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Methamphetamine

How does methamphetamine use affect HIV prevention?

what is methamphetamine?

Methamphetamine (meth, also called crystal, speed, Tina, ice, crank) is a powerful, illegal stimulant and is similar to amphetamine. It can be taken orally, snorted, smoked, injected and inserted rectally and can affect the user for several hours or more depending on how much is used.1 Meth is cheap, widely available and has a high potential for abuse and addiction. Meth users describe the positive effects to be feelings of euphoria, loss of appetite, heightened self esteem and increased desire for and intensity of sex. However, meth also has many negative short and long-term effects, including damaging brain neurons, high blood pressure, oral hygiene problems, depression, anxiety, paranoia and psychotic symptoms such as paranoid delusions and hallucinations. Symptoms of overdose include chest pain, elevated body temperature, rapid heart rate and rapid shallow breathing. Meth is widely used, both nationally and internationally, with over one million users in the US.2 Although lifetime meth use has increased dramatically since the early 1990s, the number of abusers has remained steady and meth abuse is far less common than cocaine abuse.3 In recent years, meth use has increased in some locales and sub-populations, particularly on the East Coast.

how does meth use affect HIV?

Meth use can heighten one’s HIV risk through unsafe injection and sexual behaviors. If a person injects meth, sharing needles and injection equipment can transmit HIV. Many users consider meth a sexual drug, using it specifically to intensify and prolong sex and increase disinhibition. Meth tends to dry out the skin on the penis, anus and vagina, which may lead to tears and cuts and HIV transmission, especially with extended sex play, multiple partners and more aggressive sex associated with meth use. Meth can both increase sex drive and decrease men’s ability to get and maintain an erection. As a result, some men using meth may choose receptive anal sex (“bottoms”), or may choose to combine meth with erectile dysfunction drugs such as Viagra. Both meth and Viagra use are independently associated with unprotected anal sex.4

how does meth use affect HIV risk?

Meth use and abuse is a very real concern among gay men and other men who have sex with men (MSM). Research on meth use in other populations, such as heterosexuals, is limited. Gay and bisexual men report using meth and other stimulants at rates 10 times greater than the general population.5 This is particularly concerning because HIV is more common in this population than among heterosexuals. The use of meth for sexual reasons has been found to be more common among HIV+ men.6,7 The reasons for meth use among MSM vary, and may include strong cultural expectations of sexual prowess in some parts of the gay community.8 Several studies of MSM (primarily gay-identified men) have found that users are 2-3 times more likely than non-users to engage in unprotected anal sex, have condoms break or slip off, acquire a sexually transmitted disease, or become infected with HIV.9 In fact, these elevated risks occur among frequent and occasional users alike.10 A study of HIV- MSM found that men using stimulants were twice as likely to become infected as non-users, even when accounting for specific risky sexual behavior like unprotected anal sex with HIV+ partners.11 This suggests that meth use may contribute to HIV infection above and beyond increasing the likelihood that users will engage in risky behavior. While there is ample evidence of the link between HIV risk and meth use among MSM, some studies also show high levels of HIV risk behavior among heterosexuals. In one study, 86% of users reported engaging in “marathon sex” while high on meth. More than a third reported injecting, and of those, 47% had shared and/or borrowed needles.12

how does meth affect HIV+ persons?

Meth use and abuse can have negative consequences for HIV+ persons. HIV protease inhibitors (particularly ritonavir) may increase the potential for adverse reactions or overdose. Being high on meth may cause HIV+ persons to forget to take–or be unconcerned with taking–their medications. Meth use may also affect HIV+ persons’ overall health by increasing dehydration, sleeplessness and weight loss.13

what’s being done?

The high potential for addiction to meth and the intentional combination of meth and sex pose unique challenges for sexual risk-reduction efforts for meth users. However, a variety of approaches are available. Meth and HIV prevention efforts should focus on: 1) preventing initial use of meth among non-users by influencing community norms, 2) discouraging occasional users from becoming regular users, 3) minimizing health risks for current users, and 4) increasing drug treatment capacity and getting meth abusers into accessible programs. There have been several social marketing campaigns addressing the prevention of meth use. “Crystal Mess” and “Got Meth?” addressed negative consequences of meth use among gay men and youth, respectively. “Silence=Meth” calls for the gay community to take action around meth use.14 A harm-reduction approach may be better suited to those currently not choosing to cease meth use entirely, such as is offered at the Stonewall Project for MSM in San Francisco, CA.15 Those injecting meth should be referred to needle exchange programs and provided education and counseling on safer injection and sex practices. Life in the FASTLANE is a harm reduction-based program to reduce sexual risk among heterosexual active meth users. Using four weekly 90-minute one-on-one counseling sessions, FASTLANE increased intentions for safer sex and protected sex acts.16 For meth users ready to quit using, several programs are available. Some users may benefit from 12-step programs like Crystal Meth Anonymous, Narcotics Anonymous and LifeRing.17 The Positive Reinforcement Opportunity Project (PROP), uses positive conditioning to help gay and bisexual men stay off meth. Participants get urine tests 3 times a week for 12 weeks. Each time the test is negative for meth, they get positive reinforcement and vouchers good for food, medical bills, personal care items and more.17 Perhaps the best studied meth treatment approach is the Matrix Model, which is a behavioral intervention using 48 group and individual sessions over 16 weeks.18 Another study with MSM compared a variation of this model with contingency management (providing vouchers of increasing value for meth-negative urine), a combination of both approaches, and a gay-specific version of Matrix.19 All groups showed substantial reductions in meth use and sexual risk behavior one year later. While there are no medications currently approved to treat meth dependence, this may prove to be an effective approach. Currently, several studies, such as BUMP, are testing the feasibility of providing the antidepressant bupropion to meth-dependent MSM.20

what are next steps?

The gay community needs to address the very real pressure in some sub-communities to party and be highly sexually active21, and to ask the question “is drug use worth the risks men are taking?” It is not enough to attempt to reduce drug and alcohol use and abuse without also addressing the powerful sexual reasons why MSM use drugs, and explore ways to develop a healthy and satisfying sex life without drugs. Research into potentially effective treatment, counseling, medication and harm reduction approaches continues. Counselors and health care providers should be trained on the symptoms and effects of meth use and how to discuss meth and other substance use with clients and patients in a non-judgmental way. Providers can refer users to locally accessible meth harm reduction, treatment and HIV prevention programs when appropriate.

Says who?

