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Effect of treatment on prevention
What is the effect of HIV treatment on HIV prevention?
revised 9/03
Why HIV treatment and prevention?
Traditionally, HIV prevention efforts have focused on uninfected persons at risk, encouraging them to adopt and maintain safer sex and drug-using behavior that would keep them uninfected. Less attention was paid to prevention among persons who were already infected, where the priority was maintaining their health in the face of a devastating disease. Providers and programs for prevention and care were distinct and separate. While such a division was always short-sighted (naturally the behavior of both HIV+ and HIV- persons influence transmission), in today’s era of more effective treatment for HIV, it is even more important that prevention and care be permanently linked. More effective treatment, also known as highly active anti-retroviral therapy or HAART, can have differing effects on HIV prevention. On the one hand, HAART has dramatically improved the length of survival and the physical well-being of persons living with HIV/ AIDS, and with it has increased the opportunities for transmission of the virus to others. On the other hand, treatment may decrease the opportunity for HIV transmission by lowering the amount of HIV virus shed through blood and genital secretions. The availability and use of HAART also may have produced changes in attitudes that can help or hinder HIV prevention. Prevention efforts must therefore carefully weigh and address the potential positive and negative effects of HAART on HIV transmission.
Can treatment benefit prevention?
There is a variety of evidence supporting HAART’s beneficial effect on HIV prevention, both in the acquisition of infection among HIV- persons and in the transmission of infection from HIV+ persons to others. First, the provision of anti-retroviral treatment to HIV+ women and their infants around the time of delivery has been shown to reduce mother-to-child transmission.1 Treatment is thought to work by reducing the mother’s infectiousness and/or by blocking the establishment of infection in the infant. Second, follow-up of healthcare workers exposed to HIV through needlestick injuries or other accidental contact with body fluids found that persons taking anti-retroviral post-exposure prophylaxis (PEP) were less likely to become infected compared to those who did not.2 The concept has been extended to the provision of PEP to prevent HIV infection resulting from episodes of unprotected sex or needle-sharing.3 A third argument is indirect. HAART can dramatically reduce the levels of virus in the blood, often to the point of becoming undetectable by current tests. Although not a one-to-one relation, lower blood levels of virus tend to correlate with lower genital fluid levels of virus.4,5 At least one study in Africa observed that low blood viral load translated to low likelihood of sexual transmission; no HIV transmissions were observed among discordant couples when the partner’s blood viral load was under 1500 copies per ml.6 If treatment can reduce blood levels of virus to below this level, the reasoning goes, then it can prevent HIV transmission. This conclusion, while appealing, has not been proven. Even in patients on HAART, virus remains in many tissues of the body, inside cells and in the blood despite being undetectable with tests.7 While it is probably true that a low viral load makes someone less infectious, viral loads fluctuate over time due to changes in adherence, the development of drug resistance or the natural history of infection. While the evidence suggests treatment can reduce infectiousness, it does not eliminate it at all points in time. Until the conditions when someone is not infectious are well-defined, it is safest to assume that an HIV+ person remains potentially infectious for life. On a different level, HAART can help prevention by providing hope to persons affected by AIDS. There is greater incentive to seek HIV testing (and therefore risk reduction counseling) when effective HIV treatment is available and greater disincentive when it is not, especially where high stigma of HIV exists. Moreover, communities devastated by friends and families getting sick and dying may view HIV infection as inevitable and self care and prevention take low priority. A study in Baltimore, MD, found that informal caregivers were more likely to promote prevention messages in the community when their friends and family had access to HIV treatment, giving them hope for the future.8
Can treatment harm prevention?
HIV+ persons and HIV- persons have been having sex and/or injecting drugs since the beginning of the epidemic, before the advent of HAART. In the past few years, however, there have been increases in sexually transmitted diseases (STDs) and sexual risk behavior in the US and across the developed world.9-12 These increases might be a sign of upcoming increases in HIV infection. It is difficult to determine if this is due to improved treatment or not. Outbreaks of syphilis among men who have sex with men (MSM) have occurred in several cities across the US. Around half of the men in these outbreaks were HIV+, with many receiving treatment. In San Francisco, CA, acquiring an STD after AIDS diagnosis was associated with the use of HAART.10 STDs can promote HIV transmission by increasing HIV infectiousness in HIV+ persons and increasing susceptibility to HIV in HIV- persons.13 Internationally, increases in sexual risk behavior and STDs have been documented among both HIV- and HIV+ MSM in the last few years. In London, Manchester and Brighton, England, Amsterdam, the Netherlands and Sydney, Australia, high-risk sexual behavior increased since 1996, especially among MSM.14 These increases in sexual risk behavior in recent years have led to heated discussion on the role of “treatment optimism” in HIV transmission. Treatment optimism means that people are more likely to engage in sexual risk behavior because they believe treatment will make them or their partners less infectious or they believe that HIV is less serious a disease than before. In fact, a recent review of studies on treatment optimism in three continents found few gay men were optimistic overall and the association between optimism and sexual risk behavior was inconsistent.14 That is, treatment optimism may be causing an increase in sexual risk behavior among some communities or segments of communities of gay men, but not among others. The trade-offs between the potential benefits of HAART in reducing the likelihood of HIV transmission and potential harm resulting from increased risk behavior have been included in many complex mathematical models of the epidemic. The models suggest that HIV transmission can increase in a community where greater than 50% of infected persons are on HAART if risk behavior increases on the order of 10% or more.15
What needs to be done?
HIV care programs provide opportunities for treatment and prevention to work together. Health care providers can take a greater role in HIV prevention, making prevention activities an expected part of medical care. Key prevention components can include regular risk reduction counseling and STD screening. Training and support are needed for HIV care providers unfamiliar with these roles. Programs outside medical care settings are needed to help HIV+ and HIV- persons avoid transmission.16 These prevention programs should incorporate a variety of strategies, including counseling and training on when and how to disclose HIV status, how to maintain consistent condom use in the absence of disclosure, how to address HIV-related stigma, and how to keep intimacy in serodiscordant and seroconcordant relationships. This should be available for HIV+ and HIV- persons in the context of managing a healthy sex life. Communities impacted by HIV need better understanding of and access to research on when and how persons are infectious and how to best use HIV treatment to reduce the risk of transmission, so that they can make appropriate informed decisions. Persons who know they are HIV-, know they are HIV+, or do not know their serostatus all need community-level prevention messages that address sexual and drug-related behavior. New HIV tests that are easier to use and give faster results should facilitate increased testing for those who do not know their status. HIV testing should be made more widely available through as many outlets as possible, including anonymous and confidential test sites and home collection kits. The fight against the HIV/AIDS epidemic should not be divided into treatment for HIV+’s and prevention for HIV-’s. Treatment will not eliminate the epidemic in the absence of prevention programs for HIV- and HIV+ persons; prevention will not work unless relevant to those infected and uninfected.
