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What are the HIV prevention needs of crack cocaine users?

Prepared by Margaret R. Weeks PhD, Institute for Community Research and Pamela DeCarlo, CAPS Fact Sheet 66, December 2009

Is crack cocaine an issue?

Yes. Although many people think of it as a drug of the 80s, crack cocaine is still around. HIV prevention has traditionally focused on injecting drug use and other stimulants like methamphetamine. But many people use more than one drug and may be using these drugs in different ways, for example, smoking crack and injecting heroin. Crack use alone and crack use combined with other drugs present real risks for HIV transmission and acquisition. Crack cocaine is a powerfully addictive stimulant drug. Crack is a rock crystal, which can be smoked or dissolved and injected. It is relatively cheap and readily available on the street in mainly low-income urban areas. Crack is highly addictive and the effects of the drug are short-lived (about 5 minutes), making it necessary to use more to maintain a high. Recent studies of crack users show high rates of HIV infection. In Harlem, New York, 23.9% of users and sellers of crack were HIV+¹; in Los Angeles, California, 24% of older low-income MSM were HIV+²; and 22.4% of female street sex workers in Miami, Florida were HIV+³.

Who uses crack?

While crack use may vary geographically by race, age and sexual orientation, most crack use is concentrated in inner city communities that are impoverished and disadvantaged and have limited access to many services. These are the same neighborhoods with high rates of unemployment, homelessness, violence, substance abuse, HIV, sexually transmitted diseases (STDs) and other risks. However, some crack users do not fit these characteristics and are still at very high risk of health related consequences of crack use.

How does crack affect HIV transmission risk?

Risk of HIV and other sexually transmitted diseases can vary by level of crack use and addiction. Crack’s short-lived high and addictiveness can create a compulsive cycle in which users quickly exhaust their resources and turn to other ways to get the drug, including exchanging sex for money or drugs (such as a “hit” of crack)⁴. Trading sex in these circumstances often creates extremely risky situations that may include high numbers of partners, sex while under the influence and drug-related violence. This environment makes it hard to engage in safer behaviors and contributes to inconsistent condom use.^5,6 In one study, HIV infection was associated with intensive, daily crack smoking among women engaged in survival sex.^5,7 Crack use is also associated with very high rates of other STDs, including syphilis, gonorrhea, and chlamydia. Lesions and abrasions associated with these infections increase opportunities for infection with HIV, especially during repeated or protracted sex, common among crack users.⁸ Crack is often smoked in make-shift pipes that use a glass pipette (tube) or a broken car antenna as a mouthpiece. These crack pipes can lead to cuts and burns on the lips, which are associated with HIV transmission.⁹ It is not known if this is due to sharing pipes between users or sexual transmission during oral sex. Some research shows possible risk of pneumonia and tuberculosis transmission through sharing of crack pipes as well.¹⁰

How does crack affect HIV+ persons?

Crack use affects HIV+ persons on many levels: biological, social and behavioral. On a biological level, crack use can accelerate HIV disease progression.¹¹ One study found that persistent crack users were over three times as likely to die from AIDS-related causes as non-users.¹² On a social level, most crack users who are HIV+ live in disadvantaged and impoverished communities, which present a variety of barriers to health. Crack users with HIV are less likely than HIV+ non-users to have access to basic medical services and more likely never to have been in HIV primary care.¹³ They are less likely to have a regular healthcare provider and to initiate medical care and treatment.¹⁴ On a behavioral level, crack users have low rates of adherence to HIV therapy once they have begun treatment.¹⁵ And HIV+ crack users are more likely than HIV+ non-users to continue to engage in high risk sexual behaviors with HIV- or unknown status partners after learning their HIV status.¹³

What’s being done?

The Risk Avoidance Partnership (RAP) Project in Hartford, Connecticut, trained active drug injectors and crack users to deliver an HIV, hepatitis, and STD prevention intervention to hard-to-reach drug users both inside and outside of their networks. The Peer Health Advocates (PHAs) received training in risk reduction and health promotion, communication skills and the importance of health advocacy. Crack users in RAP helped to design special “crack kits” they distributed to encourage use of rubber tips on crack pipes; kits also included male and female condoms and “dental dams” (flat latex sheets for use when performing oral sex on women). Study participants reported significant risk reduction.¹⁶ Using a harm reduction model, a needle exchange program in Ottawa, Canada distributes safety kits to crack users to reduce the risk of cuts and burns and potential transmission from sharing crack pipes and to decrease needle sharing. The kits include glass stems, rubber mouthpieces, brass screens, chopsticks, lip balm and chewing gum. Recipients reported less injecting and less sharing of pipes.^10,17 JEWEL (Jewelry Education for Women Empowering their Lives) was an economic empowerment and HIV prevention project for crack-using women involved in prostitution in Baltimore, Maryland. 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 daily crack use.¹⁸ Two separate intervention trials compared a standard National Institute on Drug Abuse HIV prevention intervention to woman-focused, culturally-specific interventions for female African-American crack cocaine users. The two interventions were grounded in motivation and empowerment theories and addressed the reality of the daily lives of women and the violence and poverty of their inner-city neighborhoods. Women in the culturally-specific interventions reported more reductions in sexual risk behaviors¹⁹ as well as improvements in employment and housing status.²⁰

What still needs to be done?

While there is still no medical treatment for crack or cocaine abuse and dependence, several behavioral treatments have demonstrated efficacy for helping people to initiate abstinence and to prevent relapse to cocaine use. These include contingency management, cognitive behavioral therapy, and motivational interviewing.²¹ Currently available treatment for crack dependence tends to be limited to 12-step programs, which have little evidence of efficacy. Further development and testing of efficacious behavioral and medical treatments are needed to help crack users overcome the intense cravings associated with crack addiction. Federal sentencing laws currently give far harsher penalties for crack cocaine than for powdered cocaine.²² Using a 100-to-1 ratio, a person who sells a small amount of crack receives the same sentencing as a person who sells 100 times that amount of powder cocaine, resulting in prisons packed with low-level, predominantly African American offenders. In 2008, over 80% of offenders sentenced for crack-related federal crimes were Black and 10% were White. Activists and legislators are working to change the legislation, and to make it retroactive for those currently incarcerated.²³ Stronger public policy around sentencing guidelines are needed. Substance use is complicated and HIV prevention has tended to simplify efforts into either reducing needle sharing and needle use, or reducing sexual risk. However, many IDUs also use crack, and often smoke crack when they’ve stopped injecting. Programs for IDUs should address poly-drug use, including crack use, and sexual risk reduction in the context of complex psychological and social needs and pressures associated with addiction. Crack users face a variety of barriers to remaining healthy, and programs need to take a more holistic approach to prevention.²⁴ Crack users often need basic services such as childcare, safe shelter, food security, basic necessities and substance abuse treatment before they can think about HIV prevention.²⁵ Interventions should not simply focus on drug and sex risks, but should address these basic survival needs as well as education, employment, housing and job training.

Says who?

