Library

Resource

HIV counseling and testing

What Is the Role of Counseling and Testing in HIV Prevention?

why is C&T important?

HIV counseling and testing (C&T) is an important part of a continuum of HIV prevention and treatment services. C&T is one of the main times when a comprehensive individual risk assessment is taken, making it the best opportunity for accurate referrals to more intensive services. C&T is also one of the primary entry points into prevention and other services. C&T uses short, client-centered counseling that can be effective in increasing condom use and preventing sexually transmitted diseases (STDs).1 Knowing one’s HIV status, whether HIV- or HIV+, is key to preventing the spread of HIV and accessing counseling and medical care. It is estimated that one-fourth of all HIV+ persons in the US do not know they’re infected.2 A survey of young men who have sex with men (MSM), found that 14% of young Black MSM were HIV+. Among those, 93% were unaware of their infection, and 71% reported it was unlikely they were HIV+.3 Recently, the Centers for Disease Control and Prevention (CDC) announced an initiative aimed at expanding C&T in the US.4 Their Strategic Plan for 2005 strives to decrease by 50% the number of people who don’t know their HIV status.5 If this goal is met by 2010, an estimated 130,000 new HIV infections may be prevented, saving over $18 billion.6

how is C&T done?

C&T has three distinct components: risk assessment and counseling before the blood or oral sample is taken, testing of the sample, and counseling and referral with the test results.7 C&T can be confidential-a person’s name is recorded with the test results-or anonymous-no name is recorded with the test. Publicly funded HIV C&T takes place in testing centers, community health clinics, community-based organizations, outreach programs, mobile vans, STD and family planning clinics and local health departments, among other venues. Although public health workers are trained in C&T procedures, most HIV testing in the US occurs in private doctors’ offices. Many people prefer being tested as part of a routine check-up, instead of public health sites. However, testing in private venues does not offer anonymity, and patients who get tested as part of routine medical care may not receive adequate counseling or referrals.8 Other venues also test for HIV, such as emergency rooms, jails/prisons, military recruitment sites and Job Corps. HIV testing in the US is mandatory to get some insurance and medical benefits, apply for some jobs, join the military, give blood or enter the US as an immigrant. HIV testing is compulsory for federal prison inmates and sex offenders in some states.

what about rapid testing?

The standard testing method for the past 20 years has been a needle blood draw. In the past 10 years, a mouth swab (OraSure) that tests cells from inside the cheek has also been available. Results are sent to a lab for the ELISA test and a Western Blot to confirm an initially positive result, with an average wait of 1-2 weeks between sample collection and the provision of results. With this method, many persons don’t return for their test results, and nationally 31% of persons who test HIV+ don’t return to find out their results.4 Rapid testing is now available with a finger stick (OraQuick). With this method, results are known in 20 minutes, eliminating the need for a return visit for results. However, if a client’s tests is reactive, he receives a preliminary positive result. A second blood test (needle draw or OraSure) is required to confirm the result with a standard Western Blot. Final confirmation still takes 1-2 weeks. National data indicate that with rapid testing, 95% of clients who received a preliminary positive result returned for their confirmatory results.9 Rapid testing will change the way C&T is conducted, although clients can still opt to get their results later. Because the client needs to wait for 20 minutes for the results, the counselor takes the blood early in the session and has a “captive audience” for risk assessment and counseling. Test counselors can conduct the blood test themselves, or a separate staff person can do the finger stick and read results. Counseling with rapid testing can be more intense and client-focused due to the immediacy of getting results. It is hoped that rapid testing will dramatically increase the number of persons who know their results.

what makes good C&T?

Good C&T depends on counselors who are properly trained and have enough experience. Counselors must protect the confidentiality of client information, obtain informed consent before testing and provide effective counseling services and appropriate referrals. Counselors should establish relationships with key service agencies to make sure the referrals they give clients reflect their needs, priorities, culture, age, sexual orientation and language. C&T counselors should be evaluated regularly to assure quality and be provided with support and ongoing training.7 With rapid testing, counselors need different training as they can be both the counselor and the lab. Rapid testing requires stable temperatures, adequate lighting, and careful attention to detail. Also, rapid testing is not rapid counseling. Counselors need to work closely with clients to develop a reasonable risk reduction step and to make sure their clients are actually ready to receive the test results. It is also important to obtain a second blood sample for confirmation if a client tests positive.10

what’s being done?

The Department of Public Health (DPH) in Florida made a deliberate effort to improve their C&T services and increase the number of people who know they are HIV+. State funded testing sites targeted venues with high-risk persons, including CBOs, prisons/jails and outreach settings. They also began using OraSure for testing in the field. In 2002, the DPH reported a 2% seropositive rate for blood draws and 3.2% for OraSure. In jails they found a 3.6% seropositive rate. They also used partner counseling and referral services (PCRS) and in 2002, 80% of HIV+ people gave names of partners, 64% of partners were located and counseled, and 13% of partners who tested were HIV+.11 In Minneapolis, MN, rapid testing was offered at a variety of agencies serving primarily African American clients. Venues included drug treatment programs, homeless shelters, teen clinics, sex offender groups and halfway houses. Almost all (99.7%) of clients received their test results and counseling, and 95% reported they would rather have a finger stick than a blood draw.12 Wisconsin’s AIDS/HIV Program wanted to increase the number of high-risk persons accessing testing. In the early 90s, tests jumped from 6000 per year to between 20,000-30,000. The number of high-risk persons tested, however, remained the same while seroprevalence rates dropped from 3.5% to 0.5%. In the late 90s, the program shifted its philosophy from one of public education to case finding. Publicly funded sites were reduced from 126 to 55 serving the greatest percentage of high-risk persons and persons of color. In one year, the seroprevalence rate improved to .75%, the number of low-risk persons tested decreased 42%, high-risk persons tested increased 6%, and testing among persons of color improved 18%.13

what is the future of C&T?

