Library

¿Cuál es el papel de la consejería y prueba en la prevención del VIH?

¿por qué es tan importante la C&P?

La consejería y prueba (C&P) del VIH es un componente importante en la gama de servicios de prevención y tratamiento del VIH. Ya que la visita para la C&P incluye una evaluación individual integral de riesgo, ésta ofrece la mejor oportunidad para remitir al cliente a otros servicios más intensivos. Por otra parte, la C&P es una de las entradas a los servicios de prevención y a otros servicios. La consejería breve y enfocada en el cliente que la C&P proporciona puede incrementar el uso de condones y evitar la propagación de las enfermedades de transmisión sexual (ETS).¹ Conocer la condición de VIH, ya sea VIH- o VIH+, es clave para evitar la transmisión del VIH y para obtener consejería y atención médica. Se calcula que la cuarta parte de las personas VIH+ en los EE.UU. no saben que están infectadas.² Una encuesta entre hombres jóvenes que tienen sexo con hombres (HSH) encontró que el 14% de los jóvenes negros HSH eran VIH+. El 93% de éstos desconocían estar infectados y el 71% afirmaron que era poco probable que fueran VIH+.³ Hace poco los Centros para el Control y Prevención de Enfermedades (CDC, siglas en inglés) anunciaron una iniciativa para expandir la C&P en EE.UU.⁴ Su plan estratégico del año 2005 pretende reducir en un 50% el número de personas que ignoran su condición de VIH.⁵ Si se cumple esta meta para el año 2010, se calcula que se prevendrán unas 130,000 nuevas infecciones de VIH, ahorrándose así más de $18 mil millones.⁶

¿cómo se realiza la C&P?

La C&P tiene tres componentes: 1) la evaluación de riesgos y consejería antes de obtener la muestra de sangre o bucal, 2) el análisis de la muestra y 3) la consejería y remisión a otros servicios a la entrega de los resultados.⁷ La C&P puede ser confidencial (el nombre de la persona se registra con el resultado) o anónima (el nombre no se registra con el resultado). Los servicios de C&P financiados con fondos públicos se realizan en centros de pruebas, clínicas y organizaciones comunitarias, programas de alcance comunitario, unidades móviles, clínicas de planificación familiar y de ETS y en departamentos de salud locales, entre otros lugares. Aunque los trabajadores de salud pública están capacitados para implementar los procedimientos de C&P, la mayoría de las pruebas del VIH en EE.UU. se realizan en consultorios médicos privados. Muchas personas prefieren hacerse la prueba del VIH como parte de un chequeo médico regular en lugar de ir a un centro de salud pública. Sin embargo, las pruebas de los consultorios privados no son anónimas y es posible que los pacientes no reciban la consejería o las remisiones adecuadas.⁸ Las pruebas del VIH también se efectúan en otros lugares como las salas de emergencia, las cárceles y prisiones, los centros de reclutamiento militar y en el Cuerpo de Trabajo. En EE.UU., la prueba es obligatoria para recibir algunos beneficios de seguro y médicos, así como para solicitar ciertos trabajos, ingresar a las fuerzas armadas, donar sangre o entrar al país como inmigrante.

¿qué tal las pruebas rápidas?

En los últimos 20 años el método general ha sido obtener una muestra por venipunción (sacar sangre). Desde hace 10 años, también se obtienen muestras de la mucosa bucal (OraSure) para analizar las células. Los resultados se envían a un laboratorio que realiza la prueba ELISA seguida por la Western Blot para confirmar un resultado inicialmente positivo. El tiempo de espera entre la toma de la muestra y la provisión de los resultados suele ser de una a dos semanas. Con este método, muchas personas no regresan para recoger sus resultados. En EE.UU., el 31% de las personas con pruebas VIH+ no vuelven por sus resultados.⁴ La prueba rápida por medio de una punción del dedo (OraQuick) ya está disponible. Este método entrega resultados en 20 minutos. Sin embargo, si la prueba resulta reactiva, el cliente recibirá un resultado preliminar positivo y deberá tomársele otra muestra confirmatoria (por venipunción o con OraSure) para realizar la prueba habitual (Western Blot) cuyos resultados tardarán 1-2 semanas. Los datos nacionales indican que el 95% de los clientes con un resultado preliminar VIH+ a la prueba rápida regresaron por sus resultados confirmatorios.⁹ Aunque la gente sigue teniendo la opción de las pruebas tradicionales, la prueba rápida cambiará la C&P. Ya que se necesita esperar 20 minutos para recibir los resultados, una vez que el consejero obtiene la muestra de sangre en la primera parte de la sesión, se dispone de un “público cautivo” para realizar la evaluación de riesgos y la consejería. Los consejeros mismos pueden efectuar la prueba de sangre, o en su defecto otro trabajador de salud puede hacer la punción y lectura los resultados. Debido a los resultados inmediatos, la consejería de la prueba rápida puede ser más intensa y enfocada en el cliente. Se espera que la prueba rápida produzca un incremento dramático en el número de personas que conocen sus resultados.

