What Are African-Americans’ HIV Prevention Needs?

revised 9/99

Are African-Americans at risk for HIV?

Yes. Many African-Americans are at high risk for HIV infection, not because of their race or ethnicity, but because of the risk behaviors they may engage in. As with other ethnic/racial groups, HIV risk depends not on who you are, but on whether you engage in risk-taking behaviors with an HIV+ partner, and whether you have access to care, education and prevention services. The majority of AIDS cases among African-Americans occur among persons aged 25-44, and among men. While African-Americans comprise 13% of the US population, they are disproportionately affected by HIV, accounting for 37% of total AIDS cases in the US. In 1998, almost two-thirds (62%) of AIDS cases among all women were among African-Americans. Likewise, African-Americans accounted for over half (53%) of all AIDS cases among injection drug users (IDUs). In 1998, 62% of all children with AIDS were African-American.

Who are African-Americans at risk?

African-Americans, like many ethnic/racial groups, represent a diverse population. Their diversity is evident in their immigrant status, religion, socioeconomic status, geographic locales and the languages they speak. For example, African-Americans are White collar and working class, Christians and Muslims. They reside in inner-city and rural neighborhoods, are the descendants of slaves and recent Caribbean immigrants. Current epidemiological surveillance data do not record these social, cultural, economic, geographic, religious and political identities that may more accurately predict risk. HIV transmission in African-American communities is primarily viewed as a problem among heterosexual IDUs and their sexual partners. Among African-American men, however, the cumulative proportion of AIDS cases attributed to homosexual/bisexual activity (38%) is greater than that attributed to injection drug use (35%). African-American adolescents have, with few exceptions, markedly higher seroprevalence rates compared to White adolescents. Some sexually-active young African-American women are at especially high risk for HIV infection, especially those from poorer neighborhoods. A study of disadvantaged out-of-school youth in the US Job Corps found that young African-American women had the highest rate of HIV infection in the study. Women 16-18 years old had 50% higher rates of infection than young men.

What puts African-Americans at risk?

Injection drug use has played a major role in HIV infection among African-Americans. Although the majority of IDUs in the US are White, HIV infection is higher for Black IDUs than White IDUs. Unemployment and poverty are significant co-factors which may have led to high rates of addiction and high rates of risk behaviors such as sharing needles. In fact, the HIV and drug use epidemic among African-Americans is focused in a small number of inner-city urban neighborhoods of color, an indication that the epidemic may have more to do with geography and poverty than race. While attitudes in the African-American community are slowly changing, homophobia and negative attitudes toward gay men still exist. For young African-American men who have sex with men (MSM), these negative attitudes may cause low self-esteem , lack of community and psychological distress, all of which contribute to risk-taking behaviors. Many African-American women, especially adolescent women, are at high risk for heterosexually acquired HIV. African-American women may not want to or may not be able to negotiate condom use because they may think it would interfere with physical and emotional intimacy, imply infidelity by themselves or their partner or result in physical abuse. Some women may also be in denial or be unaware of their own risk. Over one-third (35%) of AIDS cases among African-American women reported in 1998 were classified as “risk not reported or identified.” It is thought that a majority of these women are infected through heterosexual sex with IDUs and/or gay or bisexual partners.

What are obstacles to prevention?

Communities of color in this country, including African-Americans, have experienced persistent inequalities in social benefits, health care, education and job opportunities. Economic disparities continue to exacerbate the health status of African-Americans and other communities of color in the US. As a result, African-Americans report high rates of diseases and mortality. In addition, many African-Americans hold a distrust of government programs and health institutions. Some African-Americans believe that the effects of AIDS on the community are the results of deliberate efforts and omission of responsibility by the US government. Effective community-based prevention programs must address these concerns. AIDS has been seen as a primarily gay issue in the African-American community. In addition, homophobia exists in the African-American family, church and community on both a personal and institutional level. Many homosexually active African-American men may have been reluctant to respond to the AIDS epidemic for fear of alienation.

What’s being done?

African-American adolescents in Philadelphia, PA were offered an HIV prevention program addressing both abstinence and safer sex. Abstinence intervention participants reported less sexual intercourse after 3 months, but not at 6- or 12- month follow-ups. For youth who reported prior sexual experience, those in the safer sex intervention reported less sexual intercourse than those in the abstinence intervention at 3-, 6- and 12-month follow-ups. Both safer sex and abstinence-only approaches reduced HIV sexual risk behaviors in the short-term, but safer sex interventions may have longer-lasting effects and may be more effective for sexually experienced youth. Some faith communities are responding to HIV in innovative ways. In Tennessee, the Metropolitan Interdenominational Church began an outreach program to IDUs in four poor, predominantly African-American neighborhoods. The program provides sterile needles, condoms, case management and prevention education. They are developing a church-based harm reduction program model for use in other faith communities. The Well is a community-based drop-in center for African-American women that promotes self-help and wellness in a low income housing project in Los Angeles, CA. The Well offers peer support “sister circles”, exercise classes, community health education, a lounge/library, a nurse practitioner’s office, and a partnerships with other community health organizations. The well incorporates HIV/STD education into general education that addresses all aspects of women’s lives. In 1999, in response to the disproportionate impact of HIV on communities of color in the US, the Congressional Black Caucus (CBC) Initiative earmarked $186 million to be spent on community-based HIV prevention programs for communities of color.

What needs to be done?

Researchers and service providers need a better understanding of the role of cultural and socioeconomic factors in the transmission of HIV, as well as the effect of racial inequality on public health. In addition, public health officials should consider changing epidemiological surveillance to include other demographic information such as social, economic and cultural factors. These efforts need to influence the design of HIV prevention messages, services and programs. In the second decade of the AIDS epidemic, homophobia and AIDS denial have yet to be fully countered. Public health institutions should seek out partnerships with African-American faith communities and incorporate spiritual teachings on compassion to ignite a community response. HIV prevention for African-Americans must occur at the community level. Comprehensive programs should link with other health services, such as substance abuse programs, family planning services and STD clinics.

Says who?