1. Cretzmeyer M, Sarrazin MV, Huber DL, Block RI, Hall JA. Treatment of methamphetamine abuse: research findings and clinical directions. Journal of Substance Abuse Treatment. 2003;24:267-277. 2. SAMHSA. Methamphetamine use, abuse and dependence: 2002, 2003 and 2004. The NSDUH Report. September 2005. 3. King RS. The next big thing? Methamphetamine use in the US. Report prepared by The Sentencing Project. June 2006. 4. Mansergh G, Shouse RL, Marks G, et al. Methamphetamine and sildenafil (Viagra) use are linked to unprotected receptive and insertive anal sex, respectively, in a sample of men who have sex with men. Sexually Transmitted Infections. 2006;82:131-134. 5. Stall R, Paul JP, Greenwood G, et al. Alcohol use, drug use and alcohol-related problems among men who have sex with men. Addiction. 2001;96:1589-1601. 6. Semple SJ, Patterson TL, Grant I. Motivations associated with methamphetamine use among HIV+ men who have sex with men. Journal of Substance Abuse and Treatment. 2002;22:149-156. 7. Halkitis PN, Shrem MT, Martin FW. Sexual behavior patterns of methamphetamine-using gay and bisexual men. Substance Use & Misuse. 2005;40:703–719. 8. Diaz RM, Heckert AL, Sanchez J. Reasons for stimulant use among Latino gay men in San Francisco: a comparison between methamphetamine and cocaine users. Journal of Urban Health. 2005;82:i71-78. 9. CDC. Methamphetamine use and HIV risk behaviors among heterosexual menpreliminary results from five northern California counties. Morbidity and Mortality Weekly Report. 2006;55:273-277. 10. Colfax G, Vittinghoff E, Husnik MJ, et al. Substance use and sexual risk: a participant- and episode-level analysis among a cohort of men who have sex with men. American Journal of Epidemiology. 2004;159:1002-1012. 11. Koblin BA, Husnik MJ, Colfax G, et al. Risk factors for HIV infection among men who have sex with men. AIDS. 2006;20:731-739. 12. Semple SJ, Patterson TL, Grant I. The context of sexual risk behavior among heterosexual methamphetamine users. Addictive Behavior. 2004;29:807-810. 13. New York State Department of Health AIDS Institute. Methamphetamine and HIV: basic facts for service providers. https://www.health.ny.gov/diseases/aids/providers/prevention/harm_reduction/crystalmeth/dearcolleagueletter.htm  14. www.crystalmess.net; https://www.justthinktwice.gov/drugs/methamphetamine; 15. www.tweaker.org 16. Patterson TL, Mausbach B, Semple SJ, et al. Life in the fastlane: testing the efficacy of a behavioral intervention to reduce high risk sexual behaviors among HIV-negative, heterosexual methamphetamine users. Presented at the International AIDS Conference, Toronto, Canada, August 2006. #MOAC0205 17. www.na.org; www.unhooked.com; www.crystalmeth.org; www.propsf.com 18. Rawson RA, Marinelli-Casey P, Anglin MD, et al. A multi-site comparison of psychosocial approaches for the treatment of methamphetamine dependence. Addiction. 2004;99:708-717. 19. Shoptaw S, Reback CJ, Peck JA, et al. Behavioral treatment approaches for methamphetamine dependence and HIV-related sexual risk behaviors among urban gay and bisexual men. Drug and Alcohol Dependence. 2005;78:125-134. 20. http://www.sfcityclinic.org/providers/dph_speed_brochure.pdf 21. Green IA, Halkitis PN. Crystal methamphetamine and sexual sociality in an urban gay subculture: An elective affinity. Culture, Health and Sexuality. 2006;8:317-333. *All websites accessed July 2006

Prepared by Robert Guzman MPH, San Francisco DPH; Pamela DeCarlo, CAPS September 2006 . Fact Sheet #61E Special thanks to the following reviewers of this Fact Sheet: David Celentano, Grant Colfax, Perry Halkitis, Mark Hammer, Jeff Klausner, David Knapp Whittier, Jennifer Lorvick, Alix Lutnick, Jean Malpas, Gordon Mansergh, Tim Matheson, Tracey Packer, Joseph Palamar, Jimmy Palmieri, Jim Peck, Brady Ralston, Cathy Reback, Steve Shoptaw, Michael Siever, Hanne Thiede, Steven Tierney, Chad Upham, Will Wong. 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 2006, University of California

Resource

Prevention in health care settings

How can HIV prevention be integrated into health care settings?

Prepared by Carol Dawson-Rose RN PhD, Janet Myers PhD MPH, and Karen McCready MA; CAPS Fact Sheet 68, July 2010

Why is HIV prevention important in health care settings?

HIV prevention is an important part of health care for all individuals. It is particularly key for those at risk of becoming infected, as well as for those who are already infected, who can then avoid transmitting HIV to others and stay healthy themselves. Many strategies can be used in health care settings to optimize HIV prevention, including: assessing HIV risk; enhancing access to HIV testing; providing HIV-infected patients with disclosure and partner services; screening and treating patients for problem drinking, drug use and sexually transmitted infections (STIs); and providing the best possible care to HIV-infected individuals including access to anti-retroviral therapy (ARVs) and adherence counseling.

Do health care settings have a role in finding new infections?

Health care settings are important sites for providing access to HIV testing and prevention messages, for finding new infections and for linking infected individuals into HIV care. In 2006, the CDC issued guidelines for primary health care providers suggesting expanded access to HIV testing for all patients 13 to 64 years old.1 Providing HIV testing as a routine part of care has been most productive in emergency room and labor and delivery settings,2,3 although community health centers have also provided important new access.4 Testing programs have also proven effective in helping pregnant women to not transmit HIV to their babies.3 One key strategy for expanding testing is rapid test technology.5 Rapid tests allow providers to perform a test and deliver the results in under an hour, although a confirmatory test is required for positive rapid test results. Appropriate follow-up care can be planned before the patient leaves the health care facility. Especially when HIV testing is newly introduced, providers in health care settings need to learn how to integrate HIV testing into regular care, and to refer patients for additional support services if needed. Providers should also be trained in documenting test results to ensure they are shared with other health care providers and to maintain the confidentiality of client information. Providers must ensure that HIV-infected persons get the care and support they need. Linkage to care is an important and often overlooked piece of integrating HIV testing into health care. Individuals who are just finding out they are infected often need a great deal of help and support to find an HIV provider, to make an appointment and to show up at that appointment. Intensive case management models show promise in enhancing linkages to care for newly-diagnosed individuals.6

What other HIV prevention strategies work in health care settings?

