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What Are U.S. Latinos’ HIV Prevention Needs?

revised 4/02

Are Latinos at risk for HIV?

HIV continues to be a major health threat for Latinos in the US, many of whom are disadvantaged due to racism, economic disparities and language barriers. Latinos in the US (including residents of Puerto Rico) are disproportionately affected by HIV, accounting for 18% of total AIDS cases while comprising 14% of the US population.¹ The majority of AIDS cases among the Latino population in 2000 were concentrated among those born in the continental US (35%) and Puerto Rico (25%), followed by those born in Mexico (13%), Central or South America (8%) and Cuba (2%). An additional 18% were reported from Latinos with unknown place of birth (15%) or born elsewhere (3%).²

What puts Latinos at risk?

Latinos in the US include a diverse mixture of racial and ethnic groups and cultures. Latinos share common factors with other ethnic groups that increase vulnerability to HIV, such as discrimination,³ poverty, lack of information, substance use and negative attitudes toward condoms. AIDS case rates and risk behaviors among Latinos in the US vary by region. In the Northeast and along the eastern seaboard, where many Latinos from Puerto Rico live, Latino rates are up to three times higher than the national average.⁴ In this region, the main risk for transmission is injection drug use, believed to be fueled by the concentration of heroin availability. By comparison, in the West and Southwest, the majority of AIDS cases occurs among men who have sex with men (MSM), although cases are also high among injection drug users (IDUs) in certain areas. In 2000, 47% of AIDS cases among Latino men were attributed to sex with men, 33% to injection drug use, and 14% to sex with women. In the same year, 65% of AIDS cases among Latina women were attributed to sex with men, and 32% to injection drug use.¹ Thus, among both male and female Latinos, as with most other groups, unprotected sex with an HIV+ man is the most common route for becoming infected with HIV, followed by the sharing of an unclean syringe/needle with an HIV+ person. HIV risk dynamics among immigrant and migrant Latinos can be more complex than among US born Latinos, as they are dealing with conflicting cultural norms while trying to adjust to life in a new country. For some, this results in higher risk; for others, lower risk. Levels of acculturation, poverty, employment, migrant labor conditions and connection to traditional Latino values can influence HIV risk.⁶

What are barriers to prevention?

The social and political climate in the US today poses serious problems for effective HIV prevention in Latino communities. Racial and ethnic discrimination, anti- immigrant attitudes, policies on mandatory testing for immigrants, and fear of deportation for undocumented immigrants can prevent many Latinos from receiving and accessing adequate resources and services for HIV prevention, including HIV counseling and testing. Traditionally in Latino cultures, sex and sexuality are not discussed. For some Latina women, this sexual silence dictates that they should not know about or talk to men about sex because it suggests promiscuity. Therefore, their ability, comfort and success in insisting on condom use with male partners may be limited. Sexual silence can prevent MSM from discussing their sexual preference, instilling low self-esteem and personal shame. In addition, the lack of parental discussions and education regarding sex and condoms seems to contribute to the disproportionate number of unintended pregnancies, sexually transmitted diseases and HIV cases among Latino youth.⁹ Injection drug use is one of the main risk factors for HIV transmission, yet many IDUs do not have access to clean needles and drug treatment. Access is even more difficult for monolingual, immigrant Latino IDUs who may not use needle exchange sites or other public services due to lack of knowledge and fear of being recognized or deported.

How does culture affect prevention?

Familismo is a traditional Latino commitment to family and a central support to family members. Familismo can be a powerful incentive in helping heterosexual Latino men reduce unprotected sex with casual partners outside of primary partnerships. However, for many Latino MSM, familismo and homophobia can create conflict because families may perceive homosexuality as wrong. MSM are forced to separate their sexual identity from their family life, leading to low self-esteem and personal shame.⁸ Machismo may lead men to view sex as a way to prove masculinity. This can mean that frequency and type of sex are most often determined by men, leaving women in fear of violence or abandonment if they resist male sexual advances.7Machismo may also be used as an excuse for unprotected sex.

What’s being done?

Prevention Point Philadelphia, in collaboration with other AIDS organizations, operated a full service needle exchange site from a van that traveled to an area with many shooting galleries. The van offered needle exchange, oral HIV testing, bilingual social service and drug treatment referrals and medical care. The van reached many homeless, Spanish-speaking Puerto Rican IDUs who were regular shooting gallery users. Many of them had never accessed preventive medical care or social services. In San Antonio, TX, a three-session small group intervention was offered to English-speaking Mexican-American women who had a sexually transmitted disease (STD). The intervention sought to help women recognize their risk for HIV and other STDs, make a plan to change and then build skills to help reduce those risks. The intervention significantly reduced rates of subsequent STDs.¹¹ Hermanos de Luna y Sol, is an ongoing intervention for Latino gay/bisexual men at Mission Neighborhood Health Center in San Francisco, CA, based on empowerment education and social support. The program provides outreach, six structured discussion sessions and ongoing support to maintain behavior change. Sessions deal with the common history of oppression among Latino gay men, social support and community and emotional issues around sex and sexuality. The impact of AIDS and HIV transmission are discussed in the final two sessions. The program has been successful in recruiting men and increasing condom use among participants.¹² Mujeres Unidas y Activas is a community education, organizing and advocacy project created by and for Latina immigrant and refugee women in San Francisco, CA. The project includes components such as information meetings, friendship circles, workshops and advocacy. Although the project was not developed to specifically target HIV risk behaviors, women who attended up to nine types of activities showed increases in sexual communication comfort, were less likely to maintain traditional sexual gender norms and reported changes in decision-making power.¹³

What still needs to be done?

Latinos are concerned about the HIV epidemic and are motivated to learn and to teach their children about prevention.¹⁴ Providers and social service agencies should capitalize on this by providing Spanish-language or bilingual education and services such as anonymous and confidential HIV testing. Incorporating HIV prevention messages into general health services, Spanish media and religious settings would decrease stigma and increase access to HIV prevention programs. As Latinos, we must attempt to break the silence around sexuality in our communities and overcome homophobia. Latinos can encourage healthy sexuality by discussing gender role expectations, teaching children about sexuality and accepting diversity in our own community. Programs can build upon the protective aspects of Latino culture and emphasize resiliency. Larger societal factors such as poverty, racism and homophobia must also be addressed in order to reduce their impact on risk behavior.