1. Centers for Disease Control and Prevention. HIV/AIDS Sur-veillance Report . 1998;10:1-43. 2. National Commission on AIDS. The challenge of HIV/AIDS in communities of color. 1994. 3. Moss N, Krieger N. Measuring social inequalities in health: report on the conference of the National Institutes of Health . Public Health Reports. 1995;110:302-305. 4. Valleroy LA, MacKellar DA, Karon JM, et al. HIV infection in disadvantaged out-of-school youth: prevalence for US Job Corps entrants, 1990 through 1996 . Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 1998;19:67-73. 5. Substance Abuse and Mental Health Services Administration . Preliminary results from the 1997 national household survey on drug abuse . US Department of Health and Human Service: Rockville, MD; 1999. 6. Fullilove, RE, Fullilove MT. HIV prevention and intervention in the African American community: a public health perspective. In: AIDS Knowledge Base. PT Cohen, ed. Lippincott, Williams & Wilkins. 1999. 7. Stokes JP, Peterson JL. Homophobia, self-esteem, and risk for HIV among African American men who have sex with men . AIDS Education and Prevention. 1998;10: 278-292. 8. Wingood GM, DiClemente RJ. Pattern influences and gender-related factors associated with noncondom use among young adult African American women . American Journal of Community Psychology. 1998;26:29-52. 9. Wingood GM, DiClemente RJ. The effects of having a physically abusive partner on the condom use and sexual negotiation practices of young adult African-American women . American Journal of Public Health. 1997;87:1016-1018. 10. Dalton HL. AIDS in blackface . Daedalus. 1989:118:205-227. 11. Thomas SB, Quinn SC. The Tuskegee Syphilis Study, 1932 to 1972: implications for HIV education and AIDS risk education programs in the black community . American Journal of Public Health. 1991;81: 1498-1506. 12. Peterson JL. AIDS-related risks and same-sex behaviors among African American men. In AIDS, Identity and Community. Herek GM, Greene B, eds. Sage Publications: Thousand Oaks, CA; 1995:85-104. 13. 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. 14. Sander E. Church based harm reduction programs. Presented at the 12th World AIDS Conference, June 1998,Geneva, Switzerland. Abst. #33380. 15. Elliott Brown KA, Jemmott FE, Mitchell HJ, et al. The Well: a neighborhood-based health promotion model for black women . Health and Social Work. 1998;23:146-152. Prepared By John Peterson Phd*, Gina Wingood ScD, MPH**, Ralph Diclemente PhD**, Pamela Decarlo***, Kathleen Quirk MA*** *Department Of Psychology, Georgia State University, **Rollins School Of Public Health, Emory University, ***CAPS September 1999. Fact Sheet #15ER Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © September 1999, University of California.

How Does Mental Health Affect HIV Prevention?

What does mental health have to do with HIV prevention?

A s much as the HIV epidemic has changed over the past 20 years, most reasons for continued high risk behavior have remained very much the same. Some factors that contribute to these behaviors are: loneliness, depression, low self-esteem, sexual compulsivity, sexual abuse, marginalization, lack of power and oppression. These issues do not have quick fixes. Addressing these basic issues requires time and effort and may extend beyond the capabilities of most HIV prevention programs. One thing we have learned from HIV prevention research is that “one size does not fit all.” Programs need different components to address the different needs of clients. Increasing knowledge, skills building and increasing access to condoms and syringes are good methods, but don’t work for everyone or on their own. For many, the barriers to behavior change are mental health problems. This fact sheet focuses on non-acute mental health issues and does not address the effect of severe mental illness or brain disorders on HIV prevention. What people do and what they experience affects their mental health. Substance use and abuse, discrimination, marginalization and poverty are all factors that impact mental health and, in turn, can place people at risk for HIV infection.

Do mental health issues affect HIV risk?

Yes. The decision to engage in risky sexual or drug using practices may not always be a consciously made “decision.” Rather, it is based on an attempt to satisfy some other need, for example: LOW SELF-ESTEEM. For many men who have sex with men (MSM), low self-esteem and internalized homophobia can impact HIV risk-taking. Internalized homophobia is a sense of unhappiness, lack of self-acceptance or self-condemnation of being gay. In one study, men who experienced internalized homophobia were more likely to be HIV+, had less relationship satisfaction and spent less social time with gay people.¹ Male-to-female transgender persons (MTFs) identify low self-esteem, depression, feelings of isolation, rejection and powerlessness as barriers to HIV risk reduction. For example, many MTFs state that they engage in unprotected sex because it validates their female gender identity and boosts their self-esteem.² ANXIETY AND DEPRESSION. Young adults who suffer from anxiety and depression are much more likely to engage in high risk activities such as prostitution, both injection and non-injection drug use and choosing high risk partners. One study that followed inner-city youths for several years found that change in risk behavior was not associated with knowledge, access to information, counseling or knowing someone with AIDS. Reducing symptoms of depression and other mental health issues were, however, associated with reductions in HIV-related risk behaviors.³ SEXUAL ABUSE. Persons who experience incidents of sexual abuse during childhood and adolescence are at a significantly higher risk of mental health problems and HIV risk behavior. A study of adult gay and bisexual men found that those who had been abused were much more likely to engage in unprotected anal intercourse and injecting drug use.⁴ For many women, sexual abuse is combined with physical and/or emotional abuse in childhood or adolescence. HIV risk is only one of the consequences of this abuse for women. Women may turn to drug use as a way of coping with abuse experience(s). They may also have difficulty adjusting sexually, causing difficulty negotiating condom use with partners and increasing the likelihood of sexual risk taking.⁵ Women who have been abused have higher rates of sexually transmitted diseases (STDs) including HIV.⁶ POST-TRAUMATIC STRESS DISORDER (PTSD). PTSD may account for high sexual risk-taking activities. In one study among female crack users in the South Bronx, NY, 59% of women interviewed were diagnosed with PTSD due to violent traumas such as assault, rape or witness to murder, and non-violent traumas such as homelessness, loss of children or serious accident.⁷  A national study of veterans found that substance abusers who suffered from PTSD were almost 12 times more likely to be HIV-infected than veterans who were not substance abusers nor suffering from PTSD.⁸

What factors impact mental health?

