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Can hepatitis C (HCV) transmission be prevented?

Prepared by Alice Asher RN, MS, CNS and Kimberly Page PhD MPH Fact Sheet: 46 September 2010

What is the hepatitis C virus (HCV)?

Hepatitis C virus is blood borne virus affects the liver. It is principally acquired and transmitted by blood-to-blood contact, most commonly among injection drug users (IDU). Other common infectious viruses that affect the liver are Hepatitis A and B which have other routes of infection. Unlike hepatitis A and B, there is no vaccine for HCV. About 3.2 – 4 million Americans are estimated to be infected with HCV.¹ In the US, 8,000 to 10,000 deaths per year are attributed to HCV-associated liver disease and that is expected to triple in the next 10-20 years.

Who’s at risk for HCV?

The population at highest risk for HCV are people who inject drugs; principally through sharing of syringes directly or through sharing of drug preparation equipment. Among newly reported HCV cases with known risk factors, 50%-60% are attributable to injecting drugs. However, this may be underestimated due to underreporting both due to the illicit nature of IDU and lack of HCV surveillance in high risk groups.² HCV is usually acquired rapidly after a person first starts injecting drugs. As a result, prevalence of HCV among IDU is very high, ranging from 40-90%, depending on a person’s age and number of years injecting.³ Persons who received blood transfusions or an organ transplant before 1992 and hemophiliacs who received clotting factor concentrates before 1987 are also at risk for HCV. At moderate risk are persons receiving continual care (hemodialysis) for kidney failure. Others at risk include healthcare workers exposed to needlesticks with HCV+ blood.and, rarely, infants born to infected mothers. Sexual transmission of HCV is uncommon, although recent studies of HIV+ gay men show that it does occur.⁴Rough sex, fisting, sex with multiple partners and having a sexually transmitted disease (STD) or HIV appear to increase a person’s risk of HCV.⁵ This is likely due to blood contact during sex.

What does HCV infection look like?

HCV infection can range of in severity from a mild illness lasting a few weeks to a serious, lifelong illness that damages the liver.5 The majority of people infected with HCV do not experience symptoms related to their infection. Because of this, testing is the only way to confirm HCV infection. The first period after HCV infection is referred to as the “acute” period. Acute HCV infection generally lasts about 6 months after someone is infected with the virus. About 25% of people who become infected with HCV will spontaneously clear the virus on their own in the first 6 months. Studies have shown that women are more likely to spontaneously clear the virus than men. Even for those who have cleared HCV, re-infection can occur. While many who become re-infected will clear the virus again, this is not guaranteed, and a subsequent infection may become chronic. Those who do not clear or resolve their HCV infection are considered chronically infected. Most people with chronic infection remain asymptomatic for 20-30 years, and some will never develop symptoms of advanced disease. However, 60-70% of people with chronic HCV ultimately will develop some degree of liver disease.⁵ People with chronic infection whose liver disease has started to progress often report increasing levels of fatigue and stomach pain. The symptoms of chronic HCV are often are vague and unspecific and may go undiagnosed. This again underlines the importance of testing for anyone at risk of HCV. Chronic HCV infection causes liver damage that can turn into cirrhosis (scarring of the liver) and liver cancer.⁵ Up to 20% of chronically infected individuals will develop cirrhosis and 5% will develop liver cancer. Alcohol and drugsincluding marijuana and even tobaccocan speed up the rate of liver damage significantly.

Can HCV be treated?

The short answer is yes, there is a treatment for HCV, but currently available treatments will not work for everybody. Before starting a treatment regimen, it is important to stabilize any mental or other health problems. Undergoing antiviral treatment for HCV is a long, difficult and expensive process, so determining whether treatment is the right choice is a decision that should be made between a patient and a care provider. There are two approved antiviral medications used for the treatment of HCV: pegylated interferon alpha (often referred to as “peg”) and ribavirin. Peg interferon is taken by injection once a week. Ribavirin is an oral tablet that is taken daily. When taken together, the medications are effective in clearing the HCV virus 40-80% of the time, depending on the genotype of the virus.⁷ Hepatitis C has 6 chemical types (1-6), called genotypes, and they differ in how they respond to treatment. People of color, especially African-Americans and Latinos, have lower response rates to treatment, compared to other groups.⁷ New drugs are being developed that may be more effective than currently available treatments and may be available in the very near future. Treatment during the acute phase of infection is significantly more likely to be effective⁸, so identifying HCV early can be beneficial. While herbal remedies are popular among people living with HCV, none have been proven effective at clearing the HCV virus or in improving liver health.⁹ HCV treatment can be successful for active drug users. Nonetheless, daily drug and alcohol use can adversely affect treatment eligibility and completion. Engaging in drug or alcohol treatment programs while being treated for HCV can be helpful.

How does HCV affect HIV?

About one-quarter of all people in the US living with HIV are also infected with HCV. Persons who are both HIV+ and HCV+ (coinfected), can experience a much faster progression of liver disease and have higher HCV viral loads and higher rates of cirrhosis than do people who have HCV but not HIV.¹⁰ Liver damage from HCV infection also can increase the toxicity of medications used to treat HIV. As persons living with HIV who are on effective medications lead longer lives, liver disease has become the leading cause of non-AIDS-related deaths among HIV+ persons, due to HCV and HBV infection.¹¹ Treatment for HCV infection in an HIV+ person can be effective. Side effects and drug interactions, however, can be hard to manage. It is important the coinfected person be on well-managed HIV treatment before starting treatment for HCV.

How can HCV be prevented?

HCV prevention can take many forms.¹² Currently, targeted prevention strategies and harm reduction programs, including increased availability of clean syringes and increased access to drug treatment programs have the greatest potential to slow transmission of HCV. Educating those at risk, especially about the risks associated with shared injecting and ancillary equipment is very important. Encouraging the use of condoms, lubrication and gloves during high-risk sexual practices also can help reduce HCV transmission. Behavioral risk reduction prevention programs have had mixed results in decreasing risks associated with HCV transmission. Two peer-led interventions were effective in reducing injection risk behaviors in HIV negative and positive IDUs. The Study to Reduce Intravenous Exposures (STRIVE) and Drug Users Intervention Trials (DUIT) both provided information, enhanced risk-reduction skills, and motivated behavior change through peer education training. Although participants in these programs reported decreases in sharing syringes and drug preparation equipment,^13,14 rates of new HCV infections among HCV negative participants in the DUIT Study did not decrease (neither did HIV infections). The UFO Study conducts HCV-related research and provides hepatitis, HIV and STD prevention services including testing, counseling, support and education tailored to young adult IDUs under age 30 in San Francisco, CA. Young injection drug users comprise a group for whom few health-related resources or programs are targeted.¹⁵ For persons who are infected with HCV or at risk of becoming infected with HCV, it is important to get regular healthcare. A healthcare provider can help monitor HCV infection and liver health and make important decisions about prevention and treatment. Support and education groups are valuable in learning more about HCV infection and about the experience of living with HCV, treating HCV and preventing HCV transmission to others. People infected with HCV should be screened and vaccinated for HBV and should be strongly encouraged to stop or decrease alcohol use.

