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What Is Post-Exposure Prevention (PEP)?

Why PEP now?

There is still no cure for AIDS. Prevention remains the most effective way to halt the epidemic. The best way to avoid HIV infection is to avoid exposure in the first place through sexual abstinence, having only uninfected sex partners, consistent condom use, injection drug use abstinence, and consistent use of sterile injection equipment.¹ However, recently we have learned a lot about treating HIV and understanding the progression of HIV disease. Protease inhibitors used in combination with other HIV drugs have been extremely effective in reducing the levels of HIV in the blood and restoring health to many patients.² For HIV-uninfected persons who are exposed to HIV, there may be a window of opportunity in the first few hours or days after exposure in which these highly active drugs may prevent HIV infection. A study of health care workers showed that treatment with AZT after needlestick exposure to HIV-infected blood reduced the odds of HIV infection by 81%.^3,4 The study was not designed to test the efficacy of AZT for post-exposure treatment and has some limitations. Following consultations, the findings from this study and other data led the Centers for Disease Control and Prevention (CDC) to recommend post-exposure prevention (more commonly known as post-exposure treatment, post-exposure prophylaxis or PEP) for some health care workers who are accidentally exposed to HIV-infected body fluids. Since PEP is recommended for health care workers, it is only logical that PEP be considered for people exposed to HIV through sex or injection drug use, especially since these are more common sources of HIV infection.

What are components of PEP?

There are no federal recommendations governing PEP for sexual or injection drug use exposure although the CDC is currently studying the matter. Many physicians and clinics across the country currently offer PEP in widely varying forms.⁵ Most forms of PEP involve providing one or several anti-HIV drugs within 72 hours of possible exposure. These drugs are then taken for a 4-6-week period. Before PEP is implemented, a thorough risk assessment should be conducted to determine a patient’s level and frequency of risk-taking, as well as the HIV status of the patient’s partner. Patients should be informed of the potential side effects and difficulty taking the drugs and should be assisted to develop strategies to successfully take the drugs as prescribed. Partner notification and counseling can be part of a PEP program. One of the potential advantages of PEP is the opportunity to reach and counsel people at high risk for HIV. PEP programs should include a behavioral counseling component to help patients develop skills for avoiding future exposure to HIV and to deal with the fear of becoming infected. Referrals to HIV prevention, substance abuse, medical, mental health and housing programs should also be included to help patients address important risk factors.⁶ Unprotected sexual intercourse can result not only in HIV infection, but in other sexually transmitted diseases (STDs) and unintended pregnancy. PEP programs should offer testing and treatment for other STDs and testing for pregnancy. STD infection has been shown to increase the risk of HIV transmission 2- to 5-fold, and treating STDs is an effective HIV prevention intervention.⁷

Does PEP work?

No one knows for sure. The idea of providing potent anti-HIV drugs to prevent infection makes sense biologically, but some people believe the study of health care workers and AZT is not definitive, and there have been no studies on PEP for sexual or injection exposure. The potency of the new anti-HIV drugs, however, is a compelling, if unproven, reason to offer PEP treatment after exposure to a life threatening disease.⁸

What are disadvantages of PEP?

One of the biggest fears about PEP is that people will return to unsafe sexual and drug using practices if they believe that PEP will prevent them from becoming infected. There is some evidence that treatment advances, including PEP, may be leading to increasing incidence of unsafe sex in the US.⁹ For example, rates of gonorrhea among men who have sex with men have recently increased for the first time since the early 1980s.¹⁰ Another fear is that misuse of PEP drug therapies may cause a person to develop a resistant strain of HIV. If PEP drug therapy is unsuccessful and a person does develop a drug-resistant virus, the new anti-HIV drugs may not be as effective for treating that person. This can occur not only with PEP, but with any combination therapy treatment. PEP regimens can be both complicated and prohibitively expensive to follow. PEP drugs need to be taken at specific times of the day on a regular schedule. About one-third of the health care workers who received PEP never finished the regimen because of difficulty taking the drugs. Side effects of the drugs can be severe and debilitating, and long-term effects are still unknown. A typical dosage for four weeks can cost $600-1,000 including the medicine, blood tests and clinic visits. Prescribing PEP can be a complicated decision for clinicians, and should be done on an individual basis. Many believe that a person with single case of unprotected sexual- or needle-related exposure to an HIV+ partner would be a good candidate for PEP. However, many people worry that providing PEP repeatedly to a person with ongoing high-risk behavior may cause disinhibition for unsafe sex and could also be toxic.

