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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
Resource

Condoms

What is the role of male condoms in HIV prevention?

revised 01/05

do condoms work?

Yes. The condom is one of the only widely available and highly effective HIV prevention tools in the US.1 When used consistently and correctly, latex male condoms can reduce the risk of pregnancy and many sexually transmitted infections (STIs), including HIV by about 80-90%1-6. Condoms, including female condoms, are the only contraceptive method that is effective at reducing the risk of both STIs and pregnancy. When placed on the penis before any sexual contact, the male condom prevents direct contact with semen, sores on the head and shaft of the penis and discharges from the penis and vagina. Condoms thus should effectively reduce the transmission of STIs that are transmitted primarily through genital secretions such as gonorrhea, trichomoniasis, chlamydia, hepatitis B and HIV.1-6 Because condoms only cover the penis, they provide less protection from STIs primarily transmitted through skin-to-skin contact such as genital herpes, syphilis, chancroid and genital warts. Abstinence, mutual monogamy between uninfected partners, reducing the number of sexual partners and correctly and consistently using condoms during intercourse are all essential to slowing the spread of HIV/STIs.7 Condom effectiveness depends heavily on the skill level and experience of the user. Appropriate education, counseling and training on partner negotiation skills can greatly increase the ability of a person to use a condom correctly and consistently.2

what are the advantages?

Accessibility. Using condoms does not require medical examination, prescription or fitting. Condoms can be bought at drug stores, grocery stores, vending machines, gas stations, bars and the internet, and are distributed free at many STI and HIV clinics. Sexual enhancement. Using condoms can help delay premature ejaculation. Lubricated condoms can make intercourse easier and more pleasurable for women. And condoms do away with the “wet spot” left by semen leakage after sex. Using condoms helps reduce anxiety and fears of pregnancy and STIs so that men and women can enjoy sex more. Protect fertility. Some STIs can affect a woman’s ability to get pregnant; condoms can protect against some STIs and therefore help reduce the risk of infertility.8

what are the disadvantages?

Lack of cooperation. Women cannot directly control whether a condom is used and have to rely upon male cooperation. When men refuse, condom use may be impossible. Physical problems. Many men and their partners complain that condoms reduce sensitivity. Proper condom use requires an erect penis. Some men cannot consistently maintain an erection so condom use becomes difficult. Trying different kinds of condoms (such as thinner condoms) and using water-based lubricant can help increase sensation. Embarrassment. Some men and women may be embarrassed to buy condoms at a store, or take free condoms from a clinic. Others may be embarrassed to suggest or initiate using condoms because they perceive condom use implies a lack of trust or intimacy.9

how are they used?

The most important key messages for condom use are quite simple: 1) Use a new condom every time, with every act of intercourse, if there is a risk of pregnancy or STIs. 2) Before penetration, carefully unroll the condom onto the erect penis, all the way to the base. Put it on before the penis comes in contact with the partner’s vagina or anus. 3) After ejaculation (while the penis is still erect), hold the rim of the condom against the base of the penis during withdrawal.2,10 Even with adequate training and access to condoms, people won’t always use condoms perfectly. In the real world, people may fall in love, or make mistakes, or get drunk or simply decide not to use condoms. Having sex under the influence of alcohol and/or drugs greatly increases the chances of condom non-use, misuse and failure.11

what are concerns?

Condom education/distribution in schools. Although schools can be an important source of information on HIV/STIs, only 2% of public schools have school-based health centers, and only 28% of those make condoms available to students.13 In 2000, persons aged 15-24 had 9.1 million new cases of STIs and made up almost half of all new STI cases in the US. 47% of US high school students have had sexual intercourse.15 Condom breakage and slippage (condom failure). Condom quality has been improving16 and for most users condom failure is relatively rare. About 4% of condoms break or slip off.2 However some persons report much higher rates. In one study, gay men who were unemployed and reported amphetamine and/or heavy alcohol use were more likely to report condom failure. Men who were frequent users of condoms and used lubricant reported less failure11. Counseling and education on condom use can greatly reduce condom failure.2 Effectiveness of N-9. Condoms lubricated with the spermicide nonoxynol-9 (N-9) often cost more, have no proven protective advantage over condoms without N-9, have a shorter shelf life and might be harmful if used excessively. Many manufacturers have discontinued N-9 condoms.2,16

what works?