Many persons who suffer from mental health problems turn to substance use as a means of coping. Substance use has been shown to decrease inhibitions and impair judgement, which can contribute to HIV risk-taking. Injection drug users (IDUs) who suffer from depression are at higher risk for needle sharing.⁹ Environmental factors such as poverty, racism and marginalization can lead to mental health problems such as low self-esteem which can in turn, lead to substance use and other HIV risk behaviors. Inner-city young adults with high rates of HIV risk behaviors also experience higher rates of suicidality, substance misuse, antisocial behavior, stressful events and neighborhood murders.¹⁰

What’s being done?

Addressing mental health issues does not only mean getting clients to see an individual counselor or therapist. Community-level and structural programs can also address mental health needs. For example, a program can hire a trained facilitator and offer support groups for survivors of sexual abuse. Open houses or drop-in centers where individuals can meet each other can serve to combat loneliness and depression. Offering mobile vans that deliver syringe exchange as well as clothing or food can reach isolated groups that are at high risk for mental health problems and HIV. The Bodyworkers Program in New York, NY, provides MSM sex workers with free HIV prevention and mental health counseling, peer counseling and access to medical services. Male body workers, escorts, street hustlers, porn stars, go-go dancers and others cited several mental health issues that are barriers to accessing prevention and medical services. They are: mistrust, shame, isolation, fear of personal relationships, sexual compulsivity, depression, low self-esteem, substance abuse and a history of physical/sexual abuse.¹¹ The HAPPENS (HIV Adolescent Provider and Peer Education Network for Services) Program in Boston, MA, provides a network of youth-specific care to HIV+, homeless and at-risk youth. The program conducts street outreach, offers individual HIV risk reduction counseling and links youth to appropriate social, medical and mental health services. All health care visits include a mental health intake and mental health services are offered both on a regular basis and at times of crisis.¹² A program in New Haven, CT, used a street-based interactive case management model to reach drug-using women with or at risk for HIV. Case managers traveled in mobile health units to provide intensive one-on-one counseling on-site. Counseling often included discussions among members of the client’s family and peers. Case managers also provided transportation, crisis intervention, court accompaniment, family assistance and donated food and clothing.¹³

What are the implications for prevention programs?

Persons working in HIV prevention need to be aware of the close association between mental health, social and environmental factors and an individual’s ability to make and maintain behavior changes. Prevention program staff should be trained to look for and identify mental health problems in clients. If mental health staff are not available on-site, programs can provide referrals to counselors as needed. Some service agencies have integrated mental health services into their overall services and can provide counseling as part of their prevention interventions. Mental health issues are often overlooked because of stigma on an institutional and individual level. These issues may vary across communities and by geographic region. Addressing mental health problems is an integral part of health promotion and should be a part of HIV prevention. It is not about labeling or putting people down, but aboutproviding accurate diagnoses and treatments for mental and physical health.

Says who?

1. Ross MW, Rosser BR. Measurement and correlates of internalized homophobia: a factor analytic study. Journal of Clinical Psychology. 1996;52:15-21. 2. Clements-Nolle K, Wilkinson W, Kitano K. HIV Prevention and Health Service Needs of the Transgender Community in San Francisco. in W. Bockting & S Kirk editors: Transgender and HIV: Risks, prevention and care. Binghampton, NY: The Haworth Press, Inc. 2001; in press. 3. Stiffman AR, Dore P, Cunningham RM, et al. Person and environment in HIV risk behavior change between adolescence and young adulthood. Health Education Quarterly. 1995;22:211-226. 4. Bartholow BN, Doll LS, Joy D, et al. Emotional, behavioral and HIV risks associated with sexual abuse among adult homosexual and bisexual men. Child Abuse and Neglect. 1994;9:747-761. 5. Miller M. A model to explain the relationship between sexual abuse and HIV risk among women. AIDS Care. 1999;1:3-20. 6. Petrak J, Byrne A, Baker M. The association between abuse in childhood and STD/HIV risk behaviors in female genitourinary (GU) clinic attendees. Sexually Transmitted Infections. 2000;6:457-461. 7. Fullilove MT, Fullilove RE, Smith M, et al. Violence, trauma and post-traumatic stress disorder among women drug users. Journal of Traumatic Stress. 1993;6:533-543. 8. Hoff RA, Beam-Goulet J, Rosenheck RA. Mental disorder as a risk factor for HIV infection in a sample of veterans. Journal of Nervous and Mental Disease. 1997;185:556-560. 9. Mandel W, Kim J, Latkin C, et al. Depressive symptoms, drug network, and their synergistic effect on needle-sharing behavior among street injection drug users. American Journal of Drug and Alcohol Abuse. 1999;25:117-127. 10. Stiffman AR,Doré P, Earls F, et al. The influence of mental health problems on AIDS-related risk behaviors in young adults. Journal of Nervous and Mental Disease. 1992;180:314-320. 11. Baney M, Dalit B, Koegel H, et al. Wellness program for MSM sex workers. Presented at the International Conference on AIDS, Durban, South Africa. 2000. Abstract #MoOrD255. 12. Woods ER, Samples CL, Melchiono MW, et al. Boston HAPPENS Program: a model of health care for HIV-positive, homeless and at-risk youth. Journal of Adolescent Health. 1998;23:37-48. 13. Thompson AS, Blankenship KM, Selwyn PA, et al. Evaluation of an innovative program to address the health and social service needs of drug-using women with or at risk for HIV infection. Journal of Community Health. 1998;23:419-421.

PREPARED BY JIM DILLEY, MD*, PAMELA DECARLO** *AIDS HEALTH PROJECT, **CAPS September 2001. Fact Sheet #42E

Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © September 2001, University of California

What is the role of theory in HIV prevention?

What is theory and how can it help?

A theory describes what factors or relationships influence behavior and/or environment and provides direction on how to impact them. Theories used in HIV prevention are drawn from several disciplines, including psychology, sociology and anthropology. A theory becomes formalized when it is carefully tested with the results repeatable in a number of different settings, and generalizable to various communities.¹ Both formal and informal (or implicit) theories first begin with an individual’s observation about a person or phenomenon. Informal theories—those conceived by service providers— are not usually “tested,” yet these intuitive beliefs about why people do what they do are very useful and often similar to concepts found in formal theories conceived by academics. Theories can help providers frame interventions and design evaluation. When designing or choosing an intervention, theory can show what factors should be targeted and where to focus interventions. Theories can help define the expected outcome of an intervention for evaluation purposes. Also, basing programs on a tested theory gives it scientific support, especially if the program hasn’t been evaluated.² HIV prevention providers are frequently required to use theory in the development of prevention interventions. It’s common, though, for providers to pick a theory based on their intervention. Because many providers are not trained or supported in using theory, they can miss the opportunity to use it as a process for thinking critically about a community in the development of programs.