Says who?
1. Mofenson LM. Technical Report: Perinatal Human Immunodeficiency Virus Testing and Prevention of Transmission. Pediatrics. 2000;106:E88. 2. 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. 3. Kahn JO, Martin JN, Roland ME, et al. Feasibility of postexposure prophylaxis (PEP) against human immunodeficiency virus infection after sexual or injecting drug use exposure: the San Francisco PEP study. Journal of Infectious Diseases. 2001;183: 707-714. 4. Barroso PF, Schechter M, Gupta P, et al. Adherence to antiretroviral therapy and persistence of HIV RNA in semen. Journal of Acquired Immune Deficiency Syndromes. 2003;32:435-440. 5. Goulston C, McFarland W, Katzenstein D. Human immunodeficiency virus type 1 RNA shedding in the female genital tract. Journal of Infectious Diseases. 1998;177:1100-1103. 6. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and risk of heterosexual transmission of HIV-1 among sexual partners. Presented at the Conference on Retroviruses and Opportunistic Infections. Jan 30-Feb 2;2000. Abst# 193. 7. Zhu T, Wang N, Carr A, et al. Genetic characterization of human immunodeficiency virus type 1 in blood and genital secretions: evidence for viral compartmentalization and selection during sexual transmission. Journal of Virology. 1996;70:3098-3107. 8. Knowlton AR. Social network approaches to HIV prevention and care: theoretical and methodological considerations of intervention. Presented at the International AIDS Conference, Barcelona, Spain. 2002. ThOrE1501. 9. Valdiserri RO. Preventing new HIV infections in the US: what can we hope to achieve? Presented at the 10th Conference on Retroviruses and Opportunistic Infections, Boston, MA. February 10-14, 2003. 10. Scheer S, Chu PL, Klausner JD, et al. Effect of highly active antiretroviral therapy on diagnoses of sexually transmitted diseases in people with AIDS. Lancet 2001 Feb 10;357(9254):432-5. 11. Katz MH, Schwarcz SK, Kellogg TA, et al. Impact of highly active antiretroviral treatment on HIV seroincidence among men who have sex with men in San Francisco. American Journal of Public Health. 2002;92:388-394. 12. Stolte IG, Coutinho RA. Risk behaviour and sexually transmitted diseases are on the rise in gay men, but what is happening with HIV? Current Opinions in Infectious Diseases. 2002;15:37-41. 13. Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sexually Transmitted Infections. 1999;75:3-17. 14. Elford J, Bolding G, Sherr L. HIV optimism: fact or fiction? FOCUS. 2001;8:1-3. 15. Blower S, Schwartz EJ, Mills J. Forecasting the future of HIV epidemics: the impact of antiretroviral therapies and imperfect vaccines. AIDS Reviews. 2003;5:113-125. 16. Collins C, Morin SF, Shriver MD, et al. Designing Primary Prevention for People Living with HIV. Monograph published by the AIDS Policy Research Center & Center for AIDS Prevention Studies. March, 2000.prevention.ucsf.edu/uploads/publications/pozmono.pdf (Accessed 4/20/06)
Prepared by Willi McFarland* and Pamela DeCarlo** *San Francisco Department of Public Health, **CAPS September 2003. Fact Sheet #27ER Special thanks to the following reviewers of this Fact Sheet: Angela Kashuba, Mitch Katz, Jeffrey Klausner, Kimberly Page-Shafer, Jack Summerside, Dan Wohlfeiler.
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 2003, University of California
Disclosure assistance (PCRS)
What is the role of disclosure assistance services in HIV prevention?
why assistance for disclosure?
After more than 20 years of the HIV epidemic, with advances in treatment and increases in understanding and acceptance of HIV, getting an HIV+ diagnosis still can be a traumatic experience. HIV+ persons must come to terms with their own infection and be concerned with possible infection in past and future partners. Talking to partners about HIV is especially hard because even though it is a manageable disease, HIV still is not curable. Disclosure assistance services (also known as partner counseling and referral services or PCRS) are an array of voluntary and confidential services available to persons living with HIV and their exposed sex and/or needle-sharing partner(s). Disclosure assistance is cost effective and can play a critical role in identifying those individuals most at risk for HIV infection, and linking those who are infected to early medical care and treatment.1,2,3 Most HIV+ persons make the decision to disclose or not disclose to their partners on their own. But HIV+ persons may want support for telling their partners about HIV, whether by encouragement for self-disclosure or by having someone who is well-trained carefully and confidentially notify a partner for them. In one study, persons who received disclosure assistance were over three times more likely to have informed a partner of their risk.4 In the past few years, HIV counseling and testing programs across the US have shifted their emphasis from testing anyone, to finding and testing persons at greatest risk for HIV infection.5 At general HIV testing sites, around 1% of clients tested are found to be HIV+, whereas 8-39% of clients tested through disclosure assistance are found to be HIV+.2
what is disclosure assistance?
Often, disclosure assistance or PCRS mistakenly has been seen as only provider disclosure, but there are three forms of assistance: Self disclosure–The client chooses to notify a partner him/herself. The disclosure assistance provider guides and prepares the client before disclosure. Currently, most HIV+ persons choose this method. Dual disclosure–The client chooses to notify a partner in the presence of a provider. The provider supports the client during disclosure and acts as a resource for the partner. This method is rarely chosen and requires highly skilled providers. Provider disclosure (anonymous third party)–The client prefers a professional to notify a partner, and gives his/her provider identifying and locating information for partner(s). Most often, providers give this info to Disease Intervention Specialists (DIS) who then locate and notify the named partners, keeping client identity strictly confidential. This method is chosen less often, yet it is the only one with client anonymity. For the partners of an HIV+ client, disclosure assistance services can include: being notified of exposure to HIV, HIV prevention counseling, HIV testing options, referrals for HIV medical evaluation if positive and referrals for other social or medical services.6
how does it work?
Disclosure assistance services are first offered when a person receives a positive HIV test result. It is not a one-time only service, but should be offered as clients’ risk circumstances and needs change. The main element is helping HIV+ persons tell their sexual and/or needle-sharing partners about possible HIV exposure. The quality and use of disclosure assistance services can vary widely. Services differ from state to state: some have legal mandates to provide it, some offer it through HIV, STD or combined HIV/STD programs, and states can receive referrals from clinicians, health departments or testing sites.7 Services can be provided by HIV service agencies, health departments and most clinics and hospitals. Most service agencies can provide coaching and support for self or dual disclosure and gather partner identifying and locating information which is forwarded to DIS staff. Most notification of partners has been done by DIS at local health departments because they have the capacity, expertise, trained staff and protection from liability. Good provider disclosure depends on DIS staff who are properly trained and have enough experience and knowledge of the populations they serve. DIS staff should be evaluated regularly to assure quality and be provided with support and ongoing training.6
what are the concerns?