Risk assessment. Assessing HIV risk behaviors should be a standard part of new patient intake, regardless of HIV status. In-depth HIV prevention education is not necessary for every patient. However, health care providers should ask all patients about their sexual behavior, condom use, number of sexual partners, and alcohol and illicit drug use to assess a patient’s risk for acquiring or transmitting HIV. These quick questions may lead to longer discussions and counseling about safer sex or alcohol and drug use practices.7Drug treatment. Helping patients get into alcohol or drug treatment can be an effective HIV prevention tool and can help HIV-infected persons stay healthy. Health care providers can have a profound effect on patients’ lives by showing an interest in drug-using patients and encouraging willing patients to enter drug or alcohol treatment programs. Because relapse is common in treating addictions, health care providers should use a non-judgmental approach. Screening and treating for STIs. Providers should encourage screening for STIs. They should also provide STI education, emphasize the link between HIV and STIs, and encourage screening for partners.9

How does positive prevention work in health care settings?

Prevention counseling. Brief prevention counseling delivered in health care settings at every visit has been shown to decrease the likelihood that HIV-infected individuals transmit HIV to others, particularly if interventions are tailored to sub-populations of HIV-infected patients.10 Important messages include: helping people understand the relative risks of their actions and the effectiveness of different prevention strategies such as using condoms; disclosing HIV status to sex and drug using partners; and understanding their responsibility with regard to prevention. Formal provider training is important to facilitate these approaches.11,12Viral suppression. A unique component that health care settings play in HIV prevention is helping HIV-infected persons find and adhere to an effective ARV regimen to help keep their viral load low. Some research has demonstrated that keeping the viral load below a threshold that is detectable with lab tests can help prevent up to 60% of new STIs.13 New research suggests that effective detection of HIV and treatment to reduce the viral load could reduce the overall community viral load and have a population-level impact on HIV transmission.14

How can HIV prevention capacity be increased in health care settings?

Risk assessment. Knowing how to assess risk among patients is key to HIV prevention of any kind. Having risk assessment tools and training providers to use them is critical. Written protocols. It is important to make sure that procedures are in place to guide testing efforts in health care settings.15 Having a “prevention plan” tailored to the clinic size, the service delivery model, the types of providers and the patient population is critical. Leadership. Successful clinic programs often have identified staff leaders who function as counselors or team leaders for positive prevention.16Training. Underlying all of these important components is training. Training can facilitate buy-in from clinic providers and can address provider attitudes and beliefs about risk reduction and counseling.17 Training should outline staff responsibilities and anticipate changes to clinic flow.16

What are effective models for use in health care settings?

Positive STEPs17 is a training intervention to help HIV care providers deliver prevention counseling to their patients. The model was effective in improving provider attitudes, comfort, self-efficacy and frequency of delivering prevention counseling. Partnership for Health18 is an EBI (CDC’s Effective Behavioral Intervention) for providers in HIV clinics. Medical providers are trained to deliver brief risk-reduction counseling to their patients. All clinic staff are trained to integrate prevention messages into the clinic setting, and counseling is supplemented with written information for all patients. The intervention was effective in reducing unprotected intercourse by 38% among patients who had two or more sexual partners. Positive Choice19 is an interactive “Video Doctor.” Patients at HIV clinics completed an in-depth computerized risk assessment and received tailored risk-reduction counseling from a “Video Doctor” via laptop computer and a printed educational worksheet. Providers received a Cueing Sheet on reported risks for discussion during the clinical encounter. Provider-Delivered Counseling.10,16 In a large federal demonstration project, brief counseling messages delivered by primary care providers in clinic settings were most effective in reducing risk among HIV-infected patients, although there were also benefits in programs delivered by prevention specialists and HIV-infected peers.

What needs to be done?

Health care providers need more and repeated training on how HIV prevention can be integrated into the care they deliver. There are still significant misperceptions among health care providers about who should be tested for HIV and when to implement rapid testing. Provider attitudes, beliefs and self-efficacy can affect whether or not they address prevention through HIV testing or by providing risk-reduction counseling. Methods that enhance provider uptake of HIV prevention in health care delivery settings need attention and further research. Leaders in health care settings can establish written protocols that guide HIV prevention practices, including HIV testing in their clinics. Establishing protocols, documentation and quality assurance practices can enhance testing and prevention practices in all types of health care settings.

Says who?

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. Das M, Chu PL, Santos G-M, et al. Decreases in community viral load are accompanied by reductions in new HIV infections in San Francisco. PLoS ONE. 2010;5:e11068. 15. 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. 16. 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. 17. 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. 18. 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. 19. 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.
Special thanks to the following reviewers of this Fact Sheet: Lucy Bradley-Springer, Kimberly Carbaugh, Mark Cichocki, Renata Dennis, Josh Ferrer, Mark Molnar, Quentin O’Brien, Jim Sacco. Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. To receive Fact Sheets via e-mail, send an e-mail to [email protected] with the message “subscribe CAPSFS first name last name.” ©July 2010, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected].
Resource

Pre-exposure prophylaxis (PrEP) - 2012

What is pre-exposure prophylaxis (PrEP) and is it effective in preventing HIV?

Prepared by Stephanie Cohen, MD & Al Liu, MD; SF DPH | Gabriel R. Galindo DrPH; CAPS

What is PrEP?

PrEP stands for pre-exposure prophylaxis and it is a promising biomedical HIV intervention. It is an approach to prevention where HIV-negative people take HIV drugs in order to prevent HIV infection. PrEP is started before possible exposure to HIV, and is taken on an ongoing basis.  PrEP is not a vaccine, and it is different from post-exposure prophylaxis (PEP), where the medication is started soon after exposure to HIV, and continued for 28 days only. Taking a medication before exposure has been shown to be effective in preventing other infectious diseases. Likewise, providing antiretroviral therapy to pregnant women and their infants has been used effectively for many years to prevent mother-to-child transmission of HIV [1]. PrEP can be in the form of a pill taken by mouth, known as “oral PrEP”.[2,3,4 ] In clinical trials PrEP has been provided in combination with other HIV prevention interventions, such as condom distribution, behavioral counseling, HIV testing, and screening of other sexually transmitted infections (STIs).

Why is PrEP important?

Globally there are 2.6 million new HIV infections each year, and in the US, there are an estimated 56,000 new HIV infections annually.[5] While risk reduction counseling, condoms, male circumcision and other methods have been shown to reduce HIV infections, by themselves they are not enough, and new approaches to HIV prevention are urgently needed – especially for men who have sex with men (MSM) and transgender women, the groups who disproportionately bear the greatest HIV burden in the US [6].