As rapid testing becomes more widely used, it is hoped that the number of people not returning for their test results will decrease. Rapid testing can allow for more targeted outreach to communities and persons at risk, as C&T occurs in venues that are more accessible and acceptable. Rapid testing should be implemented carefully to allow time for agencies to gain experience and clients to understand the new testing process. Greater efforts may be necessary to refer clients to effective services. Behavior change is a slow and difficult process, and many persons make changes incrementally. Linkages to other services and follow-up with clients may substantially increase the impact of the initial counseling. While training and quality assurance has traditionally centered on counseling in C&T, referrals may be the weakest part and need most improvement. Simply increasing the number of persons who know they are HIV+ will not slow the HIV epidemic sufficiently. As more persons in the US discover their HIV status, it is crucial to ensure that more prevention, social and treatment services are available both to HIV+ and HIV- persons. In addition to primary HIV prevention interventions, these should include access to quality drug and alcohol treatment, housing and employment services, STD testing and treatment, syringe exchange programs, quality medical care and adherence support to insure effective use of AIDS medications. Prepared by Steven R. Truax, PhD*, Pamela DeCarlo** *California State Office of AIDS, **CAPS

Says who?

1. Kamb ML, Fishbein M, Douglas JM,et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases. Journal of the American Medical Association. 1998;280:1161-1167. 2. Fleming P, Byers RH, Sweeney PA, et al. HIV prevalence in the United States, 2000. Presented at the 9th Conference on Retroviruses and Opportunistic Infections, Seattle, WA; February 24-28, 2002. 3. Centers for Disease Control and Prevention. Unrecognized HIV infection, risk behaviors and perceptions of risk among young black men who have sex with men – six US cities, 1994-1998. Morbidity and Mortality Weekly Reports. 2002;33:733-736. 4. Centers for Disease Control and Prevention. Advancing HIV Prevention: New Strategies for a Changing Epidemic – US, 2003. Morbidity and Mortality Weekly reports. 2003:52;329-332. https://pubmed.ncbi.nlm.nih.gov/12733863/  5. Centers for Disease Control and Prevention. HIV Prevention Strategic Plan Through 2005. www.cdc.gov/hiv/partners/ psp.htm 6. Holtgrave DR, Pinkerton SD. Economic implications of failure to reduce incident HIV infections by 50% by 2005 in the United States. Journal of Acquired Immune Deficiency Syndromes. 2003;33:171-174. 7. Centers for Disease Control and Prevention. Revised Guidelines for HIV Counseling, Testing, and Referral. Morbidity and Mortality Weekly Reports. 2001;50. 8. Haidet P, Stone DA, Taylor WC, et al. When risk is low: primary care physicians’ counseling about HIV prevention. Patient Education and Counseling. 2002;46:21-29. 9. Kassler WJ, Dillon BA, Haley C, et al. On-site, rapid HIV testing with same-day results and counseling. AIDS. 1997;11:1045-1051. 10. Fournier J, Morris P. Speed bumps and roadblocks on the road to rapid testing: a look at the integration of HIV rapid testing in an agency and community. Presented at the US Conference on AIDS, New Orleans, LA, 2003. 11. Liberti T. Florida’s HIV counseling, testing and referral program. Presented at the US Conference on AIDS, New Orleans, LA, 2003. 12. Keenan PA. HIV outreach in the African American community using OraQuick rapid testing. Presented at the National HIV Prevention Conference, Atlanta, GA. 2003. 13. Stodola J. Restructuring Wisconsin’s HIV CTR program: targeting CTR services. Presented at the US Conference on AIDS, New Orleans, LA, 2003.

January 2004. Fact Sheet #3ER Special thanks to the following reviewers of this Fact Sheet: Jena Adams, Barbara Adler, Chris Aldridge, Teri Dowling, Barbara Gerbert, Paul Haidet, Sydney Harvey, Willi McFarland, Patrick Keenan, Kathryn Phillips, Jim Stodola, Brenda Storey, Ed Wolf.

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]. © January 2004, University of California

Resource

Young gay men

What are the HIV Prevention Needs of Young Men Who Have Sex with Men?

revised 4/01

Are young MSM at risk for HIV?

Yes. Over half of all the reported HIV and AIDS cases among males aged 13-24 in the US were due to male-male sexual contact.1 Various studies found that 26% to 50% of young men who have sex with men (MSM) report recent unprotected anal intercourse, and much of this unprotected sex occurred with a partner of unknown or different HIV status.2-4 Rates of sexual risk-taking among young MSM are also increasing.5 The term young MSM includes men who self-identify as gay or bisexual, as well as non-gay/bi-identified MSM under 30 years old.6 A large number of urban young MSM are already infected with HIV. A study of 15- to 22-year-old young MSM in seven cities (Baltimore, MD; Dallas, TX; Los Angeles, CA; Miami, FL; New York, NY; San Francisco Bay Area, CA and Seattle, WA) showed a high overall HIV prevalance: 7%, ranging from 2% -12%. Moreover, 82% of the HIV+ men had no idea they were HIV+ before this testing. Young MSM of color, especially African American men, are disproportionately impacted. In the multi-city study, 14% of the African Americans tested HIV+, compared to 13% among mixed race men, 7% among Hispanics, 3% among Asians and 3% among whites.6

Why do young MSM take risks?

Unfortunately, there are no simple answers to this question. The explanations for unsafe sex are complex and multi-faceted.3,7 Adolescence and young adulthood are often characterized by experimentation and exploration of sexuality and drug using. While most young MSM will engage in some HIV risk behaviors at some point in their lives, only a small percentage are consistent risk takers. Many young MSM struggle with individual, interpersonal and societal stressors that may interfere with their ability to protect themselves.8 For some young MSM, individual factors can lead to unsafe sex, such as: feeling invulnerable to HIV; having high levels of optimism about HIV antiviral medications; perceiving that unsafe sex is more pleasurable than safer sex; being depressed or sad; having conflicting allegiance with either their racial or sexual identity; and using alcohol or other drugs (e.g. speed/crystal, poppers).8 Protecting one’s health is not necessarily a young MSM’s top concern. Interpersonal motivations may be more pressingwanting to fit in, to find companionship and intimacy. However, interpersonal issues can also contribute to unsafe sex, such as finding it difficult to communicate or negotiate safer sex with a sexual partner. Young MSM who are in a relationship are more likely to have unsafe sex than single young MSM.4 Societal factors may also influence the risk-taking of young MSM. Many young MSM find themselves isolated or rejected by traditional sources of support like family, school, or religious community.9 Homophobia, racism and poverty also place young MSM at risk. Some young MSM, especially those living on the street, are struggling with daily needs like avoiding violence, finding a place to live, or obtaining food. These pressing needs may overshadow the concern for safer sex and injection practices. Young MSM have few public places to meet each other. Gay bars and public cruising areas are some of the more visible and accessible places, offering anonymity for young men exploring their sexual identity. These venues are also associated with high levels of risk-taking. They are highly sex-charged and the bar scene’s emphasis on alcohol sets the stage for engaging in sex while intoxicated. This is consistently found to contribute to unsafe sex.10 Little is known about the Internet’s role in the lives of young MSM, including how young MSM use the Internet to obtain social support, make new friends, find romantic partners, and/or cruise for sex.