¿en qué consiste la buena C&P?

La buena C&P depende de consejeros con la preparación y la experiencia adecuadas. Los consejeros deben proteger la confidencialidad de los datos del cliente, obtener el consentimiento con conocimiento de causa antes de la prueba y proporcionar servicios de consejería eficaces y remisiones apropiadas. Es importante establecer vínculos con prestadores de servicios clave para remitir a los clientes a servicios adecuados a sus necesidades, prioridades, cultura, edad, orientación sexual e idioma. Los consejeros de C&P deben ser evaluados periódicamente para asegurar la calidad de sus servicios y deben recibir apoyo y capacitación constante.⁷ Para la prueba rápida, los consejeros necesitan otro tipo de capacitación, ya que también pueden actuar como técnicos de laboratorio. La prueba rápida requiere una temperatura estable, iluminación adecuada y una atención esmerada al detalle. Cabe señalar que la prueba rápida no equivale a la consejería rápida. Los consejeros necesitan colaborar de cerca con los clientes para formular un objetivo razonable respecto a la reducción de riesgos y asegurarse que realmente estén preparados para conocer sus resultados. Asimismo, es importante obtener otra muestra de sangre para confirmar todo resultado positivo.¹⁰

¿qué se está haciendo al respecto?

El Departamento de Salud Pública (DPH, siglas en inglés) de la Florida se propuso mejorar sus servicios de C&P y aumentar el número de personas que conocen su condición de VIH+. Los programas subvencionados por el gobierno estatal se enfocaron en ofrecer la prueba del VIH a personas de alto riesgo en las ONG, en las prisiones y cárceles, así como en programas de alcance comunitario. También utilizaron la OraSure fuera de los centros médicos. En el 2002, el DPH reportó una tasa de seropositividad del 2% para las muestras por venipunción y del 3.2% para las pruebas de OraSure. En las cárceles encontraron una tasa del 3.6% con OraSure. También ofrecieron servicios de consejería y remisión para parejas (PCRS, siglas en inglés). En el año 2002, el 80% de los clientes VIH+ dieron los nombres de sus parejas: el 64% de éstas fueron localizadas y recibieron consejería, y el 13% de las que se hicieron la prueba resultaron VIH+.¹¹ En Minneapolis, MN, se ofreció la prueba rápida en organizaciones con clientela principalmente afroamericana en lugares como centros para dejar las drogas, refugios para desamparados, clínicas para adolescentes, grupos terapéuticos para agresores sexuales y residencias de transición. Casi todos los clientes (el 99.7%) recibieron los resultados de la prueba y servicios de consejería y el 95% indicaron que preferían la punción del dedo a la de la vena.¹² El programa de SIDA/VIH de Wisconsin buscó incrementar el número de personas de alto riesgo que se hacían la prueba. Al principio de los años ‘90, las pruebas realizadas ascendieron anualmente de 6 mil a entre 20 y 30 mil. Al final de los ‘90, el programa cambió su filosofía de la educación pública a la búsqueda de casos. Los lugares subvencionados con fondos públicos se redujeron de 126 a los 55 que servían al mayor porcentaje de personas de alto riesgo y personas no caucásicas. En un año, la tasa de seroprevalencia disminuyó al .75%. Se registró una reducción del 42% en el número de personas de bajo riesgo que se hicieron la prueba y hubo incrementos de pruebas del 6% entre individuos de alto riesgo y del 18% entre personas no caucásicas.¹³

¿cuál es el futuro de la C&P?

A medida que se extiende el uso de la prueba rápida, se espera una disminución del número de personas que no regresan por sus resultados. La prueba rápida debe ser introducida cuidadosamente y gradualmente para que las organizaciones obtengan experiencia con el nuevo proceso y sus clientes lo vayan conociendo. Puede ser necesario hacer un mayor esfuerzo para remitir a los clientes a servicios eficaces. El cambio conductual es un proceso paulatino y difícil, y muchas personas realizan los cambios incrementalmente. Al remitir a los clientes a otros servicios y darles seguimiento, se puede ampliar considerablemente los efectos de la consejería inicial. Los métodos de capacitación y de control de calidad en la C&P tradicionalmente se han centrado en la consejería, por lo que las remisiones pueden ser el aspecto más débil y necesitado de mejoras. El simple incremento del número de personas enteradas sobre su condición VIH+ no disminuirá lo suficiente esta epidemia. Mientras que más personas en EE.UU. conocen su condición VIH, es imperativo disponer de más servicios de prevención, sociales y de tratamiento tanto para las personas VIH+ como para las VIH-. Además de las intervenciones primarias de prevención del VIH, estos servicios deben incluir el acceso a tratamiento de calidad para dejar las drogas y el alcohol, a servicios de vivienda y de empleo, a pruebas y tratamiento de las ETS, a programas de intercambio de jeringas, a servicios médicos de calidad así como al apoyo para apegarse al tratamiento que asegure el aprovechamiento eficaz de los medicamentos contra el SIDA.