What needs to be done?

Over the next 15 years, the global costs associated with HCV infection are projected to increase from $30 billion to $85 billion.¹⁶ Development of an HCV vaccine will significantly decrease rates of new HCV infections. Research is needed on the development of a vaccine and effective models for delivery. Increasing access to HCV testing and screening, HCV treatment, drug treatment, clean syringes and effective behavioral interventions is crucial.

Says who?

1. Armstrong GL, Wasley A, Simard EP, et al. The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Annals of Internal Medicine. 2006;144:705-714. 2. Hagan H, Snyder N, Hough E, et al. Case-reporting of acute hepatitis B and C among injection drug users. Journal of Urban Health. 2002;79:579-585. 3. Hagan H, Pouget ER, Des Jarlais DC, et al. Meta-regression of hepatitis C virus infection in relation to time since onset of illicit drug injection: the influence of time and place. American Journal of Epidemiology. 2008;168:1099-1109. 4. Urbanus AT, van de Laar TJ, Stolte IG, et al. Hepatitis C virus infections among HIV-infected men who have sex with men: an expanding epidemic. AIDS. 2009;23:F1-7. 5. Hepatitis C Fact Sheet. Prepared by the Centers for Disease Control and Prevention. 6. Page K, Hahn JA, Evans J, et al. Acute hepatitis C virus infection in young adult injection drug users: a prospective study of incident infection, resolution, and reinfection. Journal of Infectious Diseases. 2009;200:1216-1226. 7. Ghany MG, Strader DB, Thomas DL, et al. Diagnosis, management, and treatment of Hepatitis C: An update. Hepatology. 2009;49:1335-1374. 8. Kamal SM. Acute hepatitis C: a systematic review. American Journal of Gastroenterology. 2008;103:1283-1297 9. Liu JP, Manheimer E, Tsutani K, et al. Medicinal herbs for hepatitis C virus infection. Cochrane Database of Systematic Reviews. 2001;4. 10. Verucchi G, Calza L, Manfredi R, et al. Human immunodeficiency virus and hepatitis C virus coinfection: epidemiology, natural history, therapeutic options and clinical management. Infection. 2004;32:33-46. 11. Tuma P, Jarrin I, Del Amo J, et al. Survival of HIV-infected patients with compensated liver cirrhosis. AIDS. 2010;24:745-753. 12. Page-Shafer K, Hahn J, Lum PJ. Preventing hepatitis C virus infection in injection drug users: risk reduction is not enough. AIDS. 2007;21:1967-1969. 13. Latka MH, Hagan H, Kapadia F, et al. A randomized intervention trial to reduce the lending of used injection equipment among injection drug users infected with hepatitis C. American Journal of Public Health. 2008;98:853-861. 14. Garfein RS, Golub ET, Greenberg AE, et al. A peer-education intervention to reduce injection risk behaviors for HIV and hepatitis C virus infection in young injection drug users. AIDS. 2007;21:1923-1932. 15. Lum PJ, Ochoa KC, Hahn JA, et al. Hepatitis B virus immunization among young injection drug users in San Francisco, Calif: the UFO Study. American Journal of Public Health. 2003;93:919-23. 16. Shah BB, Wong JB. The economics of hepatitis C virus. Clinics in Liver Disease. 2006;10:717-34.

Special thanks to the following reviewers of this Fact Sheet: Laura Mae Alpert, Orlando Chavez, Myrna Cozen, Richard Garfein, Holly Hagan, Judy Hahn, Emalie Huriaux, Steve Livingston, Megan Mahoney, Brian McMahon, Jay Ryan, Jim Stillwell, Leslie Tobler, Anouk Urbanus. 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.” ©September 2010, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected].

What is the role of disclosure assistance services in HIV prevention?

why assistance for disclosure?

After more than 20 years of the HIV epidemic, with advances in treatment and increases in understanding and acceptance of HIV, getting an HIV+ diagnosis still can be a traumatic experience. HIV+ persons must come to terms with their own infection and be concerned with possible infection in past and future partners. Talking to partners about HIV is especially hard because even though it is a manageable disease, HIV still is not curable. Disclosure assistance services (also known as partner counseling and referral services or PCRS) are an array of voluntary and confidential services available to persons living with HIV and their exposed sex and/or needle-sharing partner(s). Disclosure assistance is cost effective and can play a critical role in identifying those individuals most at risk for HIV infection, and linking those who are infected to early medical care and treatment.^1,2,3 Most HIV+ persons make the decision to disclose or not disclose to their partners on their own. But HIV+ persons may want support for telling their partners about HIV, whether by encouragement for self-disclosure or by having someone who is well-trained carefully and confidentially notify a partner for them. In one study, persons who received disclosure assistance were over three times more likely to have informed a partner of their risk.⁴ In the past few years, HIV counseling and testing programs across the US have shifted their emphasis from testing anyone, to finding and testing persons at greatest risk for HIV infection.⁵ At general HIV testing sites, around 1% of clients tested are found to be HIV+, whereas 8-39% of clients tested through disclosure assistance are found to be HIV+.²

what is disclosure assistance?

Often, disclosure assistance or PCRS mistakenly has been seen as only provider disclosure, but there are three forms of assistance: Self disclosure–The client chooses to notify a partner him/herself. The disclosure assistance provider guides and prepares the client before disclosure. Currently, most HIV+ persons choose this method. Dual disclosure–The client chooses to notify a partner in the presence of a provider. The provider supports the client during disclosure and acts as a resource for the partner. This method is rarely chosen and requires highly skilled providers. Provider disclosure (anonymous third party)–The client prefers a professional to notify a partner, and gives his/her provider identifying and locating information for partner(s). Most often, providers give this info to Disease Intervention Specialists (DIS) who then locate and notify the named partners, keeping client identity strictly confidential. This method is chosen less often, yet it is the only one with client anonymity. For the partners of an HIV+ client, disclosure assistance services can include: being notified of exposure to HIV, HIV prevention counseling, HIV testing options, referrals for HIV medical evaluation if positive and referrals for other social or medical services.⁶

how does it work?

