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Adapting programs

Can HIV Prevention Programs Be Adapted?

Why adapt?

We know that many HIV prevention interventions have made a difference, and that prevention efforts have helped to lower rates of HIV infection in many different populations.1 But as the HIV epidemic changes, so too do the number and groups of people at risk for HIV. Adapting interventions allows us to use principles we know are effective to address the needs of those newly at risk, who may not have been studied yet. Developing new interventions is expensive and time consuming, and it makes good sense to adapt programs that have been demonstrated to be effective.2 Using existing tools and theories of successful programs can save time and money. In an age when money for prevention is limited, adapting interventions can be cost-effective.

Aren’t all populations different?

Yes and no. While each community or population is unique, there are many similarities between populations and their social, political and emotional environments. While injecting drug users in Chicago, IL may have very different needs than young gay men in Eugene, OR, both may benefit from similar aspects of programs. For example, using peer educators to help spread the message and change community norms can be effective for both groups.3,4 HIV prevention is more than simply teaching safer sex and safe drug use nuts and bolts. Prevention programs need to take into account the life context in which a person applies safer sex, and the relationship to the HIV epidemic of the person. Prevention programs need to be tailored to these different situations, not reinvented entirely.

What helps with adaptation?

Program planners can choose from a variety of elements of prevention programs that can address their own local population, setting or intervention needs. Staff training and technical assistance to understand and effectively implement programs is key for successful adaptation. Understanding the community is integral to adapting programs.5 Service organizations often know their populations best, whether through outreach or needs assessment. Before adapting an intervention, it is essential to understand the characteristics of the original program and its audience, and how they are different or similar to the new environment. Theory gives a background for behavior change, and may also be useful in assessing whether an intervention is appropriate for a different target group. For example, the Social Cognitive theory of behavior calls for learning through interactions with other people and using physical and social environments to produce change.6 Role playing, community building, interactive videos and job training can all be components of a program using this theory. Peer education has been an important element of prevention programs and serves as a powerful motivator especially for disenfranchised people. Such programs recruit peer educators who are at high risk, and teach them how to educate and help save the lives of their friends and colleagues.7 This recognizes that people in their own communities have tremendous power of persuasion and can be effective agents of change. Another successful prevention element involves addressing notions of family, community and ethnic pride.8 For example, offering parenting and communicating classes often attracts more participation from parents than offering classes specifically about HIV. Appealing to protecting and supporting the community or family-children, spouses, relatives-can be more encouraging than simply protecting oneself.

What are some examples?

The STOP AIDS project in San Francisco, CA, has served as a model for HIV prevention across the country.9 The model, based on community mobilization and outreach and small group meetings, has been adapted and used for gay men across the country.9 The STOP AIDS model has been used in Los Angeles, CA, West Palm Beach, FL, Phoenix, AZ and Chicago, IL, among other cities. In San Francisco, clients have been recruited on the streets and at bars, while in Chicago, the program has gone into schools. They have found that HIV prevention programs work better when high levels of local commitment are established in a city. Healthy Oakland Teens (HOT), a peer-based sex education program at a junior high school in Oakland, CA, trained ninth graders to lead classes on sexuality and HIV/AIDS to seventh graders. After one year, students in the program were less likely to initiate activities such as deep kissing, genital touching, and sexual intercourse.10 HOT was then adapted to address Balinese youth who were perceived at risk for HIV due to increasing HIV seroprevalence and an extensive tourist and sex industry in Bali. In Bali, researchers found that among members of traditional Balinese youth groups, only 14% of those who were sexually active had used condoms. Although most still lived at home, only 33% reported feeling comfortable discussing sexuality with their parents, while 75% felt comfortable discussing it with their peers. The HOT model of peer education was therefore seen to be appropriate, and the setting was changed from public schools to traditional Balinese youth groups which reach all Balinese youth regardless of socioeconomic status or educational level.11 One successful prevention program for gay men in small cities recruited popular opinion leaders from bars, and trained them to deliver and model prevention messages to their peers.12 This program was then adapted to address minority women in inner city housing developments. However, the program didn’t work there. The reason? Women didn’t know their neighbors, and because of high crime rates in the housing developments, were reluctant to open their doors to someone they didn’t know. This program was then reworked, starting by helping women in the housing developments establish a sense of community through potluck dinners and music festivals. As a result, not only did the women increase condom use and communication, but the community began to tackle other issues besides HIV such as drugs and violence in the housing development.13

What needs to be done?

Service organizations need to commit time and resources to training staff in effective use of prevention programs, including using theory, conducting needs assessments and reaching out to researchers and other organizations to find out what interventions have been shown to be effective. Community planning groups (CPGs) need to facilitate better communication and stable relationships between researchers, community based organizations and Health Departments. CPG Program Coordinators can help link CPGs with local researchers to help community-based prevention planners determine the best adaptations to make. Researchers need to move from small scale efficacy studies to wide scale field trials. Many interventions are effective in what can be a very controlled research environment (clients often receive payment, staff is well paid and often have advanced degrees). These interventions then need to be tested in the “real world” to see how they may need to be adapted or modified to ensure effectiveness under different conditions and with different populations. Funders need to commit funds to adaptation and pilot testing new programs at the community level. A comprehensive HIV prevention strategy uses many elements to protect as many people at risk for HIV as possible. Adapting existing interventions can be a money-saving and effective prevention strategy.

Says who?