Public health messages have traditionally urged disclosure to all sexual and drug using partners. In reality, disclosure is complex and difficult. Some HIV+ persons may fear that disclosure will bring partner or familial rejection, limit sexual opportunities, reduce access to drugs of addiction or increase risk for physical and sexual violence. Because of this, some HIV+ persons choose not to disclose. Programs need to accept that not disclosing is a valid option. Many HIV service agencies and testing and counseling sites routinely offer self disclosure and dual disclosure, working with HIV+ clients by preparing and supporting them to disclose to partners on their own. Although provider disclosure services have been used for many years with other STDs, there is a wide variety in rates of acceptance of provider disclosure in HIV: in North Carolina, 87% of newly diagnosed HIV+ persons accepted provider disclosure,8 in Florida 63.1%,9 Los Angeles, CA 60%,10 New York State 32.9%,12 Seattle, WA 32% and among anonymous testers in San Francisco, CA 3.1%.13 In Los Angeles, the most common reasons for refusal were: already notified partner (23.4%), not being ready to disclose (15.3%), being abstinent (15%) and having an anonymous partner (11%).10 Disclosing HIV status to partners can be scary, but also can be empowering. In one study, HIV+ injection drug users who disclosed their status found increased social support and intimacy with partners, reaffirmation of their sense of self and the chance to share experiences and feelings with sexual partners. Another study of HIV+ persons and their partners who received disclosure assistance found that emotional abuse and physical violence decreased significantly after notification.15
what’s being done?
Florida utilizes trained DISs to deliver disclosure assistance for all reported new HIV infections. In 2004, 63.1% of all newly infected HIV+ persons accepted provider disclosure, identifying 4,460 sex or needle-sharing partners. Among those, 21.8% had previously tested HIV+. Of the 2,518 persons notified, 84.2% agreed to counseling and testing and 11.5% were HIV+.9 The Massachusetts Department of Public Health piloted a client-centered model of disclosure assistance that is integrated into the client’s routine prevention, care and support services. The program required significant changes to the standard model of DIS provider disclosure, building close relationships between service providers and DIS to better support clients’ disclosure needs while protecting confidentiality.16 California instituted a voluntary disclosure assistance program that includes counseling and preparing HIV+ persons for self disclosure; anonymous third party provider notification; counseling, testing and referrals for notified partners; and training and technical assistance to providers in public and private medical sites. About one-third of patients opted for provider disclosure and 85% referred partners. Of the partners located, 56% tested for HIV and half had never tested before. Overall, 18% of partners tested HIV+.4
what needs to be done?
New HIV testing technologies can be useful with disclosure assistance services. Improved rapid testing is a potential invaluable tool for offering HIV tests in the field to notified partners. Nucleic acid amplification testing (NAAT) can determine acute infections, that is, new HIV infections that do not show up during the window period of other HIV tests. Combining these testing strategies with disclosure assistance can help identify newly infected persons and provide immediate counseling, support and referrals to medical or social services as needed.17 Disclosure assistance services, and particularly provider disclosure, may need extensive changes from the traditional DIS model in order to work well and be accepted within HIV services. Health departments could forge closer ties between their STD and HIV programs and with outside service agencies. HIV staff also can be trained to be DIS providers to broaden access to and comfort with disclosure services. Disclosure assistance services should be made available not only upon HIV diagnosis, but on an ongoing basis as HIV+ persons’ circumstances and needs change. It is not the role of providers to decide if a client will need or want disclosure assistance, but to offer clients support and choices, whether or not a client chooses to disclose. Prepared by Fern Orenstein MEd, CA STD Control Branch, Prevention Training Center
Says who?
1. Landis SE, Schoenbach VJ, Weber DJ, et al. Results of a randomized trial of partner notification in cases of HIV infection in North Carolina. New England Journal of Medicine. 1992;326: 101-106. 2. Golden MR. Editorial: HIV partner notification, a neglected prevention intervention. Sexually Transmitted Diseases. 2002;29:472-475. 3. Varghese B, Peterman TA, Holtgrave DR. Cost-effectiveness of counseling and testing and partner notification: a decision analysis. AIDS. 1999;13:1745-1751. 4. Eckert V. Utilization of voluntary HIV partner counseling and referral services. California Office of AIDS & STD Control Branch. Presented at the Statewide PCRS Conference, May 2004. 5. Centers for Disease Control and Prevention. Advancing HIV Prevention: New Strategies for a Changing Epidemic – US, 2003. Morbidity and Mortality Weekly Report. 2003:52;329-332.http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5215a1.htm (accessed April 2006). 6. HIV partner counseling and referral services guidance. Centers for Disease Control and Prevention. 1998. https://www.cdc.gov/hiv/guidelines/partners.html 7. Aldridge C, Randall L. Implementing partner counseling and referral services programs. Presented at the National HIV Prevention Conference, Atlanta, GA. 2005. Abst #TO-057. 8. Centers for Disease Control and Prevention. Partner counseling and referral services to identify persons with undiagnosed HIV–North Carolina, 2001. Morbidity and Mortality Weekly Report. 2003;52:1181-1184.http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5248a4.htm (accessed April 2006). 9. George D. Partner counseling and referral services (PCRS): the Florida experience. Presented at the National HIV Prevention Conference, Atlanta, GA. 2005. Abst #M3-B1605. 10. Aynalem G, Hawkins K, Smith LV, et al. Who and why? Partner counseling and referral service refusal: implication for HIV infection prevention in Los Angeles. Presented at the National HIV Prevention Conference, Atlanta, GA. 2005. Abst #MP-036. 11. Birkhead G. HIV partner counseling and referral services in New York state. Presented at the National HIV Prevention Conference, Atlanta, GA. 2005. Abst #M3-B1603. 12. Golden MR. Partner notification: where do we stand and outstanding barriers. Presented at the National HIV Prevention Conference, Atlanta, GA. 2005. Abst #T3-D1302. 13. Schwarcz S, McFarland W, Delgado V, et al. Partner notification for persons recently infected with HIV: experience in San Francisco. Journal of Acquired Immune Deficiency Syndrome. 2001;28:403-404. 14. Parsons JT, Vanora J, Missildine W, et al. Positive and negative consequences of HIV disclosure among seropositive injection drug users. AIDS Education and Prevention. 2004;16:459-475. 15. Kissinger PJ, Niccolai LM, Magnus M, et al. Partner notification for HIV and syphilis: effects on sexual behaviors and relationship stability. Sexually Transmitted Diseases. 2003;30:75-82. 16. Cranston K. Planning for HIV partner counseling and referral services in the third decade. Presented at the National HIV Prevention Conference, Atlanta, GA. 2005. Abst #T3-D1301. 17. Pilcher CD, Fiscus SA, Nguyen TQ, et al. Detection of acute infections during HIV testing in North Carolina. New England Journal of Medicine. 2005;352:1873-1883.