The following programs have been documented as effective by the Centers for Disease Control and Prevention, and are currently being replicated nationwide.17 Training on condom use and negotiation. The SISTA Project is a social skills training intervention for African American women designed to increase their comfort with and use of condoms. In small group sessions, women learn sexual assertion skills and proper condom use and discuss cultural and gender triggers that affect condom negotiation. Homework activities involve their male partners. Participants reported more condom use.18 Changing community norms. The Mpowerment Project is a community-level program developed by and for young gay men that increases peer support and acceptance for safer sex. Peer-led M-groups use a gay-positive and sex-positive approach to teach men negotiation and condom use and train and motivate them to conduct informal outreach with their friends. Participants reported decreased rates of unprotected anal intercourse.19 Combining HIV prevention with STI and unintended pregnancy prevention.The VOICES/VOCES program was implemented in an STI clinic and uses culturally-specific videos and skills building to increase condom use and negotiation among African American and Latino/a heterosexuals. The program is bilingual and includes education about different types of condoms and condom distribution. Participants reported more condom use and fewer repeat STIs.20

what needs to be done?

Better marketing and increased accessibility to condoms is needed in the US. Although condom use has increased in the past decade, there are still unacceptably high rates of STIs among sexually active adolescents and young adults and among gay men, two populations that are also at increased risk for HIV. New approaches to condom promotion are needed, ideally before the onset of sexual activity. For adolescents to use them, condoms must be easily and anonymously accessible, widely available and low cost. Distributing free condoms can also help increase condom use.21 To effectively address HIV prevention, all persons should have accurate and complete information about different prevention options. But the emphasis needs to be different for different groups. For example, while young people who have not started sexual activity need information and access to condoms, the first priority should be to encourage abstinence and delay of sexual intercourse. When targeting those at highest risk for HIV, the first priority should be to encourage correct and consistent condom use along with avoiding high-risk behaviors and partners.7 Are condoms foolproof? No. Neither are seat belts, helmets, abstinence pledges or vaccines. But in the real world we drive to work, vaccinate our children, and hope to get through the day unscathed. No public health strategy can guarantee perfect protection. The real question is not are condoms 100% effective, but how can we more effectively use condoms and other approaches to help reduce the risk of disease.

Says who?