  1. Office of Technology Assessment. The Effectiveness of AIDS Prevention Efforts. 1995.
  2. Holtgrave DR, Qualls NL, Curran JW, et al. An overview of the effectiveness and efficiency of HIV prevention programs . Public Health Reports. 1995;110:134-146.
  3. Weibel W, Jimenez A, Johnson W, et al. Positive effect on HIV seroconversion of street outreach intervention with IDUs in Chicago. Presented at the 9th International Conference on AIDS. Berlin, Germany, 1993. Abstract WSC152.
  4. Hays RB, Rebchook, GM, Kegeles SM. The Mpowerment project: a community-level HIV prevention intervention for young gay and bisexual men . American Journal of Public Health. 1996;86:1-8.
    • Contact: Susan Kegeles 415/597-9159.
  5. Herek GM, Greene B, eds. AIDS, identity, and community : the HIV epidemic and lesbians and gay men . Thousand Oaks, CA: Sage Publications; 1995.
  6. Bandura A. Social cognitive theory and exercise of control over HIV infection. In DiClemente RJ, ed. Preventing AIDS: Theories and Methods of Behavioral interventions . New York, NY: Plenum Press; 1994.
  7. Grinstead OA, Zack B, Faigeles B. Effectiveness of peer HIV education for prisoners. Presented at the Biopsychosocial Conference on AIDS; Brighton, England. 1994.
    • Contact: Barry Zack, Marin AIDS Project 415/457-2487.
  8. Díaz RM. HIV risk in Latino gay/bisexual men: a review of behavioral research. Report prepared for the National Latino/a Lesbian and Gay Organization. 1995.
    • Contact: Jose Ramón Fernández-Peña, Mission Neighborhood Health Center, 415/552-1013 X386.
  9. Wohlfeiler D. Community Organizing and Community Building Among Gay and Bisexual Men. In Minkler M, ed. Community Organizing and Community Building for Health . Rutgers University Press. (in press).
    • Contact: Dan Wohlfeiler 415/575-1545.
  10. Ekstrand ML, Siegel D, Nido V, et al. Peer-led AIDS prevention delays initiation of sexual behaviors among US junior high school students. Presented at 11th International Conference on AIDS, Vancouver, BC. 1996.
    • Contact: Maria Ekstrand 415/597-9160.
  11. Merati T, Wardhana M, Ekstrand M, et al. HIV risk taking among youth participating in peer-led AIDS education programs in traditional Balinese youth groups. Presented at the 11th International Conference on AIDS; Vancouver BC. 1996. Th.C.4411.
  12. Kelly JA, St. Lawrence JS, Stevenson LY, et al. Community AIDS/HIV risk reduction: the effects of endorsements by popular people in three cities . American Journal of Public Health. 1992;82.1483-1489.
    • Contact: Jeff Kelly 414/287-4680.
  13. Sikkema KJ, Kelly J, Heckman T, et al. Effects of community-level behavior change intervention for women in low-income housing developments. Presented at the 11th International Conference on AIDS; Vancouver BC. 1996. Tu.C.453.
Contact: Kathy Sikkema 414/287-6100.

Prepared by Pamela DeCarlo and Jeff Kelly

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 AIDS Clearinghouse at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. ©1996, University of California

Resource

Establecimientos de salud

¿Cómo puede integrarse la prevención del VIH en los establecimientos de atención de salud?

¿Por qué es importante la prevención de la infección por el VIH en los establecimientos de atención de salud?

La prevención de la infección por el VIH es una parte importante de la atención de la salud de todas las personas. Reviste particular importancia para las personas expuestas al riesgo de infección, así como para las ya infectadas, que pueden evitar la transmisión del virus a otras y mantenerse sanas. Se pueden utilizar muchas estrategias en los establecimientos de atención de salud para optimizar la prevención del VIH, incluso la evaluación del riesgo de contraerla; la mejora del acceso a las pruebas de detección del virus; la prestación de servicios de asistencia a los pacientes infectados por el VIH  para revelar su estado serológico a sus parejas; el examen y el tratamiento de los pacientes con problemas de alcoholismo, uso de drogas e infecciones de transmisión sexual (ITS); y la provisión del mejor cuidado posible a las personas infectadas por el VIH, incluyendo acceso al tratamiento antirretroviral (ART) y consejería sobre la observancia del mismo.

¿Tienen los establecimientos algún papel en la detección de nuevas infecciones?

Los establecimientos de salud son sitios importantes para proporcionar acceso a mensajes sobre el examen de detección del VIH y la prevención del mismo, detectar nuevas infecciones y vincular a las personas infectadas con atención médica. En 2006, los CDC emitieron directrices para los proveedores de atención primaria de salud en las que recomendaron el acceso ampliado a las pruebas del VIH para todos los pacientes de 13 a 64 años de edad.1 La provisión de servicios de pruebas VIH como parte ordinaria de la atención ha sido más productiva en las salas de urgencias y en las salas de trabajo de parto y de parto, 2,3 aunque los centros de salud comunitarios también han proporcionado nuevo y amplio acceso.4 Los programas de pruebas del VIH también han demostrado ser eficaces para ayudar a las mujeres embarazadas a no transmitir el VIH a sus bebés.3 Una estrategia clave para ampliar las pruebas del VIH es una tecnología basada en el uso de pruebas rápidas.5 Estas últimas permiten que los proveedores que las realizan entreguen los resultados en menos de una hora, aunque se necesita una prueba para confirmar un resultado positivo. Estas pruebas rápidas permiten que se puede planear atención de seguimiento apropiada antes de que el paciente salga del establecimiento de atención de salud. Particularmente cuando primero se introduce la prueba del VIH, los proveedores en los establecimientos de salud necesitan aprender a integrar dichas pruebas a la atención regular, y remitir a los pacientes a servicios de apoyo complementarios, en caso de que sea necesario. Los proveedores también deben recibir capacitación sobre la forma de documentar los resultados de la prueba para asegurarse de que éstos se compartan con otros proveedores y para mantener la confidencialidad de la información de los clientes. Los proveedores deben velar por que las personas infectadas por el VIH reciban la atención y el apoyo que necesitan. La vinculación a la atención es una parte importante, con frecuencia ignorada, de la integración de las pruebas del VIH al sistema de atención de salud. Las personas que apenas acaban de enterarse de que están infectadas a menudo necesitan mucho apoyo y ayuda para encontrar un proveedor del VIH, así como también hacer una cita y cumplirla. Los modelos de tratamiento intensivo de casos son prometedores para mejorar los vínculos de los pacientes recién diagnosticados con la atención médica.6