What drugs are currently being tested for PrEP?

Recently completed and ongoing studies of oral PrEP have tested the HIV drug tenofovir (also known as Viread®) alone or in combination with emtricitabine.   The combination of tenofovir and emtricitabine is known as Truvada®. These medications were chosen because they only have to be taken once daily, they have few side effects, they don’t interact with most other medications, and they have been shown to be safe and effective in animal studies of PrEP.  Different topical formulations are currently being studied in clinical trials and other forms of topical PrEP, including a vaginal ring and a gel formulated for rectal use, are also under development.[7]

How effective is PrEP in preventing HIV infection?

For MSM and transgender women, the iPrEx study results, released in November 2010, demonstrated for the first time that daily oral Truvada®  is effective for HIV prevention.[2] The iPrEx study enrolled nearly 2500 MSM (1.2% of participants were transgendered women) participants from 6 countries, and included two cities in the US. All participants received frequent HIV testing, risk reduction counseling, condoms and lubricants, and screening and treatment for STIs. Half of the participants were randomly assigned to receive Truvada®, and the other half a placebo. The participants who received Truvada® had 44% fewer HIV infections than the participants who received the placebo. This means that PrEP prevented almost half of the infections that would have occurred if the medication was not provided. The protective effect of PrEP was even higher for those who were able to take the drug more consistently, including those who had evidence of Truvada® in their blood. The effectiveness of PrEP in other populations, such as heterosexual men and women, and injection drug users, is currently unknown as clinical trials have had mixed results. Still, there are several ongoing studies happening around the world in these populations, and those results will further enhance our understanding of PrEP’s efficacy [9,10]. For detailed information on PrEP trials occurring globally, click here for a table of ongoing and planned studies [11], and here for a PrEP trials timeline [12].

Is PrEP safe?

The iPrEx trial found that Truvada® was safe and generally well-tolerated by participants in the study. There were a few mild side effects related to Truvada®, such as nausea, which were infrequent and decreased with time. While a small amount of bone loss was seen in men receiving PrEP, a finding commonly seen in HIV-positive individuals starting similar antiretroviral treatment regimens, these changes had no apparent negative health impact.  Drug resistance was not seen among those who became HIV-infected during the iPrex study. Still, HIV testing and medical evaluation before starting, and while using PrEP, are important to prevent resistance and to monitor side effects on an individual level. Like the iPrex study, there were also no significant safety concerns raised in the trials of PrEP that have been conducted among heterosexual men and women. However, it is important to note that the follow-up in these studies was relatively short. Therefore, evaluating the longer-term safety of oral PrEP is important and will require further investigation in ongoing studies. Additional research is also needed to determine how frequently people taking PrEP will need to be seen by a health care provider and how often they will need to have laboratory monitoring, including HIV testing and monitoring of kidney function.

What are current recommendations for PrEP?

In January 2011, the Centers for Disease Control and Prevention (CDC) issued interim guidance on the use of PrEP for HIV prevention in MSM.[13] The CDC emphasizes that:

  • PrEP should only be considered for MSM at high risk for HIV infection (and not other populations until additional data are available).
  • PrEP should only be used in individuals with negative HIV antibody test(s) confirmed immediately prior to starting PrEP.  If symptoms of recent HIV infection are present, PrEP should be deferred and testing for acute HIV infection should be performed.
  • PrEP should never be seen as the first line of defense against HIV. PrEP should be delivered as a part of a comprehensive prevention package that includes risk-reduction and adherence counseling, encouragement of condom use, and diagnosis and treatment of STIs.
  • PrEP should be taken daily. Only the regimen tested in iPrEx (daily Truvada®) should be used, and not other antiretroviral medications or other dosing regimens (such as intermittent or occasional use).
  • PrEP should be obtained and used in close collaboration with healthcare providers to monitor side effects, adherence, safety, and risk behaviors at regular intervals.

Individuals taking PrEP should undergo regular HIV testing and should stop taking PrEP if they test HIV-positive. Those interested in PrEP should discuss this with their physicians and should not use PrEP on their own. Comprehensive guidelines for PrEP use will be developed by the United States Public Health Service through expert consultation and community input.

What are the next steps for PrEP?

In July 2012 the U.S. Food and Drug Administration approved Truvada® to reduce the risk of HIV infection in uninfected individuals who are at high risk and who may engage in sexual activity with HIV-infected partners. Recognizing that no infectious disease has ever been eliminated through medications alone, we need to carefully consider how to best use this tool in combination with other prevention strategies to make the largest impact on HIV/AIDS in the US and worldwide. In the iPrEx, Partners PrEP and TDF-2 studies, PrEP was shown to be partially effective when used in combination with regular HIV testing, condoms and other proven prevention methods, like individual risk reduction counseling.  Combination prevention approaches that integrate biomedical, behavioral and structural components are necessary to optimize HIV prevention efforts.[14] As such, the effectiveness of PrEP depends not just on the effectiveness and safety of the drugs, but also on several other implementation factors, including good adherence to the drug, maintaining safer sex behaviors, and access to clinical and social support services. Interventions and programs that help HIV-negative individuals access PrEP, take the pills on a regular schedule, manage potential side effects, undergo regular HIV testing, and maintain safer sex and drug-using practices are key to maximizing PrEP’s effectiveness and acceptance.[15,16] Additional studies, community-wide discussions, and advocacy work are underway to try to address and assess many of these important considerations.

Says Who?