¿quién lo dice?

1. Kamb ML, Fishbein M, Douglas JM,et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases. Journal of the American Medical Association. 1998;280:1161-1167. 2. Fleming P, Byers RH, Sweeney PA, et al. HIV prevalence in the United States, 2000. Presented at the 9th Conference on Retroviruses and Opportunistic Infections, Seattle, WA; February 24-28, 2002. 3. Centers for Disease Control and Prevention. Unrecognized HIV infection, risk behaviors and perceptions of risk among young black men who have sex with men – six US cities, 1994-1998. Morbidity and Mortality Weekly Reports. 2002;33:733-736. 4. 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. 5. Centers for Disease Control and Prevention. HIV Prevention Strategic Plan Through 2005. https://www.cdc.gov/nchhstp/strategicpriorities/default.htm  6. Holtgrave DR, Pinkerton SD. Economic implications of failure to reduce incident HIV infections by 50% by 2005 in the United States. Journal of Acquired Immune Deficiency Syndromes. 2003;33:171-174. 7. Centers for Disease Control and Prevention. Revised Guidelines for HIV Counseling, Testing, and Referral. Morbidity and Mortality Weekly Reports. 2001;50. 8. Haidet P, Stone DA, Taylor WC, et al. When the risk is low: primary care physicians’ counseling about HIV prevention. Patient Education and Counseling. 2002;46:21-29. 9. Kassler WJ, Dillon BA, Haley C, et al. On-site, rapid HIV testing with same-day results and counseling. AIDS. 1997;11:1045-1051. 10. Fournier J, Morris P. Speed bumps and roadblocks on the road to rapid testing: a look at the integration of HIV rapid testing in an agency and community. Presented at the US Conference on AIDS, New Orleans, LA, 2003. 11. Liberti T. Florida’s HIV counseling, testing and referral program. Presented at the US Conference on AIDS, New Orleans, LA, 2003. 12. Keenan PA. HIV outreach in the African American community using OraQuick rapid testing. Presented at the National HIV Prevention Conference, Atlanta, GA. 2003. 13. Stodola J. Restructuring Wisconsin’s HIV CTR program: targeting CTR services. Presented at the US Conference on AIDS, New Orleans, LA, 2003.

Preparado por Steven R. Truax, PhD, CA State Office of AIDS; Pam DeCarlo, CAPS Traducción Rocky Schnaath Enero 2005. Hoja Informativa 3SR

What are Asian and Pacific Islanders’ HIV prevention needs?

revised 5/07

are APIs at risk?

Asians and Pacific Islanders (APIs) are one of the fastest growing ethnic populations in the United States.1 It is projected that by 2050, APIs together will comprise 8% of the total US population, or 34 million persons.^1,2 Asians and Pacific Islanders are extremely diverse and represent 49 different ethnic groups and over 100 languages. APIs include Chinese, Filipinos, Koreans, Hawaiians, Indians, Japanese, Samoans and Vietnamese, among other groups. Most APIs live in concentrated metropolitan areas such as Honolulu, HI; San Francisco, CA; New York City, NY and Los Angeles, CA.² Between 2001 and 2004, APIs represented less than 1% of all US HIV/AIDS cases, yet APIs had the highest estimated annual percentage increase in HIV/AIDS diagnosis rates of all race/ethnicities (8.1% for males and 14.3% for females).³ When populations such as APIs show low prevalence (overall numbers) but high increases in incidence (new diagnoses), prevention efforts are crucial to keep future HIV/AIDS cases low. Underreporting and a lack of detailed HIV surveillance mask the true nature of the epidemic among APIs. One study found that API AIDS diagnoses may be underreported by as much as 33%.⁴ This may in part be due to the misclassification of race and ethnicity in medical records, the source of information for case reports.^2,5 For example, persons with Filipino surnames may be mistakenly recorded as Latino. In addition, the lack of detailed demographic information on specific ethnicity and place of birth makes it difficult to track differences in the AIDS epidemic for API subpopulations and develop ethnically-targeted public health measures.²

who are APIs at risk?

HIV transmission in API men occurs mostly between men who have sex with men (MSM), followed by men who have high-risk heterosexual contact or are injection drug users (IDUs). In 2005, MSM transmission accounted for 71% of all API AIDS diagnoses to date.⁶ Among API women, HIV transmission occurs mostly when a woman has sex with a man who is at increased risk, followed by women who are IDUs.⁶ While API MSM are most affected by HIV/AIDS, diagnosis rates among API women have increased (14.3%), as noted above.³ The CDC does not categorize transgendered women (persons born as men but who identify and live as women), but one study showed a 13% HIV prevalence among API transgendered women in San Francisco, CA.⁷

what puts APIs at risk?