September 2005. Fact Sheet #53ER Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. ©Sepetmber 2005, University of California
Transgender men
What are transgender men’s HIV prevention needs?
Prepared by Jae Sevelius, CAPS; Ayden Scheim and Broden Giambrone, Gay/Bi/Queer Trans Men’s Working Group, Ontario Gay Men’s Sexual Health Alliance Fact Sheet 67 – Revised September 2015
Who are transmen?
Transgender (‘trans’) is an umbrella term for people whose gender identity and expression do not conform to norms and expectations traditionally associated with their sex assigned at birth. Transgender men, or transmen, are people who were assigned ‘female’ at birth and have a male gender identity and/or masculine gender expression. Transgender people may self-identify and express their gender in a variety of ways and often prefer certain terms and not others. Some who transition from female to male do not identify as transgender at all, but simply as men. In general, transmen should be referred to with male pronouns. However, if you are unsure it is best to respectfully ask a person what terms and pronouns they prefer. Accurate information about the diversity of transmen’s bodies is not widely available. Transmen have different types of bodies, depending on their use of testosterone and gender confirmation surgeries (which may include chest reconstruction, hysterectomy, metoidioplasty, phalloplasty1, etc.; see www.ftmguide.org for further information). Transmen use a broad range of terms and language to identify their sex/gender, describe their body parts, and disclose their trans status to others. For instance, some transmen are not comfortable with the terms ‘vagina’ and ‘vaginal sex’ and may prefer ‘front hole’ and ‘front sex’ or ‘front hole sex’, although this is not true for all transmen. This diversity creates unique needs and barriers for negotiating and adhering to safer sex practices that are not addressed by current HIV prevention programs.
What do we know about HIV and transmen?
The transgender community is diverse and not enough research has been conducted with trans people in general. We have very limited information about transmen in particular. To date, research related to HIV among trans people has almost exclusively focused on transwomen (people who were assigned ‘male’ at birth and have a female gender identity and/or feminine gender expression). However, there is evidence that there is a significant subgroup of transmen that engage in unprotected sex with non-trans men (trans MSM), including some transmen who engage in sex work. Several cities have conducted needs assessments that focus on or are inclusive of transmen and HIV risk, such as Philadelphia, Washington D.C, San Francisco, and the province of Ontario. The few published studies that report HIV rates among samples of transmen have reported 0–3% prevalence.2,4 These rates are self-reported, however, and are based on small, non-representative samples, so we do not have conclusive data about the actual rates. Due to the assumption of low rates of HIV among transmen relative to other high-risk groups, there has not been much research on risk behaviors among transmen. We do know that HIV prevention messages are not reaching most transmen.5 We also know that many trans MSM seek services at gay men’s organizations, where there is little to no education for transmen and their non-trans male partners.4 Providers are generally not trained to identify or serve gay and bisexual transmen in culturally sensitive ways or understand their specific risks and prevention needs.
What don’t we know about HIV and transmen?
We do not have enough information about HIV and transmen. Data collection methods at testing sites do not accurately identify and track transmen or capture their experiences, which contributes to the lack of clarity around HIV rates among transmen. Rates of HIV and sexual risk behaviors among transmen are also not well understood because transmen are often assumed to be primarily having sex with non-trans women. However, transmen, like other men, can be of any sexual orientation and may have sex with different types of partners, including (but not limited to) non-trans men, transgender women, and transgender men.6,7
What puts transmen at risk?
In one study, a majority of trans MSM reported not using condoms consistently during receptive anal and/or frontal (vaginal) sex with non-trans male partners and low rates of HIV testing and low perception of risk.4 In urban areas where HIV prevalence rates among non-trans MSM are estimated to be 17-40% and STI rates are increasing, trans MSM who engage in unprotected receptive anal and/or frontal (vaginal) intercourse with non-trans MSM may be especially vulnerable to HIV/STIs.8,9 Transmen may face complicated power and gender dynamics in their sexual relationships with non-trans men.4 For some trans MSM, having sex with a non-trans gay male partner is a powerful validation of their gay/queer male identity, especially in the early years of transition, and may be more important than insisting on condom use. Some transmen who use testosterone have reported increased sex drive and increased interest in sex with non-trans men after beginning hormone use, which may contribute to their willingness to take sexual risks.4,10 Transmen on testosterone and/or who have had a hysterectomy may have frontal (vaginal) dryness, which increases their risk for frontal (vaginal) trauma during penetration, thus increasing their risk for STIs, including HIV.10 Low self-esteem may contribute to sexual risk-taking among transmen. Rates of depression, substance use, and suicide attempts are high in this population, but multiple barriers exist to accessing culturally competent support and treatment.3,11 Drug and alcohol use is a major risk factor for every community, regardless of their gender identity. Transmen may use alcohol or drugs to enhance sexual experiences or help to relieve anxiety about their bodies during sex.4 Some transmen may feel pressure to use drugs in order to fit into some gay men’s communities or subcultures. Although we have very little information about needle sharing for hormone or drug use among transmen, it may also be a risk factor for some.
What can help?
Online dating. Many transmen meet their non-trans male sexual partners on the Internet. Meeting partners through personal ads may allow transmen to describe their body and gender identity upfront (if they choose to do so) and discuss safer sex with potential partners before meeting in person.4 Educational materials for non-trans partners. Transmen’s non-trans male partners often do not have experience with transmen nor access to education about sex with transmen, which can lead to misconceptions about safer sex. For non-trans gay men, safe sex often simply means condom use with anal sex and they may not be aware of the risks associated with frontal (vaginal) sex. See the next section for information on available materials. Greater visibility in the gay community. Gay and bisexual men need to be educated about the presence of transmen in their community. Increasing visibility and knowledge about transmen may help create a welcoming environment, help increase inclusivity, and help transmen feel more powerful in their relationships with non-trans men.7
What’s being done?
tm4m (tm4m.org) is a San Francisco-based project for transmen who play with men (or want to). They provide information, education, and support to transmen who have sex with men through monthly educational workshops and discussion groups, informational materials and continuously working to foster acceptance and build community. tm4m is a collaborative effort co-sponsored by Eros, Trannywood Pictures and TRANS:THRIVE (a program of the API Wellness Center). The Gay/Bi/Queer Trans Men’s Working Group in Ontario has conducted a needs assessment with trans MSM, developed a sexual health resource12, and a website at www.queertransmen.org. They are also providing training and consultation about trans MSM inclusion for prevention workers serving gay men across the province. All Gender Health Online is a study exploring the sexual health of non-transgender men who have sex with transgender people. The results will be used to develop an online intervention to prevent the spread of HIV and promote the sexual health of transgender people and their partners. The STOP AIDS Project in San Francisco, CA strives to include transmen in their programming and community education. They include transgender men in their mission statement and have changed their data collection methods to better reflect varying bodies and gender identities in gay men’s communities.
