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Barrier methods

Can Barrier Methods Help in HIV Prevention?

Why barrier methods?

Barrier methods are a relatively low-cost, accessible and important part of the pregnancy and sexually transmitted disease (STD) prevention landscape. Barrier methods can be physical or chemical substances which prevent pregnancy and/or block the spread of STDs including HIV. They do not include hormonal contraceptive methods. People have successfully used contraceptive physical barriers for centuries.1 Since the beginning of the HIV epidemic, the latex male condom has been the exclusive prevention tool. After two decades, there is a call to create a greater selection of barrier methods to combat HIV. Because HIV rates continue to increase among women and among men who have sex with men (MSM)2,3, it is time to strengthen both current condom use programs and develop other barrier methods that optimize usage and choice in prevention.

What methods are available?

Currently, the male and female condoms are used for the prevention of HIV, STDs and unintended pregnancy.4,5 The female condom, made of polyurethane plastic, is also used for receptive anal sex, but it was not designed for that purpose.6 The diaphragm, cervical cap and sponge are often used with a spermicide and block the cervix to prevent conception. Although studies have shown that these cervical blocking methods may also prevent certain STDs7, research has not been conducted to show that they prevent HIV. Dental dams are latex sheets used to provide a barrier in oral/anal and oral/vaginal sex. Spermicides (gels, creams, foams, or films that can be inserted into the vagina) are available for preventing pregnancy. One of the most widely used spermicides, Nonoxynol 9 (N-9), was recently tested for its ability to prevent HIV. The study of female sex workers in Thailand, South Africa, Cote d’Ivoire and Benin, randomly assigned women to use either a gel containing 52.5 mg of N-9 or a placebo, a vaginal moisturizer known as Replens. Preliminary results showed that there were more new HIV infections among the N-9 group than in the Replens group.8 In August, 2000, the CDC recommended against N-9 as a sole barrier method for HIV prevention.9 This study documented the harmful effects of a relatively large dose of N-9 on HIV infection. N-9 is commonly used in much smaller amounts as part of a condom lubricant. The impact of small doses of N-9 is not clear.

Why do we need alternatives to male condoms?

Male condoms are an extremely effective means of HIV, STD and pregnancy prevention. What most often limits condoms’ effectiveness is user failure rather than product failure. For example, users may fail to either put on a condom before genital contact or completely unroll the condom. In addition, some people fail to use a condom with every act of sexual intercourse. Some don’t use condoms because they reduce sexual sensation. For others, using condoms is seen as a barrier to intimacy. Male condom use requires male participation or negotiation. Female-controlled and receptive-partner-controlled options (such as female condoms or future microbicides) may be used without the participation or consent of the insertive partner. These methods are still detectable by sexual partners and partners can still refuse to use them. Female- and receptive-partner-controlled options can be used in situations where it is difficult to negotiate condom use such as in an abusive relationship, where there is economic disincentive to use a condom10 or where the insertive partner refuses to use a condom.5 Female-controlled HIV/STD prevention methods can be empowering11 and are vital in an HIV epidemic that is increasingly infecting women, especially in developing countries. Finally, there is no barrier method that allows women to protect themselves from HIV and still get pregnant. Hopefully, a barrier method can be developed that separates the control of fertility from the prevention of STDs. This is an important consideration for many women.2

What are the drawbacks?

Barrier methods can provide protection against HIV and STDs, yet they are not an option for everyone. Although some methods are low-cost, others, such as the female condom, may have limited accessibility because of their cost. Most barrier methods require application before each act of sexual intercourse, making consistent use more difficult. Barrier methods may not protect against STDs that are transmitted via skin-to-skin contact such as herpes and human papilloma virus (HPV). Products may be messy or may require adequate cleaning and storage, which may not be available to some people. Some barrier methods are inserted into the vagina which requires comfort and familiarity with one’s body. Diaphragms and cervical caps require a health care worker to fit the devices. Further, individuals may have sensitivities to products’ chemicals or materials, such as latex allergies.1 Barrier methods under development are addressing some of these limitations.

What about microbicides?

Microbicides are topically-applied chemical barriers that prevent HIV and/or STD transmission. They are not currently available, but are under development and being tested for efficacy as an alternative to current methods. Microbicides may come in the form of gels, creams, foams or films that can be inserted into the vagina or rectum. Development is currently focused on creating products which destroy or immobilize germs or viruses through a variety of mechanisms: breaking down the outer cell membranes of pathogens, enhancing normal vaginal defenses, providing a physical coating to the vagina or the rectum, inhibiting HIV from entering cells or preventing HIV replication if HIV does enter a cell.12 Studies show that there is large potential demand for microbicides from women in the US and internationally.13 People are also willing to participate in efficacy trials, as studies in women and MSM have shown.14,15

What’s being done?

Male condoms are currently the best comprehensive prevention method. Education and prevention campaigns must be continued to optimize condom usage while also searching for alternatives. HIV prevention efforts may be more effective among certain populations if condom use and HIV are addressed together with STD and unintended pregnancy prevention. Some STD and family planning clinics are encouraging condom use for both STDs and HIV prevention with great success.16 New physical barrier methods currently being researched include the disposable diaphragm, alternative types of cervical shields, caps and sponges and alternative types of condoms, both male and female. New materials are also under development, including various plastics and silicone rubber.2 It is also important to examine the potential for adapting current products and testing existing products for HIV prevention. As these products are already FDA approved, the testing process is not as lengthy.

What are the next steps?

