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Community-Engaged Scholarship for Health

A free, online mechanism for peer-reviewing, publishing and disseminating products of health-related community-engaged scholarship that are in forms other than journal articles.
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Risk Behavior for Gay Men

These questionnaires were used with the EXPLORE Project and cover social activity, attitude, PEP, drug use, and sexual behavior. Instruments:

Scoring: See data collection section of the EXPLORE study protocol. Reliability and/or validity: BA Koblin, MA Chesney, MJ Husnik, et al. High-Risk Behaviors among Men Who Have Sex with Men in 6 US Cities: Baseline Data from the EXPLORE Study. American Journal of Public Health. 2003 93: 926–932.

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Methamphetamine

How does methamphetamine use affect HIV prevention?

what is methamphetamine?

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

how does meth use affect HIV?

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

how does meth use affect HIV risk?

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

how does meth affect HIV+ persons?

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

what’s being done?

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

what are next steps?

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

Says who?

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

Prepared by Robert Guzman MPH, San Francisco DPH; Pamela DeCarlo, CAPS September 2006 . Fact Sheet #61E Special thanks to the following reviewers of this Fact Sheet: David Celentano, Grant Colfax, Perry Halkitis, Mark Hammer, Jeff Klausner, David Knapp Whittier, Jennifer Lorvick, Alix Lutnick, Jean Malpas, Gordon Mansergh, Tim Matheson, Tracey Packer, Joseph Palamar, Jimmy Palmieri, Jim Peck, Brady Ralston, Cathy Reback, Steve Shoptaw, Michael Siever, Hanne Thiede, Steven Tierney, Chad Upham, Will Wong. Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © September 2006, University of California

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Prevention in health care settings

How can HIV prevention be integrated into health care settings?

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

Why is HIV prevention important in health care settings?

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

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

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

What other HIV prevention strategies work in health care settings?

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

How does positive prevention work in health care settings?

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

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

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

What are effective models for use in health care settings?

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

What needs to be done?

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

Says who?

1. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings.Morbidity and Mortality Weekly Report. 2006;55:1-17. 2. Haukoos JS, Hopkins E, Byyny RL, et al. Patient acceptance of rapid HIV testing practices in an urban emergency department: assessment of the 2006 CDC recommendations for HIV screening in health care settings. Annals of Emergency Medicine. 2008;51:303-309. 3. Tepper NK, Farr SL, Danner SP, et al. Rapid human immunodeficiency virus testing in obstetric outpatient settings: the MIRIAD study. American Journal of Obstetrics and Gynecology. 2009;201:31-36. 4. Myers JJ, Modica C, Bernstein C, Kang M, McNamara K. Routine rapid HIV screening in six Community Health Centers serving populations at risk. Journal of General Internal Medicine. 2009;24:1269–1274. 5. Branson BM. State of the art for diagnosis of HIV infection. Clinical Infectious Diseases. 2007;15:S221-225. 6. Christopoulos K, Koester K, Weiser S, et al. A comparative evaluation of the development and implementation of three emergency department HIV testing programs (forthcoming) 7. Schechtel J, Coates T, Mayer K, et al. HIV risk assessment: physician and patient communication. Journal of General Internal Med. 1997;12:722-723. 8. Bruce RD. Methadone as HIV prevention: High volume methadone sites to decrease HIV incidence rates in resource limited settings. International Journal of Drug Policy. 2010;21:122-124. 9. McClelland RS, Baeten JM. Reducing HIV-1 transmission through prevention strategies targeting HIV-1-seropositive individuals. Journal of Antimicrobial Chemotherapy. 2006;57:163-166. 10. Myers JJ, Shade S, Dawson Rose C, et al. Interventions delivered in clinical settings are effective in reducing risk of HIV transmission among people living with HIV. AIDS and Behavior. 2010;14:483-492. 11. Gilliam PP, Straub DM. Prevention with positives: A review of published research, 1998-2008. Journal of the Association of Nurses in AIDS Care. 2009;20:92-109. 12. Harder & Co. Community Research. Prevention with positives: Best practices Guide. Prevention with Positives Workgroup. 2009. 13. Porco TC, Martin JN, Page-Shafer KA, et al. Decline in HIV infectivity following the introduction of highly active antiretroviral therapy. AIDS. 2004;18:81-88. 14. Das M, Chu PL, Santos G-M, et al. Decreases in community viral load are accompanied by reductions in new HIV infections in San Francisco. PLoS ONE. 2010;5:e11068. 15. Myers JJ, Steward, WT, Koester KA, et al. Written procedures enhance delivery of HIV “prevention with positives” counseling in primary health care settings. Journal of AIDS. 2004;37:S95-S100. 16. Koester KA, Maiorana A, Vernon K, et al. Implementation of HIV prevention interventions with people living with HIV/AIDS in clinical settings: Challenges and lessons learned. AIDS and Behavior. 2007;1:S17-S29. 17. Thrun M, Cook PF, Bradley-Springer LA, et al. Improved prevention counseling by HIV care providers in a multisite, clinic-based intervention: Positive STEPs. AIDS Education and Prevention. 2009;21:55-66. 18. Richardson J, Milam J, McCutchan A, et al. Effect of brief safer-sex counseling by medical providers to HIV-1 seropositive patients: A multi-clinic assessment. AIDS. 2004;18:1179-1186. 19. Gilbert P, Ciccarone D, Gansky SA, et al. Interactive “Video Doctor” counseling reduces drug and sexual risk behaviors among HIV+ patients in diverse outpatient settings. PLoS One. 2008;3.
Special thanks to the following reviewers of this Fact Sheet: Lucy Bradley-Springer, Kimberly Carbaugh, Mark Cichocki, Renata Dennis, Josh Ferrer, Mark Molnar, Quentin O’Brien, Jim Sacco. Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. To receive Fact Sheets via e-mail, send an e-mail to [email protected] with the message “subscribe CAPSFS first name last name.” ©July 2010, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected].
Resource