1. Davis WR, Johnson BD, Randolph D , et al. Risks for HIV infection among users and sellers of crack, powder cocaine and heroin in central Harlem: Implications for interventions. AIDS Care. 2006;18:158-165. 2. Ober A, Shoptaw S, Wang PC, et al. Factors associated with event-level stimulant use during sex in a sample of older, low-income men who have sex with men in Los Angeles. Drug & Alcohol Dependence. 2009;102:123-129. 3. Inciardi JA, Surratt HL, Kurtz SP. HIV, HBV, and HCV infections among drug-involved, inner-city, street sex workers in Miami, Florida. AIDS and Behavior.2006;10:139-147. 4. Edwards JM, Halpern CT, Wechsberg W. Correlates of exchanging sex for drugs or money among women who use crack cocaine. AIDS Education and Prevention. 2006;18:420-429. 5. Sharpe TT. Behind the eight-ball: Sex for crack cocaine exchange and poor Black women. Taylor and Francis, New York. 2005 6. Sterk CE, Elifson KW, Theall KP. Individual action and community context: The health intervention project. American Journal of Preventive Medicine.2007;32:S177-S181. 7. Shannon K, Bright V, Gibson K, et al. Sexual and drug-related vulnerabilities for HIV infection among women engaged in survival sex work in Vancouver, Canada.Canadian Journal of Public Health. 2007;98:465-469. 8. Miller M, Liao Y, Wagner M, et al. HIV, the clustering of sexually transmitted infections, and sex risk among African American women who use drugs. Sexually Transmitted Diseases. 2008;35:696-702. 9. Theall KP, Sterk CE, Elifson KW, et al. Factors associated with positive HIV serostatus among women who use drugs: continued evidence for expanding factors of influence. Public Health Reports. 2003;118:415-424. 10. Johnson J, Malchy L, Mulvogue T, et al. Lessons learned from the SCORE project: A document to support outreach and education related to safer crack use. June 2008. 11. Baum MK, Rafie C, Lai S, et al. Crack-cocaine use accelerates HIV disease progression in a cohort of HIV-positive drug users. Journal of AIDS. 2009;50:93-99. 12. Cook JA, Burke-Miller JK, Cohen MH, et al. Crack cocaine, disease progression, and mortality in a multicenter cohort of HIV-1 positive women. AIDS. 2008; 22:1355-1363. 13. Metsch LR, Bell C, Pereyra M, et al. Hospitalized HIV-infected patients in the era of highly active antiretroviral therapy. American Journal of Public Health. 2009;99:1045-1049. 14. Cunningham CO, Sohler NL, Berg KM, et al. Type of substance use and access to HIV-related health care. AIDS Patient Care and STDs. 2006; 20:399-407. 15. Moss AR, Hahn JA, Perry S, et al. Adherence to highly active antiretroviral therapy in the homeless population in San Francisco: a prospective study.Clinical Infectious Diseases. 2004;39:1190-1198. 16. Weeks MR, Li J, Dickson-Gomez J, et al. Outcomes of a peer HIV prevention program with injection drug and crack users: the Risk Avoidance Partnership.Substance Use & Misuse. 2009;44:253-281. 17. Leonard L, DeRubeis E, Pelude L, et al. “I inject less as I have easier access to pipes” Injecting, and sharing of crack-smoking materials, decline as safer crack-smoking resources are distributed. Int’l Journal of Drug Policy. 2008; 19:255-264. 18. Sherman SG, German D, Cheng Y, et al. The evaluation of the JEWEL projects: An innovative economic enhancement and HIV prevention intervention study targeting drug using women involved in prostitution. AIDS Care.2006;18:1-11. 19. Sterk CE, Theall KP, Elifson KW, et al. HIV risk reduction among African-American women who inject drugs: a randomized controlled trial. AIDS and Behavior. 2003;7:73-86. 20. Wechsberg WM, Lam WK, Zule WA, et al. Efficacy of a woman-focused intervention to reduce HIV risk and increase self-sufficiency among African American crack abusers. American Journal of Public Health. 2004;94:1165-1173. 21. National Institute on Drug Abuse. Research Report Series. Cocaine: Abuse and Addiction. May 2009. 22. Sentencing. Stiff sentence for HIV+ crack user affirmed on appeal. AIDS Policy & Law. 2007;22:8. 23. Emery T. Will crack-cocaine sentencing reform help current cons? Time Magazine. August 7, 2009. 24. Schlabig Williams J. Researchers adapt HIV risk prevention program for African-American women. NIDA Notes. April 2004. 25. MacMaster SA. Social service delivery preferences among African American women who use crack cocaine: What women say they need before they can be open to HIV prevention services? Journal of HIV/AIDS & Social Services.2006;5:161-179.

Special thanks to the following reviewers of this Fact Sheet: Susan Boyd, Michael Campsmith, Judith Cook, Tom Donohoe, Waleska Maldonado, Lisa Metsch, Kate Shannon, Steve Shoptaw, Claire Sterk, Bill Stewart, Tanya Telfair Sharpe. Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. To receive Fact Sheets via e-mail, send an e-mail to [email protected] with the message “subscribe CAPSFS first name last name.” ©December 2009, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected].

What are HIV+ persons’ HIV prevention needs?

revised 9/05

do HIV+ persons need prevention?

Yes. Over 1 million persons in the US are living with HIV/AIDS.¹ Advances in the early diagnosis, treatment and care of HIV+ persons have helped many people enjoy increased health and longer life. Some HIV+ persons have experienced a renewed interest in sexual or drug-using activity. This can place them at risk for acquiring additional STD infections and for transmitting HIV to their uninfected partners.² Many HIV+ persons, therefore, require programs to help them stay safe. Most HIV+ persons are concerned about not infecting others and make efforts to prevent transmission.³ However, a significant percentage of HIV+ persons struggle with prevention: from 20-50% of HIV+ persons report unprotected sex with partners who are HIV- or whose HIV status they do not know. For many HIV+ persons, the same structural, inter-personal and behavioral challenges that put them at risk for HIV persist beyond their HIV diagnosis and play a role in their inability to prevent HIV transmission.⁴ Prevention with HIV+ persons may include education and skills building interventions, efforts to test more persons who are HIV+ but do not know their status, support and testing for partners of HIV+ persons and integrating prevention into routine medical care.⁵

how is it different?

HIV prevention programs with HIV+ persons are different than programs with HIV- persons in that they must address clinical, mental and social support needs as well as build skills to prevent HIV transmission to current and future partners. Stigma. Pre-existing stigma towards gay men, women, drug users, sex workers and persons of color has helped fuel the HIV epidemic in this country by creating social conditions that foster HIV transmission.⁶ Added to this is the additional stigma of living with HIV. Previous experience of stigma (coming out as gay or as a drug user) may lead to trauma that impacts the ability to cope with HIV transmission.⁷ It is important to address these structural factors to build strength and resiliency in HIV+ communities. Disclosure. One of the foremost concerns for HIV+ persons is how, when, where and to whom to disclose their HIV status.⁸ The traditional message has been that HIV+ persons should always disclose their HIV status to partners. In reality, disclosure is complex and difficult. Some HIV+ persons decide not to disclose and not engage in risk behavior. HIV+ persons often fear that disclosure may bring partner or familial rejection, limit sexual opportunities or increase risk for physical and sexual violence. A survey of HIV+ persons found that 42% of gay men, 19% of heterosexual men and 17% of women had sex without disclosing their HIV status.⁹ HIV+ persons may disclose differently with doctors, family, friends, work colleagues and sexual and injecting partners. Responsibility. Persons with HIV live with both the experience of being infected (sometimes by someone they love and trust) and the tremendous responsibility of knowing that they can infect other people. Although the subject of responsibility is complex, prevention programs can provide support to HIV+ persons to explore and understand what it means for them individually.¹⁰

what can HIV+ persons do?

Many HIV+ persons are using strategies that limit HIV transmission. One strategy is having sex mainly with other known HIV+ persons.¹¹ Knowing that your sexual partner is also HIV+ avoids the risk of transmission and allows for sex without consistent condom use. There have been recent concerns about superinfection among HIV+ couples, where one HIV+ person might acquire another strain of HIV from their HIV+ partner. However, superinfection among such couples appears to be rare.¹² Another strategy is switching from high-risk to lower risk activities. HIV+ persons can avoid high-risk activities such as being an insertive partner (top) during anal and vaginal sex, having sex while menstruating, breastfeeding and sharing syringes. Lower risk activities can be having oral sex and being a receptive partner (bottom).¹¹

what can my agency/clinic do?

HIV+ persons are a diverse group and require prevention programs that fit their specific needs. Programs need to see the whole person, not just sex and drug use. Relationships, employment, healthcare, housing, stigma and discrimination should be addressed as needed. Listening to HIV+ persons and involving them in the design, delivery and evaluation of programs ensures that programs are relevant and useful.¹³ Prevention programs with HIV+ persons can require institutional change and adjustment for agencies and clinics that may be integrating care and prevention services for the first time. Healthcare clinics may train providers and staff to deliver prevention counseling, link with prevention and social service agencies or provide referrals to agencies. Prevention programs may train staff in treatment and care issues, forge relationships with clinics and service agencies or provide referrals. It is critical for healthcare providers to maintain a non-judgmental tone about situations and behaviors with HIV+ clients.¹⁴ It is equally important to work in collaboration with HIV+ persons to develop a concrete risk reduction plan based on the client’s needs and abilities.¹⁴ Providers should be supportive, empathic, goal-oriented and focus on a client’s strengths and resiliencies. Prevention programs need to provide clients with the knowledge, skills and resources (such as condoms, clean needles and a plan to decrease alcohol and drug use) to put the risk reduction plan in place.

what’s being done?