¿Qué otras estrategias de prevención surten efecto?

Evaluación del riesgo. La evaluación de comportamientos de riesgo de contraer el VIH debe ser una parte normal del registro de nuevos pacientes, independientemente de su estado serológico con respecto a ese virus. No todos los pacientes necesitan educación detallada en materia  de prevención del VIH. Sin embargo, los proveedores deben preguntarles a todos los pacientes sobre su comportamiento sexual, uso de preservativos, número de parejas sexuales y uso de alcohol y drogas ilícitas para evaluar el riesgo que tiene un paciente de contraer o transmitir el VIH. Estas preguntas rápidas pueden llevar a discusiones más prolongadas y a consejería sobre relaciones sexuales o prácticas de uso de alcohol y de drogas que sean más seguras.7Tratamiento por uso de sustancias. La ayuda prestada a los pacientes para entrar a un programa de tratamiento del alcoholismo o de uso de drogas puede ser un instrumento eficaz de prevención del VIH 8 y puede ayudar a las personas a mantenerse saludables. Los proveedores pueden tener un profundo efecto en la vida de los pacientes al demostrar interés en los que usan drogas y alentar a los pacientes que estén dispuestos a entrar a un programa de tratamiento de alcohol o de drogas. Considerando que una recaída o relapso es común al tratar las adicciones, los proveedores de salud deben usar un enfoque no prejuicioso en el que no se critique a los pacientes. Realización de pruebas de detección y tratamiento de ITS. Los proveedores deben alentar a las personas a realizarse pruebas de detección de ITS. También deben impartir educación sobre esas infecciones, recalcar el vínculo entre estas últimas y el VIH e instar a que las parejas a también se hagan un examen de detección.9

¿Cómo funciona la prevención con personas seropositivas en los establecimientos de salud?

Orientación en materia de prevención. Se ha demostrado que una breve sesión de orientación o consejería sobre prevención en cada consulta en los establecimientos de salud reduce la probabilidad de que las personas infectadas por el VIH transmitan ese virus a otras, particularmente si las intervenciones se adaptan a las subpoblaciones de pacientes infectados por el VIH.10 Entre los mensajes importantes cabe citar los siguientes: ayudar a las personas a entender los riesgos relativos de sus actos y la eficacia de diferentes estrategias de prevención, como el uso de preservativos; revelar su estado de VIH a las parejas sexuales y las personas con las que usan drogas; y entender su responsabilidad con respecto a la prevención. Es  importante la capacitación formal de los proveedores para facilitar la aplicación de estos enfoques.11,12Supresión del virus. Un componente singular del papel que desempeñan los establecimientos en la prevención del VIH consiste en ayudar a las personas infectadas a encontrar y observar un régimen ARV eficaz para mantener baja la carga viral. Algunas investigaciones han demostrado que el mantenimiento de la carga viral por debajo del umbral detectable a través de análisis de laboratorio puede ayudar a prevenir hasta un 60% de nuevos casos de ITS.13

¿Cómo se puede ampliar la capacidad de pre-vención del VIH en los establecimientos de salud?

Evaluación de riesgos. Es de suma importancia saber evaluar el riesgo de los pacientes para cualquier clase de actividad de prevención del VIH. Es de importancia crítica tener instrumentos de evaluación del riesgo y enseñar a los proveedores a utilizarlos. Protocolos por escrito. Es importante asegurarse de establecer los procedimientos necesarios para orientar las actividades de realización de exámenes de detección en los establecimientos de salud.14 Reviste importancia crítica tener un plan de prevención adaptado al tamaño del centro médico, el modelo de prestación de servicios, los tipos de proveedores y la población de pacientes. Liderazgo. En los programas realizados con éxito en los centros médicos a menudo se han identificado líderes dentro del personal que cumplen la función de consejeros o de líderes de equipo para realizar una prevención positiva.15Capacitación. La capacitación es el elemento fundamental de todos estos componentes de importancia. Puede facilitar la aceptación y compromiso de los proveedores de salud en los centros médicos y tener en cuenta o considerar las actitudes y creencias de los proveedores con respecto a la reducción del riesgo y la consejería.16 La capacitación debe esbozar las responsabilidades del personal y preveer los cambios en el flujo de actividades de los centros médicos.17

¿Cuáles son los modelos eficaces para ser empleados en los establecimientos de salud?