The development of alternative barrier methods must be a priority among private and public researchers alike. With over 50 microbicides in the research pipeline, one should be on the market by the year 2005. Advocacy groups have played a large role in increasing awareness and attention to microbicides and should continue advocating for accessible barrier methods.16 Although US government funding for microbicides has increased, in the 1998 fiscal year, microbicide-related research received only 1% of the National Institutes of Health AIDS research budget.17 There is no single solution to HIV and STD prevention. Prevention requires continued work on many levels, including increasing access to products, advocating for social change to eliminate unsafe situations that many people are in, and developing stronger prevention and treatment alternatives. Barrier methods are an integral part of these prevention alternatives and must be developed to their fullest potential to enhance health and prevent disease. Says who? 1. Feldblum P, Joanis C. Modern barrier methods: effective contraception and disease prevention. Family Health International. 1994. 2. The Population Council and International Family Health. The case for microbicides: a global priority . 2000. 3. Microbicides: a new weapon against HIV. American Foundation for AIDS Research (AmFAR) Report. www.amfar.org . 4. Pinkerton SD, Abramson PR. Effectiveness of condoms in preventing HIV transmission . Social Science and Medicine. 1997;44:1303-1312. 5. Elias CJ, Coggins C. Female-controlled methods to prevent sexual transmission of HIV . AIDS. 1996;3:S43-51. 6. Gibson S, McFarland W, Wohlfeiler D, et al. Experiences of 100 men who have sex with men using the REALITY condom for anal sex . AIDS Education and Prevention. 1999;11:65-71. 7. Rosenberg MJ, Davidson AJ, Chen JH, et al. Barrier contraceptives and sexually transmitted diseases in women: a comparison of female-dependent methods and condoms . American Journal of Public Health. 1992; 82:669-674. 8. UNAIDS. Nonoxynol-9 not effective microbicide, trial shows https://pubmed.ncbi.nlm.nih.gov/12296062/  9. Gayle H. Dear Colleague. Centers for Disease Control and Prevention. August 4, 2000. 10. Abdool Karim Q, Abdool Karim SS, Soldan K, et al. Reducing the risk of HIV infection among South African sex workers: socioeconomic and gender barriers . American Journal of Public Health. 1995;85:1521-1525. 11. Gollub EL. The female condom: tool for women’s empowerment . American Journal of Public Health. 2000;90:1377-1381. 12. Heise L. Topical microbicides: new hope for STI/HIV prevention. Center for Health and Gender Equity (CHANGE). Takoma Park, MD. 13. Darroch JE, Frost JJ. Women’s interest in vaginal microbicides . Family Planning Perspectives. 1999;31:16-23 14. Hammet TR, Mason TH, Joanis CL, et al. Acceptability of formulations and application methods for vaginal microbicides among drug-involved women: results of product trials in three cities . Sexually Transmitted Diseases. 2000;27:119-126. 15. Gross M, Buchbinder SP, Celum C, et al. Rectal microbicides for U.S. gay men: are clinical trials needed? Are they feasible? Sexually Transmitted Diseases. 1998;39:55-61. 16. Kamb ML, Fishbein M, Douglas JM Jr, et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. Project RESPECT Study Group . Journal of the American Medical Association. 1998;280:1161-1167. 17. Harrison PF. A new model for collaboration: the alliance for microbicide development . International Journal of Gynecology and Obstetrics. 1999;67:S39-S53. PREPARED BY Beth Freedman MPH, Nancy Padian PhD, CAPS, ARI December 2000. Fact Sheet #39E 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]. © December 2000, University of California

Resource

Intervenciones estructurales

¿Qué papel juegan las intervenciones estructurales en la prevención del VIH?

¿qué son las intervenciones estructurales?

La mayoría de las intervenciones de prevención del VIH tratan con los individuos de a uno por uno. Aún cuando muchas obtienen excelentes resultados, requieren mucho tiempo del personal y benefician a un número limitado de personas. Además, los beneficiarios de las intervenciones pueden sentirse presionados por parte de sus pares (que no reciben las intervenciones) para continuar participando en actividades de alto riesgo. Las intervenciones estructurales modifican o influencian el ambiente social, político o económico de manera que muchas personas se beneficien al mismo tiempo, quizás sin saberlo.1 El término “intervenciones estructurales” significa muchas cosas. Las intervenciones estructurales incluyen programas que efectúan cambios en el campo jurídico (frecuentemente con presión o participación comunitaria) para facilitar las conductas seguras, como la venta libre de jeringas. También pueden enfocarse en el contexto social inmediato de la actividad sexual o inyección de drogas, modificando el entorno físico o normativo en el cual éstas suceden. Como ejemplo tenemos los prostíbulos tailandeses que exigen el uso de condones. Las intervenciones estructurales abarcan también los programas que buscan reducir o eliminar la desigualdad de ingresos, el racismo y otras inequidades y formas de opresión que crean vulnerabilidad al VIH/SIDA.

¿qué estructuras producen riesgo?

¿Cómo podemos identificar las estructuras o procesos sociales, políticos o económicos que deberán modificarse? Por lo general, lo hacemos estudiando la variación natural entre áreas o grupos, o los experimentos naturales en los cuales las condiciones cambian por motivos que no sean intervenciones relacionadas con el VIH. Los estudios de la variación natural (naturally-occurring variation) han demostrado que: 1) los países pobres son los más propensos a tener una epidemia generalizada del VIH; 2) los países con mayor desigualdad de ingresos tienen tasas altas del VIH; 3) las políticas importan: los lugares en donde las jeringas se pueden comprar legalmente tienen tasas menores de prevalencia y de incidencia del VIH entre los usuarios de drogas inyectables (UDI).2 Los estudios sobre experimentos naturales indican que: 1) las transiciones sociales y políticas que de otra manera resultarían provechosas (ej. sucesos de los ’90 como la eliminación del sistema de apartheid en Sudáfrica y la terminación de la dictadura en Indonesia) fueron seguidas por grandes brotes del VIH; 2) las guerras aumentan el VIH, las enfermedades transmitidas sexualmente (ETS), la prostitución, la violación, la esclavitud sexual y el uso arriesgado de alcohol y drogas. También llevan a incrementos en el número de parejas sexuales y en la frecuencia de cambio de pareja sexual.3

¿por qué las intervenciones estructurales?

