Library

¿Qué papel juega la infección aguda en la prevención del VIH?

¿qué es la infección aguda?

El término infección aguda por VIH se refiere a la primera etapa de la infección, inmediatamente después de que una persona quede infectada y antes del desarrollo de una respuesta de los anticuerpos contra la infección. La segunda etapa de la infección es la seroconversión, cuando se forman anticuerpos específicos contra el VIH. Durante la infección aguda por VIH, existen altos niveles del virus ya que todavía no se ha desarrollado la respuesta de anticuerpos.^1,2 Determinar si hay una infección aguda por VIH es un paso crítico en los esfuerzos de prevención. Las pruebas convencionales del VIH no detectan la infección aguda, pero se calcula que casi la mitad de las nuevas infecciones tal vez ocurren cuando una persona con infección aguda transmite el VIH sin saberlo.³ Todavía no existe una definición del síndrome retroviral agudo porque existen muchos síntomas asociados con la infección aguda por VIH. Al cabo de un periodo de incubación de entre 1 y 3 semanas, aproximadamente el 50% de las personas con infección aguda por VIH padecen dolor de cabeza, dolor de garganta, fiebre, dolor muscular, anorexia, salpullido o diarrea.⁴ Los síntomas por lo general son leves y pueden durar días o semanas. Es fácil pasar por alto o ignorar las señales de infección aguda. La mitad de las personas con infección aguda nunca percibirá síntoma alguno. Asimismo, los síntomas del síndrome retroviral agudo son similares a los de otras enfermedades comunes tales como la mononucleosis infecciosa y la influenza, por lo que muchas veces la infección aguda por VIH se queda sin diagnosticar.⁴

¿cómo se detecta la infección aguda?

La infección aguda no puede detectarse con la mayoría de las pruebas del VIH habituales, pues éstas detectan los anticuerpos específicos contra el VIH en la sangre o en las secreciones bucales producidos por el sistema inmunológico durante la seroconversión. Por lo tanto, una persona muy recién infectada obtendrá un resultado negativo en las pruebas convencionales del VIH. La prueba de amplificación del ácido nucleico (PAAN) puede detectar la infección aguda por VIH buscando la presencia del virus.⁵ Ya que es costoso aplicar la PAAN en cada muestra individual, muchos centros de pruebas combinan las muestras de sangre VIH negativas para analizarlas en conjunto. Esta estrategia de aplicar la PAAN conjuntamente hace factible la detección de la infección aguda en entornos con baja incidencia de enfermedad pero con un alto volumen de pruebas.⁶ Las muestras de sangre con resultados inicialmente negativos pueden ser analizadas de forma rutinaria usando la estrategia de aplicar la PAAN conjuntamente para detectar la infección aguda por VIH. Si un cliente tiene un resultado negativo en la prueba de anticuerpos de VIH pero un resultado positivo en la prueba PAAN para la detección del virus, es importante que regrese a la clínica para recibir consejería de seguimiento y repetir la prueba para confirmar la infección por VIH.

¿qué efectos tiene sobre la prevención?

La única manera de saber si uno es VIH+ y de tomar precauciones para evitar la transmisión es someterse a una prueba del VIH. Sin embargo, pueden pasar dos o más meses después de la infección inicial antes de que se produzca un resultado VIH+ con la mayoría de las pruebas de mayor uso en la actualidad. Estos dos meses son críticos en la prevención del VIH: se calcula que casi la mitad de las transmisiones del VIH sucede durante la etapa de infección aguda,¹ precisamente cuando existen altos niveles del virus en el cuerpo.^2,3 Se ha comprobado que una carga viral elevada está asociada con un mayor riesgo de transmisión del VIH.⁷ Si las personas se encuentran en auge de infeccionsidad durante la infección aguda, es probable que en esta etapa muchas transmitan el VIH sin saberlo. Una persona con infección aguda cuya prueba de anticuerpos resulte negativa puede transmitir el VIH aunque siga las prácticas recomendadas para evitarlo como revelar su condición o estatus de VIH, tener contacto sexual o compartir equipos de inyección de drogas únicamente con personas VIH -. Las personas con infección aguda por VIH pueden beneficiarse de más consejería centrada en estrategias inmediatas de reducción de riesgos y de la aclaración de los resultados contradictorios de las pruebas. Es importante ofrecerles ayuda para revelar su condición así como pruebas y consejería para sus parejas.⁸

¿se puede tratar la infección aguda?