Positive STEPs 16 es una intervención de capacitación para ayudar a los proveedores de atención del VIH a impartir consejería de prevención a sus pacientes. El modelo fue eficaz para mejorar las actitudes, el grado de comodidad y la auto eficacia de los proveedores, así como la frecuencia con que se ofrece orientación con fines de prevención. Partnership for Health 17 es una intervención conductual eficaz de los CDC (EBI) para los proveedores en los centros médicos de atención del VIH. Se adiestra a los proveedores de atención médica para ofrecer una consejería breve sobre la reducción del riesgo a sus pacientes. Se capacita a todo el personal de los centros médicos para incorporar mensajes de prevención en dichos centros, y la consejería  se complementa con información escrita para todos los pacientes. Fue eficaz para reducir las relaciones sexuales sin protección en un 38% en los pacientes que tenían dos o más parejas. Positive Choice 18 es un sistema interactivo de un médico en video. Com parte de este modelo, los pacientes de  los centros médicos de atención del VIH completaron una detallada evaluación electrónica de su riesgo y recibieron orientación individualizada sobre la reducción del riesgo a través de un médico en video que miraban en un laptop, y una hoja de trabajo impresa y de naturaleza didáctica. Los proveedores recibieron una hoja impresa con los riesgos reportados por los pacientes para su discusión durante la visita. Consejería ofrecida por los proveedores.10,17  En un extenso proyecto federal de demostración, los breves mensajes de consejería dados por los proveedores de salud en los centros médicos fueron muy eficaces para reducir el riesgo para los pacientes con VIH, aunque también hubo beneficios en los programas realizados por especialistas en prevención y por pares infectados por el VIH.

¿Qué se necesita hacer?

Los proveedores necesitan capacitación más amplia y repetida sobre la forma de integrar la prevención del VIH a la atención que prestan. Todavía hay importantes percepciones erróneas entre los proveedores sobre quién debe realizarse la prueba del VIH y cuándo se debe poner en práctica la prueba rápida. Las actitudes, las creencias y la propia eficacia de los proveedores pueden determinar si abordan o no la prevención por medio de pruebas del VIH o de provisión de orientación sobre reducción del riesgo. Algunos métodos que mejoran el registro de la prevención del VIH por los proveedores exigen atención y más investigación. Los dirigentes de los establecimientos de salud pueden introducir protocolos por escrito para orientar las prácticas de prevención del VIH, incluso las pruebas de detección en sus centros médicos. El establecimiento de protocolos, la documentación y las prácticas de garantía de la calidad pueden mejorar las prácticas de prueba y prevención en toda clase de establecimientos de salud.

¿Quién lo dice?

1. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. Morbidity and Mortality Weekly Report. 2006;55:1-17. 2. Haukoos JS, Hopkins E, Byyny RL, et al. Patient acceptance of rapid HIV testing practices in an urban emergency department: assessment of the 2006 CDC recommendations for HIV screening in health care settings. Annals of Emergency Medicine. 2008;51:303-309. 3. Tepper NK, Farr SL, Danner SP, et al. Rapid human immunodeficiency virus testing in obstetric outpatient settings: the MIRIAD study.American Journal of Obstetrics and Gynecology. 2009;201:31-36. 4. Myers JJ, Modica C, Bernstein C, Kang M, McNamara K. Routine rapid HIV screening in six Community Health Centers serving populations at risk. Journal of General Internal Medicine. 2009;24:1269–1274. 5. Branson BM. State of the art for diagnosis of HIV infection. Clinical Infectious Diseases. 2007;15:S221-225. 6. Christopoulos K, Koester K, Weiser S, et al. A comparative evaluation of the development and implementation of three emergency department HIV testing programs (forthcoming) 7. Schechtel J, Coates T, Mayer K, et al. HIV risk assessment: physician and patient communication. Journal of General Internal Med. 1997;12:722-723. 8. Bruce RD. Methadone as HIV prevention: High volume methadone sites to decrease HIV incidence rates in resource limited settings. International Journal of Drug Policy. 2010;21:122-124. 9. McClelland RS, Baeten JM. Reducing HIV-1 transmission through prevention strategies targeting HIV-1-seropositive individuals. Journal of Antimicrobial Chemotherapy. 2006;57:163-166. 10. Myers JJ, Shade S, Dawson Rose C, et al. Interventions delivered in clinical settings are effective in reducing risk of HIV transmission among people living with HIV. AIDS and Behavior. 2010;14:483-492. 11. Gilliam PP, Straub DM. Prevention with positives: A review of published research, 1998-2008. Journal of the Association of Nurses in AIDS Care. 2009;20:92-109. 12. Harder & Co. Community Research. Prevention with positives: Best practices Guide. Prevention with Positives Workgroup. 2009. 13. Porco TC, Martin JN, Page-Shafer KA, et al. Decline in HIV infectivity following the introduction of highly active antiretroviral therapy. AIDS. 2004;18:81-88. 14. Myers JJ, Steward, WT, Koester KA, et al. Written procedures enhance delivery of HIV “prevention with positives” counseling in primary health care settings. Journal of AIDS. 2004;37:S95-S100. 15. Koester KA, Maiorana A, Vernon K, et al. Implementation of HIV prevention interventions with people living with HIV/AIDS in clinical settings: Challenges and lessons learned. AIDS and Behavior. 2007;1:S17-S29. 16. Thrun M, Cook PF, Bradley-Springer LA, et al. Improved prevention counseling by HIV care providers in a multisite, clinic-based intervention: Positive STEPs. AIDS Education and Prevention. 2009;21:55-66. 17. Richardson J, Milam J, McCutchan A, et al. Effect of brief safer-sex counseling by medical providers to HIV-1 seropositive patients: A multi-clinic assessment. AIDS. 2004;18:1179-1186. 18. Gilbert P, Ciccarone D, Gansky SA, et al. Interactive “Video Doctor” counseling reduces drug and sexual risk behaviors among HIV+ patients in diverse outpatient settings. PLoS One. 2008;3.