Muchas veces las intervenciones estructurales abarcan temas que parecen completamente ajenos VIH. Al pensar en la prevención del VIH, por lo general no se considera ni la eliminación de las desigualdades de ingresos la ni de la guerra. Pero estas realidades sociales, políticas y económicas ejercen una influencia enorme sobre las conductas de alto riesgo. Circunstancias sin relación directa con el VIH con frecuencia crean condiciones que promueven la propagación del mismo, haciendo de las intervenciones estructurales una necesidad imprescindible. Por ejemplo, en los años ‘70 el gobierno de la ciudad de Nueva York cerró las estaciones de bomberos en los barrios pobres habitados por grupos minoritarios. Como consecuencia, los incendios incontrolados destruyeron numerosos edificios, lo cual tuvo efectos muy traumáticos sobre la vida social de los residentes. El uso de drogas inyectables (y después de crack), el alcoholismo, el intercambio sexual, las pandillas y la desmoralización, se extendieron ampliamente. Posteriormente se presentaron brotes de ETS, VIH, tuberculosis y muchas otras enfermedades.4 Los gobiernos de los países ricos, incluyendo el de EE.UU., así como los bancos, las grandes empresas y otros integrantes de la élite económica, han perseguido agresivamente una política mundial organizada basada en recortes a la asistencia pública, privatización y competencia. Esto ha provocado el endeudamiento masivo de muchos países en vías de desarrollo, aumentado la desigualdad de ingresos y fomentado la formación de macrociudades en torno a enormes barrios de tugurios. Asimismo, debido a los “programas de ajuste estructural” impuestos por el Fondo Monetario Internacional, muchos países africanos, asiáticos y latinoamericanos se han visto obligados a recortar substancialmente los servicios de salud y educación. Estas políticas y programas han impedido en gran medida la provisión eficaz de intervenciones preventivas, terapias antirretrovirales y otros servicios médicos para las poblaciones infectadas.5,6

ejemplos de intervenciones estructurales

En muchos países, gran número de trabajadores sexuales tiene VIH y otras ETS. Tailandia y la República Dominicana han instituido campañas de “condones al 100%” que exigen a los propietarios de los prostíbulos que hagan cumplir el uso de condones durante todo acto sexual. Las campañas buscan el apoyo de los dueños de prostíbulos, de los trabajadores sexuales y, en cuanto sea posible, de los clientes. Estos programas han limitado considerablemente la transmisión del VIH y de las ETS al modificar el contexto social inmediato de la conducta sexual para reducir los incidentes de sexo sin protección.7,8 Las leyes de la mayoría de los estados de EE.UU. prohíben la posesión o distribución de jeringas, y muchos estados requieren receta médica para comprar jeringas. Consecuentemente, muchos UDI no llevan jeringas consigo por miedo a ser hostigados o detenidos por la policía. Para encontrar una solución jurídica a este problema, la legislatura de Connecticut aprobó la revocación parcial de las leyes sobre la receta de jeringas y la posesión de artículos para el uso de drogas. El resultado fue que los UDI redujeron en forma dramática su uso de jeringas compartidas y compraron más jeringas en farmacias. Después de la entrada en vigor de las nuevas leyes, el uso de jeringas compartidas bajó del 52% al 31%, la compra en farmacias subió del 19% al 78%, y la compra callejera disminuyó del 74% al 28%.9

¿podemos cambiar las políticas dañinas?

No es fácil evitar o terminar las guerras, ni las políticas de desarrollo urbano que perjudican a los pobres y a los grupos minoritarios, ni tampoco las políticas sexuales y de drogas que crean ambientes marginados. Sin embargo, los individuos y las comunidades pueden efectuar cambios. Los movimientos de las bases o comunitarios muchas veces son pasos iniciales necesarios para proceder a intervenciones estructurales más amplias. A veces, incluso la formación de dichos movimientos puede ser una intervención estructural. “Chico Chats,” un programa del Proyecto STOP AIDS en San Francisco, CA, ofreció talleres informativos sobre técnicas de organización y movilización comunitaria. Los participantes formaron un grupo activista llamado ¡Ya Basta! y diseñaron un video y un taller que examinaban el silencio en torno al sexo y la revelación de la homosexualidad en la familia latina. El video se está presentando en comunidades latinas en todo San Francisco.10 Organizaciones comunitarias e individuos de varios estados de EE.UU. con tasas altas de VIH entre los UDI, han creado programas de intercambio de jeringas (PIJ). Muchos PIJ han operado ilegalmente y sin apoyo. Las personas que trabajan en los PIJ y otros grupos de activistas políticos han colaborado con los oficiales públicos para invocar políticas “bajo estado de emergencia” que permitan la existencia legal de los PIJ en muchos estados.11 Los trabajadores/as sexuales de Calcuta recibieron ayuda de las autoridades de salud pública para organizar un sindicato comunitario que les permite insistir a sus clientes sobre el uso de condón. La prevalencia del VIH entre los trabajadores/as sexuales de Calcuta se ha mantenido menor que en otras ciudades de la India.12

¿qué queda por hacer?

No se puede ignorar la relación que existe entre los factores estructurales como la marginalización económica, política y social y entre las conductas que ponen a las personas en riesgo de contraer o transmitir el VIH/SIDA y las ETS.13, 14 Tampoco podemos considerar a las conductas de alto riesgo como si operaran fuera de los contextos social, político y económico. Se necesita un diálogo mas profundo sobre estos temas entre los profesionales del VIH/SIDA. Una manera de reducir posibles consecuencias negativas por el cambio de los factores estructurales, es exigir que por ley que los programas económicos, de desarrollo urbano y de política extranjera realicen anticipadamente “informes científicos sobre el impacto del VIH/SIDA”. Un primer paso posible es que las propias organizaciones de prevención del VIH investigen y publiquen sus propias “informes de impacto.”15 Las instituciones financiadoras deberán tomar en cuenta la amplísima variedad de actividades que constituyen la prevención del VIH. Muchas organizaciones comunitarias responden a todo tema relacionado con el VIH, incluyendo algunos que parecen ajenos. Parte de lo que muchas organizaciones comunitarias atienden diariamente son problemáticas mayores relacionadas con guerra, pobreza, desigualdades sociales (ej. racismo y homofobia) y leyes restrictivas. La ayuda para apoyar y organizar estos esfuerzos puede llevar a la creación de intervenciones estructurales necesarias en la prevención del VIH.