Tratar el VIH durante la etapa de infección aguda puede fortalecer el sistema inmunológico y retrasar la evolución de la enfermedad. Un estudio dio seguimiento a personas VIH+ que iniciaron la terapia antirretroviral altamente activa (TARAA o TARSA) durante la etapa de infección aguda. Sus niveles de carga viral y de células CD4 resultaron mucho mejores que las de otras personas VIH+ que iniciaron la TARAA en una etapa posterior.⁹ Los protocolos de tratamiento del VIH generalmente recomiendan que las personas VIH+ asintomáticas, con carga viral baja y con niveles de CD4 saludables esperen antes de iniciar la TARAA.¹⁰ Es posible que sea beneficioso comenzar el tratamiento durante la infección aguda. No obstante, la decisión de empezar a tomar medicamentos contra el VIH es de suma importancia, pues tienen numerosos efectos secundarios y toxicidades y actualmente no existen estudios a largo plazo sobre la eficacia del tratamiento de la infección aguda.¹¹

¿qué se está haciendo al respecto?

Carolina del Norte ha instituido un programa (Screening and Tracing Active Transmission– STAT) para identificar y tratar nuevas infecciones por VIH. Como parte del STAT y en centros financiados públicamente, toda prueba del VIH estándar que resulte negativa se vuelve a analizar aplicando la PAAN. En 2003, la PAAN detectó 23 casos adicionales de VIH, un aumento del 3.9% en la tasa de identificación de casos. Las 23 personas con infección aguda fueron notificadas, 21 iniciaron atención médica de VIH y 48 de sus parejas sexuales se hicieron la prueba del VIH y recibieron conserjería sobre reducción de riesgos y remisiones a otros servicios.⁶ En el 2003, el Departamento de Salud Pública de San Francisco empezó a hacer pruebas de detección de infección aguda por VIH entre las personas que acudieron a la clínica de ETS/ITS de la ciudad para recibir consejería y pruebas del VIH. En el 2004, se detectaron 11 casos de infección aguda por VIH, lo que refleja un aumento del 8.8% en la detección de casos de VIH. El personal del programa se encargo de contactar, notificar y manejar la situación con las parejas de todas las personas recién diagnosticadas con el virus.^8,12 En un centro hospitalario de atención urgente en Boston, MA, todos los pacientes que tenían síntomas de una enfermedad viral y que reportaron factores de riesgo de infección por VIH se sometieron a una prueba para detectar la infección aguda por VIH. La mayoría de los pacientes (el 68%) aceptaron hacerse la prueba aunque habían acudido al hospital por otros problemas no relacionados con el VIH. De los 499 pacientes que se hicieron la prueba en el año 2000, a 5 se les encontró una infección aguda por VIH y 6 tenían infección crónica. De los 5 pacientes con infección aguda por VIH, 4 regresaron para recibir los resultados de la prueba, fueron evaluados por un médico o enfermera de VIH e iniciaron la terapia antirretroviral.¹³

¿qué queda por hacer?