Says who?

1.Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, Midyear Edition. 2001;13. https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html  2. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, Year End Edition. 2000;12. https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html  3. Díaz RM, Ayala G. Social discrimination and health: the case of Latino gay men and HIV risk. National Gay and Lesbian Task Force. 4. Kaiser Family Foundation. Key Facts: Latinos and HIV/AIDS. November 2001. 5. Klevens RM, Díaz T, Fleming PL, et al. Trends in AIDS among Hispanics in the United States, 1991-1996. American Journal of Public Health. 1999;89:1104-1106. 6. Organista K, Carrillo H, Ayala G. HIV prevention with Mexican migrants: review, critique and recommendations. Journal of Acquired Immune Deficiency Syndrome. 2004;37:S227-39 7. Gómez CA, Marín BV. Gender, culture and power: barriers to HIV prevention strategies for women. The Journal of Sex Research. 1996;33:355-362. 8. Díaz RM. Latino Gay Men and HIV: Culture, Sexuality and Risk Behavior. New York: Routledge Press, 1998. 9. The National Campaign to Prevent Teen Pregnancy. Whatever Happened to Childhood? The Problem of Teen Pregnancy in the United States. 1997. 10. Porter J, Perez G. Taking it to the street: shooting gallery needle exchange site for drug injectors at highest risk for HIV. Presented at the International Conference on AIDS, Geneva, Switzerland; 1998. Abst #33402. 11. Shain RN, Piper JM, Newton ER, et al. A randomized, controlled trial of a behavioral intervention to prevent sexually transmitted disease among minority women. New England Journal of Medicine. 1999;340:93-100. 12. Hermanos de Luna y Sol. Contact: 415/552-1013 x296 13. Gómez CA , Hernandez M, Faigeles B. Sex in the New World: An Empowerment Model for HIV Prevention among Latina Immigrant Women. Health Education & Behavior. 1999;26:200-212. 14. Kaiser Family Foundation. Latinos’ View of the HIV/AIDS Epidemic at 20 Years: Findings from a National Survey. 2001. 15. Ortiz-Torres B, Serrano-Garcia I, Torres-Burgos N. Subverting culture: promoting HIV/AIDS prevention among Puerto Rican and Dominican women. American Journal of Community Psychology. 2000;28:859-881. 16. Raj A, Amaro H, Reed E. Culturally tailoring HIV/AIDS prevention programs: Why, when and how. In: Kazarian & Evans (Eds) Handbook of Cultural Health Psychology. San Diego: Academic Press, 2001; 195-239.

Prepared by Cynthia Gómez, PhD, CAPS April 2002. Fact Sheet #17ER Special thanks to the following reviewers of this Fact Sheet: Hortensia Amaro, George Ayala, Jaime Calderón-Soto, Alejandra Cano, Dennis De Leon, José Ramón Fernandez-Peña, Francisco Gonzales, Barbara Marín, Kurt Organista, Prisci Quijada, Carlos Soles, Carlos Velazquez, Luis Villanueva.

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. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © September 2001, University of California

How do sexual networks affect HIV/STD prevention?

What are sexual networks?

Focusing on risk behavior alone does not explain why some persons and communities continue to be infected with HIV and other sexually transmitted diseases (STDs) more than others. Networks help explain why persons can have the same risk behavior and yet one may have a much greater risk of contracting or transmitting HIV. Sexual networks are groups of persons who are connected to one another sexually. The number of persons in a network, how central high-risk persons are within it, the percentage in monogamous relationships and the number of “links” each has to others all determine how quickly HIV/STDs can spread through a network.¹ Sexual networks are distinct from, but often overlap with social networks.

How do networks affect transmission?

The different ways persons select partners affect how quickly HIV/STDs can spread. Exclusively monogamous persons are, by definition, not part of a sexual network. If both are HIV-negative they remain so. Serial monogamists are persons who go from relationship to relationship one at a time. If they have unprotected sex, they have a higher risk of HIV/STDs than exclusively monogamous persons. Earlier partners’ risk may affect later partners. Concurrent relationships involve having more than one sexual partner in a given period and going back and forth between them. This increases the probability for transmission because earlier partners can be infected by later partners. Further, they can serve as “nodes”, connecting all persons in a dense cluster, creating highly connected networks that facilitate transmission. Concurrent partners can connect each of their respective clusters and networks as well. Concurrency alone can fuel an epidemic even if the average number of partners is relatively low. The two networks above show that what matters is not simply risk behavior, but risk configuration. Each has 8 persons (circles) connected into 9 relationships. Two persons each have 3 partners, and the other six each have 2 partners. Yet transmission will be less efficient in network A, and prevention will be more difficult in network B. In A, in just two steps from the index person, half the network can be infected and half spared; in B, two steps can result in everyone being infected except for the person on the extreme right. In A, sparing half the population from exposure requires cutting one bridge, while in B, it requires cutting three bridges. In a word, for epidemics, the network structure is destiny.³

What are key concepts of networks?

Number of partners. Programs can focus on persons with the largest number of ties to others in a network. With HIV/STDs, this suggests that in addition to promoting condom usage, programs seek to identify those with a high number of unprotected partners. Random spread broadens transmission. An infection spreads quickest when partnering is random.⁴ When partners select one another within groups such as age, ethnicity, class, religion or other characteristics, diseases may not spread to all subgroups. When partnering is anonymous or random, a disease can spread more quickly through all groups. Core groups. Core group members have high levels of risky behaviors. They contribute a disproportionate share of HIV/STDs, and can fuel sustained transmission. Centrality. How central an HIV+ person is to a network deeply influences transmission rates in a community. In Colorado Springs, CO, network analysts found that HIV+ persons had high levels of risk behavior but were located in peripheral areas of risk networks.⁵ This network configuration may have explained the relatively low HIV transmission levels. In contrast, HIV+ persons in New York City, NY occupied central positions within their needle-sharing and sexual risk networks, which helped explain the high observed levels of infection.⁶

Can sexual networks help explain racial differences in HIV/STD rates?