What needs to be done?
We need to implement more inclusive data collection methods to better capture subgroups of transgender people. HIV prevention and care providers should not assume that all men they see were assigned ‘male’ at birth. You cannot tell if a guy is trans just by looking at him. The best method for data collection is a two-part question: 1) ask about current gender identity and 2) ask what sex was assigned at birth.13 If unsure, programs should ask transmen for their preferred name and pronoun and use those terms. If rates of HIV among transmen are indeed low, we now have the opportunity to engage in true prevention work to keep those numbers low. Gaining a better understanding of transmen’s risk behaviors and the different ways that they protect themselves will aid in providing appropriate and effective HIV prevention education to transmen and their sexual partners.
Says who?
1. It is important to note that few transmen have fully functional penises, primarily due to the relatively low rates of surgical success, high rates of complications, and the extremely high cost. 2. Herbst J, Jacobs E, Finlayson T, et al. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: A systematic review.AIDS and Behavior. 2007. 3. Clements-Nolle K, Marx R, Guzman R, et al. HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: Implications for public health intervention. American Journal of Public Health. 2001;91:915-921. 4. Sevelius J. ‘‘There’s no pamphlet for the kind of sex I have’’: HIV-related risk factors and protective behaviors among transgender men who have sex with non-transgender men. Journal of the Association of Nurses in AIDS Care. 2009;20:398-410. 5. Hein D, Kirk M. Education and soul-searching: The Enterprise HIV prevention group. In: Bockting W, & Kirk, S., editor. Transgender and HIV: Risks, prevention, and care. Binghamton, NY: The Haworth Press; 2001. p. 101-117. 6. Schleifer D. Make me feel mighty real: Gay female-to-male transgenderists negotiating sex, gender, and sexuality. Sexualities 2006;9(1):57-75. 7. Bockting W, Benner A, Coleman E. Sexual identity development among gay and bisexual female-to-male transsexuals: Emergence of a transgender sexuality. Archives of Sexual Behavior. 2009;38(5). 8. Colfax G, Coates T, Husnik M, Huang Y, Buchbinder S, Koblin B, et al.Longitudinal patterns of methamphetamine, popper (amyl nitrite), and cocaine use and high-risk sexual behavior among a cohort of San Francisco men who have sex with men. Journal of Urban Health. 2005;82:i62-i70. 9. CA Department of Health Services. California HIV counseling and testing annual report: January – December 2003. Sacramento, CA: Office of AIDS; 2006. 10. Gorton N, Buth J, Spade D. Medical therapy and health maintenance for transgender men: A guide for health care providers: Lyon-Martin Women’s Health Services; 2005. 11. Newfield E, Hart S, Dibble S, Kohler L. Female-to-male transgender quality of life. Quality of Life Research 2006;15(9):1447-57. 12. Gay/Bi/Queer Transmen’s Working Group of the Ontario Gay Men’s HIV Prevention Strategy. Primed: The Back Pocket Guide for Transmen & The Men Who Dig Them. Toronto, Ontario; 2007. 13. Center of Excellence for Transgender HIV Prevention. Recommendations for Inclusive Data Collection of Trans People in HIV Prevention, Care, and Services. San Francisco, CA: University of California, San Francisco; 2009. www.transhealth.ucsf.edu
Special thanks to the following reviewers of this Fact Sheet: Walter Bockting, AJ King, Niko Kowell, Dan Lentine, Vel McKleroy, Sarah Morgan, Emily Newfield, David Schleifer, Hale Thompson, Erin Wilson. Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. To receive Fact Sheets via e-mail, send an e-mail to [email protected] with the message “subscribe CAPSFS first name last name.” ©January 2010, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected].
Asiáticos y Isleños del Pacífico
¿Qué necesitan los asiáticos e isleños del Pacífico para prevenir el VIH?
revisado 12/07
¿corren riesgo los AIP?
Los asiáticos e isleños del Pacífico (AIP) son una de las poblaciones de minorías étnicas de mayor crecimiento en los Estados Unidos.1 Se calcula que para el año 2050 este grupo alcanzará 34 millones personas y representará el 8% de la población total de EE.UU.1,2 Los asiáticos y los isleños del Pacífico tienen una diversidad considerable que abarca 49 grupos étnicos, más de 100 idiomas y personas de origen chino, filipino, coreano, hawaiano, indio-asiático, japonés, samoano, vietnamita y otros. La mayoría vive en metrópolis grandes como Honolulu, HI; San Francisco, CA; Nueva York, NY y Los Ángeles, CA.2 Entre el 2001 y el 2004 los AIP componían menos del 1% de los casos de VIH/SIDA en EE.UU., pero también tenían el mayor porcentaje del incremento anual en las tasas de diagnóstico frente a todos los otros grupos étnicos/raciales (el 8.1% para hombres y el 14.3% para mujeres).3 Cuando grupos poblacionales como los AIP muestran una prevalencia baja (cifras totales) pero grandes incrementos en la incidencia (casos nuevos), se precisan esfuerzos de prevención para limitar futuros casos de VIH/SIDA. El subregistro de casos y la falta de una vigilancia detallada del VIH ocultan la naturaleza auténtica de la epidemia entre los AIP. Un estudio encontró que el subregistro de casos de SIDA entre AIP puede alcanzar el 33 %4. Esto podría deberse en parte al registro erróneo de raza y origen étnico en los expedientes médicos, que son la fuente de datos para el reporte de registro de casos.2,5 Por ejemplo, las personas con apellido hispano, como los filipinos, pueden ser registradas por error como latinas. La falta de detalles demográficos sobre el grupo étnico específico y lugar de nacimiento también impide el rastreo de diferencias entre subgrupos de AIP con respecto a la epidemia del SIDA y dificulta la creación de medidas de salud pública para etnias específicas.2
¿quiénes son los AIP que corren riesgo?