What programs exist?

San Francisco, CA has recently implemented a project to determine the safety and feasibility of PEP. The study offers intensive behavioral counseling, HIV testing and anti-HIV medication to persons who have been exposed within the last 72 hours. The project will not look at the effectiveness of PEP; rather it will look at whether participants comply with treatments, if there are significant side effects, and if clients change their risk behavior following the exposure.¹¹ Internationally, many countries are moving ahead with PEP. In France, the Secretary of State for Health announced in August that PEP would be made available to all accidental exposures to HIV, whether occupational, sexual or injection. In London, England, PEP is available through clinics and private physicians. In British Columbia, Canada, PEP is available in emergency rooms for patients with possible exposure.

How can PEP help?

PEP can help strengthen HIV prevention strategies by serving as a bridge between prevention and treatment, similar to STD prevention. Traditional STD prevention includes education, testing, early treatment, counseling, partner notification and follow-up. In San Francisco, one PEP program is located in an STD clinic. Many people have advocated the integration of HIV and STD strategies. PEP is a step in that direction. No one expects PEP to be 100% effective. No prevention tool is 100% effective for any medical condition, whether it be HIV, unwanted pregnancy or cancer. The best prevention effort requires a “myriad of imperfect, cumulatively effective”¹² interventions. A comprehensive HIV prevention strategy uses many elements to protect as many people at risk for HIV as possible. PEP offers the opportunity to expand the range of prevention activities, thereby expanding the possibility of saving lives.

Says who?

1. Centers for Disease Control and Prevention. Backgrounder: CDC-sponsored external consultants meeting on post-exposure therapy (PET) for non-occupational exposures to HIV. Fact sheet prepared by the CDC. July 1997. 2. Deeks SG, Smith M, Holodniy M, et al. HIV-1 protease inhibitors: a review for clinicians . Journal of the American Medical Association. 1997;277:145-153. 3. Centers for Disease Control and Prevention. Case-control study of HIV seroconversion in health-care workers after percutaneous exposures to HIV-infected blood-France, United Kingdom, and United States, January 1988-August 1994 . Morbidity and Mortality Weekly Report. 1995;44:929-933. 4. Cardo DM, Culver DH, Ciesielski CA, et al. A case-control study of HIV seroconversion in health care workers after percutaneous exposure . New England Journal of Medicine. 1997;337:1485-1490. 5. Zuger A. `Morning after’ treatment for AIDS. The New York Times. June 10, 1997. 6. Katz MH, Gerberding JL. Postexposure treatment of people exposed to the human immunodeficiency virus through sexual contact or injection-drug use . New England Journal of Medicine. 1997;336:1097-1100. 7. Wasserheit JN. Epidemiological synergy. Interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases . Sexually Transmitted Diseases. 1992;19:61-77. 8. Henderson DK. Postexposure treatment of HIV-taking some risks for safety’s sake . New England Journals of Medicine. 1997;337:1542. 9. Dilley JW, Woods WJ, McFarland W. Are advances in treatment changing views about high-risk sex? (letter) . New England Journal of Medicine. 1997;337:501-502. 10. Centers for Disease Control and Prevention. Gonorrhea among men who have sex with men-selected sexually transmitted diseases clinics, 1993-1996 . Morbidity and Mortality Weekly Report. 1997;46:889-892. 11. Perlman D. Morning-after HIV experiment starts in SF. San Francisco Chronicle. October 14, 1997. 12. Cates W. Contraception, unintended pregnancies, and sexually transmitted diseases: why isn’t a simple solution possible? American Journal of Epidemiology. 1996;143:311-318.