  1. WHO. Guidance on global scale-up of the prevention of mother-to-child-transmission of HIV: Towards universal access for women, infants and young children and eliminating HIV and AIDS among children. The Interagency Task Team on Prevention of HIV Infection in Pregnant Women, Mothers and Their Children, 2007.
  2. Grant RM, Lama JR, Anderson PL, et al. Preexposure Chemoprophylaxis for HIV Prevention in Men Who Have Sex with Men. NEJM 2010;363(27):2587-99. Epub 2010 Nov 23.
  3. Abdool Karim Q, Abdool Karim SS, Frohlich JA, et al. Effectiveness and safety of tenofovir gel, an antiretroviral microbicide, for the prevention of HIV infection in women. Science 2010;329:1168-74.
  4. Centers for Disease Control and Prevention. CDC Trials: Pre-Exposure Prophylaxis for HIV Prevention.   https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2017.pdf
  5. Hall HI, Song R, Rhodes P, et al. Estimation of HIV incidence in the United States. JAMA 2008;300(5):520-9
  6. Centers for Disease Control and Prevention. Estimates of new HIV infections in the United States. CDC. Available at: https://www.cdc.gov/hiv/statistics/overview/index.html
  7. Stone A, Harrison PF.  Microbicides – Ways Forward. Alliance for Microbicide Development: Silver Spring, MD, USA. 2010.
  8. Buchbinder SP, Liu A. Pre-exposure prophylaxis and the promise of combination prevention approaches. AIDS and Behavior. 2011:15,S1:72-79.
  9. Peterson L, Taylor D, Roddy R, et al. Tenofovir disoproxil fumarate for prevention of HIV infection in women: a phase 2, double-blind, randomized, placebo-controlled trial. PLoS Clin Trials 2007;2:e27.
  10. Grohskopf L, Gvetadze R, Pathak S, et al. Preliminary analysis of biomedical data from the phase II clinical safety trial of tenofovir disoproxil fumarate (TDF) for HIV-1 pre-exposure prophylaxis (PrEP) among U.S. men who have sex with men (MSM). Abstract no. FRLBC102, International AIDS Society 2010, Vienna.
  11. AIDS Vaccine Advocacy Coalition. (2012, April). Ongoing and planned pre-exposure prophylaxis (PREP) trials.    https://www.avac.org/prevention-option/prep
  12. AIDS Vaccine Advocacy Coalition. (2011, May). Oral and topical PrEP trials timeline. https://www.avac.org/prevention-option/prep 
  13. Smith DK, Grant RM, Weidle PJ, et al. Interim guidance: preexposure prophylaxis for the prevention of HIV infection in men who have sex with men. Morbidity and Mortality Weekly Report. 2011;60:65-68.
  14. Centers for Disease Control and Prevention. Pre-exposure prophylaxis (PrEP) for HIV prevention: Promoting safe and effective use in the United States  https://www.cdc.gov/hiv/effective-interventions/prevent/prep/index.html
  15. Underhill K, Operario D, Skeer MR, et al. Packaging PrEP to prevent HIV: An integrated framework to plan for pre-exposure prophylaxis implementation in clinical practice. JAIDS.2010;55:8-13.
  16. 16. Underhill K, Operario D, Mimiaga MJ, Skeer MR, Mayer KH. Implementation Science of Pre-exposure Prophylaxis: Preparing for Public Use. Curr HIV/AIDS Rep 2010;7:210-9.

Fact Sheet 19, October 2012 Prepared by Stephanie Cohen, MD & Al Liu, MD; SF DPH | Gabriel R. Galindo DrPH; CAPS Special thanks to the following reviewers of this Fact Sheet: David Abbott, Tom Aloisi, Susan Buchbinder, Katerina Christopoulos, Chris Collins, Jen Hect, Quarrasha Abdool Karim, Delia Molloy, Stephen Morin, Don Operario, Kristen Underhill and Dana Van Gorder.

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 Francisco 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 2012, University of California

Resource

Hombres heterosexuales

¿Qué necesita el hombre heterosexual en la prevención del VIH?

revisado 4/01

¿está el hombre heterosexual en riesgo?

Sí. En los EEUU los casos nuevos de SIDA reflejan un incremento en las infecciones por uso de drogas intravenosas (UDI) y por contacto sexual heterosexual.1 El aumento de infecciones en hombres heterosexuales por UDI ha elevado los casos de VIH en las mujeres ya que más mujeres se están infectando al tener sexo con hombres UDI. El cambio de conducta del hombre heterosexual es determinante para controlar la epidemia en los hombres heterosexuales, las mujeres y los niños. Más de la cuarta parte (28%) de todos los casos de SIDA en hombres en los EEUU se producen por UDI y por relaciones sexuales heterosexuales. De estos casos, más de tres cuartos se dan en hombres de raza no blanca (caucásica), de los cuales más de la mitad (55%) son afroamericanos.2 Los casos de VIH/SIDA (según el Centro de Control de Enfermedades (CDC) de EEUU) se clasifican por conductas de riesgo (consumo de drogas/práctica sexual) y no por autoidentificación de género ó preferencia sexual. A los hombres que se autoidentifican como heterosexuales y que tienen sexo con otros hombres se les categoriza como “hombres que tienen sexo con hombres”; los cuales, no necesariamente llegan a identificarse con los programas dirigidos a hombres gay. Los programas de prevención para hombres heterosexuales en los EEUU han tocado los temas en cuanto al uso de drogas, pero pocos han considerado la conducta sexual. Las intervenciones para el cambio de conducta en heterosexuales se han dirigido principalmente a las mujeres, Si los hombres participan es secundario ya que la intervención no estaba dirigida a ellos.

¿qué pone a los hombres en riesgo?

UDI representa el mayor riesgo para el hombre heterosexual. Las drogas no inyectables como las anfetaminas, la cocaína-crack y el alcohol, incrementan que se tomen riesgos en la conducta sexual, aumentando así el riesgo de infección con VIH. Un estudio en drogadictos UDI que no están en tratamiento de desintoxicación, determinó que los hombres que consumieron metanfetaminas tuvieron más parejas sexuales, mayor actividad sexualcon penetración anal en hombres y en mujeresy menor uso del condón, que aquellos que no las consumieron.3 El hombre puede infectarse al tener sexo desprotegido con una mujer VIH+, aunque el riesgo es mucho menor que el asociado con compartir jeringas infectadas o el sexo con otro hombre VIH+. El riesgo aumenta si la pareja masculina o femenina tiene alguna enfermedad de transmisión sexual (ETS).4 La conducta sexual de mayor riesgo para el heterosexual es el sexo anal desprotegido con otro hombre VIH+. Quizá por homofobia o miedo al rechazo, los hombres no se atreven a reportar el tener sexo con otros hombres, identificando el sexo con mujeres como su único factor de riesgo.5 En ciertos ambientes los hombres corren un riesgo mayor. En los EEUU, el 90% de los prisioneros son hombres. Las tasas de VIH entre los encarcelados son 8 a 10 veces mayores que en la población en general.6 El uso de drogas inyectables, de otras drogas ilícitas, el tatuaje y el sexo anal desprotegido entre hombres son conductas de riesgo en las prisiones.

¿qué es lo que dificulta la prevención?