La transmisión del VIH entre los AIP masculinos se da principalmente entre hombres que tienen sexo con hombres (HSH), seguidos por hombres que tienen contacto heterosexual de alto riesgo o que se inyectan drogas (UDI). En 2005, el 71% de los casos de SIDA entre los AIP hasta esa fecha se debió a la transmisión entre HSH.6 Entre las mujeres AIP, la transmisión ocurre mayormente entre mujeres que tienen coito con un hombre que tiene mayor riesgo, seguido por mujeres UDI.6 Aunque los HSH AIP son los más afectados por el VIH/SIDA, los diagnósticos entre mujeres AIP han aumentado (14.3%)3. El CDC no tiene una categoría para mujeres transgéneras (nacidos hombres pero que se consideran y viven como mujeres), sin embargo un estudio en San Francisco, CA indicó una prevalencia de VIH del 13% entre las mujeres transgéneras AIP.7
¿qué pone a los AIP en riesgo?
Entre los HSH AIP, la discriminación social y la falta del apoyo familiar, de sus semejantes y comunitario con respecto a la diversidad sexual y racial puede perjudicar la auto estima y la auto identidad positivas, lo cual aumenta el riesgo de contraer el VIH.8 En un estudio, el 57% de los hombres AIP gay en San Francisco, CA, consumieron alcohol antes del sexo anal; el 24% reportó practicarlo sin protección. Sin embargo, el 85% creía tener pocas posibilidades de contraer el VIH.9 Pocos AIP se hacen la prueba del VIH en contraste con el resto de la población de EE.UU., aunque reportan tasas similares de conductas de riesgo2 y con frecuencia demoran en buscar servicios de VIH. En un estudio entre jóvenes HSH AIP en San Francisco, CA, el 24.4 % de los participantes nunca se había hecho la prueba del VIH anteriormente. Además, el 2.6 % resultó VIH+; de este grupo el 61.5 % no sabía que era VIH positivo y el 38.5 % reportó un acto sexual reciente sin protección.10 Los AIP VIH+ que todavía no se han hecho la prueba son más propensos a actos riesgosos y a infectar a otros sin saberlo.11 Aquellos que demoran en atenderse corren un mayor riesgo de tener el SIDA avanzado en el momento del diagnóstico y de adquirir una coinfección como la hepatitis B, la tuberculosis y la PCP.5,12 Las inmigrantes AIP que trabajan en casas de masaje muchas veces realizan actividades que las exponen al VIH. Sin embargo, para muchas de ellas la sobrevivencia diaria tiene prioridad sobre la prevención del VIH. Los problemas relacionados con la policía, el trabajo sexual, la situación migratoria, la planificación familiar, el idioma y la falta de uso de condones en los centros de masaje son todos factores de riesgo para esta población.13
¿cuáles son los obstáculos?
A pesar del estereotipo de los AIP como “minoría étnica modelo”, el 17% no tiene seguro médico y no puede recibir tratamiento y otros servicios de salud adecuados.14 Debido a los escasos datos sobre la salud y los riesgos conductuales de los AIP, muchos recursos se destinan a otros grupos sin evaluar o reconocer las necesidades de los AIP.14 La norma cultural de evitar temas como la actividad sexual, la enfermedad y la muerte plantea barreras a la prevención del VIH, genera estigmas y perjudica la salud psicológica y mental de los AIP que viven con esta enfermedad.15 El 40% de los AIP habla poco o nada de inglés14 y pocos programas de intervención reflejan la diversidad cultural y lingüística de esta población. Un estudio encontró que el idioma es el obstáculo más común al acceso a servicios médicos para los AIP con VIH/SIDA.12
¿qué se está haciendo al respecto?
Existen muchos programas nacionales y locales que brindan servicios y orientación sobre la prevención del VIH para AIP.16 Otros ofrecen desarrollo de capacidades y asistencia técnica para organizaciones que los atienden.17 Por ejemplo: La Asian and Pacific Islander Coalition on HIV/AIDS (AIPCHA) desarrolló Project Bridges, una intervención comunitaria para reducir las disparidades de atención para AIP VIH+ en Nueva York. Formó enlaces con proveedores médicos y brindó manejo de casos, promoción de derechos y capacitación sobre la competencia cultural para los proveedores. Se logró aumentar la utilización de servicios y reducir las barreras a servicios para los participantes que tenían un idioma asiático como lengua principal, los que no hablaban inglés y los indocumentados.12 Life Foundation, en Honolulu, HI, ha ofrecido programas comunitarios para HSH y transgéneros de las islas del Pacífico desde 1999. “UTOPIA Hawai’i” está basado en el modelo Mpowerment y ha logrado grandes éxitos en alcanzar a isleños del Pacífico que nunca habían utilizado servicios de VIH anteriormente.18 El Health Project for Asian Women (HPAW) para las trabajadoras sexuales asiáticas de casas de masaje en San Francisco, CA, brindó dos intervenciones: una orientó a los dueños de estos negocios y otra informó a las masajistas sobre temas de salud. El personal del HPAW acompañó a las masajistas a clínicas médicas, repartió materiales para una práctica sexual más segura, y les ofreció servicios de interpretación, remisiones y promoción de derechos. Las masajistas recibieron tres sesiones de consejería y los dueños asistieron a una sesión informativa.13 El Asian & Pacific Islander Wellness Center realizó una campaña anti estigma sobre el VIH. La campaña se destinó a las comunidades chinas de San Francisco, CA por medio de carteles en las paradas de autobús, anuncios en los periódicos y un documental con la participación de dirigentes comunitarios locales, personas VIH+ y sus familias. También lideró el Día Nacional AIP para la Concienciación del VIH/SIDA, en el que organizó más de 15 eventos a lo largo de EE.UU. para aumentar la aceptación del VIH/SIDA entre familias y comunidades AIP.19
¿qué queda por hacer?
Tenemos una oportunidad de oro para mantener bajas las cifras de VIH entre los AIP, pero podríamos perderla pronto, pues tienen el mayor aumento en las tasas de diagnóstico de VIH/SIDA que cualquier otro grupo racial en EE.UU. Los programas de prevención del VIH para AIP deben centrarse en las personas que corren mayor riesgo: HSH, mujeres, transgéneros y consumidores de drogas. Los programas pueden ayudar a los AIP a crear y fortalecer sistemas de apoyo y enfocar la prevención y la atención médica, como pruebas para detectar el VIH, la hepatitis B y la tuberculosis. Se necesita diseñar y evaluar más programas que se ajusten mejor a los aspectos culturales y lingüísticos de los AIP. Para combatir el estigma en torno al VIH, a la homosexualidad, al trabajo sexual y al consumo de drogas se necesitan campañas informativas que profundicen el diálogo sobre la prevención de VIH/SIDA y la aceptación de los AIP VIH+. El trabajo conjunto entre los formuladores de políticas y nuevos colaboradores, como lo son ahora las organizaciones religiosas, puede reducir el estigma entre los AIP. Dada la enorme diversidad entre los AIP radicados en EE.UU., es importante mejorar los sistemas de vigilancia y la calidad de los datos recogidos, registrando siempre el origen étnico y el lugar de nacimiento de cada subgrupo.3 Se necesitan investigaciones sobre el VIH y las coinfecciones (la hepatitis B y la tuberculosis) y sobre la relación entre la aculturación y el VIH.