Prepared by Pamela DeCarlo*, Thomas J. Coates, PhD* *CAPS, UCSF December 1997. Fact Sheet #32E

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]. © December 1997, University of California

¿Qué necesita el hombre heterosexual en la prevención del VIH?

revisado 4/01

¿está el hombre heterosexual en riesgo?

Sí. En los EEUU los casos nuevos de SIDA reflejan un incremento en las infecciones por uso de drogas intravenosas (UDI) y por contacto sexual heterosexual.¹ El aumento de infecciones en hombres heterosexuales por UDI ha elevado los casos de VIH en las mujeres ya que más mujeres se están infectando al tener sexo con hombres UDI. El cambio de conducta del hombre heterosexual es determinante para controlar la epidemia en los hombres heterosexuales, las mujeres y los niños. Más de la cuarta parte (28%) de todos los casos de SIDA en hombres en los EEUU se producen por UDI y por relaciones sexuales heterosexuales. De estos casos, más de tres cuartos se dan en hombres de raza no blanca (caucásica), de los cuales más de la mitad (55%) son afroamericanos.² Los casos de VIH/SIDA (según el Centro de Control de Enfermedades (CDC) de EEUU) se clasifican por conductas de riesgo (consumo de drogas/práctica sexual) y no por autoidentificación de género ó preferencia sexual. A los hombres que se autoidentifican como heterosexuales y que tienen sexo con otros hombres se les categoriza como “hombres que tienen sexo con hombres”; los cuales, no necesariamente llegan a identificarse con los programas dirigidos a hombres gay. Los programas de prevención para hombres heterosexuales en los EEUU han tocado los temas en cuanto al uso de drogas, pero pocos han considerado la conducta sexual. Las intervenciones para el cambio de conducta en heterosexuales se han dirigido principalmente a las mujeres, Si los hombres participan es secundario ya que la intervención no estaba dirigida a ellos.

¿qué pone a los hombres en riesgo?

UDI representa el mayor riesgo para el hombre heterosexual. Las drogas no inyectables como las anfetaminas, la cocaína-crack y el alcohol, incrementan que se tomen riesgos en la conducta sexual, aumentando así el riesgo de infección con VIH. Un estudio en drogadictos UDI que no están en tratamiento de desintoxicación, determinó que los hombres que consumieron metanfetaminas tuvieron más parejas sexuales, mayor actividad sexualcon penetración anal en hombres y en mujeresy menor uso del condón, que aquellos que no las consumieron.³ El hombre puede infectarse al tener sexo desprotegido con una mujer VIH+, aunque el riesgo es mucho menor que el asociado con compartir jeringas infectadas o el sexo con otro hombre VIH+. El riesgo aumenta si la pareja masculina o femenina tiene alguna enfermedad de transmisión sexual (ETS).⁴ La conducta sexual de mayor riesgo para el heterosexual es el sexo anal desprotegido con otro hombre VIH+. Quizá por homofobia o miedo al rechazo, los hombres no se atreven a reportar el tener sexo con otros hombres, identificando el sexo con mujeres como su único factor de riesgo.⁵ En ciertos ambientes los hombres corren un riesgo mayor. En los EEUU, el 90% de los prisioneros son hombres. Las tasas de VIH entre los encarcelados son 8 a 10 veces mayores que en la población en general.⁶ El uso de drogas inyectables, de otras drogas ilícitas, el tatuaje y el sexo anal desprotegido entre hombres son conductas de riesgo en las prisiones.

¿qué es lo que dificulta la prevención?