Yes. Sexual networks and partner selection help explain racial differences in HIV/STD infection rates. For example, African American gay and bisexual men may take no more risk than white men, but appear to get infected much faster.⁷ In the same way, Asian American gay and bisexual men report similar risk levels but get infected at lower rates.⁸ In one national study, it was shown that heterosexual African-Americans were getting infected with bacterial STDs at rates almost five times faster than whites after controlling for individual level risk factors. Sexually transmitted infections remain in African American populations because their partner choices are more segregated than other groups. In addition, non-core African-Americans (with few partners) are more likely to choose “core” sexual partners. ⁹

What interventions influence networks?

Partner notification. Many public health departments have developed highly confidential and sound techniques of partner notification and, through network analysis, have learned to trace “up” the chain of transmission to the transmitter rather than “down” the chain to those infected.¹⁰ This allows transmitters to be identified for treatment and HIV/STD prevention counseling. Message development. In addition to promoting condom use and counseling, media messages can be tailored to encourage network fragmentation by encouraging serial monogamy (“one partner at a time”) rather than overlapping partners. Community dialogue. Community-based organizations (CBOs) can play a key role in facilitating community dialogue about difficult questions about networks: How should communities balance sexual freedoms of all–including those at highest risk–with the health and future of their entire community? What community and cultural norms contribute to risky sexual networking? Additionally, CBOs should distinguish between traditionally-defined “risk groups” and those individuals with the very highest levels of risk to focus resources on them. Addressing venues which facilitate partner mixing. In many settings, identification of partners may be impossible. However, by focusing on venues which facilitate sexual mixing between members of both high- and low-risk networks, HIV/STD prevention workers may be able to reduce transmission. For example, many men with syphilis report meeting partners over the internet and in commercial sex venues.^11,12 Working with bathhouse and sex club managers and internet service providers to negotiate respective roles in promoting safer behaviors should be a priority for HIV/STD intervention workers. In San Francisco, CA, AIDS educators and sex club owners developed a shared set of guidelines to reduce risky behavior in the clubs.¹³ In the Netherlands, the gay dating internet site www.dateguide.nl provides interactive safer sex education for every man as he logs on.¹⁴

What still needs to be done?

At the beginning of the epidemic, network analysis helped explain some of the most important features of AIDS and helped explain its causes.15 It can still be useful now for agencies, communities, and researchers to work together to encourage sexual networks that discourage HIV/STD transmission. It has long been known and understood that some individuals contribute much more to the spread of HIV/STDs than others. Ignoring that fact, and ignoring the role of sexual networks in fueling the epidemic, hampers our ability to slow HIV/STD transmission.

Says who?

1. Potterat JJ, Muth SQ, Brody S. Evidence undermining the adequacy of the HIV reproduction number formula. Sexually Transmitted Diseases. 2000;27:644-645. 2. Morris M. Sexual networks and HIV. AIDS. 1997;11:S209-216. 3. Klovdahl AS, Potterat JJ, Woodhouse D, et al. HIV infection in a social network: A progress report. Bulletin de Methodologie Sociologique. 1992;36:24-33. 4. Laumann EO, Gagnon J, Michael R, Michaels S. The Social Organization of Sexuality. Chicago: The University of Chicago Press, 1994. 5. Rothenberg RB, Potterat JJ, Woodhouse DE, et al. Social network dynamics and HIV transmission. AIDS. 1998;12:1529-1536. 6. Friedman SR, Neaigus A, Jose B, et al. Sociometric risk networks and risk for HIV infection. American Journal of Public Health. 1997;87:1289-1296. 7. Centers for Disease Control and Prevention. HIV Incidence Among Young Men Who Have Sex With Men—-Seven U.S. Cities, 1994-2000. Morbidity and Mortality Weekly Report. 2001;50:440-444. 8. Choi KH, Operario D, Gregorich S, et al. Age and race mixing patterns of sexual partnerships among Asian men who have sex with men: implications for HIV transmission and prevention. AIDS Education and Prevention. 2003;15:S53-65. 9. Laumann EO, Youm Y. Racial/ethnic group differences in the prevalence of sexually transmitted diseases in the United States: a network explanation. Sexually Transmitted Diseases. 1999;26:250-61. 10. Ghani AC, Ison CA, Ward H, et al. Sexual partner networks in the transmission of sexually transmitted diseases. An analysis of gonorrhea cases in Sheffield, UK. Sexually Transmitted Diseases. 1996;23:498-503. 11. Klausner JD, Wolf W, Fischer-Ponce L, et al. Tracing a syphilis outbreak through cyberspace. Journal of the American Medical Association. 2000;284: 447-449. 12. Williams LA, Klausner JD, Whittington WL, et al. Elimination and reintroduction of primary and secondary syphilis. American Journal of Public Health. 1999;89:1093-1097. 13. Wohlfeiler D. Structural and environmental HIV prevention for gay and bisexual men. AIDS. 2000;14:S52-S56. 14. Harternik P, van Berkel M, van den Hoek K, et al. e-Dating: a developing field for HIV prevention. Published by the Dutch AIDS Fund. www.dateguide.nl 15. Auerbach DM, Darrow WW, Jaffe HW, et al. Cluster of cases of the acquired immune deficiency syndrome. Patients linked by sexual contact. American Journal of Medicine. 1984;76:487-92. Prepared by Prepared by Dan Wohlfeiler*, John Potterat *UCSF April 2003. Fact Sheet #50E Special thanks to the following reviewers of this Fact Sheet: Buzz Bense, Peggy Dolcini, Paul Etkind, Sam Friedman, Azra Ghani, Jed Herman, Ed Laumann, Virginia Loo, Robin Miller, Michael Samuel, Tom Valente, Russell Westacott.

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

How Is Science Used in HIV Prevention?

Is science needed?

Yes. While prevention science will not give “the answer,” science fills in critical pieces of the prevention puzzle. Science used in conjunction with an agency’s experience with clients can strengthen, inspire, target, and best use limited resources in HIV prevention programs. This fact sheet will cover some of the basic elements of prevention science, what they mean, and their implications for service. Using science in prevention is now mandated in many areas. In 1994, the Centers for Disease Control and Prevention (CDC) radically changed how it makes prevention program awards. The CDC’s guidance recommends that HIV Prevention Community Planning Groups (CPGs) use epidemiology, evaluation and behavioral science theories, findings, and methodologies in developing programs.¹ Science that is applicable to HIV prevention can be broken down into five general categories:

• epidemiology,
• basic behavioral science,
• behavior change theory,
• intervention science, and
• evaluation methodology.

How is epidemiology useful?