Structural interventions

What is the role of structural interventions in HIV prevention?

What are structural interventions?

Most HIV prevention interventions deal with individuals, one by one. Many of these interventions have been very successful. However, they often require a lot of staff time and reach a limited number of persons. Furthermore, those who do receive interventions may face pressures to continue high-risk behaviors from their peers who do not receive the intervention. Structural interventions change or influence social, political, or economic environments in ways that help many people all at onceperhaps without their even knowing it.1 The term “structural interventions” means many things. Structural interventions include programs that change legal environments (often with community pressure or input) to make safer behavior easier, such as allowing syringes to be sold over the counter. They can also target the immediate social context of sexual or injection behaviors by changing the physical or normative environments within which they occur. Examples include Thai brothels that require condom use or European public health safer injection rooms. Structural interventions also include programs to reduce or abolish income inequality, racism, and other inequities and oppressions which create vulnerability to HIV/AIDS.

What structures create risk?

How can we know what social, political or economic structures or processes need changing? Generally, we learn this by studying naturally-occurring variation among areas or groups, or naturally-occurring experiments in which conditions change for reasons other than HIV-related interventions. Studies of naturally-occurring variation have shown that: 1) poor countries are more likely to have generalized HIV epidemics; 2) countries with more income inequality have higher HIV rates; 3) policies matter: localities where syringes can be bought legally have lower rates of HIV prevalence and incidence among injection drug users (IDUs).2 Studies of natural experiments indicate that: 1) otherwise-positive social and political transitions like the end of apartheid in South Africa in the 1990s, the break-up of the Soviet Union in the 1990s, and the ending of the dictatorship in Indonesia in the late 1990s were followed by large HIV outbreaks; 2) wars cause the spread of HIV, STDs, prostitution, rape, sexual bondage and high-risk substance use and lead to increased numbers of sexual partners and rates of sexual partner change.3

Why structural interventions?