En esta sociedad a los hombres no se les educa para que cuiden su salud, muchos no reciben atención médica desde la infancia hasta la edad madura (a los 40 años aproximadamente).⁷ Los hombres heterosexuales, y en especial los afroamericanos, son los más reacios para hacerse la prueba del VIH, recibir tratamiento y acudir a las citas médicas.^8,9 Muchos hombres heterosexuales no sólo saben muy poco sobre VIH/ETS, sino que tampoco creen que les concierne. Por falta de material educativo para hombres heterosexuales y de educadores de pares, el hombre heterosexual considera al VIH como un problema exclusivo del “hombre gay blanco.” El hombre es quien porta el condón (masculino) y quien tiene el poder de usarlo o no. Aunque el embarazo, las ETS y el VIH le preocupen, al hombre le puede ser difícil hablar sobre el uso del condón con su pareja. Algunos esperan que sea la pareja femenina quien mencione el tema; si ésta no lo hacen es común que ellos tampoco.¹⁰ Los jóvenes de razas no blancas frecuentemente se perciben así mismos como una “especie en peligro de extinción.”¹¹ Para muchos jóvenes urbanos de áreas marginales, el peligro y la lucha diaria por sobrevivir rebasa las preocupaciones sobre el futuro como el VIH. La pobreza, violencia y adicción refuerzan las creencias del hombre negro de que no vivirá más 25 años. Para muchos de éstos jóvenes, el recibir un balazo o acabar en prisión son sus mayores preocupaciones.¹¹

¿cómo involucrar al hombre heterosexual?

Los educadores de pares pueden ayudar a la prevención del VIH en el hombre heterosexual, aunque muy pocos hombres heterosexuales actualmente participan en la prevención del VIH. El temor y la concepción errónea de la cultura gay inhiben aún más su participación. Se necesita una educación que concientice a los hombres en general para entender y respetar los límites y las culturas sexuales. Reclutar a hombres heterosexuales puede ser una tarea difícil. Por ejemplo, abordar individualmente al afroamericano no es tan eficaz como hacerlo a través de su trabajo, líder religioso o grupo social. Además, el hombre heterosexual puede necesitar la motivación de la novia o esposa para participar en programas de prevención del VIH.¹² Las campañas dirigidas al hombre heterosexual deben centrarse en temas generales de salud, no sólo en temas sexuales. Las campañas deben promover que los hombres hablen y se responsabilicen de su salud y bienestar, y no resaltar el lado negativo del sexo (ej.: el VIH mata, tener sexo con un(a) menor puede llevarte a la cárcel). La educación debe empezar en la pre-adolescencia para así ayudar a los jóvenes a protegerse a sí mismos cuando se enfrenten el mundo de la sexualidad y las drogas.

¿qué se ha hecho?

Un programa de desarrollo de destrezas para la prevención del VIH basado en el uso de videos y diseñado para afroamericanos heterosexuales de Atlanta, ayudó a incrementar el uso del condón y redujo el sexo vaginal desprotegido. El programa mostró información videograbada sobre VIH, preguntas y respuestas y demostró el uso del condón. Además se incorporaron moderadores en vivo. Como los hombres se limitan a participar en demostraciones de situaciones sexuales, se les pidió que sugirieran diálogos relacionados con prácticas sexuales más seguras para escenas específicas de películas populares.¹³ Le Penseur Youth Services ofrece servicios educativos a jóvenes y familias del sureste de Chicago. Uno de sus programas está dirigido a miembros de pandillas e incorpora a líderes pandilleros como educadores. Le Penseur adiestró a líderes y otros miembros de pandillas para transmitir mensajes sobre sexo seguro. Un componente clave es asignar papeles definidos a estos jóvenes y oportunidades de progreso y liderazgo. Éstos jóvenes también llevaron a su casa el mensaje de que el VIH afecta al hombre heterosexual, lo que aumentó la conciencia sobre el VIH en la comunidad.¹⁴ En Baltimore, el departamento de salud abrió un Centro de Salud Masculino gratuito que sirve a hombres sin seguro médico entre las edades de 16 a 64 años. La clínica ofrece atención primaria y dental, consejería para drogodependientes, educación sobre prevención y oportunidades de empleo. El personal de salud es masculino. Cuando este centro abrió, era el único en los EEUU dirigido a los hombres sin seguro médico. El enfoque del centro es ayudar a los hombres a que se mantengan sanos, contribuyendo así a crear familias sanas.¹⁵

¿qué queda por hacer?