Epidemiology is the study of the occurrence of infections or disease in a population. It can tell you how many people are newly infected with HIV, what subpopulations have been infected, and who might be expected to be infected by HIV in the future. Behavioral epidemiology can tell you about the frequency of risk behaviors.² Using local epidemiology can help program planners target specific audiences and behavior risks that are most in need of prevention in their community. It can also help planners be more thoughtful about how to best use limited resources. Health departments and the CDC can help by collecting local data for all populations.³

How is behavioral science useful?

Basic behavioral science explores the social, behavioral and cultural influences that help explain why people put themselves at risk, and why people continue to get infected with HIV. Research on human sexuality is key to understanding how people change risky sexual behaviors and can help in program design.⁴ It does not tell service providers what to do, but can suggest new ways of thinking about program elements. For example, recent research has shown that childhood sexual abuse is a predictor for risky sexual behavior in adulthood.⁵ Knowing this, program managers can incorporate questions on early abuse into needs assessments, add a segment on childhood abuse to multi-session education interventions, develop new programs for adults who were abused and/or give special training to direct service staff on sexual abuse issues.

How is behavior change theory useful?

Behavior change theory provides a framework to ideas on why and how people change behaviors that put them at risk for HIV infection. Using behavior change theories can help when crafting an intervention, to support each component in a model as the intervention is designed.^6,7 For example, Paulo Freire’s theory of Popular Education states that teachers and students should learn from one another.⁸ Using this theory, a program can use discussion groups as opposed to lectures. This format can strengthen the intervention by empowering people to personally develop their own solutions to change their environment.

How is intervention science useful?

Intervention science explores which components of programs are more effective and which programs work well in certain populations. For example, in a recent study, the riskiest people did not attend small group educational sessions. A program for gay/ bisexual men in Portland, OR conducted outreach in bars and at community events, home meetings, and safer sex workshops. While most men attended outreach activities, few men were likely to attend safer sex workshops.⁹ Scientific study of the program showed that outreach was most likely to reach the riskiest men-younger men and men who reported unprotected anal intercourse. Interventions aimed at high risk-taking populations can rely on intensive individual outreach/counseling and/or innovative, minimally structured community-level social activities to help draw their intended audience.

How is evaluation methodology useful?

Evaluation encourages critical thinking about the process of designing interventions, and should not only occur at the end of an intervention. Good evaluation produces information about needs, service use patterns, impacts and outcomes. It also gives a voice to clients’ experiences, and allows service providers to learn about their programs so that they can make necessary changes to increase their effectiveness.¹⁰ An agency can hire a consultant or researcher for evaluation, or can conduct its own evaluation. For example, Tri-City Health Center in Fremont, CA surveyed suburban street youth to evaluate the effectiveness of their program of outreach and educational workshops. In response to youth feedback, Tri-City cancelled their scheduled workshops and added a drop-in center providing HIV education as well as support in areas such as dropping out of school, joblessness, substance abuse, abusive relationships and living with HIV.¹¹

How do people access science?

No one should need an advanced degree to understand prevention science. Several organizations exist to help translate and summarize research into understandable and usable forms. CPGs are directed to incorporate prevention science in their comprehensive plans, which are available through local and state health departments.¹² Local universities (especially schools of public health and social work, departments of sociology, psychiatry/psychology, or anthropology) are an excellent contact for research assistance.¹³ Mailing lists and newsletters from organizations that specialize in prevention science and technical assistance can also be invaluable resources.¹⁴

What still needs to be done?

To more closely link the efforts of researchers and service providers: 1) Researchers should share findings with local CBOs and with the CDC and DPHs, as well as become active members of CPGs. 2) CBOs should be more aggressive and proactive in using information outside of their agencies. 3) State DPHs and the CDC should recognize and act upon their role as translators of science. 4) National Institutes of Health, the CDC and private funders should provide adequate funding for integrating prevention science into prevention programs. 5) CBOs and researchers should forge long term partnerships to conduct collaborative projects.¹⁵ Using science in service provision is a specialized field. Most scientists are not trained in the real world application of research. Likewise, most service providers are not trained in research methods. A comprehensive HIV prevention strategy uses many elements to protect as many people at risk for HIV as possible. By closing the gap between HIV prevention science and prevention practice, we can ensure that our best efforts won’t be wasted, and we can make a difference in the fight against HIV.

Says who?

1. Valdiserri RO, Aultman TV, Curran JW. Community planning: a national strategy to improve HIV prevention programs. Journal of Community Health. 1995;20:87-100.
2. Rothman KJ. Modern Epidemiology. Boston, MA: Little, Brown and Company; 1986.
3. A database of epidemiological data for states and some cities is available on the Internet at: https://www.cdc.gov/hiv/basics/statistics.html
4. Kelly JA, Kalichman SC. Increased attention to human sexuality can improve HIV-AIDS prevention efforts: key research issues and directions. Journal of Consulting and Clinical Psychology. 1995;63:907-918.
5. Jinich S, Stall R, Acree M, et al. Childhood sexual abuse predicts HIV risk sexual behavior in adult gay and bisexual men. Presented at the 11th International Conference on AIDS, Vancouver, BC. 1996. Abstract Mo.D.1718.
6. Valdiserri RO, West GR, Moore M, et al. Structuring HIV prevention service delivery systems on the basis of social science theory. Journal of Community Health. 1992;17:259-269.
7. Herlocher T, Hoff C, DeCarlo P. Can theory help in HIV prevention? Fact sheet prepared by the Center for AIDS Prevention Studies, UCSF. August 1995.
8. Wallerstein N. Powerlessness, empowerment, and health: implications for health promotion programs. American Journal of Health Promotion. 1992;6:197-205.
9. Hoff CC, Kegeles S., Acree M, et al. Gay men at highest risk are best reached through outreach in bars and community events. Presented at the 11th International Conference on AIDS, Vancouver, BC. 1996. Abstract Tu.D.360.
10. San Francisco HIV Prevention Plan. Report prepared by the San Francisco HIV Prevention Planning Council and the Department of Public Health AIDS Office. 1996.
11. Carver LJ, Harper GW. Responding to the HIV prevention needs of suburban street youth. Presented at the 11th International Conference on AIDS, Vancouver, BC. 1996. Abstract Th.D.4921.
12. For information on your local or state Community Planning group, please contact Lynne Greabell at NASTAD (202) 434-8090.
13. A directory of universities is available here: https://www.usnews.com/best-colleges/rankings/national-universities
14. CDC (800) 458-5231 (www.cdc.gov/nchstp/hiv_aids/dhap.htm)
    • American Psychological Association (202) 336-6042
    • National Minority AIDS Council (202) 483-6622
    • National Association of People With AIDS (202) 898-0414
    • Academy for Educational Development (202) 884-8700
    • National Alliance of State and Territorial AIDS Directors (202) 434-8090
    • Council of State & Territorial Epidemiologist (770) 458-3811
    • The US Conference of Mayors (202) 293-7330
    • GMHC Education Department (212) 807-7517 (www.gmhc.org)
    • The Center for AIDS Prevention Studies - https://prevention.ucsf.edu/ 
    • Rural Prevention Center (812) 855-1718 https://rcap.indiana.edu/ 
15. Goldstein E, Wrubel J, Faigeles B, et al. Is research important for non-governmental organizations in the United States? Presented at the 11th International Conference on AIDS, Vancouver, BC. 1996. Abstract Th.C.4779.