Una publicación del Centro de Estudios para la Prevención del SIDA (CAPS) y el Instituto de Investigaciones sobre SIDA (ARI), Universidad de California en San Francisco (UCSF). Se autoriza la reproducción (citando a UCSF) más no la venta de copias este documento. También disponibles en inglés - https://prevention.ucsf.edu/resources/factsheets-english-and-spanish. Para recibir las Hojas de Datos por correo electrónico escriba a [email protected] con el mensaje “subscribe CAPSFS nombre apellido” ©UCSF 2010

Resource

Rapid testing at the US/Mexico border

What is the role of rapid testing for US-Mexico border and migrant populations?

why test for HIV?

Until recently, HIV rates in Mexico and among Mexican migrants in California appeared to be stable and relatively low; however, recent studies show that HIV may be expanding more aggressively in some populations, especially in border communities.1 One study of 374 young Latino men who have sex with men (MSM) in the San Diego/Tijuana region found high rates of HIV: 19% in Tijuana and 35% in San Diego.2 Another study of 1,068 pregnant women in labor in Tijuana found a 1.12% HIV rate.3 Yet a study of 1,041 Mexican migrants at border crossing locations in Tijuana found a 0% HIV rate.4 Getting tested for HIV is key to preventing the spread of HIV. Persons who test HIV+ can access counseling, prevention education, support services and medical care to stay healthy and not progress to AIDS. HIV- persons can access counseling and education to remain HIV-. It is estimated that 31% of all HIV+ persons in the US do not know they’re infected.5 Border and migrant populations may be at great risk for HIV yet they are less likely to be tested for HIV or return for test results. Many do not have access to (or fear accessing) traditional healthcare systems, lack transportation and frequently change address.6

why rapid testing?

Even when people are able to test for HIV, many never return for their results. In public test sites, up to 33% of persons who test HIV- and 25% of persons who test HIV+ never return for their results.7 This may be especially true for border and migrant populations because they may not have stable housing or legal status in the US. The rapid HIV test is a new approach to HIV testing that helps address many of these issues. Conventional HIV testing has been done with needle blood draws or mouth swabs which are sent to a laboratory for analysis. Clients need to return to the test site 1-2 weeks later to find out their results. With rapid tests, clients can take the test, receive counseling, and find out their results all in one visit. This can help increase the number of persons who take an HIV test and reduce the number of persons who don’t return for their results.8 Rapid testing can be done in most clinics and in non-traditional healthcare and outreach settings such as mobile vans, bars, parks and health fairs. One study of seasonal farmworkers found that men and women were more likely to accept a free HIV test if it used a finger stick and they could get results in 30 minutes.9 Many government and non-governmental agencies are moving towards rapid testing instead of conventional testing. The Centers for Disease Control and Prevention’s (CDC) Strategic Plan for 2005 seeks to increase the number of people who know their HIV status to 95%—using rapid testing is an integral part of the plan.3 In California, the goal is to have 80% of all state-funded HIV test sites use rapid tests by the end of 2006.10

how is it done?

Rapid testing uses a finger stick, blood draw or mouth swab to collect samples. The test counselor places the sample in a tube with chemicals to process it, and can read the results in 20 minutes or less. Counseling and risk reduction planning with the client can take place during the waiting time, or can be done before or after sample collection. There are four FDA-approved rapid HIV tests in the US: Reveal, OraQuick, Multispot and Uni-Gold.11 All tests are extremely accurate, with 99.6-100% sensitivity rates.12 OraQuick Advance uses a mouth swab and can be used in a wider range of settings and temperatures. Rapid testing can change the way HIV testing is done. Most HIV test sites currently have counselors and separate phelobotomists who take the blood or oral sample. With rapid testing, the test counselor can also take the sample and analyze it, becoming counselor, technician and laboratory all in one. In some sites, test counselors do the consent and counseling and a separate staff person still collects the sample and reads the results.13 Within 20 minutes, the OraQuick Rapid test will either be non-reactive—a negative test result—or reactive—a preliminary positive result. Currently, if a result shows preliminary positive, a second conventional blood or oral sample is required to confirm it. 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.

is rapid testing rapid counseling?

No. One study found no difference in STD rates after counseling with rapid tests and conventional tests.14 Rapid testing still allows for plenty of counseling time. A counselor has about 20 minutes between taking a sample and receiving the results to provide focused and specific counseling about the client’s risks and possible exposure to HIV. Counseling can be more intense due to the immediacy of hearing results.15 Clients who receive a preliminary positive result and must return for their confirmation result may be more prepared to deal with their diagnosis. Clients often have had a week to think about what testing positive means and may be more emotionally prepared to listen to and digest referrals and options the counselors can provide. Test counselors need in-depth knowledge of referral resources for client’s that may emerge in new, more focused HIV counseling sessions. Referrals should be specifically tailored to the needs of border and migrant populations, including basic needs such as healthcare, housing, legal assistance and jobs. Materials should be available in Spanish and counselors should have culturally-relevant knowledge and training in migrant and immigrant issues. Because many persons travel back and forth between the US and Mexico, referrals may need to focus on resources in both countries. Counselors typically may have concerns about the new testing procedures and counseling initially, but after they’ve been trained and have provided a number of counseling sessions, they become more comfortable and often say they wished they had become involved in HIV rapid testing sooner.16

what’s being done?