¿quién lo dice?

1. Friedman SR, O’Reilly K. Sociocultural interventions at the community level.AIDS. 1997; 11:S201-S208. 2. Friedman SR, Perlis T, Lynch J, et al. Economic inequality, poverty, and laws against syringe access as predictors of metropolitan area rates of drug injection and HIV infection. 2000 Global Research Network Meeting on HIV Prevention in Drug-Using Populations. Third Annual Meeting Report. Durban, South Africa, July 5 -7, 2000. 147-149. 3. Hankins CA, Friedman SR, Zafar T, et al. Transmission and prevention of HIV and STD in war settings: implications for current and future armed conflicts.AIDS. 2002:16(17):2245-52. 4. Wallace R. Urban desertification, public health and public order: ‘planned shrinkage’, violent death, substance abuse and AIDS in the Bronx. Social Science and Medicine. 1990;31:801-813. 5. Lurie P, Hintzen P, Lowe RA. Socioeconomic obstacles to HIV prevention and treatment in developing countries: the roles of the International Monetary Fund and the World Bank. AIDS. 1995;9:539-546. 6. Farmer P. Infections and Inequalities: the Modern Plagues. University ofCalifornia Press: Los Angeles. 1999. 7. Celentano DD, Nelson KE, Lyles CM, et al. Decreasing incidence of HIV and sexually transmitted diseases in young Thai men: evidence for success of the HIV/AIDS control and prevention program. AIDS. 1998;12:F29-F36. 8. Roca E, Ashburn K, Moreno L, et al. Assessing the impact of environmental-structural interventions. Presented at the International AIDS Conference,Barcelona, Spain. 2002. Abst #TuPeC4831. 9. Groseclose SL, Weinstein B, Jones TS, et al. Impact of increased legal access to needles and syringes on practices of injecting drug users and police officers–Connecticut, 1992-1993. Journal of Acquired Immune Deficiency Syndromes.1995;10:82-89. 10. The STOP AIDS Project. Q Action, ¡Ya Basta! San Francisco, CA. 415/865-0790 x303 11. Gostin LO. The legal environment impeding access to sterile syringes and needles: the conflict between law enforcement and public health. Journal of Acquired Immune Deficiency Syndromes. 1998;18:S60-70. 12. Piot P, Coll Seck AM. International response to the HIV/AIDS epidemic: planning for success. Bulletin of the World Health Organization. 2001;79:1106-1112. 13. Diaz RM, Ayala G, Marin BV. Latino gay men and HIV: risk behavior as a sign of oppression. Focus. 2000;15:1-5. 14. Friedman SR, Aral S. Social networks, risk potential networks, health and disease. Journal of Urban Health. 2001;78:411-418. 15. Friedman SR, Reid G. The need for dialectical models as shown in the response to the HIV/AIDS epidemic. International Journal of Sociology and Social Policy. (in press).

Preparado por Sam Friedman*, Kelly Knight** *National Development and Research Institutes, ** CAPS Traducción Rocky Schnaath Enero 2003. Hoja Informativa 46S

Resource

Sex Workers

are sex workers at risk for HIV?

Sex workers in the US may be at risk for HIV depending on the conditions of their workplace. Male, female and transgender sex workers who are most vulnerable to HIV are street-based workers, most of whom are poor or homeless, and likely to have had a history of sexual or physical abuse.1 Street-based sex workers are also commonly dependent on drugs or alcohol, and at a greater risk for violence from clients and police.2 Sex work off the street (in brothels, massage parlors, private homes or escort services) is less likely to result in HIV infection for the workers because they may exercise greater control over their working conditions and sexual transactions, including condom use. Little research has been done on rates of HIV infection among street-based sex workers across the US. In one study of drug-using female sex workers in Miami, FL, 22.4% of the women tested HIV+.3 In a study of male sex workers in Houston, TX, 26% reported testing HIV+.4

what places sex workers at risk?

Sex workers who are injection drug users (IDUs) are more likely to be HIV+ than those who do not inject drugs.2 Injection risks include sharing needles and injection equipment and being injected by someone else. IDU and other substance use (crack cocaine, methamphetamine, alcohol) can also impact sexual risks by compromising safe sexual behavior and communication.5 Persons who use crack cocaine are more likely to enter sex work and have large numbers of partners.6 The decision and ability to use condoms is a complex one that depends on many factors.7,8 Negotiating safer sex can be affected by money, if business is slow or clients offer more money for unprotected sex. Clients may use violence to enforce unsafe sex. Sex workers may use drugs before or with clients, which affects decision making and ability to use condoms. Sex workers may also be targeted by police if they are carrying condoms.5 In addition, sex workers, like many people, may choose not to use condoms with their boyfriends/girlfriends/spouses. Sex workers have elevated rates of sexually transmitted diseases (STDs), including HIV.1 One study of female, male and transgender sex workers in San Francisco, CA, reported high rates of gonorrhoea (12.4%), chlamydia (6.8%), syphilis (1.8%) and herpes (34.3%).9 Active STDs increase the likelihood of acquiring HIV. Genital trauma caused by frequent or forced intercourse also increases HIV risk.1 Violence, and the trauma associated with it, is a concern for many sex workers. Violence can include physical, sexual and verbal abuse that sex workers experienced as children, and as adults from their clients and intimate partners. It can also include the violence many street-based sex workers witness daily. This history of violence leaves many sex workers with emotional trauma, and many may turn to drug use to deal with the harsh realities of their daily lives.10

what are barriers to prevention?

The illegality of sex work in the US drives the industry underground and leads to a strong distrust of both police and public health authorities among sex workers. To avoid arrest, street-based sex workers are often forced to change how they work to avoid police.11 For example, sex workers may take less time to negotiate sexual transactions prior to getting into a client’s car, and may even agree to engage in riskier sexual activities. Conducting HIV prevention outreach or education in this environment can be difficult. Desperation and poverty can often override HIV prevention concerns. Drug-addicted persons may turn to prostitution to earn money to pay for the high cost of illegal drugs. Transgender persons may use sex work to make money for hormones or surgery. Many homeless youth have no training or means of support, and rely on prostitution for survival. Attention to the more immediate concerns of food, housing, and addiction often takes priority over concerns of HIV infection.12

what is being done?