Prepared by Ellen Goldstein and Pamela DeCarlo January 1997. Fact Sheet #25E

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]. © January 1997, University of California

¿Que papel juega hacerse la prueba del VIH en casa?

¿será factible el examen casero para la detección del VIH?

Cuando por primera vez se planteó la posibilidad de poner al alcance del público un estuche casero para la detección del VIH, esa se encontró con oposición unánime.¹ Hoy en día los Centros para el Control de Enfermedades (CDC, por sus siglas en Inglés), destacados miembros del sector salud, activistas “gay” y los defensores de la lucha contra el SIDA apoyan la idea del estuche casero para detectar el VIH.² Los estudios que se han hecho sobre la factibilidad de las pruebas caseros han demostrado que no hay barreras técnicas en su uso.³ Se ha podido examinar en casa por mas de una década. Realmente, el nombre “examen casero” tiende a mal interpretarse puesto que la persona no obtiene resultados inmediatos, a como sucede con los estuches caseros para detectar el nivel de glucosa, colesterol, presión arterial y el embarazo. En realidad las pruebas son “estuches para ser recolectados” que se pueden comprar sin receta médica en cualquier farmacia o por medio del correo. El comprador del estuche se pincha el dedo, deposita una gota de sangre en un pedazo de papel absorbente, lo envía por correo y luego llama por teléfono (después de un tiempo específico) para obtener los resultados. En la primavera del 1996, la entidad encargada de administrar las medicinas y los alimentos de los EEUU (FDA), aprobó, Confide, el primer estuche casero para la detección del VIH. El estuche, que se vendió por una empresa filial de Johnson & Johnson, y después fue retirado del mercado. El FDA después aprobó Home Access HIV-1 Test System, que esta manufacturado por la empresa Home Access Health Corporation en Chicago. Actualmente, este es el único estuche para prueba casera que ha sido aprobado por el FDA, aunque varios otros estuches no-aprobados han sido anunciados por vente en periódicos y en el Internet. El FDA previene contra el uso de estuches no-aprobados, que no han sido completamente evaluados y que “no tienen una historia documentada de entregar resultados confiables.”⁴

¿en qué forma es diferente?

Tradicionalmente, hacerse la prueba del VIH ha implicado tener que ir al doctor o a la clínica, sacarse sangre, y después regresar por los resultados y recibir apoyo psicológico. Con el nuevo examen casero se ahorrarían dos viajes. Este método hará posible que las personas que viven en áreas rurales o recónditas de la ciudad en donde las clínicas son escasas, con muchos pacientes o que impliquen un largo viaje en bus se hagan la prueba del VIH. El examen casero también brinda privacidad. Algunas personas no van al doctor o a la clínica por temor a ser vistos por algún vecino, familiar o amigo. En un cantidad de estudios, los individuos que están a riesgo han expresado su preferencia por un sistema anónimo al hacerse la prueba.⁵ El examen casero ofrece el potencial de ser totalmente anónimo. Ofrecer otra opción para hacerse la prueba significa avanzar un paso hacia la resolución del problema nacional que enfrenta el sistema de hacerse el examen del VIH. Una proporción alarmantemente alta de aquellos que están a riesgo (más del 60%) todavía no se han hecho la prueba del VIH.⁶ Obtener resultados del VIH se vuelve cada vez más y más importante ya que el sistema inmunológico necesita fortalecerse y mantener bajo control a las infecciones oportunistas. A las mujeres embarazadas se les anima a hacerse la prueba voluntaria del VIH ya que los estudios demuestran que al suministrárseles Zidovudine (AZT), este puede reducir en dos tercios la tasa de transmisión del VIH de madre a feto.⁷

¿los resultados, son confiables?

Millones de las pruebas realizadas para detectar la presencia de anticuerpos del VIH se han hecho por medio de una muestra de sangre seca.⁸  Este tipo de pruebas son bastante exactas, siempre y cuando se siga muy de cerca el protocolo de laboratorio en cuanto a la confirmación de la prueba y los mecanismos que lo garantizan. Algunos de los estuches enviados al laboratorio para ser examinados puede que no contengan la cantidad de sangre necesaria para conducir la prueba. En estos casos, los consejeros telefónicos van a tener que ser entrenados para aconsejar al cliente cuando los resultados no estén claros o por si necesitan confirmación.

¿quiénes se harán la prueba en casa?

La accesibilidad del examen casero puede brindar mayor seguridad a aquellas personas que aunque el riesgo de infección con el VIH sea bastante remota, andan buscando como reasegurarse. Si estas personas ya no pueden contar con las fuentes públicas para hacerse la prueba, puede ser que estos recursos sean utilizados para poner en práctica mas intervenciones dirigidas a los que se encuentran a mayor riesgo.⁹ Las ventas de los estuches para prueba casera no han sido tan numerosas como se esperaba de acuerdo a los resultados obtenidos de encuestas sobre las intenciones acerca de pruebas caseras. En el primer ano de vente, Home Access Health vendió 152,044 estuches; 148,039 personas llamaron para obtener sus resultados. El índice de resultados seropositivos fue 0,9%.¹⁰ Además de la negación y otras barreras psicológicas, muchos encuentran el costo por menor de $30-$40 por estuche a ser imposible. Las empresas que manufacturan los estuches de prueba casera están trabajando con varias agencias de salud publica y comunitarias, vendiéndoles los estuches al mayor para que puedan utilizarlos en sus campanas de prevención.