¿Quién lo dice?
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. Campaña anti estigma sobre el VIH
Preparado por Roshan Rahnama, Nina Agbayani, Stacy Lavilla,* John Chin, PhD** *Association of Asian Pacific Community Health Organizations (AAPCHO), **NY Academy of Medicine Traducción: Rocky Schnaath Diciembre 2007. Hoja de Dato #33SR
Abuso sexual infantil
¿Cuál es el efecto del abuso sexual infantil en la prevención del VIH?
¿qué es el abuso sexual infantil?
El abuso sexual infantil (ASI) tiene muchas definiciones, pero en esta hoja informativa nos referimos al contacto corporal no deseado antes de los 18 años, que es la edad en que se considera que una persona puede dar su consentimiento para tener contacto sexual. El ASI es una experiencia dolorosa a muchos niveles que puede tener, posteriormente, efectos profundos y devastadores en el desarrollo psicológico, psicosocial y emocional. Las experiencias de ASI pueden variar respecto a: duración (varios incidentes con el mismo agresor), grado de fuerza/coerción o grado de intrusión física (desde una caricia, a la penetración digital o al sexo oral, anal o vaginal intentado o consumado). La identidad del agresor/a (que podría ser un desconocido, una persona de confianza o un familiar) también puede influir en las consecuencias a largo plazo para las víctimas. Lo que distingue el ASI de la experimentación sexual exploratoria es el contacto indeseado o forzado o la clara desproporción de poder; comúnmente, se determina como agresor/a alguien que resulte por lo menos 5 años mayor que la víctima. El número de abusos sexuales infantiles excede el número de casos reportados a las autoridades.1 Se calcula que la prevalencia del ASI en EE.UU. es del 33% entre chicas menores de 18 años y del 10% entre chicos menores de 18 años.2 Los hombres son considerablemente menos propensos a reportar un incidente de ASI que las mujeres.3 La probabilidad de que el ASI ocurra aumenta en familias que sufren mucha tensión. Los niños están en riesgo de ser abusados sexualmente en familias que padecen estrés, pobreza, violencia y consumo de alcohol o drogas y cuyos padres y parientes tienen antecedentes de ASI.¿afecta el riesgo de contraer el VIH?
Sí. Ya que la niñez y el comienzo de la adolescencia son etapas críticas del desarrollo sexual, social y personal, el ASI puede distorsionar la autoimagen física, mental y sexual de las víctimas. Estas distorsiones, junto con los mecanismos de defensa adoptados para compensar el trauma del ASI, pueden conducir a sus sobrevivientes a prácticas de alto riesgo en el sexo y al consumir drogas, las cuales aumentan sus probabilidades de contraer el VIH.4 Quienes han sufrido el ASI pueden sentirse sin poder respecto a su sexualidad, la comunicación sexual y la toma de decisiones en la edad adulta, pues no tuvieron la oportunidad de tomar decisiones propias sobre su sexualidad durante su niñez o adolescencia. Consecuentemente, es posible que estas personas participen en prácticas sexuales de alto riesgo, sean incapaces de rechazar a una pareja sexual agresiva y sientan menos satisfacción sexual en sus relaciones. Los sobrevivientes del ASI pueden disociarse de sus sentimientos y tener dificultades para formar lazos afectivos y relaciones a largo plazo, por lo cual llegan a tener varias parejas sexuales, “aventuras de una sola noche” y relaciones sexuales cortas. Los adultos que perciben algún aspecto positivo de su propio ASI (por ejemplo, la atención que recibieron) pueden usar el sexo como una manera de consolarse o reconfortarse, una conducta que puede llevar a la promiscuidad y a patrones sexuales compulsivos.5 El ASI puede tener efectos diferentes en hombres y en mujeres. Las mujeres sobrevivientes del ASI pueden usar condones con menos frecuencia, ser menos eficaces para establecer el uso de condones con sus parejas sexuales, demostrar más pasividad sexual y atraer o sentirse atraída a parejas exageradamente controladoras.6 Los hombres que sobreviven al ASI pueden sentir un mayor grado de erotismo, exhibir una conducta agresiva y hostil y agredir a otros.7 Los adultos con historial de ASI pueden valerse de la disociación y de otros mecanismos para evitar los pensamientos, emociones y recuerdos negativos asociados con el abuso. Uno de los métodos más comunes de disociación es el abuso del alcohol y drogas. Un estudio de hombres y mujeres con antecedentes de alcoholismo y drogadicción encontró que el 34% fueron víctimas del ASI. En comparación con otros consumidores de alcohol o drogas que no fueron víctimas, los sobrevivientes del ASI con problemas de alcohol o drogas tenían más probabilidades de tener sexo por dinero o drogas, de tener una pareja VIH + o de alto riesgo y de no usar condón durante el sexo.8 La revictimización sexual también puede influir en la conducta sexual de alto riesgo. Un estudio de mujeres afroamericanas y caucásicas encontró que las sobrevivientes del ASI revictimizadas ya siendo adultas tuvieron más embarazos indeseados, abortos terapéuticos, enfermedades de transmisión sexual (ETS) y prácticas sexuales de alto riesgo que quienes sólo fueron abusadas sexualmente en la niñez.9¿qué se está haciendo al respecto?