Disclosure assistance services are first offered when a person receives a positive HIV test result. It is not a one-time only service, but should be offered as clients’ risk circumstances and needs change. The main element is helping HIV+ persons tell their sexual and/or needle-sharing partners about possible HIV exposure. The quality and use of disclosure assistance services can vary widely. Services differ from state to state: some have legal mandates to provide it, some offer it through HIV, STD or combined HIV/STD programs, and states can receive referrals from clinicians, health departments or testing sites.⁷ Services can be provided by HIV service agencies, health departments and most clinics and hospitals. Most service agencies can provide coaching and support for self or dual disclosure and gather partner identifying and locating information which is forwarded to DIS staff. Most notification of partners has been done by DIS at local health departments because they have the capacity, expertise, trained staff and protection from liability. Good provider disclosure depends on DIS staff who are properly trained and have enough experience and knowledge of the populations they serve. DIS staff should be evaluated regularly to assure quality and be provided with support and ongoing training.⁶

what are the concerns?

Public health messages have traditionally urged disclosure to all sexual and drug using partners. In reality, disclosure is complex and difficult. Some HIV+ persons may fear that disclosure will bring partner or familial rejection, limit sexual opportunities, reduce access to drugs of addiction or increase risk for physical and sexual violence. Because of this, some HIV+ persons choose not to disclose. Programs need to accept that not disclosing is a valid option. Many HIV service agencies and testing and counseling sites routinely offer self disclosure and dual disclosure, working with HIV+ clients by preparing and supporting them to disclose to partners on their own. Although provider disclosure services have been used for many years with other STDs, there is a wide variety in rates of acceptance of provider disclosure in HIV: in North Carolina, 87% of newly diagnosed HIV+ persons accepted provider disclosure,⁸ in Florida 63.1%,⁹ Los Angeles, CA 60%,¹⁰ New York State 32.9%,¹² Seattle, WA 32% and among anonymous testers in San Francisco, CA 3.1%.¹³ In Los Angeles, the most common reasons for refusal were: already notified partner (23.4%), not being ready to disclose (15.3%), being abstinent (15%) and having an anonymous partner (11%).¹⁰ Disclosing HIV status to partners can be scary, but also can be empowering. In one study, HIV+ injection drug users who disclosed their status found increased social support and intimacy with partners, reaffirmation of their sense of self and the chance to share experiences and feelings with sexual partners. Another study of HIV+ persons and their partners who received disclosure assistance found that emotional abuse and physical violence decreased significantly after notification.¹⁵

what’s being done?

Florida utilizes trained DISs to deliver disclosure assistance for all reported new HIV infections. In 2004, 63.1% of all newly infected HIV+ persons accepted provider disclosure, identifying 4,460 sex or needle-sharing partners. Among those, 21.8% had previously tested HIV+. Of the 2,518 persons notified, 84.2% agreed to counseling and testing and 11.5% were HIV+.⁹ The Massachusetts Department of Public Health piloted a client-centered model of disclosure assistance that is integrated into the client’s routine prevention, care and support services. The program required significant changes to the standard model of DIS provider disclosure, building close relationships between service providers and DIS to better support clients’ disclosure needs while protecting confidentiality.¹⁶ California instituted a voluntary disclosure assistance program that includes counseling and preparing HIV+ persons for self disclosure; anonymous third party provider notification; counseling, testing and referrals for notified partners; and training and technical assistance to providers in public and private medical sites. About one-third of patients opted for provider disclosure and 85% referred partners. Of the partners located, 56% tested for HIV and half had never tested before. Overall, 18% of partners tested HIV+.⁴

what needs to be done?

New HIV testing technologies can be useful with disclosure assistance services. Improved rapid testing is a potential invaluable tool for offering HIV tests in the field to notified partners. Nucleic acid amplification testing (NAAT) can determine acute infections, that is, new HIV infections that do not show up during the window period of other HIV tests. Combining these testing strategies with disclosure assistance can help identify newly infected persons and provide immediate counseling, support and referrals to medical or social services as needed.¹⁷ Disclosure assistance services, and particularly provider disclosure, may need extensive changes from the traditional DIS model in order to work well and be accepted within HIV services. Health departments could forge closer ties between their STD and HIV programs and with outside service agencies. HIV staff also can be trained to be DIS providers to broaden access to and comfort with disclosure services. Disclosure assistance services should be made available not only upon HIV diagnosis, but on an ongoing basis as HIV+ persons’ circumstances and needs change. It is not the role of providers to decide if a client will need or want disclosure assistance, but to offer clients support and choices, whether or not a client chooses to disclose. Prepared by Fern Orenstein MEd, CA STD Control Branch, Prevention Training Center

Says who?

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.

September 2005. Fact Sheet #53ER Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. ©Sepetmber 2005, University of California

What are transgender men’s HIV prevention needs?

Prepared by Jae Sevelius, CAPS; Ayden Scheim and Broden Giambrone, Gay/Bi/Queer Trans Men’s Working Group, Ontario Gay Men’s Sexual Health Alliance Fact Sheet 67 – Revised September 2015

Who are transmen?

Transgender (‘trans’) is an umbrella term for people whose gender identity and expression do not conform to norms and expectations traditionally associated with their sex assigned at birth. Transgender men, or transmen, are people who were assigned ‘female’ at birth and have a male gender identity and/or masculine gender expression. Transgender people may self-identify and express their gender in a variety of ways and often prefer certain terms and not others. Some who transition from female to male do not identify as transgender at all, but simply as men. In general, transmen should be referred to with male pronouns. However, if you are unsure it is best to respectfully ask a person what terms and pronouns they prefer. Accurate information about the diversity of transmen’s bodies is not widely available. Transmen have different types of bodies, depending on their use of testosterone and gender confirmation surgeries (which may include chest reconstruction, hysterectomy, metoidioplasty, phalloplasty¹, etc.; see www.ftmguide.org for further information). Transmen use a broad range of terms and language to identify their sex/gender, describe their body parts, and disclose their trans status to others. For instance, some transmen are not comfortable with the terms ‘vagina’ and ‘vaginal sex’ and may prefer ‘front hole’ and ‘front sex’ or ‘front hole sex’, although this is not true for all transmen. This diversity creates unique needs and barriers for negotiating and adhering to safer sex practices that are not addressed by current HIV prevention programs.

What do we know about HIV and transmen?