JEWEL (Jewelry Education for Women Empowering their Lives), was an economic empowerment and HIV prevention project for drug-using women involved in prostitution in Baltimore, MD. The JEWEL intervention used six 2-hour sessions that taught HIV prevention and the making, marketing and selling of jewelry. Women participants significantly reduced trading drugs or money for sex, the number of sex trade partners, and drug use, including daily crack use.13 The Health Project for Asian Women (HPAW) addressed Asian female sex workers at massage parlors in San Francisco, CA, with two interventions: Massage Parlor Owner Education Program and Health Educator Masseuse Counseling Program. HPAW staff escorted masseuses to health clinics, handed out safer sex kits and provided translation, referrals and advocacy services. Masseuses participated in a 3-session counseling intervention and massage parlor owners received an education session.14 A brief intervention for male sex workers in Houston, TX, consisted of two 1-hour sessions held a week apart. Almost two-thirds (63%) of the men who began the intervention completed it, and those that completed the intervention increased their condom use during paid anal sex.15 Breaking Free in St Paul, MN, helps primarily African American girls and women leave sex work. The program helps women in crisis stabilize, then begin an intense program of counseling and education to address the traumas associated with sex work. Breaking Free offers transitional and permanent housing, as well as an internship program to help women who may have never held a real job become employable.16 The St. James Infirmary in San Francisco, CA, a peer-based clinic for sex workers by sex workers, provides male, female and transgender sex workers with free medical services. They also offer HIV/STD screening and treatment, transgender health, harm reduction and peer counseling, psychiatric services, acupuncture, massage, support groups, food, clothing, and needle exchange. Staff conducts street and venue-based outreach to distribute safer sex supplies and offers HIV testing.9

what still needs to be done?

In the US over the past decade, there has been very little research conducted on HIV/AIDS in the sex worker population. Furthermore, past research focused largely on the role of sex workers as vectors of HIV/STDs for the general public. To prevent HIV among sex workers, it is essential not only to increase overall research efforts in this population, but to also acknowledge the greater context in which sex work is transacted, as well as the specific practice of sex workers. Researchers, public health and law enforcement officials need to hear from sex workers what they need to keep themselves safe, and work together to achieve those goals. Laws and police attitudes towards carrying condoms must be eased to allow sex workers to protect themselves. Violence against sex workers by clients, police, and other neighborhood community members must be criminalized, while sex workers should be encouraged and supported to report violent incidents. Street-based sex workers face a multitude of needs, from immediate concerns of housing, food and medical attention, to longer-range concerns such as mental health services, substance abuse treatment, violence prevention, job training and employment, HIV/STD prevention, quality health care, improved relationships with law enforcement and help leaving sex work. Increased funding and awareness is needed for public health programs that address this full range of issues sex workers face. PREPARED BY ROSHAN RAHNAMA, CAPS
Resource

Ley penal

¿Hay un papel para la ley penal dentro de la prevención del VIH?

¿por qué una ley penal?

Durante el transcurso de la epidemia del SIDA en EE.UU., se ha debatido constantemente la necesidad de leyes que castiguen a individuos que se saben VIH+ y exponen a otra persona al VIH (llamado a veces exposición intencional al VIH o con conocimiento). Gran parte del debate se ha polarizado entre la criminalización de toda exposición al VIH y ninguna criminalización. Una postura más razonable tal vez se encuentra entre los dos extremos. Las formas principales de transmisión del VIH (actividad sexual y consumo de drogas) ya son áreas controversiales en el campo legal así como en el de la salud pública. Las investigaciones, las normas sociales y los valores personales en torno al sexo y al consumo de drogas (y por lo tanto al VIH y a su prevención) varían muchísimo. No es de extrañarse que la discusión sobre el uso de la ley o derecho penal (criminal law) para castigar la exposición al VIH sea tan acalorada. Un análisis de leyes, casos y encuestas de opinión pública indica que existe apoyo para leyes que condenen por lo menos algunos comportamientos que exponen a otros al VIH, por ejemplo, leyes que imponen castigos adicionales por delitos violentos tales como violación o asalto cuando el agresor es VIH+. Sin embargo, la forma en que están redactadas las leyes actuales sobre la exposición al VIH podría perjudicar gravemente a las personas VIH+. La justificación de algunas de estas leyes se ha basado en percepciones erróneas sobre el riesgo de transmisión, lo cual puede criminalizar actos con poco o ningún riesgo de propagar el VIH. Asimismo, no existe evidencia de que el uso de la ley penal sea una estrategia eficaz para la prevención del VIH. La pregunta que surge es: ¿Cómo pueden colaborar con mayor armonía el derecho penal sobre la transmisión del VIH y los esfuerzos de salud pública para lograr mejores resultados en la comunidad?

¿cuáles son las leyes?