Existen muchos recursos para quienes sobreviven el ASI, pero escasean los programas que aumenten el bienestar psicológico y reduzcan las prácticas riesgosas relacionadas con el VIH en el sexo y en el uso de drogas. La mayoría de estos programas se enfocan en la mujer; los programas destinados a los sobrevivientes masculinos son aun más escasos. Good-Touch/Bad-Touch es una intervención integral de prevención del abuso infantil diseñada para los niños de preescolar y kindergarten hasta los del sexto año de primaria. El programa utiliza una variedad de materiales para enseñar a los niños métodos de prevención que incluyen las reglas de la seguridad corporal, en qué consiste el abuso y qué hacer si se sienten amenazados.10 En una clínica para víctimas del ASI, el Children’s Medical Center en Dallas, TX, ofrece prevención del VIH/ETS para jovencitas víctimas del abuso sexual. Las adolescentes entre 12 y 16 años reciben una evaluación individual y educación personalizada de una consejera de VIH/ ETS especializada en las necesidades de las jóvenes. La provisión de consejería sensible y cercana al momento en que se reconoce el abuso, puede ser un buen método de educación preventiva.11 En la Universidad de Stanford, CA, una intervención de terapia grupal sobre el trauma busca reducir las conductas de riesgo del VIH y la revictimización entre mujeres adultas sobrevivientes al ASI. Los grupos se centran en los recuerdos que las sobrevivientes tienen del ASI para ver si éstos les ayudan a aumentar conductas más seguras y a reducir el estrés. Las mujeres también reciben servicios de manejo de casos.12 El Visiting Nurse Service de Nueva York ofrece servicios integrales a domicilio para familias infectadas con el VIH. Los niños de estas familias corren un alto riesgo de repetir las historias y conductas de sus padres, incluyendo la adquisición del virus, el abuso de drogas o alcohol, el abuso sexual y la enfermedad mental. El programa proporciona intervenciones realizadas en el hogar que incluyen terapia del juego, educación en salud y protección sexual, consejería familiar e individual, prevención de recaídas para los padres y concientización y prevención del uso de drogas para los hijos. Al ayudar al niño a afrontar el enojo y resentimiento que sienta hacia el padre, es menos probable que dirija ese enojo hacia sí mismo y que termine repitiendo la conducta de los padres. Para romper el ciclo del VIH y del abuso en estas familias, es fundamental apoyar a cada uno de los miembros de la familia.13 En la Universidad de California, Los Ángeles, y en la Universidad King-Drew, CA, una intervención psicoeducativa pretende incrementar las conductas sanas y disminuir las prácticas de riesgo del VIH en mujeres VIH+ con antecedentes de ASI. Las mujeres aprenden técnicas de comunicación y de resolución de problemas y vinculan sus experiencias de ASI con riesgos pasados y actuales.14¿qué queda por hacer?
Aunque abordar el ASI parezca una tarea de enormes proporciones para muchos programas de prevención del VIH, existe una variedad de métodos utilizables para tratar el tema del ASI en adultos. Los programas pueden: incorporar preguntas sobre el abuso en la evaluación inicial de todos los clientes, hacer reevaluaciones periódicas, brindarles información básica sobre los efectos del ASI y remitirlos a programas de tratamiento de abuso de drogas y alcohol así como a servicios de salud mental. El personal de prevención del VIH necesita capacitación básica y apoyo para ayudar a sobrellevar los efectos de la consejería sobre el ASI y su prevalencia relativamente alta en ciertas poblaciones.15 El personal que probablemente tenga contacto con sobrevivientes del ASI como serían los profesionales médicos, consejeros religiosos, de pares, de abuso de drogas y de víctimas de violación, así como los policías para los delincuentes en libertad condicional, debe ser orientado de los efectos del ASI sobre las prácticas de riesgo en el sexo y en el uso de drogas. Estas personas también necesitan capacitación para reconocer los síntomas del ASI, afrontar la situación y remitir adecuadamente a los servicios de tratamiento existentes. Los profesionales deben mirar más allá de los síntomas del ASI e indagar sobre otras experiencias que tal vez fueron problemáticas durante la niñez. Muchas veces, los sobrevivientes del ASI son obligados a sufrir otras formas de abuso y un ambiente familiar disfuncional. Un ambiente familiar problemático puede crear condiciones favorables para el abuso y dejar al sobreviviente con poco apoyo para sobrellevar la experiencia. Preparado por Gail Wyatt PhD, Tamra Loeb PhD, Inna Rivkin PhD, Jennifer Carmona PhD, Dorothy Chin PhD, John Williams MD, Hector Myers PhD, Douglas Longshore PhD and Charlotte Sykora PhD. UCLA Women’s Health Project. Traducción: Rocky Schnaath. September 2003. Fact Sheet #52S¿quien lo dice?
1. Green AH. Overview of child sexual abuse. In SJ Kaplan (ed.), Family violence: A clinical and legal guide. Washington, DC: American Psychiatric Press. 1996;73-104. 2. Finkelhor D. The international epidemiology of child sexual abuse. Child Abuse & Neglect. 1994;18:409-417. 3. Roesler TA, McKenzie N. Effects of childhood trauma on psychological functioning in adults sexually abused as children. Journal of Nervous and Mental Disease. 1994;182:145-150. 4. Prillo KM, Freeman RC, Collier C, et al. Association between early sexual abuse and adult HIV-risky behaviors among community-recruited women. Child Abuse & Neglect. 2001;25:335-346. 5. Paul, J. Understanding childhood sexual abuse as a predictor of sexual risk-taking among men who have sex with men: The Urban Men’s Health Study. Child Abuse & Neglect. 200;125:557-584. 6. Watkins B, Bentovim A. The sexual abuse of male children and adolescents: a review of current research. Journal of Child Psychology & Psychiatry & Allied Disciplines. 1992;33:197–248. 7. Wyatt GE, Guthrie D, Notgrass CM. Differential effects of women’s child sexual abuse and subsequent revictimization. Journal of Consulting and Clinical Psychology. 1992;60:167-173. 8. Morrill AC, Kasten L, Urato M et al. Abuse, addiction and depression as pathways to sexual risk in women and men with a history of substance use. Journal of Substance Abuse. 2001;13:169-184. 9. Wyatt GE, Myers HF, Williams JK, et al. Does a history of trauma contribute to HIV risk for women of color? Implications for prevention and policy. American Journal of Public Health. 2002;92:1-7. 10. Harvey P, Forehand R, Brown C, et al. The prevention of sexual abuse: Examination of the effectiveness of a program with kindergarten-age children. Behavior Therapy. 1988;19:429-435. 11. Squires J, Persaud DI, Graper JK. HIV and STD prevention counseling for adolescent girls seen in a child abuse clinic. Presented at the 14th International AIDS Conference, Barcelona, Spain. 2002. Abst # TuPeF5249. 12. Group Interventions to Prevent HIV in High Risk Women.www.med.stanford.edu/school/ Psychiatry/PSTreatLab/TraumaStudy.html 13. Mills R, Samuels KD, Bob-Semple N, et al. Breakin the cycle: multigenerational dysfunction in families affected with HIV/AIDS. Presented at the 14th International AIDS Conference, Barcelona, Spain. 2002. Abst #. ThPeE7828. 14. Wyatt GE, Myers H, Longshore D, et al. Examining the effects of trauma on HIV risk reduction: the women’s health intervention. Presented at the International Conference on AIDS, Barcelona, Spain. 2002. Abst# WePeF6853. 15. Paul JP. Coerced childhood sexual episodes and adult HIV prevention. FOCUS. 2003;18:1-4.Special thanks to the following reviewers of this Fact Sheet: Ruth Kelley, Jay Paul, Elizabeth Radhert.