The transgender community is diverse and not enough research has been conducted with trans people in general. We have very limited information about transmen in particular. To date, research related to HIV among trans people has almost exclusively focused on transwomen (people who were assigned ‘male’ at birth and have a female gender identity and/or feminine gender expression). However, there is evidence that there is a significant subgroup of transmen that engage in unprotected sex with non-trans men (trans MSM), including some transmen who engage in sex work. Several cities have conducted needs assessments that focus on or are inclusive of transmen and HIV risk, such as Philadelphia, Washington D.C, San Francisco, and the province of Ontario. The few published studies that report HIV rates among samples of transmen have reported 0–3% prevalence.^2,4 These rates are self-reported, however, and are based on small, non-representative samples, so we do not have conclusive data about the actual rates. Due to the assumption of low rates of HIV among transmen relative to other high-risk groups, there has not been much research on risk behaviors among transmen. We do know that HIV prevention messages are not reaching most transmen.⁵ We also know that many trans MSM seek services at gay men’s organizations, where there is little to no education for transmen and their non-trans male partners.⁴ Providers are generally not trained to identify or serve gay and bisexual transmen in culturally sensitive ways or understand their specific risks and prevention needs.

What don’t we know about HIV and transmen?

We do not have enough information about HIV and transmen. Data collection methods at testing sites do not accurately identify and track transmen or capture their experiences, which contributes to the lack of clarity around HIV rates among transmen. Rates of HIV and sexual risk behaviors among transmen are also not well understood because transmen are often assumed to be primarily having sex with non-trans women. However, transmen, like other men, can be of any sexual orientation and may have sex with different types of partners, including (but not limited to) non-trans men, transgender women, and transgender men.^6,7

What puts transmen at risk?

In one study, a majority of trans MSM reported not using condoms consistently during receptive anal and/or frontal (vaginal) sex with non-trans male partners and low rates of HIV testing and low perception of risk.⁴ In urban areas where HIV prevalence rates among non-trans MSM are estimated to be 17-40% and STI rates are increasing, trans MSM who engage in unprotected receptive anal and/or frontal (vaginal) intercourse with non-trans MSM may be especially vulnerable to HIV/STIs.^8,9 Transmen may face complicated power and gender dynamics in their sexual relationships with non-trans men.⁴ For some trans MSM, having sex with a non-trans gay male partner is a powerful validation of their gay/queer male identity, especially in the early years of transition, and may be more important than insisting on condom use. Some transmen who use testosterone have reported increased sex drive and increased interest in sex with non-trans men after beginning hormone use, which may contribute to their willingness to take sexual risks.^4,10 Transmen on testosterone and/or who have had a hysterectomy may have frontal (vaginal) dryness, which increases their risk for frontal (vaginal) trauma during penetration, thus increasing their risk for STIs, including HIV.¹⁰ Low self-esteem may contribute to sexual risk-taking among transmen. Rates of depression, substance use, and suicide attempts are high in this population, but multiple barriers exist to accessing culturally competent support and treatment.^3,11 Drug and alcohol use is a major risk factor for every community, regardless of their gender identity. Transmen may use alcohol or drugs to enhance sexual experiences or help to relieve anxiety about their bodies during sex.⁴ Some transmen may feel pressure to use drugs in order to fit into some gay men’s communities or subcultures. Although we have very little information about needle sharing for hormone or drug use among transmen, it may also be a risk factor for some.

What can help?

Online dating. Many transmen meet their non-trans male sexual partners on the Internet. Meeting partners through personal ads may allow transmen to describe their body and gender identity upfront (if they choose to do so) and discuss safer sex with potential partners before meeting in person.⁴ Educational materials for non-trans partners. Transmen’s non-trans male partners often do not have experience with transmen nor access to education about sex with transmen, which can lead to misconceptions about safer sex. For non-trans gay men, safe sex often simply means condom use with anal sex and they may not be aware of the risks associated with frontal (vaginal) sex. See the next section for information on available materials. Greater visibility in the gay community. Gay and bisexual men need to be educated about the presence of transmen in their community. Increasing visibility and knowledge about transmen may help create a welcoming environment, help increase inclusivity, and help transmen feel more powerful in their relationships with non-trans men.⁷

What’s being done?

tm4m (tm4m.org) is a San Francisco-based project for transmen who play with men (or want to). They provide information, education, and support to transmen who have sex with men through monthly educational workshops and discussion groups, informational materials and continuously working to foster acceptance and build community. tm4m is a collaborative effort co-sponsored by Eros, Trannywood Pictures and TRANS:THRIVE (a program of the API Wellness Center). The Gay/Bi/Queer Trans Men’s Working Group in Ontario has conducted a needs assessment with trans MSM, developed a sexual health resource¹², and a website at www.queertransmen.org. They are also providing training and consultation about trans MSM inclusion for prevention workers serving gay men across the province. All Gender Health Online is a study exploring the sexual health of non-transgender men who have sex with transgender people. The results will be used to develop an online intervention to prevent the spread of HIV and promote the sexual health of transgender people and their partners. The STOP AIDS Project in San Francisco, CA strives to include transmen in their programming and community education. They include transgender men in their mission statement and have changed their data collection methods to better reflect varying bodies and gender identities in gay men’s communities.

What needs to be done?

We need to implement more inclusive data collection methods to better capture subgroups of transgender people. HIV prevention and care providers should not assume that all men they see were assigned ‘male’ at birth. You cannot tell if a guy is trans just by looking at him. The best method for data collection is a two-part question: 1) ask about current gender identity and 2) ask what sex was assigned at birth.¹³ If unsure, programs should ask transmen for their preferred name and pronoun and use those terms. If rates of HIV among transmen are indeed low, we now have the opportunity to engage in true prevention work to keep those numbers low. Gaining a better understanding of transmen’s risk behaviors and the different ways that they protect themselves will aid in providing appropriate and effective HIV prevention education to transmen and their sexual partners.

Says who?