Aunque en EE.UU. no existen leyes federales sobre la exposición al VIH, el Congreso ha proporcionado apoyo explícito a esfuerzos estatales. En 1990, la ley de Ryan White CARE (que provee fondos para la atención del SIDA) requirió que cada estado certificara que sus leyes criminales eran “adecuadas para enjuiciar a cualquier individuo infectado con VIH” que con conocimiento exponga al VIH a otra persona. (Este requisito fue eliminado en el 2000 cuando todos los estados certificaron que tenían dichas leyes.) Los gobiernos estatales han respondido de tres maneras generales para convertir en delito la exposición al VIH por una persona que se sabe infectada: 1) Adoptar leyes específicas sobre el VIH; 2) Depender de leyes que regulan las enfermedades de transmisión sexual (ETS) y 3) Aplicar estatutos penales generales contra el asalto o la imprudencia temeraria.1 Leyes específicas al VIH: Desde mayo del 2005, 24 estados tienen leyes que castigan específicamente la exposición al VIH como delito por separado, pero estas leyes varían significativamente. Muchas abarcan la actividad sexual, el uso de jeringas compartidas y la donación de sangre. Con menos frecuencia, mencionan otras actividades como morder y escupir que tienen poco o ningún riesgo de propagar el VIH. La mayoría de estas leyes no requieren que la persona VIH+ llegue a infectar a otro, sino que simplemente realice con conocimiento algún acto que pudiera poner a otra persona en riesgo de contraer el VIH. Los castigos por violar la ley varían entre un año en prisión, como mínimo, hasta la condena perpetua como máximo.2,3 Doce de estos estados también tienen leyes que identifican específicamente la exposición al VIH como una razón para aumentar la condena por un delito existente (por ejemplo, asalto sexual o prostitución). Otros tres estados tienen estas leyes de condena aumentada pero no tienen leyes que identifiquen la exposición al VIH como delito por separado. La amplia gama de conductas y los posibles castigos muestran la complejidad para crear leyes sobre la exposición al VIH. Si bien las leyes más ambiguas permiten mayor flexibilidad, las más específicas pueden impedir la aplicación inadecuada. Es especialmente difícil encontrar el equilibrio en un campo como el VIH/SIDA, en el cual el conocimiento sobre el virus, la transmisión y la prevención avanza y cambia constantemente. Leyes sobre las ETS y estatutos generales: Seis estados de EE.UU. se apoyan en leyes existentes sobre las ETS y 17 estados carecen de regulaciones tanto para VIH como para ETS por lo que aplican leyes penales generales.4 Sin embargo los casos de VIH no siempre se encajan fácilmente en los estatutos generales. Por ejemplo, la definición legal general del asalto como el contacto físico no deseado, escasamente contempla la naturaleza del consentimiento involucrado en conductas que pueden resultar en una exposición al VIH.

¿por qué hacer uso de la ley?

El derecho penal refleja el interés de la sociedad por proteger a las personas contra daños graves.5 En el caso de la exposición al VIH, las leyes penales se pueden aplicar para impedir que las personas VIH+ realicen actos que pudieran exponer a otros al VIH y posiblemente hacerles daño. Estos actos potencialmente dañinos son similares a otros actos prohibidos por dichas leyes. Las leyes penales se usan a veces para reflejar las normas de la comunidad sobre el comportamiento socialmente aceptable. Algunas leyes sobre la exposición al VIH requieren que la persona VIH+ revele su condición a su pareja antes de realizar cualquier actividad de alto riesgo. De esta manera, la ley sirve para establecer una norma de conducta para cierto grupo en particular y podría compartir las metas de las políticas de salud pública.6 Las leyes penales se pueden emplear para alentar que las personas VIH+ dejen de participar en actividades de alto riesgo que exponen a otros al VIH.7 Sin embargo, actualmente no existe evidencia publicada de que las leyes penales hayan logrado otra meta que no sea el castigo en el contexto de la exposición intencional al VIH.

¿cuáles son las preocupaciones?

Actualmente, ningún estudio ha comprobado que la criminalización de la transmisión del VIH sea un método eficaz de prevención del VIH.7 Además, muchas personas desconocen las leyes vigentes sobre el VIH en su estado, lo que impide que éstas influyan en su comportamiento. Entre quienes conocen dichas leyes, los estatutos podrían aumentar el estigma contra una enfermedad ya muy temida y muy malentendida. Además, la amenaza de un juicio penal puede desalentar a las personas a recibir pruebas, consejería y tratamiento del VIH.8 De esta manera, las leyes penales podrían contrarrestar los esfuerzos de salud pública porque las personas que desconocen su condición de VIH podrían ser más propensas a participar en comportamientos de alto riesgo y por lo tanto aumentar la propagación del VIH.9 Existen preocupaciones también sobre el estigma y la discriminación en las condenas por la exposición al VIH. Bajo algunas de las leyes penales más extremas sobre la exposición al VIH, las sentencias pueden ser tan largas como de 10 a 25 años. Algunas personas enjuiciadas por haber expuesto a otros al VIH han recibido estas extensas condenas aunque la víctima no resultara infectada.10 Muchas leyes castigan el fallo de revelar la condición de VIH+ a la pareja sexual, sin embargo las personas VIH+ pueden tomar medidas para evitar el contagio del VIH sin señalar su condición. Además, muchos factores pueden influir en la capacidad de la persona para revelar su infección de VIH en el contexto de su relación de pareja. Una encuesta de personas VIH+ encontró que el 42% de los hombres homosexuales, el 19% de los heterosexuales y el 17% de las mujeres reportaron haber tenido sexo sin revelar su condición de VIH.11 Asimismo, los estudios muestran que la revelación de la condición de VIH no se asocia necesariamente con el uso de condones u otra actividad para reducir el riesgo.12

¿cómo encontrar equilibrio?

Las leyes usadas para castigar la exposición al VIH varían ampliamente según el estado en los EE.UU. Aunque algunos aspectos de las leyes apoyen los esfuerzos de salud pública, otros pueden contradecirlos. Es necesario equilibrar la ley penal y las metas de salud pública de manera que ambas tengan la mayor eficacia posible. Es importante aumentar la conciencia de la existencia de estas leyes entre las organizaciones comunitarias y otras que atienden a personas VIH+. Ésto puede apoyar la meta de dichas leyes (impedir el comportamiento de riesgo) y permitir que los individuos VIH+ tengan una mayor voz en la creación de leyes que los afectan directamente. Los legisladores y formuladores de normas y políticas pueden tomar varias medidas para lograr esta justa medida. En los estados que no tienen leyes específicas sobre el VIH, no hace falta crearlas. Numerosos estados han podido tomar acción legal al respecto valiéndose de los estatutos generales. De hecho la ONUSIDA específicamente recomienda no destacar al VIH de esta manera.13 Para los estados que ya tienen leyes específicas sobre el VIH, los legisladores pueden encontrar el punto medio apoyando leyes que reflejen medidas de prevención y conocimientos exactos sobre la transmisión del VIH. Actualmente muchas leyes establecen conductas condenables sin considerar las normas de prevención emitidas por los CDC (tales como el uso del condón). Se podrían incorporar protecciones adicionales al formular leyes dirigidas únicamente a infractores persistentes después de que las medidas menos restrictivas de salud pública hayan fallado en lograr cambios de conducta.