What’s being done?

The Mpowerment Project is a multilevel, sex- and gay-positive, peer-based intervention in which young men take charge. Because HIV may not be particularly compelling for many young MSM, the project focuses on young MSM’s social concerns. The young men plan and coordinate activities to create a stronger and healthier community for themselves in which safer sex becomes the mutually accepted norm. Participants in the Project have reduced rates of unprotected anal intercourse with casual partners and boyfriends. Mpowerment, proven effective as an HIV prevention intervention, provides CBOs with training and a manual for replication.11 The COLOURS Organization in Philadelphia, PA targets young MSM of color with support groups, peer educator training and individual case management. They do street outreach at sex clubs and bars frequented by MSM of color, providing condoms and counseling to young MSM who partner with older men. They also promote gay-friendly drug and alcohol treatment services for young MSM.12 The American Psychological Association has implemented the Healthy Schools Project for Lesbian and Gay Students. The Project trains school psychologists, counselors, nurses and social workers to work effectively with gay, lesbian and bisexual students. The goal is to make schools a friendlier environment for these students and make HIV prevention education more relevant to them.13 “Chico Chats,” a program of the STOP AIDS Project in San Francisco, CA, consists of a one-month intensive series of workshops. Participants get to know each other while engaging in facilitated conversations about body image, relationships and identity and how these issues relate to HIV. Learning community organizing and mobilization techniques is a key component of these workshops as well. Participants formed an activist group called ¡Ya Basta! (Enough Already) and designed a video and workshop examining the issues of sexual silence and coming out in Latino families. The video is being shown throughout Latino communities in San Francisco.14

What else needs to happen?

Effective programs for young MSM must address the context of their lives and the individual, interpersonal and societal factors that put them at risk. Comprehensive health and sexuality education must target both those who identify as gay or bisexual and those who do not. Unfortunately, many school-based programs focus on reproduction or abstinence until marriage, further marginalizing young MSM. There is an urgent need to create prevention and wellness programs specifically for young MSM of color. Existing programs for older MSM of color should also be accessible to young MSM. These programs should address issues of sexuality, gay identity, culture, race/ethnicity, racism, homophobia, poverty and violence. Programs must also consider the HIV prevention needs of both HIV positive and HIV negative young MSM. Special attention is necessary to reach marginalized young MSM, such as those who are homeless, engaged in commercial sex work or involved with the criminal justice system. These young men may not identify as gay or bisexual, and may have immediate needs for food and shelter to address. Programs are needed that foster support for young MSM and involve them directly in planning and implementation. Support might encompass creating safe places for young MSM to socialize and access services, developing school-based sexuality and gay-awareness programs and helping young MSM advocate for greater acceptance by schools, families, religious communities, the gay community at large and communities of color.15 Societal homophobia may impede implemention of prevention programs for young MSM and may discourage young MSM from accessing prevention services.16 Political concerns must not be allowed to interfere with HIV prevention services for young MSM. Targeting young MSM with HIV prevention messages and services is an appropriate response to a grave public health threat. Unless action is taken quickly, we will lose many young men to HIV.

Says who?

  1. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report . 2000;12.
  2. Molitor F, Facer M, Ruiz JD. Safer sex communication and unsafe sexual behavior among young men who have sex with men in California. Archives of Sexual Behavior. 1999;28:335-343.
  3. Kegeles SM, Hays RB, Pollack LM, et al. Mobilizing young gay and bisexual men for HIV prevention: a two-community study . AIDS. 1999;12:1753-1762.
  4. Hays RB, Kegeles SM, Coates TJ. Unprotected sex and HIV risk-taking among young gay men within boyfriend relationships . AIDS Education and Prevention. 1997;9:314-329.
  5. Ekstrand ML, Stall RD, Paul JP et al. Gay men report high rates of unprotected anal sex with partners of unknown or discordant HIV status . AIDS. 1999;13:1525-1533.
  6. Valleroy LA, MacKellar DA, Karon JM et al. HIV prevalence and associated risks in young men who have sex with men . Young Men’s Survey Study Group. Journal of the American Medical Association. 2000;284:198-204.
  7. Strathdee SA, Hogg RS, Martindale SL et al. Determinants of sexual risk-taking among young HIV-negative gay and bisexual men . Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 1998;19:61-66.
  8. Choi KH, Kumekawa E, Dang Q et al. Risk and protective factors affecting sexual behavior among young Asian and Pacific Islander men who have sex with men: Implications for HIV prevention . Journal of Sex Education & Therapy. 1999;24:47-55.
  9. Beeker C, Kraft JM, Peterson JL, et al. Influences on sexual risk behavior in young African-American men who have sex with men. Journal of the Gay and Lesbian Medical Association. 1998;2:59-67.
  10. Greenwood GL, White EW, Page-Shafer K, et al . Correlates of heavy substance use among young gay and bisexual men: The San Francisco Young Men’s Health Study . Drug and Alcohol Dependence. 2001:61:105-112.
  11. CDC. Compendium of HIV prevention interventions with evidence of effectiveness . 1999.
  12. The COLOURS Organization, Inc . Philadelphia, PA. 215/496-0330.
  13. Clay RA. Healthy Schools project hoped to ease discrimination . APA Monitor. 1999;30.
  14. The STOP AIDS Project . Q Action, ¡Ya Basta! San Francisco, CA. 415/865-0790×303.
  15. Seal DW, Kelly JA, Bloom FR, et al. HIV prevention with young men who have sex with men: what young men themselves say is needed . AIDS Care. 200;12:5-26.
  16. Stokes JP, Peterson JL. Homophobia, self-esteem, and risk for HIV among African American men who have sex with men . AIDS Education and Prevention. 1998;10:278-292.