Rapid testing is relatively new in most border settings. A 2003 survey of 85 border health centers (community and migrant health centers, tribal organizations and programs for homeless people, among others) found that 64 (75%) offered HIV testing. Of these, 45 also provided HIV medication and counseling services. None of the sites in any state offered rapid HIV testing.17 Currently, San Diego County offers rapid testing, prevention education and linkage to medical care along the Mexico/California border in various settings such as churches, homeless shelters, parks and beaches. Staff members underwent additional training on rapid testing and single-session HIV counseling. Since offering rapid testing at all anonymous test sites, client return rates have increased from 72% to 93%.18 La Fe CARE Center in El Paso, TX, offers rapid testing at their clinic and through a mobile van that visits gay bars, nightclubs and adult bookstores downtown. The mobile van has two counselors and uses the OraQuick Advanced mouth swab HIV test. The clinic uses the OraQuick finger stick HIV test. Clients prefer getting results quickly and not having a blood draw. Since offering rapid testing, the number of clients testing at La Fe has increased from 500 in 2002 to over 2000 currently.19

what is the future of rapid testing?

The future is now. Outside of the US, rapid testing is widely used and confirmatory tests are also done with rapid test, eliminating any waiting period for persons who test HIV+. Manufacturers have been slow to seek approval for tests in the US because the FDA has strict policies about licensing new HIV tests. Rapid testing has been met with great enthusiasm in some areas and great trepidation in others. As federal and state governments increase requirements for rapid testing, resources for training, technical assistance and funding need to increase for the agencies that implement rapid testing. State and federal reimbursement protocols, as well as public and private insurance, need to be changed to encourage rapid testing. It is not enough simply to offer HIV testing to Mexican and other immigrants. Persons who test positive will need quality HIV care and treatment, and persons at risk for HIV will need culturally specific education and prevention programs. Because many persons travel back and forth between the US and Mexico, bi-national cooperation is key in addressing these issues to improve public health in both countries.

Says who?

1. Sanchez MA, Lemp GF, Magis-Rodriguez C, et al. The epidemiology of HIV among Mexican migrants and recent immigrants in California and Mexico. Journal of Acquired Immune Deficiency Syndromes. 2004;37:S204-S214. 2. Ruiz, JD. HIV prevalence, risk behaviors and access to care among young Latino MSM in San Diego, California and Tijuana, Mexico. Presented at the Binational Conference on HIV AIDS. Oakland, CA. 2002. 3. Viani RM, Araneta MR, Ruiz-Calderon J, et al. HIV-1 infection in a cohort of pregnant women in Baja California, Mexico: evidence of an emerging crisis? Presented at the International Conference on AIDS, Bangkok, Thailand. 2004. Abst #ThPeC7301. 4. Martinez-Donate AP, Rangell MG, Hovell MF, et al. HIV infection in mobile populations: the case of Mexican migrants to the US. Revista Panamaña de Salud Publica. 2005;17:26-29. 5. Centers for Disease Control and Prevention. HIV Prevention Strategic Plan https://www.cdc.gov/nchhstp/strategicpriorities/default.htm 6. Solorio MR, Currier J, Cunningham W. HIV health care services for Mexican migrants. Journal of Acquired Immune Deficiency Syndromes. 2004;37:S240-S251. 7. Kendrick SR, Kroc KA, Withum D, et al. Outcomes of offering rapid point-of-care HIV testing in a sexually transmitted disease clinic. Journal of AIDS. 2005;38:142-146. 8. Sullivan PS, Lansky A, Drake A. Failure to return for HIV test results among persons at high risk for HIV infection: results from a multistate interview project. Journal of AIDS. 2004;35:511-518. 9. Fernandez MI, Collazo JB, Bowen GS, et al. Predictors of HIV testing and intention to test among Hispanic farmworkers in South Florida. Journal of Rural Health. 2005;2:56-64. 10. Dowling T. Outreach and prevention rapid HIV testing in non-clinical settings. Presented at the Rapid Testing Conference, California 2004. 11. Reveal: www.reveal-hiv.com/ OraQuick 12. Branson BM. Point-of-care rapid tests for HIV antibodies. Journal of Laboratory Medicine. 2003;27:288-295. 13. Kassler WJ, Dillon BA, Haley C, et al. On-site, rapid HIV testing with same-day results and counseling. AIDS. 1997;11:1045-1051. 14. Metcalf CA, Douglas JM, Malotte CK, et al. Relative efficacy of prevention counseling with rapid and standard HIV testing: a randomized, controlled trial (RESPECT-2). Sexually Transmitted Diseases. 2005;32:130-138. 15. Rapid HIV antibody testing. HIV Counselor Perspectives. 2003;12:1-8. 16. Birkhead GS, San Antonio-Gaddy ML, Richardson-Moore AL, et al. Effect of training and field experience on staff confidence and skills for rapid HIV testing in New York state. Presented at the International Conference on AIDS, Bangkok, Thailand. 2004. Abst #MoPeE4103. 17. Donohoe TJ, Ribo A. Border “330″ clinics: a preliminary report on survey data and an inventory & summary of HIV border services. Needs Assessment Report of Pacific AIDS Education and Training Center and Texas/ Oklahoma AIDS Education and Training Center. July 2003. 18. HIV, STD and Hepatitis Branch, San Diego County, CA. (619) 296-2120 19. La Fe CARE Center, El Paso, TX. (915) 534-7979 20. Rapid testing for HIV: an issue brief. NASTAD HIV Prevention Update. September 2000.