La infección aguda por VIH es difícil de detectar y muchas veces se queda sin diagnosticar. Los médicos de atención primaria y los trabajadores de salud en salas de emergencia, centros de atención urgente y clínicas de ETS/ITS necesitan orientación y capacitación sobre los síntomas de la infección aguda por VIH. Los proveedores médicos con pacientes que muestran señales de enfermedad viral tales como la influenza o la mononucleosis deben hacerles una breve evaluación del riesgo de la infección por VIH y remitirlos a centros de consejería y pruebas del VIH según la necesidad. Se necesitan más centros de consejería y pruebas del VIH que ofrezcan pruebas para detectar la infección aguda, especialmente en áreas de alta incidencia y en entornos de alto riesgo tales como las clínicas de ETS/ITS. Para lograr esto, es preciso ampliar los recursos de capacitación, asistencia técnica y financieros para las organizaciones que ofrecen pruebas de infección aguda por VIH. Para fomentar el uso de la prueba PAAN se necesitan cambios en los protocolos de reembolsos estatales y federales, así como en los seguros públicos y privados. Identificar a las personas con infección aguda por VIH puede ser una estrategia eficaz de prevención del VIH, porque se enfoca en las personas con mayor riesgo de transmisión. Después de la prueba, las personas con infección aguda pueden necesitar consejería más extensa con remisiones a: atención médica, servicios sociales como el tratamiento para la drogadicción o el alcoholismo, servicios de salud mental y programas de prevención para personas VIH+. La infección aguda también es una etapa crítica para identificar a parejas sexuales y compañeros de consumo de drogas, como también lo es para ofrecer servicios de ayuda para la revelación, tales como la notificación, consejería, pruebas y remisión a servicios para las parejas.^2,16

¿quién lo dice?

1. Pilcher CD, Eron JJ, Galvin S, et al. Acute HIV revisited: new opportunities for treatment and prevention . Journal of Clinical Investigation. 2004;113:937-945. 2. Pope M, Haase AT. Transmission, acute HIV-1 infection and the quest for strategies to prevent infection . Nature and Medicine. 2003;9:847-852. 3. Wawer MJ, Gray RH, Sewankambo N, et al. Rates of HIV-1 transmission per coital act, by stage of HIV-1 infection, in Rakai, Uganda . Journal of Infectious Diseases. 2005;191:403-409. 4. Schacker T, Collier AC, Hughes J, et al. Clinical and epidemiologic features of primary HIV infection . Annals of Internal Medicine. 1996;125:257-264. 5. Quinn TC, Brookmeyer R, Kline R, et al. Feasibility of pooling sera for HIV-1 viral RNA to diagnose acute primary HIV-1 infection and estimate HIV incidence . AIDS. 2000;14:2751-2757. 6. 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. 7. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. New England Journal of Medicine. 2000;342:921-929. 8. Klausner J, Kohn R, Nieri G, et al. A comprehensive HIV surveillance & disease control program in a sentinel site: San Francisco municipal STD clinic, 2004. Presented at the National HIV Prevention Conference, Atlanta, GA, 2005. Abst # W0-L0405. 9. Hecht F, Wang L, Collier A, et al. Outcomes of HAART for acute/early HIV-1 infection after treatment discontinuation. Presented at the 12th Conference on Retroviruses and Opportunistic Infections. 2005. Abst# 568. 10. Department of Health and Human Services. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Oct 2005. aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf 11. Geise R, Maenza J, Celum CL. Clinical challenges and diagnostic approaches to recognizing acute human immunodeficiency virus infection . American Journal of Medicine. 2001;111:237-238. 12. Truong HM, McFarland W, Kellogg T, et al. Detection of acute HIV infection among STD clinic patients in San Francisco. Presented at the 13th Conference on Retro-viruses and Opportunistic Infections. 2006. Abst #914. 13. Pincus JM, Crosby SS, Losina E, et al. Acute human immunodeficiency virus infection in patients presenting to an urban urgent care center . Clinical Infectious Diseases. 2003;37:1699-1704. 14. Kuo AM, Haukoos JM, Witt MD, et al. Recognition of undiagnosed HIV infection: an evaluation of missed opportunities in a predominantly urban minority population . AIDS Patient Care and STDs. 2005;19:239-246. 15. Hightow L, MacDonald P, Boland M, et al. Missed opportunities for the diagnosis of acute infection: room for improvement. Presented at the 12th Conference on Retroviruses and Opportunis-tic Infections. 2005. Abst# 565. 16. Centers for Disease Control and Prevention. HIV transmission among black college student and non-student men who have sex with men– North Carolina, 2003 . Morbidity and Mortality Weekly Report. 2004;53:731-734.