Among API MSM, social discrimination and the lack of family, peer and community support for sexual and racial diversity can negatively impact self-esteem and positive self-identity, thereby increasing their HIV risk. In one study, 57% of gay API men in San Francisco, CA, used alcohol prior to engaging in anal intercourse; approximately 24% reported unprotected anal intercourse. However, 85% believed they were unlikely to contract HIV.:9 APIs have significantly lower rates of HIV testing than the rest of the US population, despite reporting similar rates of risk behavior², and often delay seeking HIV services. In one study of young API MSM in San Francisco, CA, 24.4% of participants had never tested for HIV. Additionally, 2.6% tested HIV+, of whom 61.5% were unaware they were positive, and 38.5% reported recent unprotected sex¹⁰. Untested HIV+ APIs are more likely to engage in high-risk behaviors and unknowingly infect other persons.¹¹ Those that delay seeking services are at greater risk of presenting with advanced AIDS at diagnosis and acquiring co-infections like hepatitis B, tuberculosis and PCP.^5,12 Immigrant API women employed in massage parlors often engage in activities that put them at risk for HIV infection. However, for many of these women, immediate survival needs take priority over HIV prevention. Problems with the police, sex work, immigration, family planning, language barriers, and a lack of condom use policies in parlors all constitute risk factors for this population.¹³

what are barriers to prevention?

Although APIs are often stereotyped as the “model minority,” 17% of APIs lack health insurance and cannot receive adequate medical treatment and healthcare services.¹⁴ Because of limited API health and behavioral risk data, resources are often channeled to other populations, without assessing or acknowledging API healthcare needs.¹⁴ Among APIs, the cultural avoidance of issues such as sexual behavior, illness and death creates barriers to HIV prevention, breeds stigmatization and negatively impacts the psychological and mental health of those living with the illness.¹⁵ Approximately 40% of APIs are limited English proficient (low or no English skills)¹⁴, and few culturally competent intervention programs exist for ethnically, culturally and linguistically diverse API populations. One study found that language is the most common barrier to receiving healthcare services for APIs with HIV/AIDS.¹²

what’s being done?

There are many national and local programs that provide HIV prevention and education services for APIs, as well as capacity building and technical assistance efforts for agencies serving APIs.¹⁷ For example: The Asian and Pacific Islander Coalition on HIV/AIDS (APICHA) developed the Bridges Project, a community-based intervention to reduce disparities in care for HIV+ APIs in New York. It created linkages with hospitals and medical providers, provided case management and advocacy services and offered cultural competency training for providers. It was effective in improving service use and reducing barriers for non-English speaking, Asian-primary-language and undocumented participants.¹² Life Foundation, in Honolulu, HI, has been running community-level programs for Pacific Islander MSM and transgenders since 1999. “UTOPIA Hawai’i” is based on the Mpowerment model and has been very successful in reaching high risk Pacific Islanders that would have never accessed HIV services before.¹⁸ The Health Project for Asian Women (HPAW) addressed Asian female sex workers at massage parlors in San Francisco, CA, with two interventions: Massage Parlor Owner Education Program and Health Educator Masseuse Counseling Program. HPAW staff escorted masseuses to health clinics, handed out safer sex kits and provided translation, referrals and advocacy services. Masseuses participated in a 3-session counseling intervention and massage parlor owners received an education session.¹³ Asian & Pacific Islander Wellness Center conducted an anti-stigma HIV media campaign targeting Chinese communities of San Francisco, CA, using bus shelter posters, newspaper advertisements and a documentary featuring local community leaders, people living with HIV and their families. They also lead the annual National Asian & Pacific Islander HIV/AIDS Awareness Day with over fifteen events across the US to increase acceptance of HIV among families and A&PI communities.¹⁹

what needs to be done?

We have a golden opportunity to keep numbers low among APIs, but that opportunity may be disappearing quickly as APIs have the highest increases in HIV/AIDS diagnosis rates of any racial group in the US. HIV prevention programs for APIs should focus on those at greatest risk, including MSM, women, transgenders and substance users. Programs can help APIs develop and strengthen support systems, as well as focus on prevention and healthcare needs, such as early testing for HIV, hepatitis B and TB. More culturally and linguistically-appropriate prevention and healthcare services for APIs need to be developed and evaluated. Stigma around HIV, homosexuality, sex work and drug use should be addressed with anti-stigma campaigns that increase discussions on HIV/AIDS prevention and lead to greater acceptance of APIs living with HIV. Collaborating with policymakers and new partners such as faith-based organizations can help to address stigma among APIs. Given the enormous diversity among APIs in the US, it is important to improve surveillance systems and quality of data and consistently collect information on subpopulation ethnicity and birthplace.³ Research is needed on HIV and co-infections (hepatitis B and tuberculosis) and on acculturation and its relationship to HIV.

Says who?