PREPARED BY Tom Donohoe* and Jay Fournier *UCLA/Pacific AIDS Education and Training Center May 2005 . Fact Sheet #S58E Special thanks to the following reviewers of this Fact Sheet: Denise Escandon Borntrager, Hector Carrillo, Carol Galper, Maria Teresa Hernández, Steve Trujillo, Rebecca Ramos, Octavio Vallejo, Rolando Viani. 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]. © May 2005, University of California

Resource

Parents and children

Why is communication important?

Sexual activity begins early for many teens. Almost four of ten (37%) 9th graders have had intercourse, and nearly seven of ten (66%) have had intercourse by 12th grade.1 Every year three million teens, or almost a quarter (1 out of 4) of all sexually experienced teens, will contract a sexually transmitted disease (STD). Chlamydia is more common among teens than among older men and women, and teens have higher rates of gonorrhea than men and women aged 20-44.2 The HIV epidemic in the US is increasingly becoming an epidemic of the young. One fourth of all new HIV infections in the US occur in people under the age of 22, and one half of all new infections occur in people under age 25.3

“I want my daughter to be prepared [for sex and puberty]. I was taken by surprise.” Parent

In spite of these staggering statistics, many parents are unaware of or in denial about their children’s sexual experience. A study of mothers and their adolescent children found that 70% of the mothers believed their sons were virgins, but only 44% of sons actually were (had not yet engaged in sexual intercourse). With daughters, 82% of mothers thought they were virgins, and only 70% of daughters actually were.4

Are parents and their kids talking?

Unfortunately, not enough. A survey of pre-adolescents and their parents in a high HIV seroprevalence neighborhood found that parents overestimate how much they talk about HIV. Kids remembered less than one-fourth of HIV discussions parents said occurred. They were most likely to remember talks with the parent that were private.5 Parents often think they’re talking to their kids about AIDS, but may be discussing medical facts and not necessarily sexuality or safer sex. A national survey found that mothers of children aged 11 and older rated themselves “unsatisfactory” on talking about issues such as: how to tell when youth are ready to be sexually active (38%), preventing HIV (40%), sexual orientation (47%) and how to use a condom (73%).6

“I think it’s sad I can’t talk to my mom about it-but it’s her loss. I can always go other places. I think that is a lot of the problem, because when you go `other places’ sometimes you get the wrong information.” Teen

What is the role of parents?

Parents can influence their children’s actions. At-risk youth in five cities took part in an HIV prevention marketing initiative. They reported that parents exerted substantial influence on sexual behavior in three ways: by communicating with them, by acting as role models and by providing direct supervision.7 Contrary to popular opinion, children do look to their parents for guidance. Kids often want to talk to their parents about HIV-related issues, but may find it difficult to do so.8 Kids may worry that parents’ disapproval and fears will prevent honest discussion, or that parents lack correct information about HIV.

“I want my boys to be respectful of others and learn to develop a relationship with a person before having sex with them.” Parent

Children learn from parents by watching what they do as well as hearing what they say. Whether parents answer, don’t answer, or get angry at children's questions can show children how to deal with difficult issues. Discussions about healthy relationships should start early and grow more sophisticated as children mature. Early talks with young children about naming body parts accurately, learning how to say no, and taking health precautions can set the stage for later education in HIV prevention and sexuality.

What are barriers to communication?

Talking about issues of sexuality with their children can be a difficult experience for many adults. When many of today’s adults were children, their parents didn’t talk about sexuality and other topics with them. Today’s parents may want to take a different approach with their own children, but have no experience to guide them.

“We didn’t talk about these things when we grew up so I’m not always used to it. I try, and I laugh…the kids are more comfortable with [talking about sex] than I am.” Parent

Youth need to carve out their own autonomy during adolescence. As young people begin to separate from their parents, they may be more resistant to parental advice. Parents may have unfounded concerns about talking to their kids, such as the fear that talking about sex will increase curiosity and cause them to experiment prematurely, or that giving information about birth control is a green light for kids to have intercourse. Some parents fear that talking about homosexuality might influence a child’s sexual orientation. In fact, open discussion with parents can help postpone sexual activity, protect from risky behavior and support the healthy sexual socialization of youth.9

What’s working?

In Los Angeles, CA, a program addressing newly arrived immigrant parents found that involving churches and health providers, providing culturally sensitive presenters in the parents’ language, and scheduling meetings during the evenings all helped to attract parents to meetings.10 Parenting and communicating classes often attract more parents than classes specifically addressing HIV, especially in religious communities. Peer education among parents has been effective. “Talking With Kids About AIDS” trains volunteers to conduct workshops with parents and guardians in a variety of community settings. Parents learn about HIV, practice communication and risk reduction skills and complete homework assignments to discuss HIV with their children. The program significantly enhances parents’ ability to initiate talks with their children.11

“Parents need to inform and guide (and get involved) with their kids more! I think it will help tremendously.” Teen

In Virginia, parent educators were trained to lead HIV information programs for parents of elementary, middle and high school students. These parents also served as resource persons for their community. Word-of-mouth recommendations from parents have been effective in attracting other parents. Parent participants reported they were more likely to talk to their children about HIV/AIDS if they felt knowledgeable on the subject.12 The Fast Road/El Camino Rapido is a training program for migrant families and educators to help families discuss healthy relationships, practice communication skills, and focus on HIV prevention. The program uses cartoon videos in English and Spanish and drawings with bubbles for spoken words and thoughts. Parents work with other parents and with their children to fill in the blanks and help stimulate discussion.