Prepared by Pilgrim Spikes MPH Phd, Bob Hays PhD, Greg Rebchook PhD, Susan Kegeles PhD, CAPS April 2001. Fact Sheet 8ER

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 2001, University of California

Resource

Asiáticos y Isleños del Pacífico

¿Qué necesitan los asiáticos e isleños del Pacífico para prevenir el VIH?

revisado 12/07

¿corren riesgo los AIP?

Los asiáticos e isleños del Pacífico (AIP) son una de las poblaciones de minorías étnicas de mayor crecimiento en los Estados Unidos.1 Se calcula que para el año 2050 este grupo alcanzará 34 millones personas y representará el 8% de la población total de EE.UU.1,2 Los asiáticos y los isleños del Pacífico tienen una diversidad considerable que abarca 49 grupos étnicos, más de 100 idiomas y personas de origen chino, filipino, coreano, hawaiano, indio-asiático, japonés, samoano, vietnamita y otros. La mayoría vive en metrópolis grandes como Honolulu, HI; San Francisco, CA; Nueva York, NY y Los Ángeles, CA.2 Entre el 2001 y el 2004 los AIP componían menos del 1% de los casos de VIH/SIDA en EE.UU., pero también tenían el mayor porcentaje del incremento anual en las tasas de diagnóstico frente a todos los otros grupos étnicos/raciales (el 8.1% para hombres y el 14.3% para mujeres).3 Cuando grupos poblacionales como los AIP muestran una prevalencia baja (cifras totales) pero grandes incrementos en la incidencia (casos nuevos), se precisan esfuerzos de prevención para limitar futuros casos de VIH/SIDA. El subregistro de casos y la falta de una vigilancia detallada del VIH ocultan la naturaleza auténtica de la epidemia entre los AIP. Un estudio encontró que el subregistro de casos de SIDA entre AIP puede alcanzar el 33 %4. Esto podría deberse en parte al registro erróneo de raza y origen étnico en los expedientes médicos, que son la fuente de datos para el reporte de registro de casos.2,5 Por ejemplo, las personas con apellido hispano, como los filipinos, pueden ser registradas por error como latinas. La falta de detalles demográficos sobre el grupo étnico específico y lugar de nacimiento también impide el rastreo de diferencias entre subgrupos de AIP con respecto a la epidemia del SIDA y dificulta la creación de medidas de salud pública para etnias específicas.2

¿quiénes son los AIP que corren riesgo?

La transmisión del VIH entre los AIP masculinos se da principalmente entre hombres que tienen sexo con hombres (HSH), seguidos por hombres que tienen contacto heterosexual de alto riesgo o que se inyectan drogas (UDI). En 2005, el 71% de los casos de SIDA entre los AIP hasta esa fecha se debió a la transmisión entre HSH.6 Entre las mujeres AIP, la transmisión ocurre mayormente entre mujeres que tienen coito con un hombre que tiene mayor riesgo, seguido por mujeres UDI.6 Aunque los HSH AIP son los más afectados por el VIH/SIDA, los diagnósticos entre mujeres AIP han aumentado (14.3%)3. El CDC no tiene una categoría para mujeres transgéneras (nacidos hombres pero que se consideran y viven como mujeres), sin embargo un estudio en San Francisco, CA indicó una prevalencia de VIH del 13% entre las mujeres transgéneras AIP.7

¿qué pone a los AIP en riesgo?

Entre los HSH AIP, la discriminación social y la falta del apoyo familiar, de sus semejantes y comunitario con respecto a la diversidad sexual y racial puede perjudicar la auto estima y la auto identidad positivas, lo cual aumenta el riesgo de contraer el VIH.8 En un estudio, el 57% de los hombres AIP gay en San Francisco, CA, consumieron alcohol antes del sexo anal; el 24% reportó practicarlo sin protección. Sin embargo, el 85% creía tener pocas posibilidades de contraer el VIH.9 Pocos AIP se hacen la prueba del VIH en contraste con el resto de la población de EE.UU., aunque reportan tasas similares de conductas de riesgo2 y con frecuencia demoran en buscar servicios de VIH. En un estudio entre jóvenes HSH AIP en San Francisco, CA, el 24.4 % de los participantes nunca se había hecho la prueba del VIH anteriormente. Además, el 2.6 % resultó VIH+; de este grupo el 61.5 % no sabía que era VIH positivo y el 38.5 % reportó un acto sexual reciente sin protección.10 Los AIP VIH+ que todavía no se han hecho la prueba son más propensos a actos riesgosos y a infectar a otros sin saberlo.11 Aquellos que demoran en atenderse corren un mayor riesgo de tener el SIDA avanzado en el momento del diagnóstico y de adquirir una coinfección como la hepatitis B, la tuberculosis y la PCP.5,12 Las inmigrantes AIP que trabajan en casas de masaje muchas veces realizan actividades que las exponen al VIH. Sin embargo, para muchas de ellas la sobrevivencia diaria tiene prioridad sobre la prevención del VIH. Los problemas relacionados con la policía, el trabajo sexual, la situación migratoria, la planificación familiar, el idioma y la falta de uso de condones en los centros de masaje son todos factores de riesgo para esta población.13

¿cuáles son los obstáculos?

A pesar del estereotipo de los AIP como “minoría étnica modelo”, el 17% no tiene seguro médico y no puede recibir tratamiento y otros servicios de salud adecuados.14 Debido a los escasos datos sobre la salud y los riesgos conductuales de los AIP, muchos recursos se destinan a otros grupos sin evaluar o reconocer las necesidades de los AIP.14 La norma cultural de evitar temas como la actividad sexual, la enfermedad y la muerte plantea barreras a la prevención del VIH, genera estigmas y perjudica la salud psicológica y mental de los AIP que viven con esta enfermedad.15 El 40% de los AIP habla poco o nada de inglés14 y pocos programas de intervención reflejan la diversidad cultural y lingüística de esta población. Un estudio encontró que el idioma es el obstáculo más común al acceso a servicios médicos para los AIP con VIH/SIDA.12

¿qué se está haciendo al respecto?