El hombre heterosexual aún necesita información básica sobre VIH y requiere de programas que protejan su salud y le enseñen cómo obtener servicios para su salud. Los programas deben considerar que el hombre heterosexual puede tener sexo con otros hombres y deben promover el sexo seguro en cada encuentro sexual. Finalmente, estos programas deben crearse junto con las mujeres para incorporar así las necesidades e inquietudes de la pareja femenina. El tratamiento anti-drogas y el acceso a jeringas estériles que ofrecen los programas de intercambio de jeringas e intercambio en farmacias son cruciales para los hombres heterosexuales. Los hombres encarcelados necesitan tener acceso a tratamientos para la desintoxicación, condones, jeringas estériles, educación sobre prevención del VIH y asesoramiento para la transición de la cárcel a la calle que disminuya el riesgo dentro y fuera de la cárcel. El hombre heterosexual debe tomar más responsabilidad para evitar el contagio del VIH. Como tradicionalmente el hombre no ha participado en asuntos de salud y prevención, hay que apoyarlo y adiestrarlo para asegurar su participación en la prevención del VIH.

¿quién lo dice?

1. CDC. HIV/AIDS Surveillance Report . 1995;7:10. 2. CDC. HIV/AIDS Surveillance Report . 2001;13:16. 3.. Molitor F, Ruiz JD, Flynn N, et al. Methamphetamine use and sexual and injection risk behaviors among out-of-treatment injection drug users . American Journal of Drug and Alcohol Abuse. 1999;25:475-493. 4. Wasserheit JN. Epidemiological synergy. Interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases . Sexually Transmitted Diseases. 1992;19:61-77. 5. Sternberg S. ‘Secret’ bisexuality among Black men contributes to rising number of AIDS cases in Black women. USA Today. March 15, 2001. 6. Hammett TM, Harmon P, Maruschak L. 1996-1997 Update: HIV/AIDS, STDs and TB in correctional facilities. Abt Associates, Inc .: Cambridge, MA; 1999. 7. Sandman D, Simantov E, An C. O . Published by The Commonwealth Fund. March 2000. 8. Fichtner RR, Wolitski RJ, Johnson WD, et al. Influence of perceived and assessed risk on STD clinic clients’ acceptance of HIV testing, return for test results, and HIV serostatus. Psychology, Health & Medicine. 1996;1:83-98. 9. Israelski D, Gore-Felton G, Wood MJ, et al. Factors associated with keeping medical appointments in a public health AIDS clinic. Presented at the 8th International AIDS Conference, Durban, South Africa. Abst# WePeD4570. 10. Carter JA, McNair LD, Corbin WR. Gender differences related to heterosexual condom use: the influence of negotiation styles . Journal of Sex & Marital Therapy. 1999;25:217-225. 11. Parham TA, McDavis RJ. Black men, an endangered species: Who’s really pulling the trigger? Journal of Counseling & Development. 1987;66:24-27. 12. Summerrise R, Wilson W. “The Black Print” model for recruitment of African-American males. Published by the Chicago, IL, Prevention Planning Group. 2000. 13. Kalichman SC, Cherry C, Brown-Sperling F. Effectiveness of a video-based motivational skills-building HIV risk-reduction intervention for inner-city African American men . Journal of Consulting and Clinical Psychology. 1999;67:959-966. 14. Summerrise R. Valuing the lives of men: HIV prevention for heterosexual men. Presented at the US Conference on AIDS, Atlanta, GA. October, 2000. 15.Sugg DK. A first for men: clinic opens in Baltimore . The Baltimore Sun. May 11, 2000. Preparado por Reginald Summerrise* y Pamela DeCarlo**, Traducción Romy Benard y Maricarmen Arjona** *Le Penseur Youth Services, Chicago, IL; **CAPS Septiembre 2001. Hoja Informativa 22SR

¿Qué necesitan las/los trabajadores sexuales en la prevención del VIH?

revisado 4/08

¿corren riesgo de contraer el VIH?