1. Scientific evidence on condom effectiveness for STD prevention. Report from the NIAID. July 2001. 2. Warner L, Hatcher RA, Steiner MJ. Male Condoms. In: Hatcher RA, Trussel J, Stewart F, et al, editors. Contraceptive Technology. New York: Ardent Media Inc. 2004:331-353. 3. Holmes KK, Levine R, Weaver M. Effectiveness of condoms in preventing sexually transmitted infections. Bulletin of the World Health Organization. 2004;82:454-461. 4. Weller S, Davis K. Condom effectiveness in reducing heterosexual HIV transmission. Cochrane Database Systematic Review. 2002;(1):CD003255. 5. Hearst N, Chen S. Condom promotion for AIDS prevention in the developing world: is it working? Studies in Family Planning. 2004;35:39-47. 6. CDC. Male latex condoms and STDs. 7. Halperin DT, Steiner MJ, Cassell MM, et al. The time has come for common ground on preventing sexual transmission of HIV. Lancet. 2004;364:1913-1915. 8. Ness RB, Randall H, Richter HE, et al. Condom use and the risk of recurrent pelvic inflammatory disease, chronic pelvic pain, or infertility following an episode of pelvic inflammatory disease. American Journal of Public Health. 2004;94:1327-1329. 9. Miller LC, Murphy ST, Clark LF, et al. Hierarchical messages for introducing multiple HIV prevention options: promise and pitfalls. AIDS Education and Prevention. 2004;16:509-25. 10. ASHA. The right way to use a male condom. 1/30/05. 11. Stone E, Heagerty P, Vittinghoff E, et al. Correlates of condom failure in a sexually active cohort of men who have sex with men. Journal of AIDS. 1999;20:495-501. 12. McElderry DH, Omar HA. Sex education in the schools: what role does it play? International Journal of Adolescent Medical Health. 2003;15:3-9. 13. Santelli JS, Nystrom RJ, Brindis C, et al. Reproductive health in school-based health centers: findings from the 1998-99 census of school-based health centers. Journal of Adolescent Health. 2003;32:443-451. 14. Weinstock H, Berman S, Cates W. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspectives in Sexual and Reproductive Health. 2004;36:6-10. 15. Youth risk behavior surveillance–US, 2003. Morbidity and Mortality Weekly Report. 2004;53:1-98. 16. Condoms: extra protection. Consumer Reports. Feb 2005. 17. https://www.cdc.gov/hiv/effective-interventions/index.html 18. DiClemente RJ, Wingood GM. A randomized controlled trial of an HIV sexual risk reduction intervention for young African-American women. Journal of the American Medical Association. 1995;274:271-276. 19. Kegeles SM, Hays RB, Pollack LM, et al. Mobilizing young gay and bisexual men for HIV prevention: a two-community study. AIDS. 1999;13: 1753–1762. 20. O’Donnell CR, O’Donnell L, San Doval A, et al. Reductions in STD infections subsequent to an STD clinic visit: using video-based patient education to supplement provider interactions. Sexually Transmitted Diseases. 1998;25:161–168. 21. Cohen DA, Farley TA. Social marketing of condoms is great, but we need more free condoms. Lancet. 2004;364:13. Prepared by Markus Steiner PhD* and Pamela DeCarlo** *Family Health International, **CAPS January 2005. Fact Sheet #2ER Special thanks to the following reviewers of this Fact Sheet: Barb Adler, Daniel Bao, Willard Cates, Bill Cayley Jr, Rick Crosby, Scott Dougherty, Ralph DiClemente, Paul Feldblum, Steve Gibson, Daniel Halperin, Norman Hearst, Mary Hoban, John James, Doug Kirby, Andrzej Kulczycki, Kay Stone, Koray Tanfer, Lee Warner, 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]. © January 2005, University of California

Resource

Gay men (MSM)

What are men who have sex with men’s (MSM) HIV prevention needs?

What do MSM need?

Men who have sex with men (MSM) are not a single homogenous group, but represent a wide variety of people, lifestyles and health needs. From middle class gay men, to homeless runaways, to injection drug users (IDUs) to incarcerated men, MSM have many different identities and associated risks for HIV and other infectious diseases. MSM refers to any man who has sex with a man, whether he identifies as gay, bisexual or heterosexual. Despite success in changing sexual behaviors, MSM continue to be disproportionately affected by HIV/AIDS. MSM account for the largest percentage of persons with AIDS in the US (53%), even as the percentage of AIDS cases among IDUs (25%) and heterosexuals (10%) has increased.1 In 1997, the prevalence rate of HIV for MSM in 4 urban communities was 17% overall, 29% for African-American MSM and 40% for MSM-IDUs.2 HIV is not an issue that exists by itself, but is woven into many aspects of men’s lives. Risk for HIV is embedded in many other core issues such as dating and intimacy, sexual desire and love, as well as alcohol and recreational drug use, homophobia, abuse and coercion, racism and self-esteem.3 HIV prevention programs must be informed by of all these elements

Sexual health

There is not enough sexuality education for young people in the US, and almost no samegender sexuality education. Like many teenagers, young MSM may only learn about sex through distorted media or pornographic images. In general, men in today’s society are pressured to prove their manhood through sexual activity and aggressiveness, while women receive messages on moderation and caretaking. Given this, many MSM face additional challenges learning about dating, intimacy and forming relationships, or about desire, sexual functioning and arousal. Discomfort with one’s sexuality and identity can lead to sexual risk taking.4 In Minnesota, “Man-to-Man: Sexual Health Seminars” are based on the sexual health model. This model assumes that if MSM are more sexually literate, comfortable and competent, they are more likely to be able to reduce risk in the context of sexual behaviors and relationships. The program uses comprehensive sexuality education, cultural specificity and empirical research to help MSM reduce HIV risk long-term. The program was effective in reducing internalized homonegativity and unprotected anal intercourse.5 HIV is not the only sexual health concern for MSM. Other sexually transmitted diseases (STDs) such as herpes and genital warts can negatively affect health and sexuality. Several states have seen an increase in drug-resistant gonorrhea among MSM, making it more difficult to treat.6