Existen muchos programas nacionales y locales que brindan servicios y orientación sobre la prevención del VIH para AIP.16 Otros ofrecen desarrollo de capacidades y asistencia técnica para organizaciones que los atienden.17 Por ejemplo: La Asian and Pacific Islander Coalition on HIV/AIDS (AIPCHA) desarrolló Project Bridges, una intervención comunitaria para reducir las disparidades de atención para AIP VIH+ en Nueva York. Formó enlaces con proveedores médicos y brindó manejo de casos, promoción de derechos y capacitación sobre la competencia cultural para los proveedores. Se logró aumentar la utilización de servicios y reducir las barreras a servicios para los participantes que tenían un idioma asiático como lengua principal, los que no hablaban inglés y los indocumentados.12 Life Foundation, en Honolulu, HI, ha ofrecido programas comunitarios para HSH y transgéneros de las islas del Pacífico desde 1999. “UTOPIA Hawai’i” está basado en el modelo Mpowerment y ha logrado grandes éxitos en alcanzar a isleños del Pacífico que nunca habían utilizado servicios de VIH anteriormente.18 El Health Project for Asian Women (HPAW) para las trabajadoras sexuales asiáticas de casas de masaje en San Francisco, CA, brindó dos intervenciones: una orientó a los dueños de estos negocios y otra informó a las masajistas sobre temas de salud. El personal del HPAW acompañó a las masajistas a clínicas médicas, repartió materiales para una práctica sexual más segura, y les ofreció servicios de interpretación, remisiones y promoción de derechos. Las masajistas recibieron tres sesiones de consejería y los dueños asistieron a una sesión informativa.13 El Asian & Pacific Islander Wellness Center realizó una campaña anti estigma sobre el VIH. La campaña se destinó a las comunidades chinas de San Francisco, CA por medio de carteles en las paradas de autobús, anuncios en los periódicos y un documental con la participación de dirigentes comunitarios locales, personas VIH+ y sus familias. También lideró el Día Nacional AIP para la Concienciación del VIH/SIDA, en el que organizó más de 15 eventos a lo largo de EE.UU. para aumentar la aceptación del VIH/SIDA entre familias y comunidades AIP.19

¿qué queda por hacer?

Tenemos una oportunidad de oro para mantener bajas las cifras de VIH entre los AIP, pero podríamos perderla pronto, pues tienen el mayor aumento en las tasas de diagnóstico de VIH/SIDA que cualquier otro grupo racial en EE.UU. Los programas de prevención del VIH para AIP deben centrarse en las personas que corren mayor riesgo: HSH, mujeres, transgéneros y consumidores de drogas. Los programas pueden ayudar a los AIP a crear y fortalecer sistemas de apoyo y enfocar la prevención y la atención médica, como pruebas para detectar el VIH, la hepatitis B y la tuberculosis. Se necesita diseñar y evaluar más programas que se ajusten mejor a los aspectos culturales y lingüísticos de los AIP. Para combatir el estigma en torno al VIH, a la homosexualidad, al trabajo sexual y al consumo de drogas se necesitan campañas informativas que profundicen el diálogo sobre la prevención de VIH/SIDA y la aceptación de los AIP VIH+. El trabajo conjunto entre los formuladores de políticas y nuevos colaboradores, como lo son ahora las organizaciones religiosas, puede reducir el estigma entre los AIP. Dada la enorme diversidad entre los AIP radicados en EE.UU., es importante mejorar los sistemas de vigilancia y la calidad de los datos recogidos, registrando siempre el origen étnico y el lugar de nacimiento de cada subgrupo.3 Se necesitan investigaciones sobre el VIH y las coinfecciones (la hepatitis B y la tuberculosis) y sobre la relación entre la aculturación y el VIH.

¿Quién lo dice?

1. Choi KH, Wong F, Sy FS. HIV/ AIDS among Asians and Pacific Islanders in the United States. AIDS Education and Prevention. 2005;17:iii-v. 2. Zaidi IF, Crepaz N, Song R, et al. Epidemiology of HIV/AIDS Among Asians and Pacific Islanders in the United States. AIDS Education and Prevention. 2005;17:405-417. 3. Racial/ethnic disparities in diagnoses of HIV/AIDS33 states, 2001-2004. Morbidity and Mortality Weekly Report. 2006;55:121-125. 4. Kelly JJ, Chu SY, Diaz T, et al. Race/ethnicity misclassification of persons reported with AIDS. Ethnicity & Health. 1996;1:87-94. 5. Wortley PM, Metler RP, Hu DJ, et al. AIDS among Asians and Pacific Islanders in the United States. American Journal of Preventative Medicine. 2000;18:208-214. 6. Cases of HIV infection and AIDS in the United States and dependent areas, 2005. HIV/AIDS Surveillance Report. 2006;17:37. 7. Operario D, Nemoto T. Sexual risk behavior and substance use among a sample of Asian Pacific Islander transgendered women. AIDS Education and Prevention. 2005;17:430-443. 8. Wilson PA, Yoshikawa H. Experiences of and responses to social discrimination among Asian and Pacific Islander gay men: Their relationship to HIV risk. AIDS Education and Prevention. 2004;16:68-83. 9. Choi KH, Operario D, Gregorich SE, et al. Substance use, substance choice, and unprotected anal intercourse among young Asian American and Pacific Islander men who have sex with men. AIDS Education and Prevention. 2005;17:418-429. 10. Do TD, Chen S, McFarland W, et al. HIV testing patterns and unrecognized HIV infection among young Asian and Pacific Islander men who have sex with men in San Francisco. AIDS Education and Prevention. 2005;17:540-554. 11. Wong F, Campsmith ML, Nakamura GV, et al. HIV testing and awareness of care-related services among a group of HIV-positive Asian Americans and Pacific Islanders in the United States: Findings from a supplemental HIV/AIDS surveillance project. AIDS Education and Prevention. 2004;16:440-447. 12. Chin JJ, Kang E, Haejin Kim J, et al. Serving Asians and Pacific Islanders with HIV/AIDS: Challenges and lessons learned. Journal of Health Care for the Poor and Underserved. 2006;17:910-927. 13. Nemoto T, Iwamoto M, Oh HJ, et al. Risk behaviors among Asian women who work at massage parlors in San Francisco: Perspectives from masseuses and owners/managers. AIDS Education and Prevention. 2005;17:444-456. 14. Ghosh C. Healthy People 2010 and Asian Americans/Pacific Islanders: Defining a baseline of information. American Journal of Public Health. 2003;93:2093-2098. 15. Kang E, Rapkin BD, Remien RH, et al. Multiple dimensions of HIV stigma and psychological distress among Asians and Pacific Islanders living with HIV illness.AIDS and Behavior. 2005;9:145-154. 16. API Capacity Building programs 17. Takahashi LM, Candelario J, Young T, et al. Building capacity for HIV/AIDS prevention among Asian and Pacific Islander organizations: The experience of a culturally appropriate capacity-building program in southern California. Journal of Public Health Management and Practice. 2007:S55-S63. 18. Utopia Hawai’i 19. Campaña anti estigma sobre el VIH

Preparado por Roshan Rahnama, Nina Agbayani, Stacy Lavilla,* John Chin, PhD** *Association of Asian Pacific Community Health Organizations (AAPCHO), **NY Academy of Medicine Traducción: Rocky Schnaath Diciembre 2007. Hoja de Dato #33SR

Resource

Childhood sexual abuse (CSA)

How does childhood sexual abuse affect HIV prevention?