1. Choi KH, Wong F, Sy FS. HIV/ AIDS among Asians and Pacific Islanders in the United States. AIDS Education and Prevention. 2005;17:iii-v. 2. Zaidi IF, Crepaz N, Song R, et al. Epidemiology of HIV/AIDS Among Asians and Pacific Islanders in the United States. AIDS Education and Prevention. 2005;17:405-417. 3. Racial/ethnic disparities in diagnoses of HIV/AIDS33 states, 2001-2004. Morbidity and Mortality Weekly Report. 2006;55:121-125. 4. Kelly JJ, Chu SY, Diaz T, et al. Race/ethnicity misclassification of persons reported with AIDS. Ethnicity & Health. 1996;1:87-94. 5. Wortley PM, Metler RP, Hu DJ, et al. AIDS among Asians and Pacific Islanders in the United States. American Journal of Preventative Medicine. 2000;18:208-214. 6. Cases of HIV infection and AIDS in the United States and dependent areas, 2005. HIV/AIDS Surveillance Report. 2006;17:37. 7. Operario D, Nemoto T. Sexual risk behavior and substance use among a sample of Asian Pacific Islander transgendered women. AIDS Education and Prevention. 2005;17:430-443. 8. Wilson PA, Yoshikawa H. Experiences of and responses to social discrimination among Asian and Pacific Islander gay men: Their relationship to HIV risk. AIDS Education and Prevention. 2004;16:68-83. 9. Choi KH, Operario D, Gregorich SE, et al. Substance use, substance choice, and unprotected anal intercourse among young Asian American and Pacific Islander men who have sex with men. AIDS Education and Prevention. 2005;17:418-429. 10. Do TD, Chen S, McFarland W, et al. HIV testing patterns and unrecognized HIV infection among young Asian and Pacific Islander men who have sex with men in San Francisco. AIDS Education and Prevention. 2005;17:540-554. 11. Wong F, Campsmith ML, Nakamura GV, et al. HIV testing and awareness of care-related services among a group of HIV-positive Asian Americans and Pacific Islanders in the United States: Findings from a supplemental HIV/AIDS surveillance project. AIDS Education and Prevention. 2004;16:440-447. 12. Chin JJ, Kang E, Haejin Kim J, et al. Serving Asians and Pacific Islanders with HIV/AIDS: Challenges and lessons learned. Journal of Health Care for the Poor and Underserved. 2006;17:910-927. 13. Nemoto T, Iwamoto M, Oh HJ, et al. Risk behaviors among Asian women who work at massage parlors in San Francisco: Perspectives from masseuses and owners/managers. AIDS Education and Prevention. 2005;17:444-456. 14. Ghosh C. Healthy People 2010 and Asian Americans/Pacific Islanders: Defining a baseline of information. American Journal of Public Health. 2003;93:2093-2098. 15. Kang E, Rapkin BD, Remien RH, et al. Multiple dimensions of HIV stigma and psychological distress among Asians and Pacific Islanders living with HIV illness.AIDS and Behavior. 2005;9:145-154. 16. API Capacity Building programs 17. Takahashi LM, Candelario J, Young T, et al. Building capacity for HIV/AIDS prevention among Asian and Pacific Islander organizations: The experience of a culturally appropriate capacity-building program in southern California. Journal of Public Health Management and Practice. 2007:S55-S63. 18. Utopia Hawai’i 19. API Wellness antistigma campaign

Prepared by Roshan Rahnama, Nina Agbayani, Stacy Lavilla,* John Chin, PhD** *Association of Asian Pacific Community Health Organizations (AAPCHO), **NY Academy of Medicine May 2007. Fact Sheet #33ER Special thanks to the following reviewers of this fact sheet: Vince Crisostomo, Chandak Ghosh, Erin Kahle, Saori Miyazaki, Lina Sheth, Lois Takahashi, Ed Tepporn, Peter Tuiolosega Silva. 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.” ©May 2007, University of CA.

El VIH sigue siendo una gran amenaza para la salud de los latinoamericanos en EEUU. Muchos de ellos se encuentran en desventaja debido al racismo, a las desigualdades económicas y a barreras lingüísticas. En EE.UU., los latinos (incluyendo los habitantes de Puerto Rico) se ven desproporcionadamente afectados por el VIH, ya que representan el 18% de todos los casos de SIDA aún cuando sólo son el 14% de la población. En el año 2001, la mayoría de los casos de SIDA entre latinos en EE.UU. la componían personas nacidas en la parte continental de EE.UU. (35%) y Puerto Rico (25%), seguidos por personas nacidas en México (13%), Centro o Sudamérica (8%) y Cuba (2%). Otro 18% lo componían latinos con un lugar de nacimiento desconocido (15%) o nacidos en otra parte (3%).

Can HIV Prevention Programs Be Adapted?

Why adapt?

We know that many HIV prevention interventions have made a difference, and that prevention efforts have helped to lower rates of HIV infection in many different populations.¹ But as the HIV epidemic changes, so too do the number and groups of people at risk for HIV. Adapting interventions allows us to use principles we know are effective to address the needs of those newly at risk, who may not have been studied yet. Developing new interventions is expensive and time consuming, and it makes good sense to adapt programs that have been demonstrated to be effective.² Using existing tools and theories of successful programs can save time and money. In an age when money for prevention is limited, adapting interventions can be cost-effective.