There are currently many programs and interventions addressing prevention with HIV+ persons in service agency and clinical settings across the US. The following programs are part of the CDC’s Replicating Effective Programs initiative.¹⁵ Healthy Relationships is a five-session risk-reduction group intervention for men and women. The program focuses on developing decision-making and problem-solving skills for making informed and safe decisions about disclosure and behavior. The groups allow HIV+ persons to interact, examine their risks, develop skills to reduce their risks and receive feedback from others. Participants reported significantly less unprotected intercourse and greater condom use at six-month follow-up.¹⁶ Choosing Life: Empowerment, Action, Results (CLEAR) offers HIV+ youth 18 one-on-one 90-minute sessions with a counselor. CLEAR seeks to build motivation and enhance self-esteem so that youth can learn to choose healthy activities over self destructive behaviors. CLEAR is divided into three modules: substance use, sexual decision-making and self care. Youth also can choose telephone sessions instead of in person sessions. Youth participating reported having fewer sexual partners, using fewer drugs and feeling less emotional distress.¹⁷ CLEAR is now known as Street Smart. Partnership for Health trained staff in HIV medical clinics to provide brief, safer-sex counseling supplemented by written information and clinic posters. The program found that counseling emphasizing the negative consequences of unsafe sex helped reduce risky behaviors with patients who reported 2 or more partners.¹⁸

what needs to be done?

Prevention programs with HIV+ persons need to pay attention to structural barriers to safer sexual and drug use behavior. For some HIV+ persons, barriers may include housing instability, lack of access to HIV care and repeated incarceration. The challenges of sexual and drug risk behavior, disclosure and responsibility need to be placed in social and structural contexts that are meaningful to HIV+ persons. There is a need to further examine how early childhood and adult trauma, sexual abuse, coming out, racism and homophobia affect an HIV+ person’s ability to maintain safer behaviors. More emphasis should be placed on couples and sexual partners, both in research and in prevention programs, because sexual risk behavior among HIV+ persons is often a shared risk decision within couples/partners.¹⁹ Prevention with positives programs present the opportunity and challenge of forging relationships and integrating services in areas that have not traditionally worked together. Treatment, prevention and social services need to work in tandem, helping clients deal with the multiple issues they may face. Involving HIV+ persons is key. Prepared by Kelly Knight MEd and Carol Dawson-Rose RN PhD, CAPS

Says who?

1. Glynn M, Rhodes P. Estimated HIV prevalence in the United States at the end of 2003. Presented at the National HIV Prevention Conference, Atlanta, GA. 2005. Abst #595. 2. Janssen RS, Valdiserri RO. HIV prevention in the Unites States: increasing emphasis on working with those living with HIV. Journal of AIDS. 2004;37:S119-S121. 3. Marks G, Crepaz N, Senterfitt JW, et al. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States. Journal of AIDS. 2005;39:446-453. 4. Crepaz N, Marks G. Towards an understanding of sexual risk behavior in people living with HIV: a review of social, psychological and medical findings. AIDS. 2002;16:135-149. 5. Centers for Disease Control and Prevention. Advancing HIV prevention: new strategies for a changing epidemic – United States, 2003. Morbidity and Mortality Weekly Report. 2003;52:329-332. 6. Herek GM, Capitanio JP, Widaman KF. Stigma, social risk, and health policy: public attitudes toward HIV surveillance policies and the social construction of illness. Health Psychology. 2003;22:533-540. 7. Knight KR. With a little help from my friends: community affiliation and perceived social support. In HIV+ Sex. PN Halkitis, CA Gómez, RJ Wolitsky, eds. American Psychological Association; Washington DC. 2005. 8. Parsons JT, Missildine W, Van Ora J, et al. HIV serostatus disclosure to sexual partners among HIV-positive injection drug users. AIDS Patient Care and STDs. 2004;18:457-469. 9. 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. 10. Wolitski RJ, Bailey CJ, O’Leary A, et al. Self-perceived responsibility of HIV-seropositive men who have sex with men for preventing HIV transmission. AIDS and Behavior. 2003;7:363-372. 11. Parsons JT, Schrimshaw EW, Wolitski RJ, et al. Sexual harm reduction practices of HIV-seropositive gay and bisexual men: serosorting, strategic positioning, and withdrawal before ejaculation. AIDS. 2005;19:S13-S25. 12. Grant RM, McConnell JJ, Herring B, et al. No superinfection among seroconcordant couples after well-defined exposure. Presented at the International Conference on AIDS. 2004. Abst #ThPeA6949. 13. National Association of People with AIDS. Principles of HIV prevention with positives. www.napwa.org/pdf/PWPPrinciples.pdf (Accessed 4/20/06) 14. Dawson-Rose C, Shade SB, Lum P, et al. The healthcare experience of HIV positive injection drug users. Journal of Multicultural Nursing and Health. 2005;11:23-30. 15. https://www.cdc.gov/hiv/effective-interventions/index.html (Accessed 4/20/06) 16. Kalichman SC, Rompa D, Cage M, et al. Effectiveness of an intervention to reduce HIV transmission risks in HIV-positive people. American Journal of Preventive Medicine. 2001;21:84-92. 17. Rotheram-Borus MJ, Swendeman D, Comulada WS, et al. Prevention for substance-using HIV-Positive young people: telephone and in-person delivery. Journal of AIDS. 2004;37:S68-S77. 18. Richardson JL, Milam J, McCutchan A, et al. Effect of brief safer-sex counseling by medical providers to HIV-1 seropositive patients: A multi-clinic assessment. AIDS.2004;18:1179-1186. 19. Remien RH, Wagner G, Dolezal C, et al. Factors associated with HIV sexual risk behavior in male couples of mixed HIV status. Journal of Psychology and Human Sexuality. 2001;13:31-48.

September 2005. Fact Sheet #37ER Special thanks to the following reviewers of this Fact Sheet: Latoya Conner, Keith Folger, Mari Gasiorowicz, Trevor Hart, Gregory Herek, Jessica Merron-Brainerd, Katie Mosack, Judith Moskowitz, Lisa Orban, Robert Remien, Kurt Schroeder, Stephen Trujillo, Tim Vincent.

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]. ©Sepetmber 2005, University of California

Is Mother-to-Child HIV Transmission Preventable?

Prepared by Sarah A. Gutin, MPH* *CAPS, Community Health Systems- School of Nursing, UCSF Fact Sheet #34ER – September 2015 Special thanks to the following reviewers of this Fact Sheet: Yvette Cuca, Carol Dawson Rose, Shannon Weber In 2012, there were 2.3 million new HIV infections globally [1]. A large proportion of people newly diagnosed with HIV worldwide are in their reproductive years and these men and women are likely to want children in the future [2-4]. Addressing the sexual and reproductive health and rights of this population is critical to addressing the spread of HIV because HIV infection in childbearing women is the main cause of HIV infection in children [5]. Treatment for those who are already infected is also central to stopping the spread of HIV to infants and to uninfected sexual partners.

How does transmission occur?

Perinatal transmission of HIV, also called vertical transmission, occurs when HIV is passed from an HIV-positive woman to her baby during pregnancy, labor and delivery or breastfeeding. For an HIV-positive woman not taking HIV medications, the chance of passing the virus to her child ranges from about 15 to 45% during pregnancy, labor and delivery. If she breastfeeds her infant, there is an additional 35 to 40% chance of transmission [6].

Is the risk of perinatal transmission always the same?

No. Global societal and economic inequities create a wide gap between women in developing nations and women in developed nations with regard to HIV prevention, voluntary counseling and testing and access to drugs which treat HIV infection and can prevent perinatal transmission. Developed countries- In many developed countries, pediatric HIV has been virtually eliminated [7]. In the US in 1994, the Public Health Service recommended HIV counseling and voluntary testing and AZT therapy for all pregnant women after the clinical trial known as “076” showed that AZT reduced rates of MTCT by two-thirds. Since then, a combination of interventions that includes treatment with ART to control the virus and make it undetectable, cesarean delivery, and avoidance of breastfeeding has helped further reduce perinatal transmission in the US, from an estimated 1,500 cases in 1992 to an estimated 162 perinatal infections in 2010 [8]. Although the estimated number of perinatal HIV infections in the US continues to decline, women of color, especially black/African American women are disproportionately affected by HIV infection and as a result, perinatal HIV infection is highest among blacks/African Americans (63%), followed by Hispanics/Latinas (22%) [8]. Although effective interventions have led to a significant reduction in the number of perinatal infections in the US, perinatal transmission still occurs. To close the final gap, the CDC has proposed a new framework to eliminate mother-to-child HIV transmission (EMCT) in the US [8]. This framework focuses on key areas including: comprehensive reproductive health care (that includes both family planning (FP) and preconception care) and comprehensive case-finding of pregnancies in HIV-infected women that is conducted through comprehensive clinical care and case management services for women and infants; case review and community action; continuous quality research in prevention and long-term monitoring of HIV-exposed infants; and thorough data reporting for HIV surveillance at the state and local health department levels [8 9]. Developing countries- Unfortunately, perinatal transmission of HIV continues to plague many developing countries despite recent prevention acceleration. In 2008, an estimated 1.4 million pregnant women in low and middle-income countries were living with HIV, of whom about 90% were in sub-Saharan African countries [7]. In 2012, UNAIDS reported that approximately 210,000 children became HIV infected [1].