Los trabajadores sexuales en EEUU pueden ser vulnerables al VIH según cuál sea su lugar de trabajo. Hombres, mujeres y transgéneros que trabajan en la calle, en su mayoría pobres o desamparados con antecedentes de abuso sexual o físico, corren el mayor riesgo de contraer el VIH.¹ Muchos sexo servidores que trabajan en la calle también dependen de las drogas o alcohol y corren un mayor riesgo de sufrir violencia a manos de sus clientes y de la policía.² El servicio de sexo fuera de la calle–en prostíbulos, casas de masaje o por medio de servicios de acompañante–supone menos riesgo de infección por VIH porque los trabajadores sexuales pueden controlar mejor sus condiciones laborales y transacciones sexuales, incluido el uso de condones. Se han realizado pocas investigaciones sobre las tasas de infección de VIH entre sexo servidores que trabajan en la calle a lo largo de EEUU. En un estudio de sexo servidoras consumidoras de drogas en Miami, FL el 22.4 % resultó ser VIH+.³ Otro estudio de trabajadores sexuales masculinos en Houston, TX encontró que el 26 % afirmaron ser VIH+.⁴

¿qué los pone en riesgo?

Los sexo servidores que son usuarios de drogas inyectables (UDI) tienen más probabilidades de resultar VIH+ que los no usuarios. Los riesgos por inyección incluyen compartir agujas/ jeringas y otro equipo de inyección previamente usados, así como ser inyectados por otra persona. La inyección y otras formas de consumo de drogas (cocaína en roca, etanfetamina, alcohol) también pueden aumentar los riesgos sexuales al disminuir la protección y la comunicación sexuales.⁵ Las personas que usan cocaína en roca (crack) son más propensas a entrar al sexo servicio y a tener numerosas parejas sexuales.⁶ La decisión y la capacidad de usar condones es un asunto complejo y depende de muchos factores.^7,8 La necesidad económica, la falta de clientes y los clientes que ofrecen pagar más por tener relaciones sin protección pueden perjudicar la negociación del sexo más seguro. Además, hay clientes que pueden recurrir a la violencia para conseguir relaciones sin condón. Si los trabajadores sexuales se drogan junto con sus clientes o antes de atender a ellos, esto afecta su capacidad para tomar decisiones y usar condones.⁵ También pueden ser un blanco de la policía si cargan con condones. Asimismo, al igual que muchas otras personas, los trabajadores sexuales pueden optar por no usar condones con sus novios/novias/esposos. Los sexo servidores tienen tasas más altas de infecciones de transmisión sexual (ITS), entre ellas el VIH. Un estudio en San Francisco, CA reportó tasas altas de gonorrea (el 12.4 %), clamidia (el 6.8 %), sífilis (el 1.8 %) y herpes (el 34.3 %) entre los trabajadores sexuales (hombres, mujeres y transgéneros).⁹ La presencia de una ITS activa aumenta la probabilidad de adquirir el VIH, como hace también el trauma genital producido por el coito frecuente o forzado.¹ La violencia, y el trauma que conlleva, es una preocupación para muchos trabajadores sexuales. La violencia puede incluir el abuso físico, sexual y verbal ocurrido en la niñez, o bien en la edad adulta a manos de clientes y parejas íntimas. También abarca la violencia diaria presenciada por muchos trabajadores sexuales de la calle. El historial de violencia deja a muchos trabajadores sexuales con trauma emocional, y muchos pueden recurrir al consumo de drogas para ayudarles a afrontar la dura realidad de la vida diaria.¹⁰

¿cuáles son los obstáculos?

La naturaleza ilícita del trabajo sexual en EEUU lo ha convertido en una industria clandestina y ha creado en los trabajadores sexuales una fuerte desconfianza hacia las autoridades policiales y de salud pública. Muchos sexo servidores que trabajan en la calle se ven obligados a cambiar sus prácticas laborales con el fin de evitar ser detenidos por la policía.¹¹ Por ejemplo, pueden dedicar menos tiempo a la negociación de las transacciones sexuales antes de subirse al vehículo del cliente o incluso aceptar participar en actividades más riesgosas. Puede ser difícil realizar actividades de prevención, extensión y orientación sobre el VIH en este ambiente. La desesperación y la pobreza muchas veces anulan la prevención del VIH. Los adictos pueden recurrir a la prostitución como fuente de dinero para comprar drogas. Las personas transgénero pueden usar el trabajo sexual para cubrir los gastos de hormonas o cirugía. Muchos jóvenes sin hogar no tienen capacitación laboral u otra manera de generar ingresos, por lo que recurren a la prostitución para sobrevivir. Responder a las necesidades más inmediatas de alimentación, vivienda y adicción con frecuencia toma precedencia sobre la preocupación de infectarse por VIH.¹²

¿qué se está haciendo al respecto?