1. It is important to note that few transmen have fully functional penises, primarily due to the relatively low rates of surgical success, high rates of complications, and the extremely high cost. 2. Herbst J, Jacobs E, Finlayson T, et al. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: A systematic review.AIDS and Behavior. 2007. 3. Clements-Nolle K, Marx R, Guzman R, et al. HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: Implications for public health intervention. American Journal of Public Health. 2001;91:915-921. 4. Sevelius J. ‘‘There’s no pamphlet for the kind of sex I have’’: HIV-related risk factors and protective behaviors among transgender men who have sex with non-transgender men. Journal of the Association of Nurses in AIDS Care. 2009;20:398-410. 5. Hein D, Kirk M. Education and soul-searching: The Enterprise HIV prevention group. In: Bockting W, & Kirk, S., editor. Transgender and HIV: Risks, prevention, and care. Binghamton, NY: The Haworth Press; 2001. p. 101-117. 6. Schleifer D. Make me feel mighty real: Gay female-to-male transgenderists negotiating sex, gender, and sexuality. Sexualities 2006;9(1):57-75. 7. Bockting W, Benner A, Coleman E. Sexual identity development among gay and bisexual female-to-male transsexuals: Emergence of a transgender sexuality. Archives of Sexual Behavior. 2009;38(5). 8. Colfax G, Coates T, Husnik M, Huang Y, Buchbinder S, Koblin B, et al.Longitudinal patterns of methamphetamine, popper (amyl nitrite), and cocaine use and high-risk sexual behavior among a cohort of San Francisco men who have sex with men. Journal of Urban Health. 2005;82:i62-i70. 9. CA Department of Health Services. California HIV counseling and testing annual report: January – December 2003. Sacramento, CA: Office of AIDS; 2006. 10. Gorton N, Buth J, Spade D. Medical therapy and health maintenance for transgender men: A guide for health care providers: Lyon-Martin Women’s Health Services; 2005. 11. Newfield E, Hart S, Dibble S, Kohler L. Female-to-male transgender quality of life. Quality of Life Research 2006;15(9):1447-57. 12. Gay/Bi/Queer Transmen’s Working Group of the Ontario Gay Men’s HIV Prevention Strategy. Primed: The Back Pocket Guide for Transmen & The Men Who Dig Them. Toronto, Ontario; 2007. 13. Center of Excellence for Transgender HIV Prevention. Recommendations for Inclusive Data Collection of Trans People in HIV Prevention, Care, and Services. San Francisco, CA: University of California, San Francisco; 2009. www.transhealth.ucsf.edu

Special thanks to the following reviewers of this Fact Sheet: Walter Bockting, AJ King, Niko Kowell, Dan Lentine, Vel McKleroy, Sarah Morgan, Emily Newfield, David Schleifer, Hale Thompson, Erin Wilson.   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.” ©January 2010, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected].

¿Cuáles son las necesidades de los indígenas norteamericanos y nativos de Alaska (IN/NA) para la prevención del VIH?

¿están en riesgo de contraer el VIH?

Sí. Los indígenas norteamericanos y nativos de Alaska (IN/NA) son una población única dentro de los EEUU, no sólo por la opresión que han sufrido durante el desarrollo de este país, sino también por su lucha continua por ser tomados en cuenta en el combate contra la epidemia del VIH/SIDA. Sin embargo, los IN/NA no son tan únicos que sean invulnerables a las mismas conductas que ponen a todas las personas en peligro de contraer el VIH. La larga historia de opresión de los IN/NA en los Estados Unidos ha tenido efectos devastadores sobre la salud y el bienestar de los pueblos indígenas. Esta historia, que incluye la colonización, la prohibición de los idiomas indígenas y de sus prácticas religiosas, y siglos de reubicación forzada, ha generado una desconfianza justificada de los programas e instituciones médicas del gobierno estadounidense.¹ Este legado sigue formando la experiencia de los IN/NA, que están excesivamente afectados por la pobreza, problemas de salud, violencia familiar y abuso de drogas y alcohol. Todos estos factores están asociados con el riesgo de VIH.² Al final del año 2000, los IN/NA representaban 2,337 casos de SIDA y 871 casos de VIH. Los IN/NA constituyen el 1% de la población total de EEUU y un poco menos del 1% de los casos reportados de SIDA y VIH³. Aunque estas cifras parecen reducidas en relación con otros grupos, el efecto es considerable. El bajo número de casos reportados y la falta de vigilancia detallada del VIH entre los IN/NA podría estar causando un conteo muy incompleto de las infecciones por VIH. Por otra parte, muchas veces los datos sobre la raza o grupo étnico de los IN/NA se anotan incorrectamente por las suposiciones que se hacen en base a su nombre, color de la piel y lugar de residencia, y hasta por el uso intencionado de datos engañosos por parte de la persona IN/NA.⁴ Un estudio de datos sobre las ETS en Oklahoma encontró que el 35% de los casos de clamidia y más del 60% de los casos de gonorrea entre los IN/NA se habían reportado incorrectamente como casos hispanos o angloamericanos.⁵

¿cuáles son los riesgos para los IN/NA?

La investigación sobre el VIH entre los IN/NA tiene una historia corta que empezó al principio de la década de los ’90 con unos cuantos estudios sobre comportamientos arriesgados. Según los CDC, las categorías más comunes de transmisión del VIH entre los hombres IN/NA son: hombres que tienen sexo con otros hombres (HSH) 51%, HSH usuarios de drogas inyectables (UDI) 13% y UDI heterosexuales 12%. Entre las mujeres, el mayor riesgo es el contacto heterosexual (41%), seguido del UDI (32%).³ Sin embargo, estos datos no incluyen información de California, que tiene la población indígena más grande de todos los 50 estados de EEUU.⁶ Los pueblos IN/NA están desmesuradamente afectados por factores sociales, conductuales y económicos que están asociados con el riesgo de VIH. Los IN/NA sufren más pobreza y desempleo: el 32% de ellos viven por debajo de la línea de pobreza, en comparación con el 13% de la población general de EEUU.⁷ Los indígenas norteamericanos también tienen tasas altas de uso de drogas y alcohol, ETS y violencia.⁸ Debido a su consumo de alcohol, los IN/NA tienen las tasas más altas de mortalidad relacionada con el alcohol entre todas las poblaciones de EEUU.⁹ Un estudio de usuarios de drogas NA encontró que el consumo de alcohol fue el factor que más aumentó su riesgo de contraer el VIH. Muchos individuos reportaron que habían perdido el conocimiento cuando tomaron alcohol y se enteraron más tarde que habían tenido sexo sin protección con personas completamente desconocidas o con quienes de otra manera no hubieran aceptado como pareja sexual.¹⁰ El mismo estudio demostró que las mujeres nativas de Alaska tienen un riesgo alto de infectarse por gonorrea y por VIH. Las mujeres NA estaban más propensas a inyectarse drogas que las mujeres de cualquier otro grupo étnico y sus parejas sexuales tendían ser UDI angloamericanos. Las parejas sexuales compuestas por una mujer NA y un hombre angloamericano usaron condones con menos frecuencia que otras parejas compuestas por una combinación de grupos étnicos.¹¹ En los estados con poblaciones de IN/NA superiores a 20,000, las tasas de gonorrea y sífilis son dos veces mayores que entre otros grupos étnicos.⁷ Las personas con ETS son más propensas tanto a transmitir el VIH como a infectarse si se exponen al virus. Un estudio entre adolescentes indígenas en más de 200 escuelas en reservaciones a lo largo de EEUU reveló que los jóvenes practicaban varias conductas arriesgadas: el uso de alcohol, tabaco y otras drogas; actividades sexuales sin protección suficiente; y comportamientos suicidas. En la mayoría de los casos, el uso de drogas se asociaba con otros comportamientos peligrosos.¹²

¿cuáles son los obstáculos?