Can perinatal transmission of HIV be reduced?

Yes. Perinatal transmission encompasses a variety of highly effective interventions that have huge potential to improve maternal and child health. Advances in treatment and new classes of drugs have provided the opportunity to greatly reduce rates of perinatal transmission worldwide. Also, perinatal transmission can be reduced by preventing unintended pregnancies. Preventing unintended pregnancies is one of the most effective ways to prevent HIV infection in infants and stop spread of the epidemic to children [10]. For that reason, preventing unintended pregnancies among women living with HIV and offering family planning to delay, space or end childbearing is one of the four WHO pillars in the comprehensive approach to preventing perinatal transmission [7]. However, we have still not addressed the root cause of perinatal transmission, mainly heterosexual HIV transmission. The best way to prevent perinatal HIV transmission is to prevent HIV transmission in the mother and father. In order to reduce perinatal transmission, all pregnant women should have access to free or low-cost prenatal care and voluntary HIV testing and counseling. If a pregnant woman is HIV-positive, she should have access to lifelong ART to treat HIV and improve her own health and to decrease the chances of HIV infection in her infant. In June 2013, the WHO published updated guidelines on the diagnosis of HIV, the care of people living with HIV(PLHIV) and the use of ART for treating and preventing HIV infection [1]. In the US, the Department of Health and Human Services recommends that all HIV-infected pregnant women should be given ART during pregnancy to prevent perinatal transmission of HIV, regardless of whether ART is indicated for the woman’s own health [11]. Perinatal transmission can be reduced to less than 2% if a woman is on ART, has a low or undetectable viral load, follows the recommended treatment regimen and does not breastfeed [7 8]. Careful management during labor and delivery can also help reduce perinatal transmission, for example by avoiding unnecessary instrumentation and not prematurely rupturing membranes [12]. Also, although universal prenatal HIV testing is the standard in the US, if prenatal care has not been provided, the patient has HIV, or her HIV status is undocumented, it is critical for hospitals to determine a laboring patient’s HIV status upon admission. Even without the use of ART during the pregnancy, the use of ART during labor and for the infant can reduce the risk of perinatal transmission to between 6 to 13% [13]. It is therefore recommended that rapid HIV testing be performed in Labor and Delivery units on pregnant women with no HIV test during their pregnancy or with risk factors for infection since their last test [14]. In developing countries, perinatal transmission has been a priority since 1998, following the success of short-course zidovudine and single-dose nevirapine clinical trials [7]. In recent years, single-dose nevirapine as the primary antiretroviral medicine option for HIV-positive pregnant women to prevent transmission to their infants has been phased out, in favor of more effective and simplified triple ART regimens [1]. The WHO now recommends that all pregnant and breastfeeding women with HIV, regardless of CD4 count or clinical stage, should initiate a triple ART regimen which should be maintained for the duration of perinatal transmission risk, which includes pregnancy, delivery and throughout the breastfeeding period (this is known as Option B). In countries were more than one percent of the population has HIV (these are known as generalized epidemics) and where there is often limited access to tests that indicate the severity of HIV illness (such as CD4 testing), limited partner testing, long duration of breastfeeding and high rates of fertility, the WHO recommends that women meeting treatment eligibility criteria should continue lifelong ART (this strategy is referred to as Option B+) [12]. There are many benefits to lifelong treatment for all pregnant and breastfeeding women and these include increased coverage of those needing ART for their own health, a reduction in the number of women stopping and starting ART during repeat pregnancies, early protection against perinatal transmission in future pregnancies, reduced risk of infecting a partner who is HIV-negative and decreased risk of medication failure or the development of resistance [12]. The ultimate goal is to find the most effective and sustainable regimens for HIV treatment and the prevention of perinatal transmission worldwide. Economics, politics, poor infrastructure, access to healthcare and medications, stigma and cultural norms all pose significant challenges to providing this standard of care everywhere and not all PLHIV have equal access to treatment.

What are the barriers to the prevention of perinatal transmission?

Pregnant women face many difficult decisions, including decisions around HIV testing, treatment options and infant feeding. Understanding the barriers that women face and addressing barriers at various levels can help in realizing the full potential of prevention of perinatal transmission programs. A recent review article found that barriers to the prevention of perinatal transmission often fell into three broad categories that included the individual, their partners and community, and health systems [15]. At the individual level, studies suggest that a lower maternal education level, younger maternal age, and poor knowledge of HIV transmission and ART are associated with not receiving and/or not taking ART in order to treat and prevent the spread of HIV [15]. Additionally, a woman’s male partner(s), extended family, greater community and health care setting all influence her decision and ability to take advantage of prevention of perinatal transmission programs. Many qualitative studies have found that stigma regarding HIV status and fear of disclosure to partners and family members is a major barrier to the uptake of perinatal prevention interventions [15]. Women living with HIV also continue to report that stigma and discrimination, especially in health care settings, continue to be a barrier to accessing adequate information and services [1]. In various studies, PLHIV have reported negative staff attitudes and this has been cited as a barrier to returning to facilities for care [15]. In developing countries, health systems issues are also a barrier to greater prevention uptake. Key barriers that have been identified include a shortage of trained clinic staff, high patient volumes, long wait times, and brief and poor counseling sessions [15]. In addition, a lack of access or shortages of medications, including ART, as well as stock-outs of HIV test kits and condoms have been reported. Poor access to healthcare overall (long distances to facilities) and poor integration of services also contributes to low ART uptake.

What about breastfeeding?

Breastfeeding is usually the healthiest choice for both infants and mothers. However, HIV transmission can occur during breastfeeding, with chances of transmission increasing the longer the infant is breastfed. In the countries with the highest perinatal HIV rates, it is estimated that more than half of the children newly infected with HIV acquire it during the breastfeeding period [1]. However, the risk of transmitting HIV to infants through breastfeeding is low in the presence of ART [12]. Therefore, providing ART to mothers throughout the breastfeeding period is a critical step needed to further reduce rates of perinatal transmission [1]. It is recommended that HIV-positive mothers do not breastfeed when formula feeding is safe, well accepted and readily available. In the US, both the Centers for Disease Control and Prevention and the American Academy of Pediatrics recommends that HIV-infected women refrain from breastfeeding regardless of their ART status to avoid postnatal transmission of HIV to their infants through breast milk [16 17]. However, formula feeding requires clean water for mixing formula. Many women in developing countries do not have access to clean water or sanitation and cannot afford formula, and therefore cannot avoid breastfeeding. In developing countries where breastfeeding is the norm, formula feeding may also alert a woman’s family or community that she is HIV-positive, which may result in stigma or other negative repercussions. Therefore, the WHO recommends that when breastfeeding is unavoidable, mothers should take ART while breastfeeding and that infants should receive 6 weeks of prophylaxis with once-daily nevirapine [12]. The WHO further recommends that mothers known to be infected with HIV (and whose infants are HIV uninfected or of unknown status) should exclusively breastfeed for the first 6 months of life, introducing appropriate complementary foods thereafter, and continue breastfeeding for the first 12 months of life. It is recommended that breastfeeding should only stop when a nutritionally adequate and safe diet without breast-milk can be provided [12]. Access to ARVs during this extended breastfeeding period is critical [12].

What’s being done?