Preparado por Hong-Ha M. Truong, PhD, MS, MPH*; Christopher D. Pilcher MD** *CAPS, *Gladstone Institute of Virology and Immunology, **University of North Carolina Chapel Hill Mayo 2006 . Fact Sheet #59S Special thanks to the following reviewers of this Fact Sheet: Michael Busch, Andrew Forsyth, Karlissa Foy, Sabine Kinloch-de Loes, Mario Legault, Elizabeth Londoño, Willi McFarland, Jon Pincus, Elisabeth Puchhammer-Stöckl, Kathleen Sikkema.

Should we teach only abstinence in sexuality education?

Why all the fuss?

Schools have become a battleground in the nation’s culture wars. In the fight over the hearts, minds-and libidos-of our nation’s teenagers, the latest skirmish involves sex education. The question is not whether education about sexuality belongs in the schools (there is well nigh universal accord on this score),¹ but rather, how to approach the topic. “Just say no” is the answer, at least according to a growing number of champions of “abstinence only” curricula. Abstinence-only approaches include discussions of values, character building and refusal skills, while avoiding specific discussions of contraception or safer sex. Comprehensive sexuality education begins with abstinence but also acknowledges that many teenagers will choose to have sex and thus need to be aware of the consequences and how to protect themselves. Such programs include instruction in safe sex behavior, including use of condoms and other contraceptives.² The abstinence-only sex education movement has been propelled by the persistent but mistaken belief that comprehensive sexuality education itself somehow seduces teenagers into sexual activity. By this reasoning it follows that schools should either ignore the issue or discuss sexuality only in terms of fear and disease. The casualties in this war are teenagers themselves, denied information about how to prevent pregnancy or sexually transmitted diseases in the highly likely event that they have sexual intercourse.

Policy developments

Abstinence-only proponents got a big boost when, as part of the federal welfare reform legislation, Congress earmarked $50 million dollars per year for the next five years for abstinence-only school programs. Eight specific criteria have been established for programs, including the mandate that their “exclusive purpose” be teaching the “social, psychological and health gains” to be realized from abstinence. The block grant requires 75 percent matching funds from other public or private sources, for an annual total of more than $87 million.³ Every state in the union applied for the federal abstinence funding. Some expect to use it only for children in early grades or for media campaigns, a strategy which avoids putting a teacher in the position of being unable to answer a question about birth control or barrier methods of protection from high school students.⁴

Abstinence for whom? until when?

Abstinence-only curricula typically seek to encourage abstinence from sexual activity until marriage. In support of this goal, abstinence proponents use arguments that fly in the face of both science and human experience. The federal abstinence provisions include the statement: “Sexual activity outside the context of marriage is likely to have harmful psychological and physical effects.” This conclusion is as unsubstantiated as it is startling, in light of the statistic that 93 percent of American men and 80 percent of American women between ages 18 and 59 were not virgins on their wedding night.⁴ In the debate over the role for abstinence in sexuality education, little pain is taken to avoid the distinction, for example, between abstinence for 12 or 13-year olds versus 17 or 18-year-olds. Few could argue with a near exclusive focus on abstinence for young children. For older teens, sexuality education needs to be relevant for the substantial share of adolescents who choose to have sex. Two thirds (66%) of American high school seniors have had sex.⁵ Pleas to abstain from sex until marriage must also be considered in light of the current average age at which Americans first tie the knot (approximately 24 for women and 26 for men).⁶ Moreover, the exhortations to avoid sex until marriage have little, if any, meaning for gay teens.

Great expectations?