Con frecuencia el VIH se vuelve invisible dentro de las comunidades IN/NA que afrontan muchos otros problemas graves y más visibles, tales como el alcoholismo, la diabetes y el desempleo. Por lo tanto, muchas veces se niega tajantemente que el VIH sea un problema. Al igual que en muchas otras comunidades muy unidas, puede ser difícil mantener la confidencialidad en las comunidades IN/NA, especialmente en zonas rurales. Esto puede dificultar algunas actividades importantes de prevención, como el llegar a hacerse la prueba del VIH, hablar con profesionales médicos sobre prácticas sexuales, obtener tratamiento para dejar las drogas, o comprar condones en tiendas locales. Los HSH IN/NA tienen una amplia gama de identidades, desde “gay” hasta “doble espíritu” y pueden no responder a servicios diseñados para hombres homosexuales urbanos.¹³ Los HSH IN/NA pueden sentirse aislados y evitar buscar los servicios que necesitan a causa del estigma y la negación que existen en torno a la homosexualidad en algunas comunidades IN/NA. Los IN/NA consideran que ellos pertenecen a naciones indígenas soberanas, cada una con su propio gobierno. Las relaciones entre estos gobiernos tribales y los gobiernos estatales y federal son muy complejas. Muchos gobiernos estatales y locales se equivocan al suponer que el Servicio de Salud Indígena (IHS, siglas en inglés) es la única institución responsable de las necesidades médicas de los IN/NA. Menos del 1% del presupuesto del IHS se dedica a comunidades urbanas, pero más de la mitad de todos los IN/NA en EEUU viven en zonas urbanas. Como consecuencia, muchas veces se les niega a las tribus y organizaciones IN/NA las mismas oportunidades para recibir fondos que otros ciudadanos tienen.

¿qué es lo que se está haciendo?

Para responder al aumento de casos de ETS y VIH entre los adolescentes de una tribu rural de Arizona, educadores en salud tribales colaboraron con representantes de las escuelas y del departamento de salud pública para establecer varios programas. Entre ellos se incluyen clínicas, pláticas presentadas por indígenas norteamericanos VIH positivos, dramas sobre el VIH producidos por y para jóvenes, reuniones comunitarias, y anuncios de radio y en la prensa. Los casos de ETS y VIH en esta tribu alcanzaron el máximo en 1990 y en los seis años siguientes se redujeron gradualmente hasta conseguir una reducción total del 69%.¹⁴ El Grupo de Trabajo de Pueblos Indígenas (Indigenous People’s Task Force o IPTF) de Minneapolis, MN, promueve la salud y la educación para personas indígenas. Su programa de educación de pares y teatro llamado Gikinooamaagad (Guerreros/Maestros) brinda a los jóvenes instrucción integral sobre la prevención del VIH/SIDA, el teatro y enseñanzas tradicionales. Los programas del IPTF han sido reconocidos por el Cirujano General de EEUU.¹⁵ El Centro de Recursos de Salud para Indígenas Norteamericanos de Tulsa, OK, ofrece un grupo social para hombres indígenas “doble-espíritu.” El grupo les ayuda a formar un sentimiento de comunidad, aumentar su autoconfianza y reducir sus conductas arriesgadas. El programa también presenta un taller para mejorar las relaciones de pareja que ayuda a los participantes a determinar lo que quieren de sus relaciones, a reconocer y manejar las situaciones que promueven comportamientos riesgosos, y a aumentar sus habilidades de negociación.¹⁶

¿qué queda por hacer?

Si bien las comunidades IN/NA son diferentes entre sí, éstas comparten un sentido de orgullo, autodeterminación, espiritualidad y adaptabilidad que les ha ayudado a luchar contra la infección por VIH. Dichos empeños deben empujarse para asegurar que se mantenga la prevención del VIH. Esto no puede suceder sin la cooperación y colaboración de las diversas agencias que trabajan con los IN/NA, tales como los sistemas tribales de servicios de salud, los departamentos de salud gubernamentales y las organizaciones no lucrativas. Por ejemplo, para permitir que las comunidades IN/NA tengan más acceso a los recursos de prevención, es preciso simplificar el complicado sistema de canalización de fondos. El VIH debe hacerse visible en las comunidades IN/NA para evitar su propagación. La visibilidad se puede aumentar obteniendo datos confiables sobre el VIH, incluyendo a los IN/NA en el diseño y realización de programas de prevención del VIH, respondiendo al estigma con respecto a la homosexualidad y al uso de drogas, y formando conexiones con programas de prevención de ETS, violencia, embarazos no deseados, y abuso de alcohol y drogas.

¿quién lo dice?

1. National Institutes of Health. Women of color health data book: adolescents to seniors. 1999. NIH publication #99-4247.www4.od.nih.gov/orwh/WOCEnglish.pdf (accessed January 2002). 2. Vernon I. Killing Us Quietly: Native Americans and HIV/AIDS. University of Nebraska Press, 2001. 3. Centers for Disease Control and Prevention. U.S. HIV and AIDS cases reported through December 2001, Year-end edition. HIV/AIDS Surveillance Report. 2001;13 (2). (accessed April 2006). 4. Rowell RM, Bouey PD. Update on HIV/AIDS among American Indians and Alaska Natives. The IHS Primary Care Provider. 1997;22:49-53. (accessed April 2006). 5. Thoroughman DA, Frederickson D, Cameron HD, et al. Racial Misclassification of American Indians in Oklahoma state surveillance data for sexually transmitted diseases. American Journal of Epidemiology. 2002;155(12): 1137-41. 6. Smith AS, Ahmed B, Sink L. US Census Bureau. An Analysis of State and County Population Changes by Characteristics: 1990-1999. Working Paper Series No. 45. (accessed April 2006). 7. Centers for Disease Control and Prevention. HIV/AIDS among American Indians and Alaskan Natives – United States, 1981-1997. Morbidity and Mortality Weekly Report. 1998;47:154-160. (accessed April 2006). 8. Morrison-Beedy D, Carey MP, Lewis BP, et al. HIV risk behavior and psychological correlates among Native American women: an exploratory investigation. Journal of Women’s Health and Gender-Based Medicine. 2001:10;487-494. 9. Indian Health Service. Trends in Indian Health–1997. U.S. Department of Health and Human Services, Public Health Service, Indian Health Service, Office of Planning, Education, and Legislation, Division of Program Statistics. 1998. 10. Baldwin JA, Maxwell CJ, Fenaughty AM, et al. Alcohol as a risk factor for HIV transmission among American Indian and Alaska Native drug users. American Indian and Alaska Native Mental Health Research. 2000;9:1-16. 11. Fisher DG, Fenaughty AM, Paschane DM, et al. Alaska Native drug users and sexually transmitted disease: results of a five-year study. American Indian Alaska Native Mental Health Research. 2000;9:47-57. 12. Potthoff SJ, Bearinger LH, Skay CL, et al. Dimensions of risk behaviors among American Indian youth. Archives of Pediatric and Adolescent Medicine. 1998;152:157-163. 13. National Native American AIDS Prevention Center. HIV Prevention for gay/bisexual/two-spirit Native American men. 1996. https://www.nnaapc.net/ (accessed April 2006). 14. Yost D, Hamstra S, Roosevelt L. HIV/AIDS and STD prevention in a rural Arizona Indian tribe. Presented at the International Conference on AIDS, Geneva, Switzerland. 1998. Abst #43162. 15. Indigenous People’s Task Force, 1433 East Franklin Ave. Suite 18A, Minneapolis, MN 55404. Contact Sharon Day 612/870-1723.www.indigenouspeoplestf.org (accessed January 2002). 16. Indian Healthcare Resource Center of Tulsa, 550 South Peoria, Tulsa, OK 74120. Contact Tommy Chesbro 918/382-1275 https://www.ihcrc.org/(accessed January 2002).