Aren’t all populations different?

Yes and no. While each community or population is unique, there are many similarities between populations and their social, political and emotional environments. While injecting drug users in Chicago, IL may have very different needs than young gay men in Eugene, OR, both may benefit from similar aspects of programs. For example, using peer educators to help spread the message and change community norms can be effective for both groups.^3,4 HIV prevention is more than simply teaching safer sex and safe drug use nuts and bolts. Prevention programs need to take into account the life context in which a person applies safer sex, and the relationship to the HIV epidemic of the person. Prevention programs need to be tailored to these different situations, not reinvented entirely.

What helps with adaptation?

Program planners can choose from a variety of elements of prevention programs that can address their own local population, setting or intervention needs. Staff training and technical assistance to understand and effectively implement programs is key for successful adaptation. Understanding the community is integral to adapting programs.⁵ Service organizations often know their populations best, whether through outreach or needs assessment. Before adapting an intervention, it is essential to understand the characteristics of the original program and its audience, and how they are different or similar to the new environment. Theory gives a background for behavior change, and may also be useful in assessing whether an intervention is appropriate for a different target group. For example, the Social Cognitive theory of behavior calls for learning through interactions with other people and using physical and social environments to produce change.⁶ Role playing, community building, interactive videos and job training can all be components of a program using this theory. Peer education has been an important element of prevention programs and serves as a powerful motivator especially for disenfranchised people. Such programs recruit peer educators who are at high risk, and teach them how to educate and help save the lives of their friends and colleagues.⁷ This recognizes that people in their own communities have tremendous power of persuasion and can be effective agents of change. Another successful prevention element involves addressing notions of family, community and ethnic pride.⁸ For example, offering parenting and communicating classes often attracts more participation from parents than offering classes specifically about HIV. Appealing to protecting and supporting the community or family-children, spouses, relatives-can be more encouraging than simply protecting oneself.

What are some examples?

The STOP AIDS project in San Francisco, CA, has served as a model for HIV prevention across the country.⁹ The model, based on community mobilization and outreach and small group meetings, has been adapted and used for gay men across the country.⁹ The STOP AIDS model has been used in Los Angeles, CA, West Palm Beach, FL, Phoenix, AZ and Chicago, IL, among other cities. In San Francisco, clients have been recruited on the streets and at bars, while in Chicago, the program has gone into schools. They have found that HIV prevention programs work better when high levels of local commitment are established in a city. Healthy Oakland Teens (HOT), a peer-based sex education program at a junior high school in Oakland, CA, trained ninth graders to lead classes on sexuality and HIV/AIDS to seventh graders. After one year, students in the program were less likely to initiate activities such as deep kissing, genital touching, and sexual intercourse.¹⁰ HOT was then adapted to address Balinese youth who were perceived at risk for HIV due to increasing HIV seroprevalence and an extensive tourist and sex industry in Bali. In Bali, researchers found that among members of traditional Balinese youth groups, only 14% of those who were sexually active had used condoms. Although most still lived at home, only 33% reported feeling comfortable discussing sexuality with their parents, while 75% felt comfortable discussing it with their peers. The HOT model of peer education was therefore seen to be appropriate, and the setting was changed from public schools to traditional Balinese youth groups which reach all Balinese youth regardless of socioeconomic status or educational level.¹¹ One successful prevention program for gay men in small cities recruited popular opinion leaders from bars, and trained them to deliver and model prevention messages to their peers.¹² This program was then adapted to address minority women in inner city housing developments. However, the program didn’t work there. The reason? Women didn’t know their neighbors, and because of high crime rates in the housing developments, were reluctant to open their doors to someone they didn’t know. This program was then reworked, starting by helping women in the housing developments establish a sense of community through potluck dinners and music festivals. As a result, not only did the women increase condom use and communication, but the community began to tackle other issues besides HIV such as drugs and violence in the housing development.¹³

What needs to be done?

Service organizations need to commit time and resources to training staff in effective use of prevention programs, including using theory, conducting needs assessments and reaching out to researchers and other organizations to find out what interventions have been shown to be effective. Community planning groups (CPGs) need to facilitate better communication and stable relationships between researchers, community based organizations and Health Departments. CPG Program Coordinators can help link CPGs with local researchers to help community-based prevention planners determine the best adaptations to make. Researchers need to move from small scale efficacy studies to wide scale field trials. Many interventions are effective in what can be a very controlled research environment (clients often receive payment, staff is well paid and often have advanced degrees). These interventions then need to be tested in the “real world” to see how they may need to be adapted or modified to ensure effectiveness under different conditions and with different populations. Funders need to commit funds to adaptation and pilot testing new programs at the community level. A comprehensive HIV prevention strategy uses many elements to protect as many people at risk for HIV as possible. Adapting existing interventions can be a money-saving and effective prevention strategy.

Says who?