Homophobia, racism and self esteem

Homophobia and racism are prevalent in the US. Internal and external homophobia and racism can lead to low self-esteem, which can lead to increased risk behavior such as sexual aggression, difficulty negotiating safer sex, and drug or alcohol abuse. MSM of color are disproportionately affected by many social and health-related ills such as HIV. African American and Latino MSM are more likely than their White counterparts to engage in high-risk activities and to be HIV-infected. Social and cultural factors may limit the ability of MSM of color to protect themselves from HIV. A study of Latino gay men in urban centers found that men who reported high-risk behavior also reported significantly higher rates of financial hardship, experiences of racism and homophobia, incidence of domestic violence and a history of coercive childhood sexual abuse.7 Hermanos de Luna y Sol, an HIV prevention intervention for Latino gay/bisexual men in San Francisco, CA, deals with the common history of oppression among Latino gay men, including issues of homophobia, machismo, sexual abuse, racism and separation from family and culture.8 In Washington, DC, US Helping US (UHU) is a multi-modal prevention program for Black MSM that addresses the psychological and emotional stress that they may experience as racially and sexually oppressed minorities. UHU provides mental health services, community building and anti-homophobia social marketing.9

Alcohol and recreational drug use

The prevalence of drug use is higher among MSM than among heterosexuals,10 although decreases recently have been noted in all alcohol and drug use categories except amphetamines.11 In many areas of the US, gay bars--often sex-charged environments where alcohol and drugs are prevalent--are the only venues for MSM to meet and socialize with each other. Drug use may vary greatly by region and subculture. Substance use puts MSM at risk for HIV for several reasons: 1) MSM-IDUs are at risk if they share infected injection equipment; 2) substance use is associated with high risk sexual behavior; 3) background HIV prevalence rates are higher for MSM-IDUs and MSM who abuse drugs but do not inject, increasing the likelihood of transmission.12 Substance use can serve as a trigger or an excuse for unprotected sex. Some MSM have trouble having sex without getting high first; others prefer having sex while high, believing recreational drugs increase their libido. For some MSM, drug use provides a sense of community and bonding at gay clubs and circuit parties. A survey of MSM who attend circuit parties found that serodiscordant unprotected anal sex was more likely to occur among men who used amphetamines (speed), Viagra and amyl nitrites (poppers).13 For many MSM-IDUs, drug use, rather than sexual orientation, forms their personal identity. Many MSM-IDUs identify as heterosexual. Too often MSM-IDUs are missed in prevention programs that target MSM but leave out IDUs, or programs that target IDUs but don’t address sexual orientation. MSM-IDUs have high rates of HIV infection, high frequency of unprotected sex and high rates of poverty, addiction and its related social and physical ills.12 The Stonewall Project in San Francisco, CA is a harm reduction program for MSM who use speed. The project provides education and assistance and has been successful at reaching MSM of different sexual and social identities.14 Across the US, several cities have opened social centers for gay men where no alcohol is served and drugs are not allowed. One HIV prevention program for young gay men helps develop community centers where young men can socialize without alcohol.15

What is sexual risk?