¿Quién Lo Dice?

1. McKinney MM, Marconi K. Delivering HIV services to vulnerable populations: a review of CARE Act funded research. Public Health Reports. 2002;117:99-113. 2. Wolf LE, Vezina R. Crime and punishment: is there a role for criminal law in HIV prevention policy? Whittier Law Review. 2004;25: 821-886. 3. HIV Criminal Law and Policy Project. https://www.hivlawandpolicy.org/. Accessed March 2005. 4. Sullivan KM, Field MA. AIDS and the coercive power of the state. Harvard Civil Rights & Civil Liberties Law Review. 1988;23: 139-197. 5. Gostin LO. Public health law in a new century: part I: law as a tool to advance the community’s health. Journal of the American Medical Association. 2000;283: 2837-2841. 6. Marks G, Burris S, Peterman TA. Reducing sexual transmission of HIV from those who know they are infected: the need for personal and collective responsibility. AIDS. 1999;13:297-306. 7. Lazzarini Z, Klitzman R. HIV and the law: integrating law, policy, and social epidemiology. Journal of Law and Medical Ethics. 2002;30:533-547. 8. Lazzarini Z, Bray S, Burris S. Evaluating the impact of criminal laws on HIV risk behavior. Journal of Law and Medical Ethics. 2002; 30:239-253. 9. Gostin LO, Hodge JG. The “names debate”: the case for national HIV reporting in the United States. Albany Law Review. 1998;61: 679-742. 10. In Brief: Maximum Sentence. AIDS Policy & Law. 1998;13:16. 11. Ciccarone DH, Kanouse DE, Collins RL, et al. Sex without disclosure of positive HIV serostatus in a US probability sample of persons receiving medical care for HIV infection. American Journal of Public Health. 2003;93:949-954. 12. Stein MD, Freedberg KA, Sullivan LM, et al. Sexual ethics. Disclosure of HIV-positive status to partners. Archives of Internal Medicine. 1998;158:253-257. 13. United Nations Program on AIDS (UNAIDS). Handbook for Legislators on HIV/AIDS, Law and Human Rights. 1999:51.

Preparado por Leslie Wolf, JD, MPH y Richard Vezina, MPH, CAPS Traducción Rocky Schnaath Septiembre 2005. Hoja Informativa 57S

Resource

Cost effectiveness

Can cost-effectiveness analysis help in HIV prevention?

Why invest in HIV prevention?

HIV prevention is still our best hope for fighting the HIV/AIDS epidemic. The estimated lifetime cost of care and treatment for just one HIV+ person is about $195,000.1 Given 40,000 new infections a year, it will cost more than $6 billion in future years to care for everyone who gets infected this year alone.2 By keeping people from becoming infected, HIV prevention not only saves lives and slows down the epidemic, it also reduces the number of persons who require expensive medical regimens to combat their HIV disease. The cost of the AIDS epidemic is incurred not only in dollars, but also in the suffering and death of friends, family and loved ones. The loss to society is untold. We lose productivity and creativity, as well as health and social service dollars. AIDS has a high cost to society because it predominantly affects young adults in their prime for work and childbearing. In 1998, HIV was the fifth leading cause of death in the US for persons aged 25-44, the leading cause of death for African American men aged 25-44 and the third leading cause of death for African American women in the same age group.3

What is cost-effectiveness analysis?

The term cost-effectiveness analysis refers to the economic analysis of an intervention. In HIV prevention, one measure of cost-effectiveness is the cost per HIV infection averted. This is affected by many factors: intervention cost, number of people reached, their risk behaviors and HIV incidence, and the effectiveness of the intervention in changing behavior. The purpose of cost-effectiveness analysis is to quantify how these factors combine to determine the overall value of a program. Cost-effectiveness analysis can determine if an intervention is cost-saving(cost per HIV infection averted is less than the lifetime cost of providing HIV/AIDS treatment and care) or cost-effective (cost per HIV infection averted compares favorably to other health care services such as smoking cessation or diabetes detection). Community-based organizations (CBOs), community planning groups (CPGs) and health departments often face the difficult task of choosing from a spectrum of HIV prevention strategies in order to best address the HIV prevention needs of the riskiest populations in their community. Knowing the cost-effectiveness of programs can help them decide how to save the most lives with the limited resources available.4 Cost-effectiveness analyses also break down the costs and resources needed to implement interventions—personnel, training, supplies, transportation, rent, overhead, volunteer services, etc. This can help CBOs decide if they can implement an intervention.

What are the limitations?

Cost-effectiveness is an important consideration but is only one of many factors that should be considered when making program decisions. Cost-effectiveness models do not take everything into account—sometimes they omit important but hard to quantify factors like family stability, freedom from HIV-related stigma and social justice. In addition to helping clients reduce their HIV risk, many interventions also help clients get into stable housing, out of abusive relationships or into drug treatment programs. These outcomes are not easily quantifiable in cost-effectiveness models. HIV prevention cost-effectiveness estimates cannot be generalized easily because the effectiveness of programs is determined by rates of infection and risk behaviors that may vary greatly across populations. Unlike a surgical procedure, which is likely to be as effective in Cleveland as it is in Dallas, HIV prevention programs can be more or less effective depending on the status of the epidemic in a community at risk.5 More and more, HIV prevention programs are being asked to “prove their worth” by showing they are cost-saving or cost-effective. Just because a program doesn’t save society money, doesn’t mean it’s not good or needed. A program that does not save money might still be cost-effective; or, it might not be cost-saving or cost-effective yet still be something that society wants and needs.

What programs are cost-effective?