1. Office of Technology Assessment. The Effectiveness of AIDS Prevention Efforts. 1995.
2. Holtgrave DR, Qualls NL, Curran JW, et al. An overview of the effectiveness and efficiency of HIV prevention programs . Public Health Reports. 1995;110:134-146.
3. Weibel W, Jimenez A, Johnson W, et al. Positive effect on HIV seroconversion of street outreach intervention with IDUs in Chicago. Presented at the 9th International Conference on AIDS. Berlin, Germany, 1993. Abstract WSC152.
4. 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.
5. Herek GM, Greene B, eds. AIDS, identity, and community : the HIV epidemic and lesbians and gay men . Thousand Oaks, CA: Sage Publications; 1995.
6. Bandura A. Social cognitive theory and exercise of control over HIV infection. In DiClemente RJ, ed. Preventing AIDS: Theories and Methods of Behavioral interventions . New York, NY: Plenum Press; 1994.
7. Grinstead OA, Zack B, Faigeles B. Effectiveness of peer HIV education for prisoners. Presented at the Biopsychosocial Conference on AIDS; Brighton, England. 1994.
   • Contact: Barry Zack, Marin AIDS Project 415/457-2487.
8. Díaz RM. HIV risk in Latino gay/bisexual men: a review of behavioral research. Report prepared for the National Latino/a Lesbian and Gay Organization. 1995.
   • Contact: Jose Ramón Fernández-Peña, Mission Neighborhood Health Center, 415/552-1013 X386.
9. Wohlfeiler D. Community Organizing and Community Building Among Gay and Bisexual Men. In Minkler M, ed. Community Organizing and Community Building for Health . Rutgers University Press. (in press).
   • Contact: Dan Wohlfeiler 415/575-1545.
10. 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.
11. Merati T, Wardhana M, Ekstrand M, et al. HIV risk taking among youth participating in peer-led AIDS education programs in traditional Balinese youth groups. Presented at the 11th International Conference on AIDS; Vancouver BC. 1996. Th.C.4411.
12. 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.
13. Sikkema KJ, Kelly J, Heckman T, et al. Effects of community-level behavior change intervention for women in low-income housing developments. Presented at the 11th International Conference on AIDS; Vancouver BC. 1996. Tu.C.453.

Contact: Kathy Sikkema 414/287-6100.

Prepared by Pamela DeCarlo and Jeff Kelly

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]. ©1996, University of California

What works best in HIV prevention globally?

what does HIV look like internationally?

With 39 million people living with HIV worldwide, the HIV/AIDS epidemic threatens every aspect of global economic development.^1,2 In 2005, over 4 million people were newly infected with HIV, and almost 3 million died of an AIDS-related illness. HIV/AIDS is among the top 10 causes of death in developing countries, and the leading cause of death in Sub-Saharan Africa. Although Sub-Saharan Africa is the hardest-hit region, HIV is spreading into parts of Asia and Eastern Europe with alarming speed. HIV is transmitted primarily through three mechanisms: sexual intercourse (about 80% of infections worldwide);³ exposure to infected blood or blood products,including injecting drug use; and transmission by HIV+ mothers to their newborns. The international community recognizes the urgency of stopping the AIDS epidemic, yet funding, political will, accountability and human resources have fallen short of needs. Although known interventions could prevent nearly two-thirds of new infections projected to occur between 2002 and 2010, fewer than one in five people at high risk of infection have access to the most basic prevention services.⁴

how is prevention tailored?

Prevention studies and national experiences over the past 20 years strongly suggest that strategies are likely to be most effective when they are carefully tailored to the nature and stage of the epidemic in a specific country or community. Despite a limited amount of rigorous evaluation on prevention programs, evidence demonstrates that tailoring prevention strategies to a region’s epidemic profile is most effective and cost-effective.⁵

• Low-level epidemics occur in regions where the HIV prevalence in the general population is low (less than 1%) and the highest prevalence in a key population is also low (less than 5%). Key populations include sex workers, men who have sex with men (MSM) and injecting drug users (IDUs).
• Concentrated epidemics occur in regions where the HIV prevalence in the general population is less than 1% and the highest prevalence in a key population is more than 5%.
• Generalized low-level epidemics occur in regions where the HIV prevalence in the general population is 1%-10% and the highest prevalence in a key population is 5% or over.
• Generalized high-level epidemics occur in regions where the HIV prevalence in the general population is 10% or over and the highest prevalence in a key population is 5% or over.