The perception of sexual risk for HIV varies among MSM and may change from one sexual situation to another. Throughout the HIV epidemic, MSM have engaged in sophisticated decision-making about what they consider to be risky.16 Some men decide for themselves it is OK to not use a condom if they are the top (insertive partner), if they are having oral sex or if their or their partner’s viral load is undetectable. MSM may make these decisions because the scientific evidence of HIV risk is cloudy, or simply because they are comfortable with some level of risk. HIV prevention programs should help MSM to make realistic and healthy choices based on factual information. MSM have engaged in a hierarchy of strategies for maintaining safer sex that are fluid and context-dependent. Most MSM are able to manage sexual risk with effective strategies such as monogamy with concordant partners, consistent condom use with repeated testing, condom use outside of relationship or abstinence. Other MSM use strategies that are not known to be effective (see above paragraph). A small minority of MSM choose to engage in known risk activities such as unprotected anal intercourse without knowledge of partner serostatus. Unprotected anal intercourse between an HIV+ and an HIV- man remains the greatest risk for HIV transmission among MSM. This has proven to be the biggest challenge for HIV prevention. The intimacy of skin-to-skin contact during intercourse is a powerful and important draw. Many MSM feel their sexual identity, as well as the hard-won goals of gay sexual liberation, are based on having sex--including anal intercourse--in a free and unconstricted manner. A majority of MSM consistently manage sexual risk, yet there is little understanding or research of men who are largely safe, and how their values of nurturance and caretaking, ethics, hopes for collective survival, or relations with friends and community help support them. Only recently have HIV+ MSM been targeted with messages and programs featuring “prevention altruism” that make use of MSM’s strengths. HIV prevention efforts need broader, more emotionally-resonant concepts that build on what is good in MSM’s lives.17

Says who?

  1. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report. 2000;12.
  2. Catania JA, Osmond D, Stall RD, et al. The continuing HIV epidemic among men who have sex with men. American Journal of Public Health. in press.
  3. Seal DW, Kelly JA, Bloom FR, et al. HIV prevention with young men who have sex with men: what young men themselves say is needed. AIDS Care. 2000;12:5-26.
  4. Robinson BE, Bockting W, Rosser BRS, et al. The sexual health model: a sexological approach to long-term HIV risk reduction. Presented at the XIII International Conference on AIDS, Durban, South Africa, July 2000. Abst #ThPeD5613.
  5. Rosser BRS, Bockting WO, Rugg DL, et al. A sexual health approach to long-term HIV risk reduction among men who have sex with men: results from a randomized controlled intervention trial. Presented at the XIII International Conference on AIDS, Durban, South Africa, July 2000. Abst #WePeD4718.
  6. Altman LK. Gonorrhea shows its resistant side; disease control agency tells doctors of new recommendations. Milwaukee Journal Sentinel. October 2, 2000. p. 5G.
  7. Diaz RD, Ayala G, Bein E. Social oppression, resiliency and sexual risk: findings from the national Latino gay men’s study. Presented at the National HIV Prevention Conference, Atlanta, GA, Aug 29-Sep 1, 1999. Abst#287
  8. Díaz RM. Latino Gay Men and HIV: Culture, Sexuality, & Risk Behavior. NY:Routledge. 1998.
  9. Simmons R. Towards developing a comprehensive program for effective HIV prevention among racially oppressed gay men, bisexuals and MSM. Presented at the XIII International Conference on AIDS, Durban, South Africa, July 2000. Abst #TuPeD3839.
  10. Stall R, Wiley J. A comparison of alcohol and drug use patterns of homosexual and heterosexual men: the San Francisco men’s health study. Drug Alcohol Dependency. 1988;22:63-73.
  11. Crosby M, Stall R, Paul J, et al. Alcohol and drug use patterns have declined between generations of younger gay/bisexual men in San Francisco. Drug and Alcohol Dependence. 1998;52:177-182.
  12. Rhodes F, Deren S, Wood MM, et al. Understanding HIV risks of chronic drug-using men who have sex with men. AIDS Care. 1999;11:629-648.
  13. Colfax G, Mansergh G, Vittinghoff E, et al. Drug use and high-risk sexual behavior among circuit party participants. Presented at the XIII International Conference on AIDS, Durban, South Africa, July 2000. Abst #TuPeC3422.
  14. Stonewall Project. 415/502- 1999.
  15. Kegeles SM, Hays RB, Pollack LM, et al. Mobilizing young gay and bisexual men for HIV prevention: a two-community study. AIDS. 1999;13:1753-1762.
  16. Williams AM. Condoms, risk and responsibility. Presented at the HIV Prevention Summit, Half Moon Bay, CA, June 2000.
  17. Nimmons D. In this together: the limits of prevention based on self-interest and the role of altruism in HIV safety. Journal of Psychology & Human Sexuality. 1998;10:75-87

Prepared by Michael Crosby PhD and Pamela Decarlo, CAPS December 2000

Resource

What are transgender women’s HIV prevention needs?