Primary prevention of HIV among men and women of childbearing age: Various tools are now available to prevent HIV infections in men and women of childbearing age. Pre-exposure prophylaxis (PrEP), which is a special course of HIV treatment that aims to prevent people from becoming infected with HIV, has been found to protect against HIV-1 infection in heterosexual men and women and reduce HIV transmission by 67 to 75% [18 19]. PrEP is intended for people at-risk of becoming infected with HIV, for example in the case of couples where one partner is HIV-positive and the other is HIV-negative. In countries with generalized HIV epidemics, voluntary medical male circumcision for HIV-negative male partners in relationships with a positive partner has been shown to reduce the risk of HIV-acquisition in men by between 38% to 66% [20]. Using ART to decrease the chance of HIV transmission, a concept known as treatment as prevention, has also recently been found to be very efficacious, with studies in heterosexual populations showing that adherence to ART is very effective at preventing transmission of HIV to HIV-negative partners [21-23]. Couples-testing with treatment for infected partners in discordant partnerships is also a promising approach. Integrating couples counseling and partner testing into routine clinic and community services can increase the number of couples in which the status of both partners is known and can help identifying sero-discordant couples [24]. Preventing unintended pregnancies and Safer Conception Options: Preventing unintended pregnancies among women living with HIV (WLHIV) is a powerful prevention strategy. One study found that even modest reductions in the numbers of pregnancies among WLHIV could avert HIV-positive births at the same rates as the use of ART for PMTCT [25]. One targeted approach to strengthening FP programs is to integrate FP within HIV services. In Kenya, a recent cluster-randomized trial tried to determine whether integrating FP services into HIV care was associated with increased use of more effective contraceptive methods such as sterilization, IUDs, implants, injectables and oral contraceptives. Women seen at integrated sites were significantly more likely to use more effective methods of FP at the end of the study [26]. This makes the case for integrating FP within HIV care. Reducing the unmet need for FP will reduce new HIV infections among children and improve overall maternal and infant health. For HIV-positive or serodiscordant couples who would like to have children, there are many options available to make conception safer. When offering preconception care, HIV-positive couples will have specific needs, many of which can be addressed during their routine HIV care. When offering preconception counseling for HIV-positive women, the CDC recommends that health care providers should discuss a variety of topics, including: reproductive options and actively assessing women’s pregnancy intentions on an ongoing basis; Counseling on safe sexual practices that prevent HIV transmission to sexual partners, protect women from acquiring sexually transmitted diseases, and reduce the potential to acquire more virulent or resistant strains of HIV; Using ART to attain a stable, maximally suppressed maternal viral load prior to conception to decrease the risk of perinatal transmission and of HIV transmission to an uninfected partner; and encouraging sexual partners to receive counseling and HIV testing and, if infected, to seek appropriate HIV care[11]. For couples who want to conceive, in which one or both are HIV-positive, the positive partner should be on ART and have achieved maximal suppression of HIV infection. ART for the positive partner may not be fully protective against sexual transmission of HIV and so the administration of PrEP for the HIV-negative partner may offer an additional tool to reduce the risk of transmission. For discordant couples, when the positive partner is a woman, the safest conception option is artificial insemination. In discordant couples where the positive partner is male, the safest conception option is the use of donor sperm from an HIV-uninfected male with artificial insemination. When the use of donor sperm is unacceptable, the use of sperm preparation techniques together with either intrauterine insemination or in vitro fertilization is an option [11]. Preventing HIV transmission from WLHIV to infants: Increasing access to ART for WLHIV is critical to saving the lives of women and their children. The number of pregnant WLHIV receiving ART for their own health has increased from 25% in 2009 to 60% in 2012 [1]. One of the greatest success stories has been in Malawi where a policy of providing lifelong ART to all pregnant and breastfeeding women (irrespective of CD4 count or clinical status– a strategy referred to as Option B+) was enacted in 2011. Since then, Malawi increased the estimated coverage of women in need of ART from 13% in 2009 to 86% in 2012. The implementation of Option B+ has resulted in a 748% increase in the number of pregnant and breastfeeding women starting ART, from 1,257 in the second quarter of 2011 to 10,663 in the third quarter of 2012 [27]. As a result of Option B+, the perinatal transmission rate for women on ART is expected to be reduced, from approximately 40% without intervention to less than 5%. By decentralizing treatment services and offering lifelong HIV treatment to all pregnant and breastfeeding women, Malawi has been able to increase ART coverage both during pregnancy and the breastfeeding period [1]. Providing treatment, care and support to WLHIV and their children and families: Increasing access to ART for pregnant women living with HIV for their own health is critical to saving the lives of women and their children. Even developing countries, which at first lagged behind in reducing the number of children newly infected with HIV, have made great gains in recent years. In 2013, UNAIDS reported that in 7 high burden countries where access to treatment has increased, the rates of HIV transmission to children has fallen by 50% or more [1].

What still needs to be done?

HIV is a preventable disease. Perinatal transmission is best prevented by effective, accessible and sustainable HIV prevention, access to HIV testing, early diagnosis and linkage to treatment programs for women, men and their children, access to family planning and abortion services to prevent unintended pregnancies, and access to an ongoing supply of ARVs to improve the health of women and their children. Structural interventions are also needed that increase access to health centers, improve health care infrastructure, provide food supplementation, and HIV treatments. Women are the key to the HIV response and the number of women acquiring HIV has to be reduced. All women have a right to be treated for HIV infection, not simply because they are bearing a child. All women living with HIV who are eligible for ART need to have access to it. Unfortunately, too many women are still lost along the prevention cascade and never get the care or treatment they need and deserve. Providing women with access to high quality healthcare for themselves and their families, whether they are HIV-positive or not, is imperative.

Says who? 1. UNAIDS. AIDS by the numbers. Geneva, Switzerland, 2013. 2. Kanniappan S, Jeyapaul MJ, Kalyanwala S. Desire for motherhood: exploring HIV-positive women’s desires, intentions and decision-making in attaining motherhood. AIDS care 2008;20(6):625-30 doi: 10.1080/09540120701660361[published Online First: Epub Date]|. 3. Beyeza-Kashesya J, Kaharuza F, Mirembe F, et al. The dilemma of safe sex and having children: challenges facing HIV sero-discordant couples in Uganda. African health sciences 2009;9(1):2-12 4. Cooper D, Moodley J, Zweigenthal V, et al. Fertility intentions and reproductive health care needs of people living with HIV in Cape Town, South Africa: implications for integrating reproductive health and HIV care services. AIDS and behavior 2009;13 Suppl 1:38-46 doi: 10.1007/s10461-009-9550-1[published Online First: Epub Date]|. 5. UNAIDS. We Can Prevent mothers fom dying and babies from becoming infected with HIV. Geneva, Switzerland, 2010. 6. De Cock KM, Fowler MG, Mercier E, et al. Prevention of mother-to-child HIV transmission in resource-poor countries: translating research into policy and practice. JAMA : the journal of the American Medical Association 2000;283(9):1175-82 7. WHO. PMTCT Strategic Vision 2010-2015: Preventing mother-to-child transmission of HIV to reach the UNGASS and Millenium Development Goals. Geneva, Switzerland, 2010. 8. CDC. HIV Among Pregnant Women, Infants, and Children in the United States. Atlanta, 2012. 9. Nesheim S, Taylor A, Lampe MA, et al. A framework for elimination of perinatal transmission of HIV in the United States. Pediatrics 2012;130(4):738-44 doi: 10.1542/peds.2012-0194[published Online First: Epub Date]|. 10. Nakayiwa S, Abang B, Packel L, et al. Desire for children and pregnancy risk behavior among HIV-infected men and women in Uganda. AIDS and behavior 2006;10(4 Suppl):S95-104 doi: 10.1007/s10461-006-9126-2[published Online First: Epub Date]|. 11. Department of Health and Human Services Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. In: Bureau HA, ed. Washington, DC, 2014. 12. WHO. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: Recommendations for a public health approach. Geneva, Switzerland, 2013. 13. Kourtis AP, Lee FK, Abrams EJ, et al. Mother-to-child transmission of HIV-1: timing and implications for prevention. The Lancet infectious diseases 2006;6(11):726-32 doi: 10.1016/S1473-3099(06)70629-6[published Online First: Epub Date]|. 14. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control 2006;55(RR-14):1-17; quiz CE1-4 15. Gourlay A, Birdthistle I, Mburu G, et al. Barriers and facilitating factors to the uptake of antiretroviral drugs for prevention of mother-to-child transmission of HIV in sub-Saharan Africa: a systematic review. Journal of the International AIDS Society 2013;16(1):18588 doi: 10.7448/IAS.16.1.18588[published Online First: Epub Date]|. 16. American Academy of Pediatrics Committee on Pediatric A. HIV testing and prophylaxis to prevent mother-to-child transmission in the United States. Pediatrics 2008;122(5):1127-34 doi: 10.1542/peds.2008-2175[published Online First: Epub Date]|. 17. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Secondary Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States.  18. Celum C, Baeten JM. Tenofovir-based pre-exposure prophylaxis for HIV prevention: evolving evidence. Current opinion in infectious diseases 2012;25(1):51-7 doi: 10.1097/QCO.0b013e32834ef5ef[published Online First: Epub Date]|. 19. Baeten JM, Donnell D, Ndase P, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. The New England journal of medicine 2012;367(5):399-410 doi: 10.1056/NEJMoa1108524[published Online First: Epub Date]|. 20. Siegfried N, Muller M, Deeks JJ, et al. Male circumcision for prevention of heterosexual acquisition of HIV in men. The Cochrane database of systematic reviews 2009(2):CD003362 doi: 10.1002/14651858.CD003362.pub2[published Online First: Epub Date]|. 21. Donnell D, Baeten JM, Kiarie J, et al. Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis. Lancet 2010;375(9731):2092-8 doi: 10.1016/S0140-6736(10)60705-2[published Online First: Epub Date]|. 22. Grant RM, Lama JR, Anderson PL, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. The New England journal of medicine 2010;363(27):2587-99 doi: 10.1056/NEJMoa1011205[published Online First: Epub Date]|. 23. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. The New England journal of medicine 2011;365(6):493-505 doi: 10.1056/NEJMoa1105243[published Online First: Epub Date]|. 24. Medley A, Baggaley R, Bachanas P, et al. Maximizing the impact of HIV prevention efforts: Interventions for couples. AIDS care 2013 doi: 10.1080/09540121.2013.793269[published Online First: Epub Date]|. 25. Sweat MD, O’Reilly KR, Schmid GP, et al. Cost-effectiveness of nevirapine to prevent mother-to-child HIV transmission in eight African countries. Aids 2004;18(12):1661-71 26. Grossman D, Onono M, Newmann SJ, et al. Integration of family planning services into HIV care and treatment in Kenya: a cluster-randomized trial. Aids 2013;27 Suppl 1:S77-85 doi: 10.1097/QAD.0000000000000035[published Online First: Epub Date]|. 27. Centers for Disease Control and Prevention. Impact of an innovative approach to prevent mother-to-child transmission of HIV–Malawi, July 2011-September 2012. MMWR. Morbidity and mortality weekly report 2013;62(8):148-51