The sex education debate sometimes grows so heated as to lose a sense of proportion. Great expectations are heaped on school-based programs. Most teaching is assessed by measuring its impact on knowledge rather than behavior outside of the classroom.⁷ It is a tall order to establish the relationship between classroom sex education and changes in behaviors such as delays in initiating intercourse or increases in contraceptive use. Classroom instruction must be factored into the conflicting mix of influences from peers, parents, churches and a media barrage of pro-sex messages. If all young people had safe and secure lives, a “just say no” message by itself might be useful. But for most, risk taking is part of a constellation of internal and external influences. A 1995 national survey reported that 16% of girls whose first intercourse was before age 16 reported that initiation of intercourse was not voluntary. School-based programs by definition also fail to reach many of those at highest risk, such as “runaway” or “throwaway” youth.⁹ Abstinence-only or abstinence plus? The best sex education begins with abstinence as a starting point, both encouraging it for young people who are not ready for sex and supporting those who choose it for whatever reason. Abstinence-only proponents have criticized more comprehensive approaches for focusing only on “plumbing,” sending “mixed messages” and ignoring values. Clearly, the best sex education programs address more than the biology of sex and risk (although kids are owed the basic facts on how their bodies work and how to protect themselves against unintended pregnancy and sexually transmitted diseases). So far, abstinence-only programs have failed to meet scientific tests of proven effectiveness. A recent review found only six published studies in the peer-reviewed literature examining abstinence-only programs.¹⁰ None was found effective, in part due to poor evaluation; one was clearly ineffective. If the federal government is going to fund approaches absent any proof of significant program effects, state officials who accept federal dollars should insist that the programs be thoroughly and rigorously evaluated. The new quarter billion dollar federal program for abstinence-only teaching furthers a religious and political, not a public health agenda.¹¹ Political agendas and discomfort with teen sexuality obstruct the ability to conduct research on which programs work best in preventing HIV and unintended pregnancies. It is not enough to agree on what adults would like young people to hear. Delivery of politically palatable-rather than effective-curricula may serve the interest of adults, but will cheat many young people.

What really works?

For all their antipathy, abstinence-only advocates and comprehensive sexuality education proponents share common goals: the prevention of unintended pregnancies, HIV and other STDs. A number of comprehensive sex education curricula examined in rigorous studies have achieved modest delays in sexual intercourse, reductions in number of partners, and increases in contraceptive use. A national review outlined a variety of elements of effective programs: tailoring to the age and experience of the audience; focus on risky sexual behavior; sound theoretical foundation; provision of basic facts about avoiding risks of unprotected sex; acknowledgement of social pressures to have sex; and practice in communication, negotiation and refusal skills.¹⁰ The guardians of quality education, including teachers, parents, school boards, and legislators have a duty to consider more than the leanings of one advocacy group or another. Credible, objective evidence about the ability of specific programs to achieve their goals is essential. Decision makers need to separate value questions from questions of effectiveness in sex education, and find the common ground.

Says who?

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

Prepared by Chris Collins* and Jeff Stryker* *CAPS, UCSF September 1997. Fact Sheet #30E 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 AIDS Clearinghouse at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © September 1997, University of California

Instrument

The survey instrument was based on more than 100 open- ended interview and 2 focus groups with Hispanics in San Francisco, held to identify Hispanic men's perceptions of the consequences of condom use with primary and secondary sexual partners, difficulties with condom use, and normative aspects of condom use. The instrument was developed originally in Spanish and a back-translation procedure was used to assure that the English version was equivalent in meaning. Both the Spanish and English versions were pretested with at least 20 persons. The final version of the interview required an average of 24 minutes to complete. Most interview questions had four or five-level Likert-type response scales. The reported reliabilities were for the sample of 361 Hispanic men, reporting 1 or more secondary female sexual partners, who responded to the question on condom use with a secondary partner or partners. Frequency of using and carrying condoms. The extent of condom use with a secondary sexual partner was assessed by the question, "When you had sex with someone other than your wife or primary partner in the last 12 months, how often did you use condoms?" The extent of carrying condoms was assessed by the question, "How often do you carry a condom with you?" Each item was recorded using a five-point response scale from "always" to "never." Self-efficacy to use condoms. Four questions were developed to assess perceived ability to use condoms:

• "Would you be able to refuse sex if you partner didn't want you to use a condom?"
• "Would you use condoms even if you had to stop to buy them or look for them?"
• "Would you use condoms even if you had been drinking or using drugs?" and,
• "Would you be able to use a condom with a secondary partner?"