How can theory guide programs?

Answering the questions in the framework below can help in selecting the most appropriate theories and interventions for a particular community:³

1. Which communities/populations are targeted for services?
2. What are the specific behaviors that put them at risk for HIV/STDS?
3. What are the factors that impact risk-taking behaviors?
4. Which factors are the most important and can be realistically addressed?
5. What theory(ies) or models best address the identified factors?
6. What kind of intervention can best address above factors?

Behaviors that place people at risk for STDS/HIV acquisition and transmission are often the result of many complex factors operating at multiple levels. Theories of behavior change usually address one or more these levels and include individual, interpersonal, community, and structural and environmental factors. Many researchers and providers use a combination of factors from several theories to guide their programs. Following are select theories and models and examples of programs that use them.

Structural and policy level

These theories look at societal and environmental influences on health, including laws, policies, customs, economic conditions and social inequalities (e.g. racism, classism, sexism). Social Disorganization Theory states that where social institutions, norms and values are no longer functioning, high rates of violence, drug abuse, poverty and disease occur. Theory of Gender and Power views the differences in labor, power dynamics, and relationship-investment between women and men as structures that can produce inequalities for women and increase women’s risk and vulnerability to HIV.⁵ Family to Family is a structural intervention that strengthens family functioning and the bonds that connect families to each other in Harlem, NY. Designed to address a broad range of social issues, the program seeks to foster strong relationships in a community with high rates of violence, drug abuse and HIV infection, thus influencing the social determinants of individual risk behavior.⁶

Community level

Empowerment Education Theory, based on Paulo Freire’s popular education model, engages groups to identify and discuss problems.⁷ Once the issue is fully understood by community members, solutions are jointly proposed, agreed, and acted upon. This seeks to promote health by increasing people’s feelings of power and control over their lives. Diffusion of Innovation helps understand how new ideas or behaviors are introduced to, and are spread into and then accepted by a community.⁸ Voices of Women of Color Against HIV/AIDS (VOW) in New York City, is a community organizing intervention based on empowerment theory that aims to increase the involvement of women of color in all aspects of HIV prevention. Women meet monthly to discuss HIV/AIDS issues. VOW organizes trainings on topics of highest concern, and helps women advocate for formulating or changing policies. VOW has met with legislators, given public testimony and organized a women’s policy conference.⁹

Interpersonal level

Social Cognitive Theory views the adoption of behaviors as a social process influenced by interactions with a person and others in their environment.¹⁰ Two primary components of this theory are: 1) modeling of behaviors we see others performing, and 2) self-efficacy, a person’s belief that s/he is capable of performing the new behavior in the proposed situation. Social Support/Social Networks describes the impact of social relationships on health and well-being, where social networks refers to a web of social relationships and social support is the aid and assistance received through those relationships.¹¹ Lista Para Accion is an intervention in Long Beach, CA, that works with Latino gay men and is based on social support and social cognitive theories. The program features four skills-based workshops held in a local Latino dance club. Participants who complete all four workshops can become “Compadres” or community leaders who serve as a support network or “second family” for new workshop participants.¹²

Individual level

The Health Belief Model proposes that in order for persons to change their behaviors they must first believe they are susceptible to a particular condition, and that the severity of that condition is serious.¹³ Stages of Changeexplains the process of incremental behavior change, from having no intentions to changing, to maintaining safer behaviors.¹⁴ The five stages are: Precontemplation, Contemplation, Preparation, Action and Maintenance. Theory of Reasoned Action sees intention as the main influence on behavior.¹⁵ Intentions are a combination of attitudes toward the behavior as well as perceived opinions of peers, both heavily influenced by social norms. Students Together Against Negative Decisions (STAND) is a peer educator training in a rural Georgia county that is based on stages of change and diffusion of innovations theories. HIV prevention training topics are sequenced to match each of the stages of change. STAND prepares teens to initiate conversations with their peers about sexual risk reduction, then assess a person’s stage of change and suggest specific activities. Peer educators reported a sevenfold larger increase in condom use and a 30% decrease in unprotected intercourse.¹⁶

What else is there?

Besides tested and implicit theories, there are strategies that are used as frameworks for programs. Harm Reduction accepts that while harmful behaviors exist, the main goal is to reduce their negative effects.¹⁷ Community Organizing/Mobilization approaches encourage communities to advocate for healthier conditions in their lives.¹⁸ Providers have tremendous insight into what puts their clients at risk for HIV and why. Funders need to accept both tested and implicit theories as a valid base for programs, which often go beyond HIV prevention to address violence, poverty and drug abuse.

Says who?