Preparado por Ron Rowell MPH*, Paul Bouey PhD MPH** *San Francisco Foundation, **Pangaea Global AIDS Foundation Tradución Rocky Schnaath Abril 2002. Hoja Informativa 43S

Si sabemos lo que funciona al prevenir el VIH — ¿porqué no sacamos mayor provecho?

¿qué hemos aprendido?

Hace quince años, en Los Angeles, CA, se diagnosticaron los primeros 5 casos de SIDA entre hombres homosexuales. Desde entonces el SIDA se ha extendido a más de medio millón de personas en los EEUU y actualmente es la causa líder de muertes entre los Norteamericanos de 25 a 44 años de edad. Estos quince años han sido testigos del gran avance logrado tratando de entender como detener esta enfermedad. Sin embargo, en estos quince años no se ha visto la implementación de programas eficaces de prevención a gran escala en las tareas de prevención del VIH en los EEUU. Si sabemos lo que funciona, ¿porqué no lo ponemos a prueba? No es necesario que la tarea de prevención sea perfecta para ser efectiva. Los modelos epidemiológicos demuestran que el simple hecho de reducir por mitad el número de conductas de riesgo puede detener esta epidemia.¹ Los programas que a continuación mencionamos son algunas de las intervenciones que han dado muestras de eficacia y que deberían ser replicadas aunque no se haya obtenido un 100% en la reducción de las conductas de riesgo.

¿cuáles programas parecen funcionar?

Se estima que la mayoría de los 41,1000 nuevos casos anuales de infección con VIH son atribuidas a los Usuarios de Drogas Intravenosas (UDIs), a sus parejas sexuales y a su descendencia.² Ya sabemos como detener la transmisión del VIH entre los UDIs: comenzar las tareas de prevención apenas se registren los primeros brotes de infección, proveer el material que se usa para inyectarse esterilizado por medio de los programas de intercambio de jeringuillas o a través de las farmacias, crear programas capaces de reclutar a los UDIs en esta lucha, y proveer programas de rehabilitación de drogas de acuerdo a las circunstancias.³ En Tacoma Washington, ciudad donde los esfuerzos de prevención para los UDIs empezaron en el año 1988, la prevalencia del VIH entre los ellos se ha mantenido entre el 3-4%. En la ciudad de Nueva York, en donde los esfuerzos de prevención para los UDIs encontraron resistencia en sus inicios, nos encontramos con un incremento del 10% hasta más del 50% en cinco años.³ Connecticut implementó el programa ideal de prevención del VIH: sin costo alguno al estado y con resultados sumamente positivos. Esto se logro haciendo un simple cambio sustancial a las leyes que giran en torno a la paraphernalia y a la compra de jeringas lo cual produjo una dramática reducción en el uso de jeringas usadas y un incremento en las ventas de jeringas nuevas entre los UDIs. A raíz de la implementación de estas nuevas leyes se observó una reducción en el uso de jeringas usadas del 52% al 31%, la venta en las farmacias subió del 19% al 78%, y las ventas en las calles cayeron del 74% al 28%.⁴ Actualmente, el hombre gay y/o bisexual cuenta con la mayoría de los casos de infección con VIH, y con el 25% anual de nuevas infecciones en los EEUU. Sabemos cuales son las estrategias de intervención que funcionan entre el hombre gay y bisexual: pequeños grupos de apoyo, la práctica de ciertas destrezas o la creación de estas, proveer consejería, pruebas del VIH y programas de recultamiento llevados a cabo por miembros del grupo en cuestión, líneas telefónicas de asistencia, programas televisivos e intervenciones a nivel comunitario. Uno de los programas exitosos fue implementado en varias ciudades de tamaño mediano. En este programa se entrenó a las personas más populares del ámbito social para transmitir mensajes de reducción de riesgo en bares de homosexuales. Debido a esto, se redujeron las relaciones sexuales sin protección.⁵ Otro de los programas exitosos usó la estrategia de promover una norma o patrón de conducta por medio de fiestas, días de campo y juegos de voliból. Esto ocasionó un descenso en las relaciones sexuales sin protección del 40% al 31%.⁶ Un cuarto de todas las nuevas infecciones en los EEUU ocurre entre los jóvenes menores de 22 años. Sabemos cuales son las estrategias para tratar el caso de los adolescentes: los programas eficaces de educación sexual en las escuelas. En una revisión a 23 programas implementados en las escuelas se descubrió que aquellos jóvenes que participaron en estos programas estaban menos propensos a participar en actividades sexuales y aquellos que estaban teniendo relaciones sexuales lo hacían con menos frecuencia usando métodos anticonceptivos.⁷ La prueba voluntaria del VIH y el tratamiento con AZT a las mujeres embarazadas VIH positivas redujo en dos tercios el riesgo de transmisión del VIH de la madre al feto.⁸ Aunque los efectos secundarios que esta medicina ocasiona aún están por verse.

¿comó se limita la prevención?