En esta sociedad a los hombres no se les educa para que cuiden su salud, muchos no reciben atención médica desde la infancia hasta la edad madura (a los 40 años aproximadamente).7 Los hombres heterosexuales, y en especial los afroamericanos, son los más reacios para hacerse la prueba del VIH, recibir tratamiento y acudir a las citas médicas.8,9 Muchos hombres heterosexuales no sólo saben muy poco sobre VIH/ETS, sino que tampoco creen que les concierne. Por falta de material educativo para hombres heterosexuales y de educadores de pares, el hombre heterosexual considera al VIH como un problema exclusivo del “hombre gay blanco.” El hombre es quien porta el condón (masculino) y quien tiene el poder de usarlo o no. Aunque el embarazo, las ETS y el VIH le preocupen, al hombre le puede ser difícil hablar sobre el uso del condón con su pareja. Algunos esperan que sea la pareja femenina quien mencione el tema; si ésta no lo hacen es común que ellos tampoco.10 Los jóvenes de razas no blancas frecuentemente se perciben así mismos como una “especie en peligro de extinción.”11 Para muchos jóvenes urbanos de áreas marginales, el peligro y la lucha diaria por sobrevivir rebasa las preocupaciones sobre el futuro como el VIH. La pobreza, violencia y adicción refuerzan las creencias del hombre negro de que no vivirá más 25 años. Para muchos de éstos jóvenes, el recibir un balazo o acabar en prisión son sus mayores preocupaciones.11

¿cómo involucrar al hombre heterosexual?

Los educadores de pares pueden ayudar a la prevención del VIH en el hombre heterosexual, aunque muy pocos hombres heterosexuales actualmente participan en la prevención del VIH. El temor y la concepción errónea de la cultura gay inhiben aún más su participación. Se necesita una educación que concientice a los hombres en general para entender y respetar los límites y las culturas sexuales. Reclutar a hombres heterosexuales puede ser una tarea difícil. Por ejemplo, abordar individualmente al afroamericano no es tan eficaz como hacerlo a través de su trabajo, líder religioso o grupo social. Además, el hombre heterosexual puede necesitar la motivación de la novia o esposa para participar en programas de prevención del VIH.12 Las campañas dirigidas al hombre heterosexual deben centrarse en temas generales de salud, no sólo en temas sexuales. Las campañas deben promover que los hombres hablen y se responsabilicen de su salud y bienestar, y no resaltar el lado negativo del sexo (ej.: el VIH mata, tener sexo con un(a) menor puede llevarte a la cárcel). La educación debe empezar en la pre-adolescencia para así ayudar a los jóvenes a protegerse a sí mismos cuando se enfrenten el mundo de la sexualidad y las drogas.

¿qué se ha hecho?

Un programa de desarrollo de destrezas para la prevención del VIH basado en el uso de videos y diseñado para afroamericanos heterosexuales de Atlanta, ayudó a incrementar el uso del condón y redujo el sexo vaginal desprotegido. El programa mostró información videograbada sobre VIH, preguntas y respuestas y demostró el uso del condón. Además se incorporaron moderadores en vivo. Como los hombres se limitan a participar en demostraciones de situaciones sexuales, se les pidió que sugirieran diálogos relacionados con prácticas sexuales más seguras para escenas específicas de películas populares.13 Le Penseur Youth Services ofrece servicios educativos a jóvenes y familias del sureste de Chicago. Uno de sus programas está dirigido a miembros de pandillas e incorpora a líderes pandilleros como educadores. Le Penseur adiestró a líderes y otros miembros de pandillas para transmitir mensajes sobre sexo seguro. Un componente clave es asignar papeles definidos a estos jóvenes y oportunidades de progreso y liderazgo. Éstos jóvenes también llevaron a su casa el mensaje de que el VIH afecta al hombre heterosexual, lo que aumentó la conciencia sobre el VIH en la comunidad.14 En Baltimore, el departamento de salud abrió un Centro de Salud Masculino gratuito que sirve a hombres sin seguro médico entre las edades de 16 a 64 años. La clínica ofrece atención primaria y dental, consejería para drogodependientes, educación sobre prevención y oportunidades de empleo. El personal de salud es masculino. Cuando este centro abrió, era el único en los EEUU dirigido a los hombres sin seguro médico. El enfoque del centro es ayudar a los hombres a que se mantengan sanos, contribuyendo así a crear familias sanas.15

¿qué queda por hacer?

El hombre heterosexual aún necesita información básica sobre VIH y requiere de programas que protejan su salud y le enseñen cómo obtener servicios para su salud. Los programas deben considerar que el hombre heterosexual puede tener sexo con otros hombres y deben promover el sexo seguro en cada encuentro sexual. Finalmente, estos programas deben crearse junto con las mujeres para incorporar así las necesidades e inquietudes de la pareja femenina. El tratamiento anti-drogas y el acceso a jeringas estériles que ofrecen los programas de intercambio de jeringas e intercambio en farmacias son cruciales para los hombres heterosexuales. Los hombres encarcelados necesitan tener acceso a tratamientos para la desintoxicación, condones, jeringas estériles, educación sobre prevención del VIH y asesoramiento para la transición de la cárcel a la calle que disminuya el riesgo dentro y fuera de la cárcel. El hombre heterosexual debe tomar más responsabilidad para evitar el contagio del VIH. Como tradicionalmente el hombre no ha participado en asuntos de salud y prevención, hay que apoyarlo y adiestrarlo para asegurar su participación en la prevención del VIH.

¿quién lo dice?

1. CDC. HIV/AIDS Surveillance Report . 1995;7:10. 2. CDC. HIV/AIDS Surveillance Report . 2001;13:16. 3.. Molitor F, Ruiz JD, Flynn N, et al. Methamphetamine use and sexual and injection risk behaviors among out-of-treatment injection drug users . American Journal of Drug and Alcohol Abuse. 1999;25:475-493. 4. Wasserheit JN. Epidemiological synergy. Interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases . Sexually Transmitted Diseases. 1992;19:61-77. 5. Sternberg S. ‘Secret’ bisexuality among Black men contributes to rising number of AIDS cases in Black women. USA Today. March 15, 2001. 6. Hammett TM, Harmon P, Maruschak L. 1996-1997 Update: HIV/AIDS, STDs and TB in correctional facilities. Abt Associates, Inc .: Cambridge, MA; 1999. 7. Sandman D, Simantov E, An C. O . Published by The Commonwealth Fund. March 2000. 8. Fichtner RR, Wolitski RJ, Johnson WD, et al. Influence of perceived and assessed risk on STD clinic clients’ acceptance of HIV testing, return for test results, and HIV serostatus. Psychology, Health & Medicine. 1996;1:83-98. 9. Israelski D, Gore-Felton G, Wood MJ, et al. Factors associated with keeping medical appointments in a public health AIDS clinic. Presented at the 8th International AIDS Conference, Durban, South Africa. Abst# WePeD4570. 10. Carter JA, McNair LD, Corbin WR. Gender differences related to heterosexual condom use: the influence of negotiation styles . Journal of Sex & Marital Therapy. 1999;25:217-225. 11. Parham TA, McDavis RJ. Black men, an endangered species: Who’s really pulling the trigger? Journal of Counseling & Development. 1987;66:24-27. 12. Summerrise R, Wilson W. “The Black Print” model for recruitment of African-American males. Published by the Chicago, IL, Prevention Planning Group. 2000. 13. Kalichman SC, Cherry C, Brown-Sperling F. Effectiveness of a video-based motivational skills-building HIV risk-reduction intervention for inner-city African American men . Journal of Consulting and Clinical Psychology. 1999;67:959-966. 14. Summerrise R. Valuing the lives of men: HIV prevention for heterosexual men. Presented at the US Conference on AIDS, Atlanta, GA. October, 2000. 15.Sugg DK. A first for men: clinic opens in Baltimore . The Baltimore Sun. May 11, 2000. Preparado por Reginald Summerrise* y Pamela DeCarlo**, Traducción Romy Benard y Maricarmen Arjona** *Le Penseur Youth Services, Chicago, IL; **CAPS Septiembre 2001. Hoja Informativa 22SR