What is childhood sexual abuse?

Childhood sexual abuse may be defined in many ways, but this fact sheet refers to unwanted sexual body contact prior to age 18, the age of consent to engage in sex. CSA is a painful experience on many levels that can have a profound and devastating effect on later physiological, psychosocial and emotional development. CSA experiences can vary with respect to duration (multiple experiences with the same perpetrator), degree of force/coercion or degree of physical intrusion (from fondling to digital penetration to attempted or completed oral, anal or vaginal sex). The identity of the perpetrator–ranging from a stranger to a trusted figure or family member–may also impact the long-term consequences for individuals. To distinguish CSA from exploratory sexual experimentation, the contact should be unwanted/coerced or there should be a clear power difference between the victim and perpetrator, often defined as the perpetrator being at least 5 years older than the victim. Many more children are sexually abused than are reported to authorities.1 Estimates of the prevalence of CSA in the US are about 33% for females under the age of 18 and 10% in males under 18 years of age.2 Men are significantly less likely than women to report CSA when it occurs.3 CSA is more likely to occur in families under duress. Children are at risk for CSA in families that experience stress, poverty, violence and substance abuse and whose parents and relatives have histories of CSA.

Does CSA affect HIV risk?

Yes. Because childhood and early adolescence are critical times in a person’s sexual, social and personal development, CSA can distort survivors’ physical, mental and sexual images of themselves. These distortions, combined with coping mechanisms adopted to offset the trauma of CSA, can lead CSA survivors into high-risk sexual and drug-using behaviors that increase the likelihood of HIV infection.4 Persons who experience CSA may feel powerless over their sexuality and sexual communication and decision-making as adults because they were not given the opportunity to make their own decisions about their sexuality as children or adolescents. As a result, they may engage in more high-risk sexual behavior, be unable to refuse sexually aggressive partners and have less sexual satisfaction in relationships. CSA survivors may have difficulties forming attachments and long term relationships and may dissociate from their feelings, resulting in having multiple sexual partners, “one night stands” and short-term sexual relationships. Adults who perceive positive aspects of their own CSA (such as gaining attention) may also use sex as a soothing or comforting strategy, which can lead to promiscuity and compulsive sexual patterns.5 The effects of CSA may be different for adult men and women. Female survivors of CSA may have lower condom self-efficacy with partners, use condoms less frequently, exhibit more sexual passivity and attract or be attracted to overly controlling partners.6 Male survivors of CSA may experience higher levels of eroticism, exhibit aggressive, hostile behavior and victimize others.7 Adults with CSA histories may use dissociation and other coping efforts to avoid negative thoughts, emotions and memories associated with the abuse. One of the most common dissociation methods is alcohol and drug abuse. A study of men and women with a history of substance abuse found that 34% had experienced CSA. CSA survivors with substance abuse problems were more likely than substance abusers who had not experienced CSA to exchange sex for money or drugs, have an HIV+ or high-risk partner and not use condoms.8 Sexual revictimization can also influence high-risk sexual behavior. One study of African American and white women found that CSA survivors who experience revictimization as adults had more unintended pregnancies, abortions, STDs and high-risk sexual behaviors than those who experienced only CSA.9

What’s being done?

There are many resources for CSA survivors, but few programs exist to reduce HIV-related sexual and drug-using risk behaviors and increase psychological well being. Most of these programs focus on women; there are even fewer programs for male CSA survivors. Good-Touch/Bad-Touch is a comprehensive child abuse prevention intervention designed for pre-school and kindergarten through sixth grade students. The program uses a variety of materials to teach children prevention skills including personal body safety rules, what abuse is and what action to take if threatened.10 The Children’s Medical Center in Dallas, TX, provides HIV/STD prevention for young female sexual abuse victims at a child abuse clinic. Adolescent females between 12 and 16 years old receive one-on-one evaluation and personalized education from an adolescent-focused HIV/STD counselor. Providing sensitive counseling close to the time of recognition of abuse can be a good method for prevention education.11 At Stanford University, CA, a trauma-focused group therapy intervention seeks to reduce HIV risk behavior and revictimization among adult women survivors of CSA. The groups focus on survivors’ memories of CSA to see if this helps increase safer behaviors and reduce stress. The women also receive case management.12 The Visiting Nurse Service of New York offers comprehensive in-home services to HIV-infected families. The children in these families are at high risk for repeating the histories and behaviors of their parents, including HIV infection, substance abuse, sexual abuse and mental illness. The program provides home-based interventions that include play therapy, health and safe sex education, family and individual counseling, relapse prevention for the parent and drug awareness and prevention for the children. Helping the child deal with anger and resentment towards the parent lessens the likelihood that their anger will be displaced on themselves, thus repeating the behavior of the parent. Supporting each family member is key to breaking the cycle of HIV and abuse in these families.13 At the University of California, Los Angeles, and King-Drew University, CA, a psychoeducational intervention aims to increase healthy behavior and decrease HIV risk behaviors in HIV+ women with histories of CSA. Women are taught communication and problem-solving tools and link CSA experiences to past and current areas of risk.14

What needs to be done?