The following activities are relevant across all epidemic profiles:

• surveillance of risk behaviors, sexually transmitted infections (STIs) and HIV
• school-based sex education
• peer-based programs
• information, education, and communication (IEC)
• STI screening and treatment
• voluntary counseling and testing (VCT)
• harm reduction for IDUs
• condom promotion, distribution and social marketing
• blood safety practices
• prevention of mother-to-child transmission (MTCT) and universal precautions

low-level epidemic

Providing widespread VCT, screening for STIs and postexposure prophylaxis may not be cost-effective in a low-level epidemic. In this setting, such as in the Middle East and North Africa, HIV/AIDS control strategies should emphasize:

• individual-level interventions that target key populations
• limited education through the mass media
• prevention programs for HIV+ persons
• VCT that is available to key populations with the highest levels of risk behavior and infection rates
• MTCT prevention to known HIV+ mothers
• addressing market inefficiencies in condom procurement and distribution—including strategies such as bulk purchases and incentives
• responding to community attitudes toward sexual activity, as they may dictate people’s response to sex education materials.

concentrated epidemic

In a concentrated epidemic, as in East Asia and the Pacific, Europe and Central Asia, Latin America and the Caribbean, and South Asia, prevention priorities should include:

• promotion of VCT among key populations
• HIV screening of pregnant women, guided by individuals’ risk profiles
• peer-based programs for key populations to educate individuals at risk, promote safer behaviors and distribute condoms
• needle exchange and drug substitution programs for IDUs
• STI screening and treatment for key risk groups
• targeted distribution and promotion of condoms to key populations, linked to VCT and STI care.

Contextual factors—such as government acceptance of needle exchange programs, incarceration of drug users and harassment of sex workers—will likely have a major impact on the effectiveness of prevention efforts. HIV/AIDS is typically concentrated in socially or economically marginalized populations in concentrated epidemics, so attention to socioeconomic factors and to stigmatization of key populations will be vital.

generalized low-level epidemic

Here, as in some countries in Sub-Saharan Africa (Tanzania), targeted interventions must be maintained or strengthened. Interventions for broader populations must be aggressively implemented. Prevention priorities should include:

• maintaining surveillance in the entire population, with a focus on young people
• extending mass media IEC beyond basic education
• providing routine VCT and STI screening and treatment beyond key populations
• strengthened condom distribution to ensure universal access
• offering HIV screening to all pregnant women
• broadening peer approaches and targeted IEC to include all populations with higher rates of STIs and risk behavior.

Contextual factors remain critical, but population level factors now have greater priority. The most important is likely to be the status of women, especially with regard to their ability to control their sexual interactions, to negotiate VCT, to be protected from abuse and to have property rights following the death of a spouse.

generalized high-level epidemic

In a generalized high-level epidemic, such as in some countries in Sub-Saharan Africa (Botswana and Zimbabwe), an attack on all fronts is required. Prevention efforts should focus on broadly based, population-level interventions that can mobilize an entire society. Prevention should include:

• offering routine, universal VCT and STI screening and universal treatment
• distributing condoms free in all possible venues
• providing VCT for couples seeking to have children
• counseling pregnant women and new mothers to make informed choices for breastfeeding
• implementing individual-level approaches to innovative mass strategies with accompanying evaluations of effectiveness
• using the mass media as a tool for mobilizing society and changing social norms
• using venues to reach large numbers of people for a range of interventions—workplaces, transit venues, political rallies, schools, universities and military camps

In a generalized high-level epidemic, contextual factors—such as poverty and the fragility of the health care infrastructure—will dramatically affect service provision at every level. The status of women becomes an overriding concern in this setting, requiring priority action to radically alter gender norms and reduce the economic, social, legal and physical vulnerability of girls and women.

what needs to be done?

The magnitude and seriousness of the global pandemic calls for action. The appropriate mix and distribution of prevention and treatment interventions depends on the stage of the epidemic in a given country and the context in which it occurs. In the absence of firm data to guide program objectives, national strategies may not accurately reflect the priorities dictated by the particular epidemic profile, resulting in highly inefficient investments in HIV/AIDS prevention and care. This waste undoubtedly exacerbates funding shortfalls and results in unnecessary HIV infections and premature deaths.

Says who?

1. The information in this fact sheet is taken directly from the following chapter: Bertozzi S, Padian NS, Wegbreit J, et al. HIV/AIDS Prevention and Treatment. In: Disease Control Priorities in Developing Countries. April 2006. 2. UNAIDS (Joint United Nations Programme on HIV/AIDS). 2006 Report on the global AIDS epidemic. 3. Askew I, Berer M. The contribution of sexual and reproductive health services to the fight against HIV/AIDS: A review. Reproductive Health Matters. 2003;11:51–73. 4. Stover J, Bertozzi S, Gutierrez JP, et al. The global impact of scaling-up HIV/AIDS prevention programs in low- and middle-income countries. Science. 2006;311:1474-1476. 5. Wegbreit J, Bertozzi S, Demaria LM, et al. Effectiveness of HIV prevention strategies in resource-poor countries: tailoring the intervention to the context. AIDS. 2006;20:1217-1235.

Prepared by Nancy Padian PhD, Womens Global Health Imperative, UCSF; Stefano Bertozzi, PhD; Instituto Nacional de Salud Publica, Mexico January 2007. Fact Sheet #62E Special thanks to the following reviewers of this fact sheet: James Curran, Michael Merson, John Stover, Kwaku Yeboah. 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.