1. Goldman KD, Schmalz KJ. Theoretically speaking: overview and summary of key health education theories. Health Promotion Practice. 2001:2;277-281. 2. Centers for Disease Control and Prevention. Evaluating CDC-Funded Health Department HIV Prevention Programs. December 1999.https://www.cdc.gov/hiv/dhap/peb/index.html  3. Freeman A, Vogan S, Rietmeijer K, et al. Bridging theory and practice: a course on apply-ing behavioral theory to STD/HIV prevention. Presented at National HIV Prevention Conference, Atlanta, GA; 1999. Abst #263. 4. Elliott MA, Merrill FE. Social disorganization. New York, NY: Harper; 1961. 5. Wingood GM, DiClemente RJ. Application of the theory of gender and power to examine HIV-related exposures, risk factors and effective interventions for women. Health Education and Behavior. 2000;27:539-565. 6. Fullilove RE, Green L, Fullilove MT. The Family to Family pro-gram: a structural intervention with implications for the prevention of HIV/AIDS and other community epidemics. AIDS. 2000;14S1;S63-S67. 7. Wallerstein N. Powerlessness, empowerment and health: implications for health promotion programs. American Journal of Health Promotion. 1992;6:197-205. 8. Rogers EM. Diffusion of Innovations. Third edition. New York, NY: The Free Press:1983. 9. Elcock S, Goodman D. Women of color doing it for ourselves: HIV prevention policies. Presented at the National HIV Prevention Conference, Atlanta , GA. 1999, Abst. #443. 10. Bandura A. Social cognitive theory and exercise of control over HIV infection. In DiClemente RJ (ed) Preventing AIDS: Theories and Methods of Behavioral Interventions. New York, NY: Plenum Press; 1994. 11. Glanz K, Marcus Lewis F, Rimer BK, Eds. Health Behavior and Health Education: Theory, Research and Practice. 2nd Edition. San Francisco: Jossey-Bass, Inc. 1997. 12. Buitron M, Corby N, Rhodes F. Creating a culturally appropriate behavioral prevention intervention for Spanish speaking gay men from an existing risk-reduction program. Presented at the International Conference on AIDS, Geneva, Switzerland, 1998. Abst # 335553. 13. Rosenstock IM, Strecher VJ, Becker MH. The health belief model and HIV risk behavior change. In DiClemente RJ (ed) Preventing AIDS: Theories and Methods of Behavioral Interventions. New York, NY: Plenum Press; 1994. 14. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change. Applications to addictive behaviors. American Psychologist. 1992;47:1102-1114. 15. Fishbein M, Middlestadt SE. Using the theory of reasoned action as a framework for under-standing and changing AIDS-related behaviors. In Wasserheit JN (ed) Primary Prevention of AIDS: Psychological Approaches. 1989. 16. Smith MU, DiClemente RJ. STAND: A peer educator training curriculum for sexual risk reduction in the rural South. Preventive Medicine. 2000;30:441-449. 17. Brettle RP. HIV and harm reduction for injection drug users. AIDS. 1991;5:125-136. 18. Community organizing and community building for health. M Minkler, ed. New Brunswick, NJ: Rutgers University Press. 1997.

PREPARED BY ALICE GANDELMAN MPH*, BETH FREEDMAN MPH** *California HIV/STD Prevention Training Center,**CAPS January 2002. Fact Sheet #14ER Special thanks to the following reviewers of this Fact Sheet: David Cotton, Pat Coury-Doniger, Ann Freeman, Andy Handler, Julie Lifshay, Matthew Staley, Javid Syed.

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

¿Qué papel juegan los servicios de notificación de parejas en la prevención del VIH?

¿por qué la notificación de parejas?

A más de 20 años del inicio de la epidemia y a pesar de los avances en conocimiento, tratamiento, y aceptación del VIH, la experiencia de recibir un diagnóstico VIH+ aún puede resultar traumática. La gente VIH+ debe asimilar la realidad de su propia infección al tiempo de preocuparse por la posible infección de parejas pasadas y futuras. Es difícil hablar con la pareja sobre el VIH, pues aunque puede controlarse, aún no tiene cura. La ayuda con la notificación de parejas (conocida como servicios de asesoramiento y referencia para parejas o PCRS en inglés) es una serie de servicios voluntarios y confidenciales para personas VIH+ y para sus parejas sexuales y/o de inyección de drogas. Estos servicios son costo-efectivos y tienen un papel crítico tanto identificando individuos a mayor riesgo de infección como remitiendo oportunamente a servicios médicos a quienes estén infectados. La mayoría de las personas VIH+ deciden por su cuenta si revelan o no su condición a sus parejas, pero muchas veces necesitan apoyo para hablar directamente con éstas o para que cuidadosa y confidencialmente lo haga un profesional. En un estudio, las personas que recibieron ayuda con la notificación triplicaron la probabilidad de informar a sus parejas sobre el riesgo contraído. En años recientes, los programas de consejería y pruebas del VIH en los EE.UU. han cambiado de aplicar la prueba a todo mundo, a identificar y ofrecer pruebas a los más vulnerables a infectarse. En los sitios generales de pruebas del VIH cerca de un 1% resulta VIH+, comparado con el 8 al 39% que resulta de los programas de notificación de parejas.

¿qué es la notificación de parejas?

La notificación de parejas no siempre la efectúa un profesional médico; de hecho, puede realizarse de tres maneras: Notificación personal- La persona infectada bajo la orientación de un consejero habla directamente con su pareja. La mayoría de las personas VIH+ prefieren este método. Notificación dual- La persona informa a su pareja en presencia de un profesional de salud, quien apoya durante la conversación y sirve de recurso a la pareja notificada. Este método se usa rara vez y requiere de profesionales muy especializados. Notificación por un profesional de salud (un tercero anónimo)- La persona elige que un profesional notifique a la pareja proporcionando los datos de contacto de la misma. Comúnmente, un proveedor de salud entrega la información a especialistas en intervención de enfermedades (EIE) quienes buscan y notifican a las parejas identificadas, manteniendo confidencialmente la identidad del notificante. Este método es el único que permite anonimato. Para las parejas notificadas, los servicios de notificación incluyen: información sobre su exposición al VIH, consejería de prevención del VIH y pruebas, y si su resultado es positivo, remisión a una evaluación médica y a otros servicios pertinentes.

¿cómo funcionan estos servicios?

Se ofrecen cuando la persona recibe un resultado VIH+. No debe ofrecerse una sola vez, sino repetidamente según cambien las circunstancias de riesgo y las necesidades de la persona. El propósito es ayudar a las personas VIH+ a informar a sus compañeros sexuales y/o de inyección de drogas sobre una posible exposición al VIH. La calidad y el uso de los servicios de notificación de parejas en EE.UU. pueden variar de estado a estado. Algunos están obligados a ofrecerlos por ley, otros por medio de programas de VIH/ITS o reciben remisiones de médicos, departamentos de salud o de sitios de pruebas. Las organizaciones de servicios de VIH, los departamentos de salud y la mayoría de las clínicas y hospitales pueden notificar parejas. Las organizaciones de servicios pueden asesorar y apoyar en la notificación personal o dual, u obtener los datos de las parejas y proporcionarlos a los EIE para notificación. La mayoría de las notificaciones la realizan los departamentos de salud pues tienen la capacidad, el conocimiento, el personal y la protección contra demandas legales. Una buena notificación depende de EIE con la capacitación, la experiencia y los conocimientos adecuados. Es importante que los EIE reciban apoyo y preparación continua así como evaluaciones periódicas de rendimiento para asegurar la calidad de sus servicios.