Although dealing with CSA may seem like a daunting task for many HIV prevention programs, there are a variety of usable approaches to address CSA in adults. Programs can: include questions on abuse during routine client screening, reassess clients over time, provide basic education on the effects of CSA and offer referrals for substance abuse and mental health services. Program staff need basic training and support to help cope with the effects of CSA counseling and the relative high prevalence in certain populations.15 Persons who are likely to interact with CSA survivors such as medical and other health professionals, religious and peer counselors, including alcohol, substance abuse and rape counselors, and probation officers need to be educated on the effects of CSA on sexual and drug risk behaviors. They also need training on how to recognize symptoms of CSA and how to address these issues or provide appropriate referrals for treatment. Professionals should look beyond CSA symptoms and inquire about other childhood experiences that may have been problematic. CSA survivors often are forced to contend with other types of abuse and a dysfunctional family environment. A poor family environment may set the tone for abuse to occur and leave the survivor with little support to cope with the experience.

Says who?

1. Green AH. Overview of child sexual abuse. In SJ Kaplan (ed.), Family violence: A clinical and legal guide. Washington, DC: American Psychiatric Press. 1996;73-104. 2. Finkelhor D. The international epidemiology of child sexual abuse. Child Abuse & Neglect. 1994;18:409-417. 3. Roesler TA, McKenzie N. Effects of childhood trauma on psychological functioning in adults sexually abused as children. Journal of Nervous and Mental Disease. 1994;182:145-150. 4. Prillo KM, Freeman RC, Collier C, et al. Association between early sexual abuse and adult HIV-risky behaviors among community-recruited women. Child Abuse & Neglect. 2001;25:335-346. 5. Paul, J. Understanding childhood sexual abuse as a predictor of sexual risk-taking among men who have sex with men: The Urban Men’s Health Study. Child Abuse & Neglect. 2001;125:557-584. 6. Watkins B, Bentovim A. The sexual abuse of male children and adolescents: a review of current research. Journal of Child Psychology & Psychiatry & Allied Disciplines. 1992;33:197–248. 7. Wyatt GE, Guthrie D, Notgrass CM. Differential effects of women’s child sexual abuse and subsequent revictimization. Journal of Consulting and Clinical Psychology. 1992;60:167-173. 8. Morrill AC, Kasten L, Urato M, et al. Abuse, addiction and depression as pathways to sexual risk in women and men with a history of substance use. Journal of Substance Abuse. 2001;13:169-184. 9. Wyatt GE, Myers HF, Williams JK, et al. Does a history of trauma contribute to HIV risk for women of color? Implications for prevention and policy. American Journal of Public Health. 2002;92:1-7. 10. Harvey P, Forehand R, Brown C, et al. The prevention of sexual abuse: Examination of the effectiveness of a program with kindergarten-age children. Behavior Therapy. 1988;19:429-435. 11. Squires J, Persaud DI, Graper JK. HIV and STD prevention counseling for adolescent girls seen in a child abuse clinic. Presented at the 14th International AIDS Conference, Barcelona, Spain. 2002. Abst # TuPeF5249. 12. Group Interventions to Prevent HIV in High Risk Women.www.med.stanford.edu/school/ Psychiatry/PSTreatLab/TraumaStudy.php 13. Mills R, Samuels KD, Bob-Semple N, et al. Breakin the cycle: multigenerational dysfunction in families affected with HIV/AIDS. Presented at the 14th International AIDS Conference, Barcelona, Spain. 2002. Abst #. ThPeE7828. 14. Wyatt GE, Myers H, Longshore D, et al. Examining the effects of trauma on HIV risk reduction: the women’s health intervention. Presented at the International Conference on AIDS, Barcelona, Spain. 2002. Abst# WePeF6853. 15. Paul JP. Coerced childhood sexual episodes and adult HIV prevention. FOCUS. 2003;18:1-4
Prepared by Gail Wyatt PhD, Tamra Loeb PhD, Inna Rivkin PhD, Jennifer Carmona PhD, Dorothy Chin PhD, John Williams MD, Hector Myers PhD, Douglas Longshore PhD and Charlotte Sykora PhD UCLA Women’s Health Project September 2003. Fact Sheet #52E Special thanks to the following reviewers of this Fact Sheet: Ruth Kelley, Jay Paul, Elizabeth Radhert.
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]. © September 2003, University of California
Resource

Levels of prevention

How does HIV prevention work on different levels?

what are levels?

HIV prevention is not just about changing individual behavior. Many other factors also influence HIV transmission, such as relationships with family and friends, community norms, access to health care and local laws. Working on different levels means addressing all these factors through multiple approaches: individual, couple/family, community, medical and legal.1 HIV prevention programs for injecting drug users (IDUs) in the US have included interventions on many different levels. These programs have incorporated interventions such as: intensive street outreach to educate IDUs, drug treatment, syringe exchange, community-building and empowerment efforts and adherence programs for HIV+ IDUs. Where these efforts are in place, rates of HIV among IDUs have remained stable.1 Prevention efforts addressing multiple levels have reversed HIV epidemics in Uganda and Thailand, and averted an epidemic in Senegal. Senegal, for example, used prevention programs on the individual level (HIV counseling and testing), community level (HIV education in schools, condom promotion among sex workers), medical level (treatment of sexually transmitted diseases [STDs]), and structural/political level (mobilizing religious and political leaders to talk openly about HIV) to maintain one of the lowest rates of HIV infection in Sub-Saharan Africa.3

individual level

Many prevention programs help individuals change risky behavior. Project EXPLORE was a randomized trial of an individually-based counseling intervention for men who have sex with men. EXPLORE recognized that different men experience different individual, interpersonal and situational factors associated with risk. The program tailored the intervention to each man’s needs. Ten counseling modules used motivational interviewing to assess risk behavior, enhance sexual communication, understand substance use and recognize triggers to unsafe sex.4 Project RESPECT was a randomized HIV counseling trial conducted at STD clinics in five cities in the US with high HIV seroprevalence. The program evaluated whether interactive counseling is more effective than informational messages in reducing risk behaviors and preventing HIV and other STDs. The program found relatively little difference between 4- and 2-session interactive counseling interventions, but found lower rates of new STDs among the interactive counseling groups compared to groups that only received information. Reported condom use increased in all groups, with significantly greater protection among those in interactive counseling.5