Transgender is an umbrella term for persons whose gender identity and expression does not conform to norms and expectations traditionally associated with their sex assigned at birth. Transgender persons may self-identify as transgender, female, male, trans-woman or -man, transsexual, cross-dresser, bigender, gender queer, gender questioning, MtF, FtM or one of many other transgender identities, and may express their genders in a variety of masculine, feminine and androgynous ways. Transgender persons may prefer and identify with certain terms and not others, so it is best to ask participants and clients what they prefer. For this fact sheet, we use the term transgender women. The transgender community is diverse and more research is needed. From what we know, transgender women have higher rates of HIV and HIV-related risks than transgender men. While this fact sheet focuses on transgender women, we are developing other fact sheets on transgender men and the general transgender population.
Resource

Estigma

¿Cuál es el efecto del estigma en el tratamiento y prevención del VIH?

¿qué es el estigma del VIH/SIDA?

El estigma relacionado con el VIH/SIDA es un concepto complejo que se refiere al prejuicio, la exclusión, el desprestigio y la discriminación dirigidos hacia personas percibidas como infectadas por el SIDA o el VIH, y también hacia sus parejas, amistades, familias y comunidades.1,2 Muchas veces el estigma del VIH/SIDA reafirma las desigualdades sociales basadas en el sexo, la raza, el grupo étnico, la clase social, la sexualidad y la cultura de las personas. En EE.UU. por mucho tiempo ha existido el estigma hacia muchas poblaciones excesivamente afectadas por el VIH. El mismo VIH ha agravado el estigma de la homosexualidad, del consumo de drogas, de la pobreza, del trabajo sexual y de la condición de minoría racial.3 El estigma del VIH/SIDA es un problema no sólo en EE.UU. sino en todo el mundo, y tiene varias formas, entre ellas: 1) el ostracismo, el rechazo y el soslayo de las personas con SIDA; 2) la discriminación contra las personas con SIDA por parte de sus familias, proveedores médicos, comunidades y gobiernos; 3) la realización de pruebas obligatorias del VIH sin consentimiento previo ni la debida protección de la privacidad; 4) la puesta en cuarentena de personas VIH+; y 5) la violencia contra personas que parecen tener SIDA, ser VIH+ o pertenecer a “grupos de alto riesgo”.1

¿cómo puede afectar a la prevención?

El estigma del VIH/SIDA se suma al estrés que sienten las personas VIH+ y plantea desafíos para los esfuerzos de prevención del VIH. Pruebas del VIH. El temor a las consecuencias de una prueba positiva del VIH puede impedir que algunas personas se la hagan. Un estudio de hombres y mujeres en siete ciudades estadounidenses reveló que el estigma se asociaba con una menor probabilidad de hacerse la prueba del VIH.4 Es menos probable que las personas que son VIH+ sin saberlo intenten evitar transmitir el VIH a otros.<sup5 Conductas más protegidas. Algunas personas VIH+ pueden temer que la revelación de su condición de VIH o el uso de condones cause el rechazo de su pareja, limite su oportunidad de tener relaciones sexuales o aumente el riesgo de violencia física y sexual. Un estudio de hombres rurales que tienen sexo con hombres (HSH) encontró que los hombres que pensaban que los proveedores médicos en su comunidad eran intolerantes hacia las personas VIH+ también reportaron más conductas sexuales de alto riesgo.6 Programas de prevención. El estigma en torno al VIH, a la homosexualidad, al comercio sexual y al consumo de drogas dificulta la provisión de servicios de prevención del VIH en una variedad de ambientes. La idea de integrar la prevención del VIH en un contexto sanitario y comunitario más extenso es ampliamente aceptada, pero muchos lugares comunitarios (iglesias, negocios, cárceles, prisiones y escuelas) se han resistido a dialogar francamente sobre el VIH.7

¿cómo puede afectar al tratamiento?