A variety of intervention strategies for injection drug users were shown to be cost-effective: needle exchange (typically $4,000-40,000 per HIV infection averted, or HIA), HIV testing and counseling ($5,000-10,000 per HIA) and drug treatment ($40,000 per HIA which may not include important benefits like crime reduction).6 Project LIGHT, a randomized, controlled multisite HIV prevention trial, tested a seven-session small group intervention based on cognitive-behavioral therapy. Project LIGHT found the multi-session intervention to be more effective at reducing sexual risk than a comparison 1-hour videotape session. However, the seven-session intervention was also more expensive to implement. Cost-effectiveness analysis showed that the multi-session intervention was not only more effective than the videotape session in reducing risk, but also was more cost-effective.7 Safer Choices, a school-based HIV, STD and pregnancy prevention program, achieved a 15% increase in condom use and an 11% increase in contraceptive use among sexually active students. By preventing cases of HIV, chlamydia, gonorrhea, pelvic inflammatory disease and pregnancies, Safer Choices saved $2.65 in medical and social costs for every dollar spent on the program.8 The Mpowerment Project is a community-level HIV prevention intervention run by and for young gay and bisexual men. Mpowerment took place in a mid-sized city with low HIV prevalence and used community building and peer influence to alter the norms of the gay community. The program proved to be cost-effective even with resource- intensive components such as personnel, renting a community space and running social events. Mpowerment was estimated to avert 5-6 HIV infections over 5 years, with cost per HIA of $14,600-18,300.9 In the developing world, where the need for aggressive HIV prevention efforts is profound, interventions have been found to be very cost-effective. This is because the epidemic is very severe, and because program costs (such as personnel) are low in these countries. Estimates of cost-effectiveness include: STD control and condom promotion in commercial sex workers ($8-10 per HIA), female condom promotion in high-risk women (cost-saving), voluntary counseling and testing (about $70 per HIA in HIV-discordant couples, $300 overall), community STD control ($350 per HIA), and mother-to-child transmission reduction with nevirapine ($300-500 per HIA).10

What does cost-effective analysis show?

  • All other things being equal, interventions targeted to high-seroprevalence areas tend to be more cost-effective than interventions that are not targeted.
  • Low cost doesn’t mean cost-effective. If a client needs an intensive intervention, spending the money may be the most cost-effective choice in the long run.
  • Reaching more clients for the same money isn’t always the best thing to do. Giving everyone a brochure produces little behavior change, whereas working intensively to help high-risk clients use condoms correctly, communicate safer sex desires to their partners and learn to recognize and avoid high-risk situations can result in pronounced behavior change.113

What still needs to be done?

Cost-effectiveness analyses can help determine how to save the most lives with limited funding. Neglecting cost-effectiveness information may waste scarce prevention dollars, and thereby miss the opportunity to save lives.12 To this end, simpler cost-effectiveness models and improved technical assistance are needed to help public health decision-makers make better use of cost-effectiveness information.13

Says who?

1. Holtgrave DR, Pinkerton SD. Updates of cost of illness and quality of life estimates for use in economic evaluations of HIV prevention programs. Journal of Acquired Immune Deficiency Syndromes. 1997;16:54-62. 2. Holtgrave DR, Pinkerton SD. The economics of HIV primary prevention. In JL Peterson & RJ DiClemente (eds). Handbook of HIV Prevention. New York: Plenum Press, 2000; 285-296. 3. Centers for Disease Control and Prevention. Mortality slide series.https://www.cdc.gov/hiv/library/slidesets/index.html. 4. Kahn JG. The cost-effectiveness of HIV prevention targeting: how much more bang for the buck? American Journal of Public Health. 1996;86:1709-1712. 5. Pinkerton SD, Johnson-Masotti AP, Holtgrave DR, et al. Using cost-effective league tables to compare interventions to prevent sexual transmission of HIV. AIDS. 2001;15:917-928. 6. Kahn JG. Economic evaluation of primary HIV prevention in intravenous drug users. In Holtgrave DR, ed. Handbook of Economic Evaluation of HIV Prevention Programs. New York:Plenum Press, 1998. 7. Pinkerton SD, Holtgrave DR, Johnson-Masotti AP, et al. Cost-effectiveness of the NIMH Multisite HIV Prevention intervention. AIDS and Behavior. 2002;6:83-96. 8. Wang LY, Davis M, Robin L, et al. Economic evaluation of Safer Choices. Archives of Pediatric and Adolescent Medicine. 2000;154:1017-1024. 9. Kahn JG, Kegeles SM, Hays R, et al. Cost-effectiveness of the Mpowerment Project, a community-level intervention for young gay men. Journal of Acquired Immune Deficiency Syndromes. 2001;27:482-491. 10. Marseille EA, Hofmann PB, Kahn JG. HIV prevention should be funded before HAART in Sub-Saharan Africa. Lancet. In press 11. Centers for Disease Control and Prevention. Compendium of HIV Prevention Interventions with Evidence of Effectiveness. November 1999. 12. Institute of Medicine. No time to lose – getting more from HIV prevention. Washington, DC: National Academy Press; 2000. 13. Pinkerton SD, Holtgrave DR. A method for evaluating the economic efficiency of HIV behavioral risk reduction interventions. AIDS & Behavior. 1998;2:189-201.

Further reading:

DR Holtgrave (ed). Handbook of Economic Evaluation of HIV Prevention Programs. New York: Plenum Publishers, 1998. Gold MR, Siegel JE, Russell LB, Weinstein MC (eds). Cost- effectiveness in Health and Medicine. New York: Oxford University Press, 1996.

Prepared by James G. Kahn*, Steven D. Pinkerton**, David R. Holtgrave*** *Institute for Health Policy Studies, UCSF; **Center for AIDS Intervention Research, Medical College of Wisconsin; ***Rollins School of Public Health, Emory University January 2002. Fact Sheet #12ER Special thanks to the reviewers of this Fact Sheet: Kim Compoc, Karin Coyle, Paul Farnham, Susan Fernyak, Celia Friedrich, Anne Haddix, Ana Johnson-Masotti, Susan Klein, Frank Laufer, Rani Marx, David Perlman, Katherine Phillips, Ron Stall, Mike Sweat, Gary Zarkin.

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]. © February 2002, University of California