¿Qué necesitan los hombres negros para evitar el VIH?

¿quiénes son los hombres negros?

Los hombres negros y los afroamericanos no se pueden encasillar en una sola categoría “unitalla”. Ellos son padres, hermanos, tíos e hijos en las comunidades negras. Son médicos, abogados, barberos y conductores de autobuses; son cristianos y musulmanes y hablan muchos idiomas. Sin embargo, no toda persona de aspecto negro o afroamericano se identifica con estas etiquetas. En EEUU, los hombres negros son un grupo diverso que abarca, entre otros, a afrocubanos, caribeños, brasileños y africanos.

¿por qué el VIH es una preocupación?

Actualmente, el VIH es una crisis de salud mayúscula entre los hombres negros y afroamericanos de cualquier edad u orientación sexual.¹ En el año 2000, el SIDA fue la primera causa de muerte entre los hombres negros de 35-44 años de edad y la tercera causa de muerte de hombres negros entre 25 y 44 años de edad.² Las tasas del VIH entre afroamericanos jóvenes que tienen sexo con otros hombres (HSH) son más elevadas que entre cualquier otro grupo racial o étnico.² El VIH/SIDA no es la primera crisis de salud que encaran los hombres negros, ni será la última. Los hombres negros afrontan muchas disparidades médicas y están desproporcionadamente afectados por muchas enfermedades como la hipertensión, el cáncer y las cardiopatías. El VIH plantea otro tipo de desafío debido a su transmisión por medio del contacto sexual y del consumo de drogas, temas difíciles de tocar y cargados de estigma en muchas comunidades.

¿cuáles son los factores de riesgo del VIH?

La primera causa de infección por VIH entre los hombres afroamericanos es el sexo, ya sea con hombres o con mujeres.¹ En EE.UU. hemos confundido la conducta sexual con la identificación sexual de los hombres negros.³ Por ejemplo, un hombre negro que tiene sexo con hombres y mujeres puede pertenecer a la clasificación de riesgo de los CDC (centros de control de enfermedades) de “contacto sexual de hombre a hombre;” por los investigadores como “bisexual” o “HSH,” por la prensa como “incógnitos” o que tienen relaciones con otros hombres discretamente (on the down low), por grupos activistas como “amante del mismo sexo” o por sus parejas como “heterosexual.” El consumo de drogas inyectables es la segunda causa de infección por VIH entre hombres negros¹. Muchos consumidores de drogas padecen adicción, pobreza, falta de vivienda, estigma, depresión, enfermedad mental y trauma anterior, todas éstas situaciones que favorecen la transmisión del VIH, por ejemplo al compartir equipos de inyección.⁴

¿qué afecta al riesgo del VIH?

Sabemos que el VIH se transmite entre hombres (sean negros o no) por medio del sexo anal o vaginal sin protección con una persona VIH+ o por usar los equipos de inyección de una persona VIH+. Sabemos mucho menos sobre el efecto de las fuerzas psicosociales, contextuales, políticas e históricas sobre las prácticas de riesgo de los hombres negros. Es necesario resolver los problemas de educación, empleo y encarcelamiento, especialmente entre los hombres marginados económicamente. Los hombres negros y afroamericanos son discriminados en la educación y en el empleo. En la escuela, muchos niños negros son etiquetados como “problemáticos” y son remitidos a clases de “educación especial,” lo cual reduce el número de varones negros que ingresan a la escuela secundaria.⁵ Consecuentemente, muchos hombres negros no consiguen empleo bien remunerado y quedan sumamente desfavorecidos en nuestra economía tecnológica. La falta de empleo está vinculada con condiciones que pueden aumentar el riesgo del VIH, tales como el consumo de alcohol y drogas, el sexo comercial, la falta de vivienda y el encarcelamiento. Casi la tercera parte de los hombres negros han estado encarcelados como adolescentes o adultos.⁶ El ciclo de entrar, salir y regresar a la cárcel puede perjudicar la capacidad de los hombres negros de encontrar y mantener tanto empleo como relaciones personales. Entre menos hombres negros haya en la comunidad, menos oportunidades tendrán las parejas negras para la monogamia a largo plazo y mayores serán las posibilidades de tener múltiples parejas, lo que puede aumentar el riesgo de transmitir el VIH/ETS.⁷ En EE.UU. existe una larga historia de explotación y objetivización sexual del varón negro. Con frecuencia a los hombres negros se les describe según su supuesta afición o proeza sexual en lugar de reconocerlos como seres complejos y multidimensionales con sus fortalezas y debilidades.⁸

¿cuáles son los factores protectores?

Muchas organizaciones en todo el país promueven la fuerza y la unidad entre hombres negros. Grupos fraternales, barberías y grupos cívicos, como “100 Black Men” y otros, fortalecen a los hombres negros ofreciéndoles modelos positivos a seguir, promoviendo la historia y cultura afroamericana y colaborando con empresas y universidades.⁹ Los sistemas de apoyo familiares, comunitarios y espirituales son importantes para proteger a los jóvenes negros contra el VIH. Las familias unidas con padres que vigilen a sus hijos y hablen con ellos son la clave para promover conductas saludables.¹⁰ Las iglesias negras pueden ofrecer información sobre la prevención del VIH; también pueden poner el ejemplo respondiendo a las necesidades de los consumidores de drogas, homosexuales y personas VIH+ sin estigmatizarlos.¹¹

¿qué se está haciendo al respecto?

