia University, **CAPS April 2003. Fact Sheet #49E Special thanks to the following reviewers of this Fact Sheet: Roberta Downing, Beth Freedman, Doug Kirby, Mary McKay, Lydia O’Donnell, Birdy Paikoff, Pam Woody.

Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © April 2003, University of California

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