¿cuáles son las inquietudes al respecto?

Los mensajes de salud pública han exhortado a la notificación a toda pareja sexual y/o de inyección de drogas, pero esta notificación es difícil y compleja. Algunas personas VIH+ deciden no revelar su condición por temor al posible rechazo familiar o de la pareja, a menos oportunidades sexuales, a menos acceso a drogas o mayor riesgo de violencia física y sexual. Los programas de VIH deben aceptar que “no notificar” es también una opción válida. Aunque por muchos años se han usado los servicios de los profesionales de salud para notificar sobre otras ITS, respecto al VIH existe un amplio rango en los índices aceptación de este tipo de notificación: En Carolina del Norte, el 87% de personas VIH+ recientemente diagnosticadas aceptó la notificación por un profesional, en Florida el 63.1%, en Los Ángeles, CA el 60%, en el Estado de Nueva York el 32.9%, en Seattle, WA el 32% y entre los recipientes de pruebas anónimas en San Francisco, CA el 3.1%. En Los Ángeles, las razones más comunes de rechazo de la notificación fueron: Pareja ya notificada (23.4%), no estar listo/a para revelar su condición (15.3%), abstinencia sexual (15%) y pareja anónima (11%). La revelación de la condición de VIH a las parejas puede ser motivo de temor, pero también fuente de poder. En un estudio, los consumidores VIH+ de drogas inyectables que revelaron su condición encontraron un aumento en el apoyo social y en la intimidad con sus parejas, una reafirmación de su sentido de sí mismos y la oportunidad de compartir experiencias y sentimientos con sus parejas sexuales. Otro estudio de personas VIH+ y sus parejas que recibieron ayuda con la notificación encontró que el abuso emocional y la violencia física disminuyeron notablemente después de la notificación.

¿qué se está haciendo al respecto?

En Florida, los EIE brindan servicios de notificación de parejas para todo caso nuevo de VIH reportado. En el 2004, el 63.1% de las personas recién diagnosticadas con VIH aceptó la notificación de parejas por un profesional, con la consecuente identificación de 4,460 parejas sexuales o de inyección de drogas. De estas parejas, el 21.8% ya había resultado VIH + anteriormente. De las 2,518 personas notificadas, el 84.2% aceptó recibir consejería y pruebas; el 11.5% resultó VIH+. El Departamento de Salud de Massachusetts lanzó un programa piloto de notificación de parejas “centrado en el cliente” el cual se integró a los servicios rutinarios de prevención, atención y apoyo. El programa requirió modificaciones importantes al modelo habitual de notificación de los EIE; se formaron vínculos estrechos entre los proveedores de servicios y los EIE para responder mejor a las necesidades de notificación de parejas mientras se protegía la confidencialidad. California instituyó un programa de notificación voluntaria que incluye: Consejería y preparación para que las personas VIH+ revelen la información personalmente; notificación anónima por un tercero; consejería, pruebas y remisión a servicios para las parejas identificadas; y capacitación y asistencia técnica para profesionales médicos en centros públicos y privados. Cerca de un tercio de los pacientes optó por la notificación por un tercero y el 85% remitió a sus parejas. De las parejas localizadas, el 56% se hizo la prueba (la mitad nunca se la había hecho) y el 18% de todas las parejas resultó VIH+.

¿qué queda por hacer?

Las nuevas tecnologías de pruebas del VIH pueden ser útiles en los servicios de notificación. La prueba rápida mejorada es una herramienta invaluable para ofrecer pruebas a las parejas notificadas. La prueba de amplificación de ácido nucleico (NAAT, en inglés) puede determinar infecciones agudas, nuevas infecciones que no se detectan durante el periodo de ventana de otras pruebas. Combinando estas estrategias de pruebas con la notificación de parejas se podría identificar a personas recién infectadas y que éstas reciban atención y servicios inmediatamente. Para que la notificación de parejas (especialmente la realizada por un tercero) funcione bien dentro de los servicios de VIH pueden requerirse de modificaciones extensivas al modelo tradicional de los EIE. El personal de prevención general de VIH puede capacitarse como EIE para ampliar el acceso y la confianza a éstos servicios. Los departamentos de salud pueden conectar más sus programas de VIH, ITS y con organizaciones externas. Los servicios de notificación deben ofrecerse no sólo en el diagnóstico inicial del VIH, sino constantemente según cambien las circunstancias y las necesidades de las personas VIH+. No les corresponde a los profesionales de salud decidir si la persona necesita o desea ayuda para notificar a sus parejas; el apoyo y las opciones deben ofrecérsele independientemente de cuál sea su decisión en ese momento. Preparado por Fern Orenstein MEd CA STD Control Branch, Prevention Training Center Septiembre 2005. Hoja #53SR **********

¿quién lo dice?