Se implementó un programa de prevención el VIH con adolescentes afroamericanos en Filadelfia, PA, que abarcaba tanto la abstinencia sexual como la protección durante las relaciones sexuales. Los participantes de la intervención de abstinencia reportaron menos actos sexuales después de 3 meses, pero no en las encuestas de seguimiento realizadas a los 6 y 12 meses después. Entre los jóvenes con experiencia sexual anterior al programa, aquellos que participaron en la intervención sobre el sexo más seguro reportaron menos actos sexuales que los participantes de la intervención de abstinencia según las encuestas de seguimiento realizadas a los 3, 6 y 12 meses. Ambos métodos redujeron a corto plazo las conductas riesgosas con respecto al VIH, pero es posible que las intervenciones enfocadas en la protección en el sexo tengan efectos más duraderos que las intervenciones sobre la abstinencia, y que también logren mejores resultados entre jóvenes con previa experiencia sexual.¹² Desde hace muchos años, “People of Color in Crisis” (POCC) en Brooklyn, NY ofrece actividades de prevención del VIH/SIDA y otras intervenciones para hombres y mujeres negras. “Many Men, Many Voices” es una intervención grupal interactiva y experiencial para hombres homosexuales no caucásicos. Sus facilitadores capacitados dirigen seis sesiones semanales para ayudar a los hombres a sentirse protegidos y aceptados con un apoyo social positivo.¹³ “Concerned Black Men” (CBM) es una organización de servicio establecida y dirigida por hombres negros con el fin de ofrecer modelos positivos a seguir a los niños negros. CBM tiene 21 sedes a lo largo de EE.UU. que brindan programas de prevención de la violencia, el consumo del alcohol y drogas, del embarazo y de ETS/VIH, al tiempo que promueven la autoestima, resolución de conflictos y plantación para asistir a la universidad.¹⁴ El “Down Low Barbershop Project” colabora con barberos y estilistas en comunidades negras para brindar a los hombres negros información sobre el VIH, condones y recomendaciones para pruebas y consejería de VIH gratuitas. Los barberos participan en dos capacitaciones de 8 horas sobre la prevención del VIH y luego reclutan a diez clientes para que asistan a una capacitación de 4 horas. La participación de los propietarios de barberías, barberos y clientes es pagada, y los clientes que asisten reciben un vale para un corte de pelo gratuito. El Down Low Barbershop Project se realiza a través de los programas “Brother to Brother” en Seattle, WA y “Us Helping US” en Washington, DC.¹⁵

¿qué queda por hacer?

Las agencias de prevención del VIH deberán reconocer las bases culturales y sociales de la comunidad negra.¹⁶ La brecha entre ricos y pobres sigue creciendo y la mayoría de las infecciones por VIH ocurre en comunidades pobres.³ Los programas deben responder a los problemas de empleo, educación, encarcelamiento, adicción y estigma, además de las conductas riesgosas relacionadas con el sexo y con el consumo de drogas. Para contar con un ambiente de confianza que favorezca las conversaciones abiertas sobre temas delicados relacionados con el sexo y con el consumo de drogas, los programas de investigación y de prevención deben llevarse a cabo en ambientes familiares lejos de los clubes, bares y otros lugares donde prevalece el sexo.¹⁷ La colaboración con organizaciones culturales, religiosas y cívicas que históricamente han llegado a los hombres negros puede ayudar a reclutar e involucrar a estos hombres.¹⁸ Los programas de prevención deben vincularse con programas de tratamiento de drogas, prevención de la violencia, enriquecimiento académico, planificación familiar, fortalecimiento cultural y organizaciones empresariales; todo esto con el fin de apoyar a los hombres negros en general tomando en cuenta la riqueza y la complejidad de la vida moderna del hombre negro.

¿quién lo dice?

1.Centers for Disease Control and Prevention. HIV/AIDS among African Americans. 2003.https://www.cdc.gov/hiv/group/racialethnic/africanamericans/index.html  2. Key Facts: African Americans and HIV/AIDS. Report published by the Kaiser Family Foundation. September 2003.http://www.kff.org/hivaids/hiv6090chartbook.cfm 3. Beatty LA, Wheeler D, Gaiter J. HIV prevention research for African Americans: current and future directions. Journal of Black Psychology. 2004;30:40-58. 4. Galea S, Vlahov D. Social determinants and the health of drug users: socioeconomic status, homelessness and incarceration. Public Health Reports. 2002;117: S135-S145. 5. Davis JE. Early schooling and academic achievement of African American males. Urban Education. 2003;38:515-537. 6. Braithwaite RL, Arriola KR. Male prisoners and HIV prevention: a call for action ignored. American Journal of Public Health. 2003;93:759-763. 7. Adimora A, Schoenbach VJ. Contextual factors and the Black-White disparity in heterosexual HIV transmission. Epidemiology. 2002;13:707-712. 8. Whitehead TL. Urban low-income African American men, HIV/AIDS, and gender identity. Medical Anthropology Quarterly. 1997;11:411-447. 9. Bailey DF, Paisley PO. Developing and nurturing excellence in African American male adolescents. Journal of Counseling and Development. 2004;82:10-17. 10. “This is my reality–the price of sex: an inside look at Black urban youth sexuality and the role of the media.” Report published by Motivational Educational Entertainment. January 2004. https://www.meeproductions.com/ 11. Miller RL. African American churches at the crossroads of AIDS. FOCUS. 2001;10:1-5. 12. Jemmott JB III, 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. 13. People of Color in Crisis (POCC), Brooklyn, NY. http://www.pocc.org/ 14. Concerned Black Men, Washington, DC. http://www.cbmnational.org/ 15. Sanders E. Seattle HIV program enlists barbershops: Black men get a trim and a frank discussion. The Boston Globe. January 1, 2004. The Down Low Barbershop Program: www.brotobro.com, www.ushelpingus.com. 16. Darbes LA, Kennedy GE, Peersman G, et al. Systematic review of HIV behavioral prevention research in African Americans. The Cochrane Review. March 2002. 17. Malebranche DJ. Black men who have sex with men and the HIV epidemic: next steps for public health. American Journal of Public Health. 2003;93:862-865. 18. Summerrise R, Wilson W. “The Black Print” model for recruitment of African-American males. Published by the Chicago, IL, Prevention Planning Group. 2000.

Preparado por Darrell P. Wheeler, PhD, MPH, ACSW; Hunter College, NY Traducción Rocky Schnaath Enero 2005. Hoja Informativa 54S

¿Qué necesítan los sordos en la prevención del VIH?

¿están a riesgo de contraer el VIH?

Si. Se estima que en los EEUU existen de 7,000 a 26,000 personas carentes del sentido auditivo infectadas con el VIH.¹ Sin embargo, los Centros para el Control de Enfermedades (CDC por sus siglas en Inglés) actualmente no recopilan información acerca de los que padecen de sordera y VIH o SIDA. Maryland fue el primer estado en incluir preguntas relacionadas con el sentido auditivo en el área de consejería y al realizar pruebas de detección. En Maryland, el 4.3% de la población sorda padecen de la infección con VIH.² Existen cerca de dos millones de personas que no pueden oir, y una de cada 10 Norteamericanos padecen de problemas auditivos. Las personas que carecen del sentido auditivo han luchado por mucho tiempo por obtener igualdad en acceso a servicios sociales y médicos, educación y empleos. Actualmente en los EEUU, existe poca información sobre VIH y sordera, pocos servicios de prevención o tratamiento, y escasa investigación para los sordos.³

¿cuáles son los factores de riesgo?

Existen altos índices de abuso de substancias en la communidad sorda. Una de cada siete personas (1 de 7) que no oyen tiene una historia de abuso de sustancias versus una de cada diez (1 de 10) reportada por la población sin problemas auditivos.³ El abuso de las sustancias puede ser un factor de riesgo para contraer el VIH ya que reduce la inhibición y altera el juicio, lo cual puede conducir a conductas sexuales poco seguras. Compartir el equipo de inyección es otro de los riesgos de transmisión del VIH. Existe muy poca educación sobre el VIH o sobre sexualidad en las escuelas para sordos, especialmente en escuelas para adolescentes. Debido a esto, las personas sordas poseen un menor conocimiento y están menos concientes de los riesgos de transmisión del VIH, tratamiento y prevención. Si los niños sordos no aprenden sobre el VIH u otras enfermedades de transmisión sexual, no van a tener el vocabulario adecuado para hablar del tema entre ellos. Un estudio entre estudiantes de una escuela para sordos descubrió que los adolescentes del 9 al 12 grado tenían un conocimiento extremadamente limitado sobre el SIDA. Los estudiantes solamente acertaron 8 de la 35 preguntas básicas sobre SIDA.⁴ Los hombres sordos que tienen sexo con hombres pueden sufrir discriminación dentro de la comunidad de sordos. Por este motivo, los hombres sordos que tienen sexo con hombres esconden a menudo su identidad y pueden llegar a presentar comportamientos sexuales furtivos, anónimos y de mucho riesgo. Muchos hombres sordos que tienen sexo con hombres también desean tener relaciones con hombres no sordos, lo cual dificulta aún mas la comunicación sobre la práctica segura del sexo.³ Se ha descubierto que los niños discapacitados, incluyendo a niños sordos, están a mayor riesgo de sufrir abuso sexual tanto en la escuela como en el hogar. En un estudio a niños sordos y no sordos de un instituto de lenguaje se descubrió que el 54% de los varones sordos reportó abuso, comparado con el 10% reportado por los no-sordos. Las niñas sordas reportaron índices de abuso del 50% comparado con el 25% reportado por las niñas no sordas. El abuso sexual a temprana edad es un fuerte indicador de los comportamientos sexuales de alto riesgo, del abuso de sustancias, e infección con VIH en la edad adulta.⁶

¿cuáles son las barreras en la prevención?