couple/family level

The Visiting Nurse Service of New York offers comprehensive in-home services to families affected by HIV, substance abuse, sexual abuse and mental illness. The children in these families are at high risk for repeating the histories and behaviors of their parents. The program provides home-based interventions that include play therapy, health and safe sex education, family and individual counseling, relapse prevention for the parent and drug awareness and prevention for the children. Helping children deal with anger and resentment towards their parents lessens the likelihood that their anger will be displaced on themselves, thus repeating the behavior of the parent. Supporting each family member is key to breaking the cycle of dysfunction in these families.6 Interventions that promote safer sexual behaviors for both members of a couple can also be important. Project Connect was a six-session relationship-based intervention for women in a heterosexual relationship. Women attended separately or with their partners. The sessions emphasized communication, negotiation and how gender roles affect relationship dynamics. Project Connect helped decrease risky behaviors for couples receiving the intervention together and for couples where the woman attended alone.7

community level

Community-level programs can reach large numbers of people and can therefore be cost-effective. The Mpowerment Project promoted a norm of safer sex among young gay men through a variety of social, outreach and small group activities designed and run by young men themselves. They found that young men engaging in unsafe sex who were unlikely to attend workshops were more likely to be reached through outreach activities such as dances, movie nights, picnics and volleyball games. Rates of unprotected anal intercourse fell from 40% to 31% after the intervention.8 A community-level intervention with ethnically-diverse adolescents living in low-income housing, uses skills training, modeling, peer norm and social reinforcement to reduce sexual risk. Using social events and peer leaders nominated for training and team building, the program attracted neighborhood youth. The peer leaders developed small media prevention messages and planned community-wide events. Workshops for parents were also offered. The community intervention was shown to be more effective in delaying onset of first intercourse than education or skills building only.9

medical level

In the past few years, various medical approaches have been shown to be effective in HIV prevention. For example, antiretroviral drugs used to treat HIV have also been used to help prevent mother to child transmission (MTCT) of HIV, and to prevent transmission after accidental exposures (post-exposure prophylaxis or PEP). Neither of these approaches completely prevents transmission, but MTCT can reduce the risk of transmission by one half to two-thirds. Similarly, because antiretroviral drugs can greatly reduce the viral load in HIV+ persons, it is possible that widespread use could decrease the sexual transmission of HIV.3 Children’s Hospital Los Angeles teamed with community-based prevention organizations to provide an integrated care model for youth with and at high risk for HIV infection. The model offered a general medical clinic for youth and psychosocial services such as counseling and case management. Peer educators also conducted extensive street outreach where high-risk youth congregate. The program developed a computerized referral system for local youth services available on the Internet.11

policy/legal level

HIV infection is closely linked to and often fueled by structural factors such as poverty, discrimination and lack of power for women. The Center for Young Women’s Development is a peer-run organization in San Francisco, CA that promotes self-sufficiency, community safety and youth advocacy among young women aged 14-18 who are involved in the juvenile justice, foster care systems and/or have lived on the streets. The Center provides employment, leadership and training for young women to educate others in their community. Equipped with the knowledge and opportunity to train others, young women are more likely to incorporate these skills into their own lives.12 Political and legislative factors can also hamper HIV prevention. For example, there is currently a ban on federal funding for needle exchange programs in the US. Connecticut addressed the problem of access to clean needles through a program that cost the state nothing and was highly effective. A partial repeal of needle prescription and drug paraphernalia laws resulted in dramatic reductions in needle sharing, and increases in pharmacy purchase of syringes by IDUs. Needle sharing dropped from 52% before the new laws to 31% after implementation, street purchase fell from 74% to 28%, and pharmacy purchase rose from 19% to 78%.13

what have we learned?

Prevention is more than a single program or intervention. A comprehensive HIV prevention strategy addresses multiple levels to protect as many people at risk for HIV as possible. We should learn from and promote the effectiveness of HIV prevention programs already in place, as well as continue to evaluate these programs.

Says who?

1. Kelly JA, Kalichman SC. Behavioral research in HIV/AIDS primary and secondary prevention: recent advances and future directions. Journal of Consulting and Clinical Psychology. 2002;70:629-639. 2. Vlahov D, Des Jarlais DC, Goosby E, et al. Needle exchange programs for the prevention of human immunodeficiency virus infection: epidemiology and policy. American Journal of Epidemiology. 2001;154:S70-77. 3. Valdiserri RO, Ogden LL, McCray E. Accomplishments in HIV prevention science: implications for stemming the epidemic. Nature Medicine. 2003;9:881-886. 4. Chesney MA, Koblin BA, Barresi PJ, et al. An individually tailored intervention for HIV prevention: Baseline data from EXPLORE study. American Journal of Public Health. 2003;93:933-938. 5. Kamb ML, Fishbein M, Douglas JM Jr, et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. Project RESPECT Study Group. Journal of the American Medical Association. 1998;280:1161-1167. 6. Mills R, Samuels KD, Bob-Semple N, et al. Breakin’ the cycle: multigenerational dysfunction in families affected with HIV/AIDS. Presented at the 14th International AIDS Conference, Barcelona, Spain. 2002. Abst #ThPeE7828. 7. El-Bassel N, Witte SS. Gilbert L, et al. The efficacy of a relationship-based HIV/STD prevention program for heterosexual couples. American Journal of Public Health. 2003;93:963-969. 8. Hays RB, Rebchook GM, Kegeles SM. The Mpowerment Project: community-building with young gay and bisexual men to prevent HIV1. American Journal of Community Psychology. 2003;31:301-312. 9. Sikkema KJ, Hoffmann RG, Brondino MJ, et al. Outcomes of a community-level intervention among adolescents in inner-city housing developments. Presented at the International Conference on AIDS, Barcelona, Spain. July 2002. Abst# WeOrD1276. 10. Fuchs J, Colfax G. A shot or a pill: exploring biomedical approaches to HIV prevention. Focus. 2004;19:1-4. 11. Schneir A, Kipke MD, Melchior LA, et al. Children’s Hospital Los Angeles: a model of integrated care for HIV-positive and very high risk youth. Journal of Adolescent Health. 1998;23(2Suppl):59-70. Computerized referral system:www.caars.net 12. Center for Young Women’s Development. www.cywd.org 13. Groseclose SL, Weinstein B, Jones TS, et al. Impact of increased legal access to needles and syringes on practices of injecting-drug users and police officers-Connecticut, 1992-1993. Journal of Acquired Immune Deficiency Syndromes. 1995;10:82-89.
Prepared by The Center for AIDS Prevention Studies, University of California, San Francisco July 2004. Fact Sheet #1ER 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]. © July 2004, University of California