1. Landis SE, Schoenbach VJ, Weber DJ, et al. Results of a randomized trial of partner notification in cases of HIV infection in North Carolina. New England Journal of Medicine. 1992;326: 101-106. 2. Golden MR. Editorial: HIV partner notification, a neglected prevention intervention. Sexually Transmitted Diseases. 2002;29:472-475. 3. Varghese B, Peterman TA, Holtgrave DR. Cost-effectiveness of counseling and testing and partner notification: a decision analysis. AIDS. 1999;13:1745-1751. 4. Eckert V. Utilization of voluntary HIV partner counseling and referral services. California Office of AIDS & STD Control Branch. Presented at the Statewide PCRS Conference, May 2004. 5. Centers for Disease Control and Prevention. Advancing HIV Prevention: New Strategies for a Changing Epidemic – US, 2003. Morbidity and Mortality Weekly Report. 2003:52;329-332.http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5215a1.htm (accessed April 2006). 6. HIV partner counseling and referral services guidance. Centers for Disease Control and Prevention. 1998. https://www.cdc.gov/hiv/guidelines/partners.html  7. Aldridge C, Randall L. Implementing partner counseling and referral services programs. Presented at the National HIV Prevention Conference, Atlanta, GA. 2005. Abst #TO-057. 8. Centers for Disease Control and Prevention. Partner counseling and referral services to identify persons with undiagnosed HIV–North Carolina, 2001. Morbidity and Mortality Weekly Report. 2003;52:1181-1184.http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5248a4.htm(accessed April 2006). 9. George D. Partner counseling and referral services (PCRS): the Florida experience. Presented at the National HIV Prevention Conference, Atlanta, GA. 2005. Abst #M3-B1605. 10. Aynalem G, Hawkins K, Smith LV, et al. Who and why? Partner counseling and referral service refusal: implication for HIV infection prevention in Los Angeles. Presented at the National HIV Prevention Conference, Atlanta, GA. 2005. Abst #MP-036. 11. Birkhead G. HIV partner counseling and referral services in New York state. Presented at the National HIV Prevention Conference, Atlanta, GA. 2005. Abst #M3-B1603. 12. Golden MR. Partner notification: where do we stand and outstanding barriers. Presented at the National HIV Prevention Conference, Atlanta, GA. 2005. Abst #T3-D1302. 13. Schwarcz S, McFarland W, Delgado V, et al. Partner notification for persons recently infected with HIV: experience in San Francisco. Journal of Acquired Immune Deficiency Syndrome. 2001;28:403-404. 14. Parsons JT, Vanora J, Missildine W, et al. Positive and negative consequences of HIV disclosure among seropositive injection drug users. AIDS Education and Prevention. 2004;16:459-475. 15. Kissinger PJ, Niccolai LM, Magnus M, et al. Partner notification for HIV and syphilis: effects on sexual behaviors and relationship stability. Sexually Transmitted Diseases. 2003;30:75-82. 16. Cranston K. Planning for HIV partner counseling and referral services in the third decade. Presented at the National HIV Prevention Conference, Atlanta, GA. 2005. Abst #T3-D1301. 17. Pilcher CD, Fiscus SA, Nguyen TQ, et al. Detection of acute infections during HIV testing in North Carolina. New England Journal of Medicine. 2005;352:1873-1883.

¿Debemos enseñar “solo-abstinencia” en la educación sexual?

¿por qué tanto alboroto?

Las escuelas se han convertido en el campo de batalla cultural de la nación. En la lucha por conquistar el corazón, mente — y líbidos — de nuestra juventud, la última contienda incluye la educación sexual. La pregunta no radica en que si la escuela es el lugar apropiado para enseñar educación sexual (en esto todos estamos de acuerdo),¹ más bien es, como abordar el tema. Con solo decir “no” se soluciona el problema, al menos esto es lo que cree una cantidad creciente de campeones del currículum basado en solo-abstinencia. Con la abstinencia se trata el tema de los valores morales, se contruye el carácter y se aprende a decir “no”, siempre y cuando se evite el tema de los anticonceptivos o el sexo seguro. Una educación sexual completa comienza con la abstinencia, pero además toma en cuenta que muchos jóvenes van a decidir tener sexo, por lo tanto tienen que saber las consecuencias y la manera de protegerse a si mismos. Estos programas incluyen la instrucción sobre el comportamiento sexual seguro, incluyendo el uso del condón y de otros anticonceptivos.² El movimiento de educación sexual basado en solo-abstinencia tiene su origen en la constante y errada creencia de que una educación sexual completa de alguna forma induce a la juventud a iniciar la actividad sexual. A causa de este razonamiento, las escuelas deben ignorar el tema o relacionar la sexualidad con el temor y la enfermedad. En esta guerra los perdedores siguen siendo los jóvenes, ya que se les niega información sobre como evitar los embarazos o las enfermedades de transmisión sexual en caso de que tengan relaciones sexuales, lo cual es muy probable.

políticas en desarrollo

Los proponentes de solo-abstinencia obtuvieron su mayor logro cuando como parte de la ley de Reforma Federal de Bienestar Social, el congreso designó 50 millones de dólares anuales por cinco años consecutivos a programas de solo-abstinencia en las escuelas. Existen ocho elementos específicos que estos programas deben cumplir, uno de estos mandatos es que el “propósito exclusivo” del programa sea el de demostrar la ganancia social, psicológica y de salud que se obtiene por medio de la abstinencia. Este tipo de fondos requiere que se recaude el 75% de la cantidad otorgada a través de fuentes públicas o privadas, para un total de $87 millones de dólares anuales.³

abstinencia, ¿para quién? y ¿Hasta cuándo?

Generalmente, el currículum de solo-abstinencia promueve abstenerse de la actividad sexual hasta el matrimonio. Para lograr esta meta, los proponentes de la abstinencia usan argumentos que pasan por alto ante la ciencia y la experiencia del ser humano. Una de las provisiones federales en cuanto a la abstinencia establece que la actividad sexual fuera del matrimonio puede ocasionar daños físicos y psicológicos. Esta conclusión resulta tan carente de validez como sorprendente si tomamos en cuenta las estadísticas que señalan que el 93 por ciento de los hombres y el 80 por ciento de las mujeres entre los 18 y 59 años de edad no eran vírgenes en su noche de bodas.⁴ En el debate acerca del papel que desempeña la abstinencia en la educación sexual, poco se hace para lograr la distinción, por ejemplo, entre los programas de abstinencia para los de 12 a 13 anõs versus los de 17 o 18 años. Todos están de acuerdo que la abstinencia se les debe enseñar a niños pequeños. Para los adolescentes mayores, la educación sexual debe ser relevante a la cantidad sustancial de adolescentes que deciden tener relaciones sexuales. Dos tercios (66%) de los adolescentes en su último año escolar han tenido relaciones sexuales.⁵ Al pedir la abstinencia sexual hasta el matrimonio, se debe tomar en cuenta el promedio actual de las edades en que los Norteamericanos contraen matrimonio por primera vez (aproximadamente 24 años en la mujer y 26 para el hombre).⁶ Es más, pedirles a los hombres gay que eviten el sexo hasta el matrimonio, tiene poco significado, si acaso lo tiene.

¿grandes expectativas?