¿cuál es la preocupación?

Una de las preocupaciones es lo adecuado del apoyo psicológico. En una clínica u oficina del Doctor, los resultados usualmente se entregan en persona. Si el paciente se siente sumamente abrumado por la noticia, hay un experto presente que le puede ayudar. Las compañías que venden el estuche casero también pondrán consejeros a la disposición, pero estos estarán a millas de distancia en la línea telefónica. A como lo expuso uno de los que critican el examen casero “el número 1-800 no te puede abrazar cuando lloras.”¹¹ Para algunos, lo remoto y lo anónimo de la orientación por teléfono les permite revelar con mayor facilidad sentimientos de dolor o información embarazosa. Además, ya existe una larga tradición en cuanto intervenir por medio del teléfono en crisis y en la prevención del suicidio. La propuesta de brindar apoyo psicológico por teléfono debería ser comparado con experiencias que actualmente ocurren al hacerse la prueba del VIH. Para muchos, la consejería ni es la adecuada, ni existe. De acuerdo a las datos arrojados por el National Health Interview Study (Estudio Nacional sobre la Salud), un tercio de aquellos que se hicieron la prueba del VIH obtuvieron los resultados por correo (16%) o por teléfono (17%). ¹² En los sitios públicos, se hacen cerca de 2,5 millones de pruebas anuales. En 1995, 25% de las personas que tuvieron resultados positivos y 33% de las personas que tuvieron resultados negativos, faltaron de regresar por sus resultados.¹³ Por contraste, 97,4% de las personas que compraron estuches de prueba casera llamaron para obtener sus resultados.¹⁰ Otra de las preocupaciones es el potencial de abuso al que el estuche casero pudiera prestarse. Algunos temen que los patrones, familiares o proveedores al cuidado de salud puedan enviar muestras de sangre sin el consentimiento de la persona. Aunque ya existen leyes que protegen en caso de que se hagan sin el permiso de la persona ya sea por discriminación o por ser VIH positivos. Estos estatutos necesitan ser enforzados; nuevas leyes de protección deberán ser creadas a medida que se adquiere experiencia con el examen casero.

¿cuáles son las limitaciones?

Un resultado positivo a la prueba no garantiza el acceso a los cuidados de salud necesarios. A como lo escribió la Comisión Nacional del SIDA “Es muy cruel que muchos de los pobres crean que van a obtener acceso al sistema de salud y servicios sociales por medio de un diagnóstico VIH positivo.”¹⁴ No obstante, esto no debería impedir que la gente busque como hacerse la prueba. “La falta de buenos servicios de salud y de servicios sociales para las personas infectadas con el VIH es argumento para incrementarlos, no para reducirlos.”¹⁵ Hacerse la prueba del VIH no necesariamente significa el final. El reto mas importante se el de lograr un acceso seguro a servicios de cuidados de salud y de apoyo psicológico continuo para todas aquellas personas que se hacen la prueba. Si estos resultan ser VIH positivos, deberían recibir los cuidados médicos necesarios para mantenerse saludables, y si el resultado es negativo deberán recibir el apoyo necesario para mantenerse negativos.

¿quién lo dice?

1. Anon. Banned at home: an FDA ruling on AIDS test. Time. 1989; April 18:26.
2. Leary WE. Government panel hears call for expanded AIDS testing. New York Times. 1994;June 23:A18.
3. Frank AP, Wandell MG, Headings MD, Conant MA, Woody G, Michel C. Anonymous HIV testing using home collection and telemedicine: a multicenter evaluation. Archives of Internal Medicine. 1997;157:309-314.
4. Center for Biologics Evaluation and Research, Food and Drug Administration (FDA). Testing yourself for HIV-1, the virus that causes AIDS–Home test system is available. 1997;July 25.
5. Hirano D, Gellert GA, Fleming K, et al. Anonymous HIV testing: the impact of availability on demand in Arizona. American Journal of Public Health. 1994;84:2008-2010.
6. Sweeney PA, Fleming PL, Karon JM, Ward JW. A minimum estimate of the number of living HIV infected persons confidentially tested in the United States. Presented at the Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) 1997;Sept.-Oct., Toronto, Canada.
7. Conner EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. New England Journal of Medicine. 1994;331:1173-1180.
8. Gwinn M, Redus MA, Granade TC. HIV-1 serologic test results for one million newborn dried-blood specimens: assay performance and implication for screening. Journal of Acquired Immune Deficiency Syndrome. 1992;5:505-12.
9. Valdiserri RO, Weber JT, Frey R, Trends in HIV seropositivity in publicly finded HIV counseling and testing programs: implications for prevention policy. American Journal of Preventive Medicine. 1998;14:31-42.
10. Home Access Health. http://www.homeaccess.com.
11. Ocamb K. Home HIV testing is near. POZ. 1994;June-July:48-52. (quoting Dennis Ouellet, LA Free Clinic).
12. Schoenborn CA, Marsh Sl, Hardy AM. AIDS knowledge and attitudes for 1992. Data from the National Health Interview Survey. Advance Data. 1994;243:1-15.
13. Centers for Disease Control. Update: HIV counseling and testing using rapid tests–United States. Morbidity and Mortality Weekly Report. 1998;47: 211-5.
14. National Commission on AIDS. Report of the Working Group on Social and Human Issues. Washington, DC: National Commission on AIDS, 1991.
15. Bayer R, Stryker J, Smith MD. Testing for HIV infection at home. New England Journal of Medicine. 1995;332: 1296-1299.

Preparado por Jeff Stryker, Traducción Sandra Galvez CAPS Revisado Deciembre 1998. Hoja Informativa 11Sr. Alentamos la reproducción de este documento; aunque, no se admite la venta de copias y UCSF deberá ser mencionada como fuente de esta información. Para obtener copias, llame por favor al National Prevention Information Network al 800/458-5231 o al Internet https://prevention.ucsf.edu/. Estas hojas informativas están disponibles en ingles. Cualquier comentario o pregunta acerca de esta hoja informativa puede ser electrónicamente dirigido al [email protected]. ©Deciembre 1998, University of California.

¿Qué necesitan los adolescentes en la prevención del VIH?