JEWEL (Jewelry Education for Women Empowering their Lives), fue un proyecto de empoderamiento económico y prevención del VIH para prostitutas consumidoras de drogas en Baltimore, MD. JEWEL presentó seis sesiones de dos horas con orientación sobre la prevención del VIH y sobre la fabricación, comercialización y venta de joyería. Las participantes disminuyeron considerablemente el intercambio de sexo por drogas o dinero, el número de parejas de intercambio sexual y su consumo de drogas, incluido el uso diario de crack.¹³ El Health Project for Asian Women (HPAW) brindó dos intervenciones para trabajadoras sexuales asiáticas de casas de masaje en San Francisco, CA: una orientada a educar a los dueños y otra de consejería e orientación para las masajistas. El personal del proyecto acompañó a las masajistas a los centros de salud, les entregó materiales de protección sexual y les brindó servicios de interpretación, de remisiones a otros servicios y de defensa de derechos. Las masajistas asistieron a tres sesiones de consejería y los dueños de las casas de masaje recibieron una sesión educativa.¹⁴ Una intervención breve para trabajadores sexuales masculinos en Houston, TX presentó dos sesiones de una hora realizadas con una semana de intervalo. Casi los dos tercios (el 63 %) de los hombres que iniciaron la intervención la completaron y también aumentaron su uso de condones para la penetración anal remunerada.¹⁵ Breaking Free, ubicado en St. Paul, MN, ayuda principalmente a muchachas y mujeres afroamericanas a dejar el sexo servicio. Las mujeres que se encuentran en crisis reciben ayuda para estabilizarse, luego participan en un programa intensivo de consejería y orientación sobre los traumas asociados con el trabajo sexual. Breaking Free ofrece vivienda transicional y permanente, así como un programa de prácticas laborales para aumentar las posibilidades de las mujeres, algunas con poca o nula experiencia previa, de conseguir un empleo convencional.¹⁶ St. James Infirmary en San Francisco, CA, es una clínica organizada para y por trabajadores sexuales la cual provee servicios médicos gratis a hombres, mujeres y transgéneros. También ofrece pruebas y tratamiento de VIH/ITS, servicios médicos especializados para transgéneros, consejería de pares y sobre reducción de daños, servicios psiquiátricos, acupuntura, masaje, grupos de apoyo, alimentos, ropa e intercambio de jeringas. El personal realiza trabajo de extensión en la calle y en lugares concretos para repartir materiales de protección sexual y ofrecer pruebas de VIH.⁹

¿qué queda por hacer?

Durante la última década se ha realizado poca investigación en EEUU sobre el VIH/SIDA entre los sexo servidores. Además, los estudios anteriores se enfocaron principalmente en el papel de los trabajadores sexuales como vectores de transmisión del VIH y de ITS al público general. Para evitar el VIH entre los trabajadores sexuales, es fundamental no sólo expandir la investigación sobre este grupo sino también reconocer el contexto más amplio en el cual el trabajo sexual se transacciona y también la práctica específica de los sexo servidores. Los investigadores, las autoridades de salud pública y las policiales necesitan escuchar a los trabajadores sexuales acerca de sus propios necesidades para mantenerse protegidos, y deben trabajar en conjunto para realizar estas metas. Las leyes y las actitudes de la policía en cuanto que los sexo servidores porten condones deben ser indulgentes para permitirles que se protejan. La violencia en contra de los trabajadores sexuales a manos de los clientes, de la policía y de otros en la comunidad deberá criminalizarse, al tiempo que se estimule y apoye a las víctimas para denunciar ante la policía los incidentes violentes. Los sexo servidores que trabajan en la calle enfrentan numerosas necesidades que van desde las inmediatas (vivienda, comida, atención médica) hasta otras de más largo plazo (salud mental, desintoxicación de drogas, prevención de la violencia, capacitación laboral y empleo, prevención del VIH/ITS, atención médica de alta calidad, mejores relaciones con las autoridades policiacas y ayuda para abandonar el trabajo sexual). Es necesario aumentar la financiación y el reconocimiento de los programas de salud pública que respondan a toda la amplia gama de necesidades encaradas por los trabajadores sexuales.