Resource

Prostitutas

¿Qué necesitan las/los trabajadores sexuales en la prevención del VIH?

revisado 4/08

¿corren riesgo de contraer el VIH?

Los trabajadores sexuales en EEUU pueden ser vulnerables al VIH según cuál sea su lugar de trabajo. Hombres, mujeres y transgéneros que trabajan en la calle, en su mayoría pobres o desamparados con antecedentes de abuso sexual o físico, corren el mayor riesgo de contraer el VIH.1 Muchos sexo servidores que trabajan en la calle también dependen de las drogas o alcohol y corren un mayor riesgo de sufrir violencia a manos de sus clientes y de la policía.2 El servicio de sexo fuera de la calle–en prostíbulos, casas de masaje o por medio de servicios de acompañante–supone menos riesgo de infección por VIH porque los trabajadores sexuales pueden controlar mejor sus condiciones laborales y transacciones sexuales, incluido el uso de condones. Se han realizado pocas investigaciones sobre las tasas de infección de VIH entre sexo servidores que trabajan en la calle a lo largo de EEUU. En un estudio de sexo servidoras consumidoras de drogas en Miami, FL el 22.4 % resultó ser VIH+.3 Otro estudio de trabajadores sexuales masculinos en Houston, TX encontró que el 26 % afirmaron ser VIH+.4

¿qué los pone en riesgo?

Los sexo servidores que son usuarios de drogas inyectables (UDI) tienen más probabilidades de resultar VIH+ que los no usuarios. Los riesgos por inyección incluyen compartir agujas/ jeringas y otro equipo de inyección previamente usados, así como ser inyectados por otra persona. La inyección y otras formas de consumo de drogas (cocaína en roca, etanfetamina, alcohol) también pueden aumentar los riesgos sexuales al disminuir la protección y la comunicación sexuales.5 Las personas que usan cocaína en roca (crack) son más propensas a entrar al sexo servicio y a tener numerosas parejas sexuales.6 La decisión y la capacidad de usar condones es un asunto complejo y depende de muchos factores.7,8 La necesidad económica, la falta de clientes y los clientes que ofrecen pagar más por tener relaciones sin protección pueden perjudicar la negociación del sexo más seguro. Además, hay clientes que pueden recurrir a la violencia para conseguir relaciones sin condón. Si los trabajadores sexuales se drogan junto con sus clientes o antes de atender a ellos, esto afecta su capacidad para tomar decisiones y usar condones.5 También pueden ser un blanco de la policía si cargan con condones. Asimismo, al igual que muchas otras personas, los trabajadores sexuales pueden optar por no usar condones con sus novios/novias/esposos. Los sexo servidores tienen tasas más altas de infecciones de transmisión sexual (ITS), entre ellas el VIH. Un estudio en San Francisco, CA reportó tasas altas de gonorrea (el 12.4 %), clamidia (el 6.8 %), sífilis (el 1.8 %) y herpes (el 34.3 %) entre los trabajadores sexuales (hombres, mujeres y transgéneros).9 La presencia de una ITS activa aumenta la probabilidad de adquirir el VIH, como hace también el trauma genital producido por el coito frecuente o forzado.1 La violencia, y el trauma que conlleva, es una preocupación para muchos trabajadores sexuales. La violencia puede incluir el abuso físico, sexual y verbal ocurrido en la niñez, o bien en la edad adulta a manos de clientes y parejas íntimas. También abarca la violencia diaria presenciada por muchos trabajadores sexuales de la calle. El historial de violencia deja a muchos trabajadores sexuales con trauma emocional, y muchos pueden recurrir al consumo de drogas para ayudarles a afrontar la dura realidad de la vida diaria.10

¿cuáles son los obstáculos?

La naturaleza ilícita del trabajo sexual en EEUU lo ha convertido en una industria clandestina y ha creado en los trabajadores sexuales una fuerte desconfianza hacia las autoridades policiales y de salud pública. Muchos sexo servidores que trabajan en la calle se ven obligados a cambiar sus prácticas laborales con el fin de evitar ser detenidos por la policía.11 Por ejemplo, pueden dedicar menos tiempo a la negociación de las transacciones sexuales antes de subirse al vehículo del cliente o incluso aceptar participar en actividades más riesgosas. Puede ser difícil realizar actividades de prevención, extensión y orientación sobre el VIH en este ambiente. La desesperación y la pobreza muchas veces anulan la prevención del VIH. Los adictos pueden recurrir a la prostitución como fuente de dinero para comprar drogas. Las personas transgénero pueden usar el trabajo sexual para cubrir los gastos de hormonas o cirugía. Muchos jóvenes sin hogar no tienen capacitación laboral u otra manera de generar ingresos, por lo que recurren a la prostitución para sobrevivir. Responder a las necesidades más inmediatas de alimentación, vivienda y adicción con frecuencia toma precedencia sobre la preocupación de infectarse por VIH.12

¿qué se está haciendo al respecto?