El estigma del VIH/SIDA también puede perjudicar la salud y el bienestar de las personas VIH+. Tratamiento. Las personas VIH+ tal vez eviten buscar tratamiento o se demoren en acudir al médico debido a la discriminación real o percibida. En un estudio nacional de adultos VIH+, el 36 % reportaron haber sido discriminado por un profesional médico, incluyendo el 8 % a quienes se les negó atención médica.8 Apoyo. Algunas personas VIH+ no tienen una red de apoyo adecuada por temor a que sus amigos o familiares las abandonen o sean objetos del mismo estigma. Un estudio de asiáticos e isleños del Pacífico (AIP) con VIH reveló altos niveles de estigma interiorizado. Los AIP no buscaron apoyo por temor a revelar su condición de VIH+, y tampoco creyeron que merecían apoyo.9 Apego o adherencia al tratamiento. El rechazo social, la desaprobación y la discriminación relacionadas con el VIH pueden mermar la motivación de las personas VIH+ para mantenerse sanas. Un estudio de mujeres y hombres VIH+ encontró que aquellos que habían experimentado el estigma también eran más propensos a faltar a sus citas médicas del VIH y a tener problemas para seguir su régimen de medicamentos.10

¿qué se está haciendo al respecto?

Los programas y las capacitaciones de reducción del estigma se realizan en todo EE.UU. y alrededor del mundo. Sin embargo, resulta difícil determinar la eficacia, por lo que existen pocos estudios publicados sobre programas exitosos que reduzcan el estigma. La mayoría de los programas cuentan con varios componentes que afrontan el estigma, entre ellas la educación, el desarrollo de habilidades y el contacto a nivel individual y comunitario con personas VIH+.11 En Texas, un programa escolar para estudiantes de preparatoria que viven en sectores urbanos pobres invitó a oradores VIH+ con el fin de disminuir las actitudes negativas hacia el VIH/SIDA. Los oradores resultaron ser un éxito entre alumnos y maestros, y tuvieron un efecto positivo sobre sus actitudes a corto plazo. La combinación de oradores VIH+ con un programa multifacético de prevención y educación del VIH tuvo un impacto aún mayor.12 El South Carolina HIV/AIDS Council (SCHAC) instituyó un programa tripartito contra el estigma. 1) Convocó reuniones comunitarias legislativas sobre temas de VIH en los condados rurales. 2) Produjo una obra de teatro educativa sobre las realidades del estigma del VIH para las comunidades y sus dirigentes. 3) Diseñó una campaña de publicidad estatal sobre el estigma del VIH/SIDA en la cual se difundieron anuncios de servicio público, carteles y artículos editoriales.13 El AIDS Institute (AI) del Departamento de Salud del Estado de Nueva York ha aprovechado intervenciones multinivel para evitar el estigma y la discriminación relacionados con el VIH. El AI ha promulgado leyes y políticas que protejan los derechos de las personas VIH+ o quienes sean vistas como tal, incluyendo leyes de confidencialidad y la inclusión del VIH/ SIDA en la ley actual contra la discriminación. También ofrece foros y consejos asesores para discutir normas y políticas, y ha establecido una oficina que gestiona reclamos de discriminación. A nivel programático, el AI provee capacitaciones sobre la diversidad y la confidencialidad para proveedores médicos, capacitación en liderazgo para personas VIH+ y métodos de mercadotecnia social para actividades de educación y concientización comunitaria.14

¿qué queda por hacer?

Tener conocimientos sobre la prevención, la transmisión y la atención del VIH puede compensar el estigma originado por la mala información y la ignorancia. Todavía se necesitan (y se necesitarán para futuras generaciones de jóvenes) programas educativos en muchas áreas y poblaciones.5 El estigma existe no simplemente en los actos de los individuos, sino dentro de amplios contextos sociales y culturales que deben tomarse en cuenta al diseñar programas para reducir el estigma. Las organizaciones y las comunidades deberán considerar los valores, las normas y los juicios morales que contribuyen al estigma de las personas VIH+ colaborando con las organizaciones religiosas, instituciones clave y líderes de opinión que ayuden a formar y a reafirmar los valores sociales.15 Los legisladores y otras autoridades necesitan considerar las implicaciones de las leyes si no desean aumentar involuntariamente el estigma relacionado con el VIH/SIDA. Las personas VIH+ deben ser involucradas en el diseño, la operación y la evaluación de los programas de reducción del estigma. Un método es capacitar y apoyar a personas VIH+ para que se movilicen y promuevan sus propios derechos.16 Los programas para la prevención, enfrentarse al diagnóstico y la adherencia al tratamiento para personas VIH+ deben afrontar directamente el estigma y sus efectos sobre la salud y el bienestar de las personas VIH+. Los programas también pueden ofrecer capacitación sobre la competencia cultural, la confidencialidad y la concientización para trabajadores de salud, consejeros y el personal de servicios sociales incluyendo los de desintoxicación, de vivienda y de salud mental. La capacitación es especialmente importante en áreas de elevado estigma como las zonas rurales y en organizaciones con pocos clientes VIH+. Es poco probable que el estigma del VIH/SIDA desaparezca pronto.16 Se están realizando investigaciones nacionales e internacionales,17 pero hacen falta otras más que midan los efectos del estigma y nos ayuden a entender qué intervenciones sirven mejor y en qué comunidades. Los programas prometedores de concientización y reducción del estigma necesitan ser evaluados y publicados para permitir la amplia reproducción de los programas eficaces.