¿Quién lo dice?

1. Rekart ML. Sex-work harm reduction. The Lancet. 2005:366: 2123-2134. 2. Vanwesenbeeck I. Another decade of social scientific work on sex work: a review of research 1990- 2000. Annual Review of Sexuality Research. 2001;12:242-289. 3. Inciardi JA, Surratt HL, Kurtz SP. HIV, HBV, and HCV infections among drug-involved, inner-city, street sex workers in Miami, Florida. AIDS and Behavior. 2006;10:139-147. 4. Timpson SC, Ross MW, Williams ML, et al. Characteristics, drug use, and sex partners of a sample of male sex workers. The American Journal of Drug and Alcohol Abuse. 2007;33: 63-69. 5. Alexander P. Sex work and health: A question of safety in the workplace. Journal of the American Medical Women’s Association. 1998;53: 77-82. 6. Maranda MJ, Han C, Rainone GA. Crack cocaine and sex. Journal of Psychoactive Drugs. 2004;36: 315-122. 7. McMahon JM, Tortu S, Pouget ER, et al. Contextual determinants of condom use among female sex exchangers in East Harlem, NYC: an event analysis. AIDS and Behavior. 2006;10:731-741. 8. Roxburgh A, Degenhardt L, Larance B, et al. Mental health, drug use and risk among street-based sex workers in greater Sydney. NDARC Technical Report No. 237. Sydney: National Drug and Alcohol Research Centre, University of New South Wales. 2005. 9. Cohan D, Lutnick A, Davidson P, et al. Sex worker health: San Francisco style.Sexually Transmitted Infections. 2006;82:418-422. 10. Romero-Daza N, Weeks M, Singer M. “Nobody gives a damn if I live or die”: violence, drugs, and street-level prostitution in inner-city Hartford, Connecticut.Medical Anthropology. 2003;22:233-259. 11. Blankenship KM, Koester S. Criminal law, policing policy, and HIV risk in female street sex workers and injection drug users. Journal of Law, Medicine & Ethics. 2002;30:548-559. 12. Yahne CE, Miller WR, Irvin-Vitela L, et al. Magdalena Pilot Project: motivational outreach to substance abusing women street sex workers. Journal of Substance Abuse Treatment. 2002;23:49-53. 13. Sherman SG, German D, Cheng Y, et al. The evaluation of the JEWEL projects: An innovative economic enhancement and HIV prevention intervention study targeting drug using women involved in prostitution. AIDS Care. 2006;18:1-11. 14. 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. 15. Williams ML, Bowen AM, Timpson SC, et al. HIV prevention and street-based male sex workers: an evaluation of brief interventions. AIDS Education and Prevention. 2006;18:204-215. 16. Valandra. Reclaiming their lives and breaking free: an Afrocentric approach to recovery from prostitution. Journal of Women and Social Work. 2007;22:195-208.www.breakingfree.net

Preparado por Roshan Rahnama, MPH, CAPS Traducido por Rocky Schnaath Septiembre 2008. Hoja de Dato #19SR

How Does Mental Health Affect HIV Prevention?

What does mental health have to do with HIV prevention?

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

Do mental health issues affect HIV risk?

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

What factors impact mental health?

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

What’s being done?

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

What are the implications for prevention programs?

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

Says who?

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

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

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

What is the role of theory in HIV prevention?

What is theory and how can it help?

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

How can theory guide programs?

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

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

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

Structural and policy level

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

Community level

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

Interpersonal level

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

Individual level

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

What else is there?

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

Says who?

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

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

Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © February 2002, University of California