¿pueden contraer los adolescentes el VIH?

Desafortunadamente, sí. Los casos de infección del VIH se incrementan más aceleradamente en los jóvenes. La mitad de todos los casos de VIH se presentan en personas menores de 25 años. De todos los casos de VIH de 1994-1997 en jóvenes de 13-24 años, 44% eran mujeres y 63% Afro-Americanos. Mientras la cifra de nuevos casos de SIDA se reduce en los diferentes grupos de edad, no se ha observado una reducción comparable en la cantidad de nuevas infecciones en los jóvenes.¹ Las relaciones sexuales implican riesgo para un joven, no solo del VIH, sino además para otras Enfermedades de Transmisión Sexual (ETS) y los embarazos no planeados. Actualmente, los adolescentes experimentan tasas alarmantes de ETS. Cada año, tres millones de jovenes entre los 13 y 18 años-es decir, un cuarto de todos con experiencia sexual-contraerán alguna ETS. La clamidia y la gonorrea ocurren con mayor frecuencia entre la juventud que en personas mayores.² En especial, algunas jóvenes Afro-Americanas y Latinas sexualmente activas corren mayor riesgo de infectarse con VIH, especialmente aquellas que provienen de barrios pobres. En un estudio de desertores escolares jóvenes en el “U.S. Job Corps” se descubrió que las jóvenes Afro-Americanas tenían mayores tasas de infección con VIH y que los índices de infección entre las mujeres entre los 16 y 18 años era mayor a las de los hombres jóvenes en un 50%.³ Otro estudio de mujeres adolescentes Afro-Americanas y Latinas reveló que las jóvenes con novios mayores que ellas (3 años mayor o más) corren mayor riesgo de infectarse con el VIH.⁴

¿cómo se exponen al riesgo?

La adolescencia es un período de desarrollo marcado por la curiosidad y la experimentación acompañada de una miríada de cambios emocionales. La conducta sexual y/o el uso de drogas suelen formar parte de esta exploración. Durante esta etapa de crecimiento y cambios, los jóvenes reciben mensajes contradictorios. Por un lado a la juventud se le exhorta a abstenerse sexualmente mientras se les satura de imágenes glamorosas de personajes de cine y televisión teniendo sexo, fumando y tomando. Este doble estándar existe para las chicas-de las que se espera se conserven vírgenes-y los chicos-con la presión de demostrar su hombría por medio de la agresividad y la actividad sexual. En nombre de la cultura, la religión y la moralidad, a la juventud suele negársele el derecho a estar informados sobre el funcionamiento de su cuerpo y los riesgos para la salud para poder protetegerse mejor.⁵ Un reciente sondeo a nivel nacional con jóvenes reveló que de 1991 a 1997, la prevalencia de la actividad sexual disminuyó en un 15% para los estudiantes masculinos, 13% en estudiantes blancos y 11% en estudiantes Afro-Americanos. Sin embargo no se presentó reducción alguna respecto a la experiencia sexual en estudiantes femeninas o en Latinos. Hubo un incremento del uso del condón del 23% en estudiantes sexualmente activos. Sin embargo, solo cerca de la mitad de los estudiantes sexualmente activos usaron condones durante su última relación sexual.⁶ No todos los adolescentes corren el mismo riesgo de infectarse con VIH. La juventud no es un grupo homogéneo, por lo tanto, dentro de esa categoría existen subgrupos que participan en mayor cantidad de actividades sexuales sin protección y abusan de las drogas, lo cual les vuelve más vulnerables al VIH y otras ETS. Esto incluye a jóvenes homosexuales o que experimentan relaciones con personas del mismo sexo, usuarios de drogas, delincuentes juveniles, desertores escolares, vagabundos, desamparados o jóvenes inmigrantes. Alcanzar a este grupo de jóvenes con actividades de prevención se dificulta debido a que no asisten a la escuela regularmente y tienen acceso limitado al sistema de salud u otros servicios similares.⁷

¿puede ayudar la educación?

Si. Las escuelas son un sitio ideal para que los jóvenes aprendan a conocer los riesgos para la salud, incluyendo el VIH, las ETS y los embarazos no planeados. A nivel nacional y global se ha comprobado, por medio de estudios, que la educación sexual a niños y jóvenes no estimula el incremento en la actividad sexual y sí ayuda a la juventud a abstenerse por más tiempo. Los programas educativos exitosos utilizan un curriculó y mensajes claros sobre los riesgos del sexo sin protección y las formas de evitar el riesgo, enseñan y practican la comunicación, tratan el tema de la influencia de la sociedad y de los medios de comunicación, y promueven que se hable del tema de la sexualidad abiertamente.⁸ Adicionalmente, los programas de prevención para adolescentes dirigidos cuidadosamente pueden ser muy efectivos a nivel de costo.⁹

¿sólo en la escuela se encuentra la solución?