Structural interventions often address issues that seem to be unrelated to HIV. When people think about preventing HIV, they don’t normally consider eliminating income inequalities or stopping war. But these social, political and economic realities greatly influence high-risk behaviors. Issues that are not directly related to HIV often create conditions that encourage the spread of HIV, making structural interventions necessary. For example, the New York City government closed fire stations in poor minority sections of the city in the 1970s. As a result, uncontrolled fires destroyed many buildings. The social lives of building residents were severely traumatized. Great overcrowding took place in surrounding poor minority areas. Injection drug use (and later crack), alcoholism, sex trading, gangs and demoralization spread widelyfollowed later by outbreaks of STDs, HIV, tuberculosis and many other ills.4 The governments of wealthy countries, including the USA, as well as banks, corporations and other economic elites have aggressively pursued an organized global policy of social welfare cutbacks, privatization and competition. This has led many developing countries into massive debt, and increased income inequality and the growth of massive cities based around giant slums. Also, International Monetary Fund-imposed “structural adjustment programs” have forced large-scale cuts in health and education services in many African, Asian and Latin American countries. These policies and progams have greatly hampered these countries from providing effective prevention interventions and/or antiretroviral therapy or other medical care for their infected populations.5,6

Examples of structural interventions

In many countries, sex workers have high rates of HIV and other STDs. Thailand and the Dominican Republic have instituted “100% condom” campaigns mandating that brothel owners enforce the use of condoms during all sex acts. These campaigns enlist the support of brothel owners and sex workers and, when possible, their customers. These programs have reduced HIV and STD transmission considerably by changing the immediate social context of sexual behaviors to reduce unprotected sex.7,8 Most US states have laws that make it a crime to possess or distribute needles and many have laws that require a prescription to buy a needle and syringe. Consequently, IDUs often do not carry syringes for fear of police harassment or arrest. To address this on a legal level, the Connecticut legislature passed a partial repeal of needle prescription and drug paraphernalia laws. This resulted in dramatic reductions in needle sharing, and increases in pharmacy purchase of syringes by IDUs. Sharing dropped from 52% to 31% after the new laws, pharmacy purchase rose from 19% to 78%, and street purchase fell from 74% to 28%.9

How can we impact harmful policies?

It is not easy to avoid or end wars, urban development policies that hurt the poor and minorities and repressive sexual and drug policies that create underground environments. However, individuals and communities can make a difference. Grassroots or community-based movements are often a necessary step to larger structural interventions. The formation of such movements can sometimes be a structural intervention if this leads to changes in power relationships or group norms. “Chico Chats,” a program of the STOP AIDS Project in San Francisco, CA, offered workshops on community organizing and mobilization techniques. Participants formed an activist group called ¡Ya Basta! (Enough Already) and designed a video and workshop examining the issues of sexual silence and coming out in Latino families. The video is being shown throughout Latino communities in San Francisco.10 Community organizations and individuals began operating needle exchange programs (NEPs) in many states with high rates of HIV among IDUs. The NEPs were often illegal and unsupported. The people working at NEPs and other politically active groups worked with public officials to invoke “state of emergency” policies to allow NEPs to exist legally in many states.11 Calcutta sex workers were aided by public health authorities to organize a community union that has enabled them to insist upon condom use. HIV prevalence among Calcutta sex workers has remained lower than in other Indian cities.12

What still needs to be done?

The relationship between structural factors such as economic, political and social marginalization and behaviors that place persons at risk for contracting or spreading HIV/AIDS and STDs cannot be ignored.13,14 Nor can high-risk behaviors be seen as operating outside of social, political and economic contexts. A more focused discussion of these issues is sorely needed in HIV/AIDS circles. One way to reduce the likelihood of negative repurcussions when structural factors change, is to legally mandate that economic, urban development and foreign policy programs conduct scientific “HIV/AIDS impact statements.” A first step might be for HIV prevention agencies to produce and publicize such HIV/AIDS impact statements themselves.15 Funders need to take into account the broad range of activities that constitute HIV prevention. Many community-based organizations find themselves responding to all issues affecting HIV, including ones that may seem unrelated. Addressing these larger issues of war, poverty, restrictive laws and social inequalities such as racism and homophobia is a part of what many agencies do on a daily basis. Helping organize and support these efforts may lead to needed structural HIV prevention interventions.

Says who?

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

Prepared by Sam Friedman*, Kelly Knight** *National Development and Research Institutes, ** CAPS January 2003. Fact Sheet #46E Special thanks to the following reviewers of this Fact Sheet: Abu Abdul-Quader, Sevgi Aral, Judith Auerbach, Kim Blankenship, John Encandela, Mindy Fullilove, Carl Latkin, Peter Lurie.

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]. © January 2003, University of California