¿Quién lo dice?

1. Herek GM. AIDS and stigma. American Behavioral Scientist. 1999;42:1102-1112. 2. Goffman E. Stigma: note on the management of spoiled identity . Prentice-Hall: Englewood, NJ. 1963. 3. Parker R, Aggleton P. HIV/AIDS-related stigma and discrimination: a conceptual framework and agenda for action. Report prepared by the Population Council, May 2002. https://pubmed.ncbi.nlm.nih.gov/12753813/&nbsp; 4. Fortenberry JD, McFarlane M, Bleakley A, et al. Relationships of stigma and shame to gonorrhea and HIV screening . American Journal of Public Health.2002;92(3):378-381. 5. Valdiserri RO. HIV/AIDS stigma: an impediment to public health . American Journal of Public Health. 2002;92(3):341-342. 6. Preston DB, D’Augelli AR, Kassab CD, et al. The influence of stigma on the sexual risk behavior of rural men who have sex with men. AIDS Education and Prevention . 2004;16(4):291-303. 7. Brooks RA, Etzel MA, Hinojos E, et al. Preventing HIV among Latino and African American gay and bisexual men in a context of HIVrelated stigma, discrimination and homophobia: perspectives of providers . AIDS Patient Care and STDs.2005;19(11):737-744. 8. Schuster MA, Collins R, Cunningham WE, et al. Perceived discrimination in clinical care in a nationally representative sample of HIV-infected adults receiving health care . Journal of General Internal Medicine. 2005;20:807-813. 9. 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(2):145-154. 10. Vanable PA, Carey MP, Blair DC, et al. Impact of HIV-related stigma on health behaviors and psychological adjustment among HIV-positive men and women .AIDS and Behavior. 2006;10:____. 11. Brown L, Macintyre K, Trujillo L. Interventions to reduce HIV/AIDS stigma: what have we learned? AIDS Education and Prevention . 2003;15(1):49-69. 12. Markham C, Baumler E, Richesson R, et al. Impact of HIV-positive speakers in a multicomponent, school-based HIV/STD prevention program for inner-city adolescents . AIDS Education and Prevention. 2000;12(5):442-454. 13. Ford Foundation HIV/AIDS anti-stigma initiative:a framework for addressing HIV/AIDS related stigma in the US.https://www.fordfoundation.org/the-latest/news/ford-foundation-initiati…; 14. Klein SJ, Karchner WD, O’Connell DA. Interventions to prevent HIV-related stigma and discrimination: findings and recommendations for public health practice . Journal of Public Health Management and Practice. 2002;8(6):44-53. 15. Ogden J, Nyblade L. Common at its core: HIV-related stigma across contexts. Report prepared by the International Center for Research on Women. 2005. https://www.icrw.org/publications/common-at-its-core-hiv-related-stigma…; 16. Stigma mitigation components in HIV/AIDS programs. In:HIV/AIDS Stigma: Theory, Reality and Response , J Holloway, R Seaton and J Crowley, eds. Health Resources and Services Administration: Rockville, MD. 2004.

Preparado por Maria Ekstrand PhD, CAPS y el National AIDS Fund Traducción: Rocky Schnaath Septiembre 2006. Hoja de Dato #60S