No. La juventud necesita recibir mensajes de prevención de formas diversas y en sitios diferentes. Las escuelas por si solas no pueden realizar esta tarea. En los EEUU, a muchas escuelas se les prohibe el uso de fondos federales si utilizan un currículo abierto en cuanto a la sexualidad. El gobierno federal asignó $50 millones anuales a aquellas escuelas cuyos programas están basados en la abstinencia-sin tocar el tema de los anticonceptivos o el sexo seguro.¹⁰ Aunque es cierto que los programas de abstinencia logran retrasar el inicio de la actividad sexual, en general, no reducen la cantidad de actividades sexuales de riesgo de la forma en que lo logran las intervenciones basadas en el sexo seguro.¹¹ Los jóvenes que no asisten a la escuela con mayor frecuencia presentan conductas que les pone a riesgo de contraer VIH/ETS, y tienen menor acceso a programas de prevención. Un sondeo nacional con jóvenes entre los 12 y 19 años de edad reveló que el 9% no asistían a la escuela. Los desertores escolares estuvieron significativamente más propensos a haber tenido relaciones sexuales que los que sí asistían, tenían 4 o más parejas sexuales y habían experimentado con el alcohol, marihuana y cocaína.¹² Deberían crearse programas de prevención más intensivos para los desertores escolares y los que están en riesgo de desertar. Es necesario que los programas dirigidos a los adolescentes que no tienen una vida estable se lleven a cabo en los sitios que ellos frecuentan tales como en centros de detención juvenil y escuelas alternativas. La instrucción impartida por miembros de este mismo grupo puede utilizar el método del empoderamiento, enseñar sobre prevención de VIH, ETS, además de movilizar y anexar recursos para los jóvenes por medio de organizaciones comunitarias y sociales.¹³ El apoyo familiar para que los jóvenes eviten caer en conductas de riesgo es de incalculable valor. Las conversaciones francas sobre condones entre padres e hijos adolescentes puede conducir a los jóvenes a adoptar conductas que les prevendrán de contraer el VIH y otras ETS. Cuando las madres hablan y contestan preguntas sobre el uso del condón previo al iniciamiento sexual, los adolescentes han reportado el uso del condón la primera y última vez que tuvieron sexo, así como un mayor uso del condón durante el transcurso de sus vidas.¹⁴ En Los Angeles, CA, el “WEHO Lounge” es una cafetería y centro de detección e información de VIH localizado entre dos discotecas “gay.” Ofrece pruebas orales de detección del VIH confidenciales, foros comunitarios semanales, consejería impartida por miembros de este grupo, distribución gratuita de condones y una biblioteca juvenil con recursos relacionados al VIH. Este “Lounge” tambien vende cafés. Al colocar este recurso en la comunidad y adaptarlo a la necesidad y hábitos de los hombres jóvenes “gay”, el programa ha tenido un exito fenomenal.¹⁵ El Proyecto VIDA de Chicago, IL, una organización que provee servicios a la comunidad, conduce prevención del VIH a mujeres Latinas entre los 12 y 24 años en riesgo de infección. VIDA recluta y conduce intervenciones dirigidas por miembros de este mismo grupo en las que se incorporan temas como el empoderamiento y la autoestima. Ellos actúan en la creencia de que es imposible separar los riesgos de contraer VIH de las presiones culturales, ambientales, interpersonales e intrasíquicas que enfrentan las jóvenes Latinas; y que es posible vencer estos obstáculos aprendido a manejar situaciones difíciles.¹⁶

¿qué queda por hacer?

Los programas de prevención para adolescentes deben tomar en cuenta las necesidades y habilidades que presenta la edad de este grupo. Los programas deben tener un enfoque en los factores contextuales que contribuyen a que los jóvenes participen en mayor cantidad de actividades sexuales y bajos índices en el uso del condón, tales como la baja auto-estima, la depresión, el uso de drogas, actividades de pandillas, la presión de vivir en ambientes urbanos turbulentos o aburridos ocasionados por la falta de empleo. Cualquier programa para adolescentes debe ser interesante, divertido e interactivo, debe incluir la opinión de los jóvenes en cuanto al diseño e implementación. Esto se aplica especialmente a jóvenes de otras culturas que no forman parte de la gran mayoría. Los programas para jóvenes inestables que corren el riesgo de contraer VIH deben implementarse en otros locales aparte de la escuela, tales como casas de refugio para jóvenes sin hogar o que se han escapado de ellos, centros comerciales, centros de detención, y centros comunitarios. No basta con que los jóvenes reciban la información adecuada ni con practicar las habilidades de auto-protección, es también necesario facilitar el acceso a los condones para poder mantenerles libres de riesgo.

¿quién lo dice?

1. Centers for Disease Control and Prevention. Young people at risk-epidemic shifts further toward young women and minorities. Fact sheet prepared by the CDC. July 1998. 2. Eng TR, Butler WT, eds. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: National Academy Press; 1996. 3. Valleroy LA, MacKellar DA, Karon JM, et al. HIV infection in disadvantaged out-of-school youth: prevalence for US Job Corps entrants, 1990 through 1996 . Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 1998;19:67-73. 4. Miller KS, Clark LF, Moore JS. Sexual initiation with older male partners and subsequent HIV risk behavior among female adolescents . Family Planning Perspectives. 1997;29:212-214. 5. UNAIDS. Force for Change: World AIDS Campaign with Young People . Report prepared by UNAIDS, The Joint United Nations Programme on HIV/AIDS for World AIDS Day 1998. 6. Centers for Disease Control and Prevention. Trends in sexual risk behaviors among high school students-United States, 1991-1997 . Morbidity and Mortality Weekly Report. 1998;47:749-752. 7. Rotheram-Borus MJ, Mahler KA, Rosario M. AIDS prevention with adolescents . AIDS Education and Prevention. 1995;7:320-336. 8. UNAIDS. Impact of HIV and sexual health education on the sexual behavior of young people: a review update . Report prepared by UNAIDS, The Joint United Nations Programme on HIV/AIDS for World AIDS Day 1997. 9. Pinkerton SD, Cecil H, Holtgrave D.R. HIV/STD prevention interventions for adolescents: cost-effectiveness considerations . Journal of HIV/AIDS Prevention and Education for Adolescents and Children. 1998;2:5-31. 10. Associated Press. Sex education that teaches abstinence wins support. New York Times. July 23,1997:A19. 11. Jemmott JB, Jemmott LS, Fong GT. Abstinence and safer sex HIV risk-reduction interventions for African-American adolescents: a randomized controlled trial . Journal of the American Medical Association. 1998;279:1529-1536. 12. Centers for Disease Control and Prevention. Health risk behaviors among adolescents who do and do not attend school-United States, 1992 . Morbidity and Mortality Weekly Report. 1994;43:129-132. 13. Zibalese-Crawford M. A creative approach to HIV/AIDS programs for adolescents . Social Work in Health Care. 1997;25:73-88. 14. Miller KS, Levin ML, Whitaker DJ, et al. Patterns of condom use among adolescents: the impact of mother-adolescent communication . American Journal of Public Health. 1998;88:1542-1544. 15. Weinstein M, Farthing C, Portillo T, et al. Taking it to the streets: HIV testing, treatment information and outreach in a Los Angeles neighborhood coffee house. Presented at the 12th World AIDS Conference, Geneva, Switzerland; 1998. Abstract #43125. 16. Harper GW, Contreras R, Vess L, et al. Improving community-based HIV prevention for young Latina women. Presented at the Biennial Meeting of the Society for Community Research and Action, New Haven, CT; June,1999.

Preparado por Gary Harper, PhD MPH* y Pamela DeCarlo**, Traducción Romy Benard Rodríguez** *Departamento de Psicología, Universidad DePaul, **CAPS

Septiembre 1999. Hoja Informativa 9SR.