El debate sobre la educación sexual, algunas veces crece a niveles fuera de proporción. La mayor parte de la enseñanza se determina midiendo el impacto que el programa ha tenido en el conocimiento, en vez de en la conducta adoptada una vez fuera del salón de clases.⁷ Es imperante establecer la relación entre las clases de educación sexual en el salón de clases y los cambios de conducta tales como el retraso del inicio de las relaciones sexuales o el incremento en el uso de los anticonceptivos. La enseñanza en los salones de clase debe tomar en cuenta la mezcla de influencias de los compañeros(as), de la iglesia , y de una ráfaga de mensajes publicitarios que promueven el sexo. Si todos tuviéramos una vida sana y segura, el simple mensaje de “solo di no” pudiera ser útil. Pero para la mayoría arriesgar forma parte de una constelación de influencias externas e internas. Una encuesta a nivel nacional reveló que el 16% de las chicas que tuvieron su primera relación sexual antes de cumplir los 16 años fue involuntaria.⁸ Los programas con base en las escuelas, por definición, fracasan en alcanzar a aquellos jóvenes que corren mayores riesgos, tales como los que han huído de sus casas y los que son echados de sus casas.⁹

¿solo-abstinencia o abstinencia y algo más?

La mejor educación sexual tiene como punto de partida la abstinencia, promoviéndola entre aquellos que no están listos para tener sexo y apoyando a aquellos que por cualquier razón deciden abstenerse. Claramente, los mejores programas de educación sexual van más allá de la biología del riesgo y del sexo (aún faltaría explicar el funcionamiento básico del cuerpo humano y como protegerse a si mismos de los embarazos no planeados y de las ETS). Hasta hoy, los programas de solo-abstinencia no han podido demostrar cientificamente su efectividad. Un estudio realizado recientemente, encontró que solamente se ha publicado la literatura de seis estudios en revistas evaluadas por expertos en la materia, en los cuales se examinaba la efectividad de los programas de solo-abstinencia.¹⁰ Ninguno de estos programas demostró ser efectivo, en parte debido al inadecuado método de la evaluación; uno de estos era claramente ineficaz. El nuevo cuarto de billón de dólares asignado a programas federales de solo-abstinencia, más que una agenda de salud pública parece más bien política y religiosa.¹¹ Las agendas políticas y la incomodidad del tema de la sexualidad en la juventud obstruyen la habilidad de conducir investigaciones sobre cuales programas son los que funcionan mejor en la prevención del VIH y de los embarazos no planeados. Proclamar currículums agradables al paladar político-en vez de efectivo- puede servir el interés de los adultos, pero defraudar el de muchos jóvenes.

¿qué es lo que realmente funciona?

A pesar de todo, los que abogan por una educación sexual basada en solo-abstinencia y los proponentes de una educación sexual completa, tienen algunas metas en común: la prevención de los embarazos no planeados, evitar la infección con VIH y de otras ETS. Una buena cantidad de curriculums sobre educación sexual completa que fueron examinados a través de rigurosos estudios han logrado un modesto retraso en el inicio de las relaciones sexuales, una reducción en la cantidad de parejas; y un aumento en el uso de anticonceptivos. En una revisión a nivel nacional se señalaron varios elementos de programas eficaces: fueron diseñados de acuerdo a la edad y experiencia de la audiencia; con un enfoque en el comportamiento sexual de riesgo; con una base teórica razonable; ofreciendo información básica sobre como evitar el riesgo de tener sexo sin protección; hacerles notar que la sociedad los empuja a tener sexo; practicar la comunicación, la negociación y las formas de decir no.¹⁰ Los encargados de mantener una educación de calidad, incluyendo a maestros, padres de familia, miembros de juntas directivas escolares, y legisladores tienen el deber de ir más allá de querer favorecer a un grupo sobre otro. Para lograr cumplir las metas específicas de un programa que dice ser efectivo es esencial que la evidencia sea creíble y objetiva. Cuando se trata del tema de la sexualidad es necesario que los que toman las decisiones separen las preguntas sobre valores morales de las de efectividad y encontrar un terreno común.

¿quién lo dice?

Kaiser Family Foundation. The Kaiser Survey on Americans and AIDS/HIV. Menlo Park, CA: 1998. 2. National Institutes of Health. Interventions to Prevent HIV Risk Behaviors. Consensus Development Conference Statement . Washington, D.C.:1997; Feb. 11-13. 3. Block Grant Guidance for the Abstinence Education Provision of the 1996 Welfare Law P.L. 104-193. For more information, contact: Department of Health and Human Services, PHS/HRSA/MCHB/OD/CB-18-20, 5600 Fishers Lane, Rockville, MD 20857, (301) 443-0205. 4. Associated Press. Sex education that teaches abstinence wins support. New York Times. July 23,1997;A19. 5. Centers for Disease Control and Prevention. Youth risk behavior surveillance-United States , 1995. Morbidity and Mortality Weekly Report. 1996;45(No. SS-4):1-86. 6. The Alan Guttmacher Institute. Sex and America’s Teenagers. New York, 1994. http://www.agi-usa.org/ 7. Kirby D. Sex and HIV/AIDS education in schools . British Medical Journal. 1995;311:403. 8. National Center for Health Statistics. National Survey of Family Growth, cycle IV : 1990 telephone reinterview. Hyattsville, MD: US Department. of Health and Human Services; 1995. 9. Rotheram-Borus MJ, Koopman C, Haignere C, et al. Reducing HIV risk behaviors among runaway adolescents . Journal of the American Medical Association. 1991;266:1237-1241. 10. Kirby D. No Easy Answers: Research Findings on Programs to Reduce Teen Pregnancy . Washington, DC: National Campaign to Prevent Teen Pregnancy; 1997. 11. Ehrhardt AA. Our view of adolescent sexuality-a focus on risk behavior without the developmental context . American Journal of Public Health. 1996;86:1523-1525. Recursos: The Alan Guttmacher Institute 120 Wall Street, New York, NY 10005, (212) 248-1111. http://www.agi-usa.org/ Centers for Disease Control and Prevention, Division of Adolescent and School Health, 4770 Buford Highway, NE MS-29, Chamblee, GA 30341, (770) 488-3251.https://www.cdc.gov/healthyyouth/index.htm Sexuality Information and Education Council of the United States (SIECUS), 130 West 42nd Street, Suite 350, New York, NY 10036, (212) 819-9770.http://www.siecus.org National School Boards Association, 1680 Duke Street, Alexandria, VA 22314, (703) 838-6722. Contact: Brenda Z. Greene. http://www.nsba.org

Preparado por Chris Collins* y Jeff Stryker*, Traducción Romy Benard-Rodríguez* *CAPS Abril 1998. Hoja Informativa 30S. versión en PDF