Para la mayoría de las personas sordas en los EEUU, el Lenguaje Americano de Signos (ASL) es su primer idioma, Inglés o Español el segundo. El ASL es un lenguaje complejo de gestos y señales con su propia gramática y sintaxis. La única forma de comunicarse en ASL es cara a cara. El material escrito sobre VIH en ASL Gráfico disponible es escaso. Aunque algunas personas sordas pueden leer material escrito tales como los panfletos utilizados en la prevención del VIH, para algunas personas sordas con un nivel de Inglés o Español limitado, estos panfletos son ineficaces.⁷ La comunidad sorda es un grupo muy unido, esto a veces significa que así como se recibe un fuerte apoyo a veces lo que se recibe es una fuerte condena. La privacidad es muy importante en esta comunidad donde las noticias vuelan muy rápido. Muchas personas sordas prefieren ir solas a hacerse la prueba de detección del VIH y a recibir consejería totalmente oral ya que traer a un intérprete o ir a una clínica para sordos pone a riesgo su privacidad aunque también a la misma vez exponen la comunicación y la comprensión.⁸ El hacerse la prueba usando un equipo casero de detección del VIH tampoco ofrece la solución al problema de la privacidad ya que estas personas necesitan a un intérprete por medio del teléfono o a través de un intermediario para conocer los resultados.

¿qué puede ayudar en la prevención?

Conocer las áreas mas fuertes de esta comunidad puede ser muy útil en los esfuerzos de prevención. El hecho de que esta comunidad sea tan unida significa que existe un mayor grado de intimidad física y emociónal. La naturaleza visual del ASL requiere tratar temas como el sexo y el uso de las drogas abiertamente y con mucha franqueza. Cuando estos temas salen a la luz, las personas sordas a menudo se sienten mas cómodas al hablar del los temas, logrando al unísono un mayor entendimiento y una mejor negociación en cuanto al comportamiento seguro.⁸ Las instituciones para sordos deben tratar temas que tradicionalmente han estado tapados o que han sido tabú en esta comunidad, tales como el abuso de la drogas y el alcohol, el abuso sexual a temprana edad y la homofobia. En 1998, la Línea Nacional del SIDA del CDC envió más de un millar de cartas a escuelas estatales para sordos ofreciendo programas educacionales sobre SIDA para estudiantes sordos o con problemas auditivos. De éstas solamente 3 escuelas respondieron.:7

¿qué se está haciendo?

Un programa creado por el Centro de Salud Mental de la Universidad Gallaudet ofrece entrenamiento sobre VIH/SIDA a profesionales de salud mental que trabajan con la comunidad sorda, utilizando videos con subtítulos o leyendas, dibujos, actividades de grupo y modelos sobre como el VIH se adhiere a las células.⁹ En París, Francia, la Unidad Móvil de Prevención de SIDA (EMIPS) utilizó una variedad de programas para llevar el mensaje a los adolescentes sordos dentro y fuera de las escuelas para sordos. Un joven educador sordo visitó escuelas para sordos y presentó una intervención en lenguaje por señas. El programa creó varias anuncios públicos exponiendo las falsas creencias del riesgo que envuelve al VIH. El programa también abrió una clínica que no requiere de cita previa en la que el Doctor(a) se comunica por medio del lenguaje por señas. Sin embargo, la clínica no estuvo muy concurrida ya que estaba demasiado identificada con el SIDA. Cuando el programa abrió un centro de detección de VIH dentro de una clínica general se obtuvo mayor éxito.¹⁰ En Minnesota, el programa para personas que carecen o tienen dificultades auditivas que dependen de sustancias químicas y otras drogas ofrecen tratamiento para los adictos al alcohol y otras drogas en los EEUU y Canadá. El personal está capacitado específicamente para tratar a personas con problemas auditivos parcial o total y en tratar el abuso de sustancias, además, han desarrollado métodos terapeúticos sin problemas de comunicación. Por otra parte, el programa ofrece entrenamiento a estudiantes y profesionales que trabajan con personas sordas, tienen además un centro de recursos para diseminar material y proveen fondos para intérpretes que asisten a reuniones de AA/NA (Alcohólicos Anónimos/Narcóticos Anónimos).¹¹

¿qué queda por hacer?

Crear material educativo y buscar la forma de llegar a esta comunidad, no solo alrededor del tema del VIH o del SIDA también sobre temas tan amplios como la salud sexual y el uso de sustancias psicotrópicas. Las escuelas para sordos necesitan ofrecer educación sobre sexualidad y sobre el uso de sustancias y proveer consejería a niños y adolescentes que hayan experimentado abuso. Los programas para sordos deben tratar temas específicos de esta comunidad, tales como negociar el sexo seguro con una pareja no sorda, abogar por los servicios del cuidado de salud y derribar las barreras que impiden tratar el problema del abuso sexual y abuso de drogas. Los programas de prevención de VIH para personas sordas deben ser lo mas claro y visuales posibles. Los programas no deben ser diseñados a manera de presentación sólamente, deben además dedicar mayor tiempo a debatir el tema, incorporar actividades físicas, fotos, muñecos, manuales gráficos en ASL y videos con subtítulos.¹² Para poder llegar a las comunidades de sordos tanto investigadores como proveedores de servicios deben aprovechar los avances tecnológicos tales como los videos interactivos y la internet.¹³ Si bien es cierto que ya se han hecho esfuerzos a todo nivel para educar a la comunidad sorda sobre el tema del VIH/SIDA, todavía existen discrepancias sobre el tipo de información crucial que debe recibir la población que realmente lo necesita. Cada estado al igual que el CDC necesita añadir preguntas sobre discapacidades al recaudar datos estadísticos para poder determinar el alcance de la epidemia en la población sorda. Se necesitan más programas que ayuden a desarrollar un mayor conocimiento y disipar los mitos acerca de la transmisión del VIH y las conductas de riesgo de las personas sordas. Los pocos programas populares que existen deben ser evaluados y replicados en toda la nación.

¿quién lo dice?

1. Friess S. Silence = Deaf . Poz Magazine. April 1998. p.60-63. 2. Personal communication. Department of Health and Mental Hygiene, State of Maryland. 1999. 3. Peinkoffer JR. HIV education for the deaf, a vulnerable minority . Public Health Reports. 1994;109:390-396. 4. Baker-Duncan N, Dancer J, Gentry B, et al. Deaf adolescents’ knowledge of AIDS. Grade and gender effects . American Annals of the Deaf. 1997;142:368-372. 5. Sullivan PM, Vernon M, Scanlan JH. Sexual abuse of deaf youth . American Annals of the Deaf. 1987;132:256-262. 6. Johnsen L, Harlow L. Childhood sexual abuse linked with adult substance use, victimization, and AIDS-risk . AIDS Education and Prevention. 1996;80:44-57. 7. Campbell D. AIDS and the deaf community. ADVANCE for Speech-Language Pathologists & Audiologists. April 26, 1999; p.10-11. 8. Morrone JJ. Peer education and the deaf community. Journal of American College Health. 1993;41:264-266. 9. Sleek S. HIV/AIDS education efforts have missed deaf community. American Psychological Association Monitor. 1999. 10. Grivois L, Houette A. Outreach programs towards deaf people targeting prevention of AIDS. Presented at the 11th International Conference on AIDS, Vancouver, Canada. June 1996. Abst. #MoD240. 11. Program celebrates ten years. Steps to Recovery. Published by the Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals. Spring/Summer 1999. 12. Gaskins S. Special population: HIV/AIDS among the deaf and hard of hearing. Journal of the Association of Nurses in AIDS Care. 1999;10:75-78. 13. Lipton DS, Goldstein M, Wellington Fahnbulleh F, et al. The interactive video-questionnaire: a new technology for interviewing deaf persons . American Annals of the Deaf. 1999;141:370-378.

Recursos:

Línea Nacional del SIDA de los CDC, Servicio Para Sordos Y Personas Con Dificultad En Oír American Sexual Health Association https://www.ashasexualhealth.org/ 

PREPARADO POR BRYAN DETERMAN** NATASHA KORDUS** Y PAMELA DECARLO*** *CLINICA MONTROSE, HOUSTON, TX, **ESCUELA PARA SORDOS DE CALIFORNIA,***CAPS Agosto 2000. Hoja Informativa 36S.