JEWEL (Jewelry Education for Women Empowering their Lives), fue un proyecto de empoderamiento económico y prevención del VIH para prostitutas consumidoras de drogas en Baltimore, MD. JEWEL presentó seis sesiones de dos horas con orientación sobre la prevención del VIH y sobre la fabricación, comercialización y venta de joyería. Las participantes disminuyeron considerablemente el intercambio de sexo por drogas o dinero, el número de parejas de intercambio sexual y su consumo de drogas, incluido el uso diario de crack.13 El Health Project for Asian Women (HPAW) brindó dos intervenciones para trabajadoras sexuales asiáticas de casas de masaje en San Francisco, CA: una orientada a educar a los dueños y otra de consejería e orientación para las masajistas. El personal del proyecto acompañó a las masajistas a los centros de salud, les entregó materiales de protección sexual y les brindó servicios de interpretación, de remisiones a otros servicios y de defensa de derechos. Las masajistas asistieron a tres sesiones de consejería y los dueños de las casas de masaje recibieron una sesión educativa.14 Una intervención breve para trabajadores sexuales masculinos en Houston, TX presentó dos sesiones de una hora realizadas con una semana de intervalo. Casi los dos tercios (el 63 %) de los hombres que iniciaron la intervención la completaron y también aumentaron su uso de condones para la penetración anal remunerada.15Breaking Free, ubicado en St. Paul, MN, ayuda principalmente a muchachas y mujeres afroamericanas a dejar el sexo servicio. Las mujeres que se encuentran en crisis reciben ayuda para estabilizarse, luego participan en un programa intensivo de consejería y orientación sobre los traumas asociados con el trabajo sexual. Breaking Free ofrece vivienda transicional y permanente, así como un programa de prácticas laborales para aumentar las posibilidades de las mujeres, algunas con poca o nula experiencia previa, de conseguir un empleo convencional.16 St. James Infirmary en San Francisco, CA, es una clínica organizada para y por trabajadores sexuales la cual provee servicios médicos gratis a hombres, mujeres y transgéneros. También ofrece pruebas y tratamiento de VIH/ITS, servicios médicos especializados para transgéneros, consejería de pares y sobre reducción de daños, servicios psiquiátricos, acupuntura, masaje, grupos de apoyo, alimentos, ropa e intercambio de jeringas. El personal realiza trabajo de extensión en la calle y en lugares concretos para repartir materiales de protección sexual y ofrecer pruebas de VIH.9

¿qué queda por hacer?

Durante la última década se ha realizado poca investigación en EEUU sobre el VIH/SIDA entre los sexo servidores. Además, los estudios anteriores se enfocaron principalmente en el papel de los trabajadores sexuales como vectores de transmisión del VIH y de ITS al público general. Para evitar el VIH entre los trabajadores sexuales, es fundamental no sólo expandir la investigación sobre este grupo sino también reconocer el contexto más amplio en el cual el trabajo sexual se transacciona y también la práctica específica de los sexo servidores. Los investigadores, las autoridades de salud pública y las policiales necesitan escuchar a los trabajadores sexuales acerca de sus propios necesidades para mantenerse protegidos, y deben trabajar en conjunto para realizar estas metas. Las leyes y las actitudes de la policía en cuanto que los sexo servidores porten condones deben ser indulgentes para permitirles que se protejan. La violencia en contra de los trabajadores sexuales a manos de los clientes, de la policía y de otros en la comunidad deberá criminalizarse, al tiempo que se estimule y apoye a las víctimas para denunciar ante la policía los incidentes violentes. Los sexo servidores que trabajan en la calle enfrentan numerosas necesidades que van desde las inmediatas (vivienda, comida, atención médica) hasta otras de más largo plazo (salud mental, desintoxicación de drogas, prevención de la violencia, capacitación laboral y empleo, prevención del VIH/ITS, atención médica de alta calidad, mejores relaciones con las autoridades policiacas y ayuda para abandonar el trabajo sexual). Es necesario aumentar la financiación y el reconocimiento de los programas de salud pública que respondan a toda la amplia gama de necesidades encaradas por los trabajadores sexuales.

¿Quién lo dice?

1. Rekart ML. Sex-work harm reduction. The Lancet. 2005:366: 2123-2134. 2. Vanwesenbeeck I. Another decade of social scientific work on sex work: a review of research 1990- 2000. Annual Review of Sexuality Research. 2001;12:242-289. 3. Inciardi JA, Surratt HL, Kurtz SP. HIV, HBV, and HCV infections among drug-involved, inner-city, street sex workers in Miami, Florida. AIDS and Behavior. 2006;10:139-147. 4. Timpson SC, Ross MW, Williams ML, et al. Characteristics, drug use, and sex partners of a sample of male sex workers. The American Journal of Drug and Alcohol Abuse. 2007;33: 63-69. 5. Alexander P. Sex work and health: A question of safety in the workplace. Journal of the American Medical Women’s Association. 1998;53: 77-82. 6. Maranda MJ, Han C, Rainone GA. Crack cocaine and sex. Journal of Psychoactive Drugs. 2004;36: 315-122. 7. McMahon JM, Tortu S, Pouget ER, et al. Contextual determinants of condom use among female sex exchangers in East Harlem, NYC: an event analysis. AIDS and Behavior. 2006;10:731-741. 8. Roxburgh A, Degenhardt L, Larance B, et al. Mental health, drug use and risk among street-based sex workers in greater Sydney. NDARC Technical Report No. 237. Sydney: National Drug and Alcohol Research Centre, University of New South Wales. 2005. 9. Cohan D, Lutnick A, Davidson P, et al. Sex worker health: San Francisco style.Sexually Transmitted Infections. 2006;82:418-422. 10. Romero-Daza N, Weeks M, Singer M. “Nobody gives a damn if I live or die”: violence, drugs, and street-level prostitution in inner-city Hartford, Connecticut.Medical Anthropology. 2003;22:233-259. 11. Blankenship KM, Koester S. Criminal law, policing policy, and HIV risk in female street sex workers and injection drug users. Journal of Law, Medicine & Ethics. 2002;30:548-559. 12. Yahne CE, Miller WR, Irvin-Vitela L, et al. Magdalena Pilot Project: motivational outreach to substance abusing women street sex workers. Journal of Substance Abuse Treatment. 2002;23:49-53. 13. Sherman SG, German D, Cheng Y, et al. The evaluation of the JEWEL projects: An innovative economic enhancement and HIV prevention intervention study targeting drug using women involved in prostitution. AIDS Care. 2006;18:1-11. 14. 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. 15. Williams ML, Bowen AM, Timpson SC, et al. HIV prevention and street-based male sex workers: an evaluation of brief interventions. AIDS Education and Prevention. 2006;18:204-215. 16. Valandra. Reclaiming their lives and breaking free: an Afrocentric approach to recovery from prostitution. Journal of Women and Social Work. 2007;22:195-208.www.breakingfree.net

Preparado por Roshan Rahnama, MPH, CAPS Traducido por Rocky Schnaath Septiembre 2008. Hoja de Dato #19SR