Hasta hoy, el gobierno Estadounidense no permite el uso de fondos federales para programas de intercambio de jeringas, a pesar de que 6 reportes auspiciados por el gobierno demostraron que estos programas ayudan a detener la transmisión del VIH sin que se haya observado un incremento en el uso de las drogas.⁹ Simultáneamente, diez estados y el DC tiene hasta hoy leyes que requieren una receta del doctor para comprar jeringas, a pesar de que 4 estudios auspiciados por el gobierno han recomendado abolir estas leyes. Mientras tanto, los centros para el tratamiento de drogas tienen con frecuencia largas listas de espera, y menos del 15% de los UDIs en los EEUU están bajo tratamiento en un momento dado.¹⁰ Hasta hace pocos años, muchos estados han logrado crear/pasar leyes que restringen la educación sexual. Por ejemplo, en ocho estados se requiere o se recomienda enseñar que la homosexualidad no es un estilo de vida aceptable en la sociedad a pesar de que los jóvenes gay/homosexuales son los que corren mayor riesgo de contraer el VIH y por lo tanto son los que necesitan más educación. A pesar de que en 26 estados se exige promover la abstinencia en las escuelas, una revisión de estos programas no comprobó la efectividad de estos en cuanto a retrasar las actividades sexuales. Solamente en 14 de los 26 estados se exige como requisito incluir en el currícula de educación sexual información acerca de los anticonceptivos, sobre las enfermedades transmitidas sexualmente y sobre el VIH.¹¹ Los fondos monetarios designados para los esfuerzos de prevención del VIH no siempre se canalizan donde más se necesitan. Por ejemplo, en el estado de California, en el año 1991 en donde el 88% de todos los casos de SIDA era atribuido a hombres homosexuales y bisexuales, solamente designaron el 5% del presupuesto para la prevención en esta población.¹² El éxito obtenido al prevenir la transmisión materno-fetal ha provocado que el gobierno federal recomiende servicios de consejería y pruebas voluntaria del VIH a toda mujer embarazada. Eso si, el hecho de hacerse la prueba no garantiza recibir el tratamiento en caso de resultar positiva. Un estudio a los centros públicos donde se hacen pruebas del VIH, encontró que casi la mitad de los clientes no tenían seguro de salud siendo las minorías raciales las que poseían menos posibilidades de tener seguro de salud.¹³ La falta de un seguro puede impedir que las mujeres reciban servicios preventivos tales como el cuidado prenatal.

¿qué podemos hacer?

El gobierno federal deberá revocar las leyes que impiden que los programas de intercambio de jeringas obtengan fondos para operar. Los gobiernos estatales necesitan revocar las leyes de paraphernalia y de prescripción en cuanto a las jeringas. Ambos gobiernos necesitan incrementar programas de mantenimiento con “Methadone”, asimismo los programas de rehabilitación de drogas como la cocaína y el crack. Los gobiernos estatales deberán implementar leyes que requieran que todo joven reciba educación más explícita sobre la sexualidad, las drogas y el VIH/SIDA de acuerdo con la edad en las escuelas, incluyendo el tema de la homosexualidad y los anticonceptivos. Los departamentos de salubridad del estado y los Grupos Comunitarios de Planeamiento a cargo de distribuir los fondos deberán darle prioridad a los programas de prevención que reflejen con mayor exactitud la epidemiología del VIH en sus comunidades. La mayor prioridad deberá estar centrada en aquellos programas dirigidos a las poblaciones que más lo necesitan: los UDIs dentro y fuera de los programas de tratamiento; hombres homosexuales y bisexuales jóvenes, UDIs y minorías; las parejas femeninas de los UDIs; y los jóvenes que corren alto riesgo. El gobierno federal necesita asegurar el acceso al cuidado médico durante la etapa inicial a aquellas personas que resulten VIH-positivas. El alto costo de los nuevos medicamentos y del tratamiento se hace inaccesible para aquellos que no poseen seguro médico. Los recientes avances en el tratamiento del VIH pueden reducir dramaticamente la cantidad de virus si se hace durante la etapa inicial, lo cual reduce el riesgo de transmisión. En el futuro, un buen tratamiento puede ser la clave para el éxito de los esfuerzos de prevención. Un programa de prevención completo y eficaz utiliza múltiples elementos para proteger a la mayor cantidad de personas a riesgo posible. La estrategia de prevención no necesariamente debe ser perfecta para obtener éxito. Sabemos lo que funciona al hacer prevención. Necesitamos aplicar este conocimiento mas plena, justa, y consistentemente.

¿quién lo dice?

1. Blower SM, McLean AR. Prophylactic vaccines, risk behavior change, and the probability of eradicating HIV in San Francisco . Science. 1994;265:1451-1454. 2. Holmberg SD. The estimated prevalence and incidence of HIV in 96 large US metropolitan areas . American Journal of Public Health. 1996;86:642-654. 3. Des Jarlais DC, Hagan H, Friedman SR, et al. Maintaining low HIV seroprevalence in populations of injecting drug users . Journal of the American Medical Association. 1995;274:1226-1231.

• Contact: Don Des Jarlais 212/387-3870 X3808.

4. 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.

• Contact: Beth Weinstein 203/509-7800.

5. Kelly JA, St. Lawrence JS, Stevenson LY, et al. Community AIDS/HIV risk reduction: the effects of endorsements by popular people in three cities . American Journal of Public Health. 1992;82:1483-1489.

• Contact: Jeff Kelly 414/287-4680.

6. Hays RB, Rebchook, GM, Kegeles SM. The Mpowerment project: a community-level HIV prevention intervention for young gay and bisexual men . American Journal of Public Health. 1996;86:1-8.

• Contact: Susan Kegeles 415/597-9159.

7. Kirby D, Short L, Collins J, et al. School-based programs to reduce sexual risk behaviors: a review of effectiveness. Public Health Reports. 1994;109:339-360. 8. Ekstrand ML, Siegel D, Nido V, et al. Peer-led AIDS prevention delays initiation of sexual behaviors among US junior high school students. Presented at 11th International Conference on AIDS, Vancouver, BC. 1996.

• Contact: Maria Ekstrand 415/597-9160.

9. Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment . New England Journal of Medicine. 1994;331:1173-1180. 10. Lurie P, Drucker E. An opportunity lost: estimating the number of HIV infections due to the US failure to adopt a national needle exchange policy. Presented at 11th International Conference on AIDS, Vancouver, BC. 1996. 11. Wiley J, Samuel M. Prevalence of HIV infection in the USA . AIDS. 1989;3(Suppl. 1):71-78. 12. Sexuality Education in America: A State-by-State Review. Report prepared by the NARAL Foundation. Washington, DC: 1995. 13. Lee PR, Franks P, Haynes-Sanstad K, et al. HIV Prevention in California: HIV Education and Prevention Evaluation. Report prepared for the Office of AIDS, California Department of Health Services, 1993. 14. Valdiserri RO, Gerber AR, Dillon BA, et al. Clients without health insurance at publicly funded HIV counseling and testing sites: implications for early intervention . Public Health Reports. 1995;110:47-52.

Preparado por Thomas J. Coates, PhD, Pamela DeCarlo; Traducción Romy Benard-Rodríguez Enero 1997. Hoja Informativa 20S.