The self-efficacy score was the mean of the four items on a four- point yes-no response scale with higher scores meaning higher efficacy (alpha = 0.55). Those with greater self-efficacy to use condoms were expected to use them more consistently with secondary partners that did those who scored lower. Negative beliefs about condoms. Sixteen items measured beliefs about the consequences of using condoms. Beliefs included "the condom might break," "the condom might come off inside your partner," and "you would feel less sexual pleasure." Responses were "yes" "probably yes," "probably no," and "no" (alpha = 0.70). Depression scale. Ten of the 20 items of the Center of Epidemiologic Studies Depression Scale (CES-D) were selected for the questionnaire, based on their factor loading for Hispanics (alpha = 0.88). The items measure sadness in the 7 days prior to the interview and have been shown to assess depression in community samples. We expected those men who reported the most depressive symptoms to report more risky behaviors than those who reported the least depressive symptoms. The scale score was a continuous variable ranging from 0 to 30, with high scores meaning more depressive symptoms. Sexual comfort. Three items were used to assess sexual comfort: being naked in front of a partner, having sex with the lights on, and having sex with a new partner. The sexual comfort score was the mean of the three items on a four-point scale ranging from "very comfortable" to "very uncomfortable" (alpha = 0.62). Persons with high levels of sexual comfort have been shown to exhibit sexual behavior that is more self-protective than persons with low levels of sexual comfort. Number of friends using or carrying condoms. Two items assessed the proportion of the respondent's close friends who carried condoms and used them with secondary partners, a measure of perceived normative condom use behavior among peers. Responses ranged on a five-point scale from "almost all" to "almost none." Myths about HIV transmission. A measure of beliefs about the casual transmission of HIV was computed by adding responses to three items, such as the likelihood of getting HIV from using public toilets. Total scores could range from 3 to 12, with higher scores representing less accurate beliefs. Demographics. Age, education, marital status, and ethnic origin were determined for each respondent. Acculturation. Acculturation, the process by which a person learns a new culture, was assessed using four language-related items. That scale has been previously shown to have good reliability and validity. Mean scores ranged from 1 to 5, with higher scores indicating more use of English, hence higher levels of acculturation (alpha = 0.90). Other variables. Positive attitude toward condom use with a secondary partner was measured with a six-level Likert-type scale ranging from "dislike a lot" to "like a lot." Knowing someone with HIV infection or AIDS and previous use of condoms to prevent disease were assessed through single items with "yes" or "no" responses.

This text is excerpted from the article "Condom use among Hispanic men with secondary female sexual partners." Marin, Barbara VanOss; Gomez, Cynthia A.; Tschann, Jeanne M.; Public Health Reports v108, n6 (Nov-Dec, 1993):742-750. COPYRIGHT U.S. Department of Health and Human Services 1993

• Stay up-to-date on research and learn what we found out from research
• Use the materials in trainings/presentations
• Advocate for services/funding
• Write grants
• Develop new or modify existing HIV prevention programs
• Evaluate current programs
• Connect with CAPS/PRC to develop new projects.

Más de un millón de personas en los EEUU se inyectan drogas con frecuencia, con un alto costo a la sociedad de más de 50 billones de dólares al sector salud, pérdidas de productividad, accidentes y crímenes. Quienes se inyectan drogas se exponen a contraer el VIH o la hepatitis arriesgando así su propia salud, la de las personas con las que comparten agujas/jeringas, sus parejas sexuales y sus descendientes.