What needs to be done?

Parent-child communication often has not been a focus of HIV prevention efforts. However, programs that involve all family members, children and adults, in educating about sexuality, values and family life, can be very effective. Programs that are most effective must involve parents and youth in program design and staffing. A comprehensive HIV prevention strategy uses many elements to protect as many people at risk for HIV as possible. Given what is at stake, family members and prevention educators must work together to ensure the future health and safety of our children.

Says who?

1. Centers for Disease Control and Prevention. Youth risk behavior surveillance-United States 1995 . Morbidity and Mortality Weekly Report. 1996;45:64. 2. Eng TR, Butler WT, eds. The Hidden Epidemic: Confronting Sexually Transmitted Diseases . Washington, DC: National Academy Press; 1996. 3. Rosenberg PS, Biggar RJ, Goedert JJ. Declining age at HIV infection in the United States (letter). New England Journal of Medicine. 1994;330:789-790. Miller K. Data from the Family adolescent risk behavior and communication study. Personal communication, Centers for Disease Control and Prevention; 1997. Krauss BJ, Goldsamt L, Pierre-Louis M. How pre-adolescents and their parents talk about HIV in a high HIV seroprevalence neighborhood. Presented at the 11th International Conference on AIDS, Vancouver BC. 1997. Abstract ThD4878. Mothers’ Voices. Mothers speak out on preventing and curing AIDS. Survey conducted by EDK Associates. 1997. Kennedy MG, Bye L, Rosenbaum J, et al. Focus group theme that will shape participatory social marketing interventions in 5 cities. Presented at the 11th International Conference on AIDS, Vancouver BC. 1997. Abstract TuD2882. Heft L, Faigeles B, Hall TL. Where are the parents in HIV education? Adolescents want their parents to talk about HIV. Presented at the 11th International Conference on AIDS, Vancouver BC. 1997. Abstract ThC4431.

  • Contact: Lisa Heft (415) 487-8088.

Leland NL, Barth RP. Characteristics of adolescents who have attempted to avoid HIV and who have communicated with parents about sex. Journal of Adolescent Research. 1993;8:58-76. Baker C, Rich R, Wulf K. Strategies to involve newly-arrived immigrant parents in HIV education. Presented at the 11th International Conference on AIDS, Vancouver BC. 1997. Abstract TuD2794.

  • Contact: Claudia Baker (213) 625-6429.

Tiffany J. HIV/AIDS education for parents and guardians: talking with kids about AIDS. Presented at the 9th International Conference on AIDS, Berlin, Germany. 1993. Abstract PO-D13-3716.

  • Contact: Jennifer Tiffany (607) 255-1942.

Rankin DL. When “just say no” isn’t enough: parents educating parents about AIDS. Presented at the National Conference on Women and HIV, Los Angeles, CA. 1997. Abstract P2.37.

  • Contact: Daphne Long Rankin (804) 828-2210.

Parent/Child Resources: Advocates for Youth 1025 Vermont Avenue NW Washington, DC 20005 (202) 347-5700 https://advocatesforyouth.org/ American Red Cross AIDS Education Office 8111 Gate-house Road Falls Church, VA 22042 http://www.redcross.org Mothers’ Voices 165 West 46th Street, Suite 701 New York, NY 10036 (888) MVOICES http://www.mvoices.org Planned Parenthood (800) 230-7526 http://www.igc.apc.org/ ppfa/ Sexuality Information and Education Council of the US 130 West 42nd Street, Suite 350 New York, NY 10036 (212) 819-9770 http://www.siecus.org

Prepared by Lisa Heft*, Ann Kurth**, Pamela DeCarlo*** *San Francisco AIDS Foundation, **Mothers’ Voices, ***CAPS September 1997. Fact Sheet #28E

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 AIDS Clearinghouse at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © September 1997, University of California

Resource

Coping Self-Efficacy Scale - Scoring

The Coping Self-Efficacy Scale (CSES) is a 26-item measure of perceived self-efficacy for coping with challenges and threats.  The scale items were developed by several of the authors (Margaret Chesney, Susan Folkman, and Jonelle Taylor) by creating sample items based upon stress and coping theory and the Ways of Coping Questionnaire, with consultation from Dr. Albert Bandura of Stanford University.  Items were refined based on pilot testing for face validity both with staff at the Center for AIDS Prevention Studies at the University of California, San Francisco, and with a sample of HIV-infected participants. Respondents are asked, “When things aren’t going well for you, or when you’re having problems, how confident or certain are you that you can do the following:”   

They are then asked to rate on an 11-point scale the extent to which they believe they could perform behaviors important to adaptive coping.  Anchor points on the scale are 0 (‘cannot do at all’), 5 (‘moderately certain can do’) and 10 (‘certain can do’). An overall CSES score is created by summing the item ratings (α = .95; scale mean = 137.4, SD = 45.6).  Our standard scoring rule with summated rating scale scores is that respondents must answer at least 80% of the scale items.  For respondents missing an item or items, we estimate an individual’s score for the missing item(s) by adding in their mean for the items that they answered for each item that they skipped, resulting in a “corrected sum.”

For Information and access to the Coping Self-Efficacy Scale, contact Mind Garden at the following direct link: https://www.mindgarden.com/488-coping-self-efficacy-scale 

Please contact Margaret Chesney, PhD for more information.