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Métodos de barrera

¿Pueden las barreras ayudar en la prevención del VIH?

¿por qué los métodos de barrera?

Los métodos de barrera son relativamente bajos en costo, de fácil acceso y juegan un papel importante en la prevención de embarazos y de Enfermedades de Transmisión Sexual (ETS). Las barreras físicas (como el diafragma, el condón, etc.) son efectivas para la prevención de embarazos y algunas de ellas para la prevención del VIH/ETS; las barreras químicas (espermicidas) previenen primordialmente el embarazo. Los métodos hormonales anticonceptivos (la pastilla, etc.) no se incluyen en ésta categoría de métodos de barrera. Durante siglos, la gente ha utilizado con éxito las barreras físicas.1 Desde el inicio de la epidemia del VIH el condón de látex para hombres ha sido el instrumento exclusivo para la prevención. Dos décadas mas tarde, se hace un llamado para crear una mayor selección de métodos de barrera para combatir el VIH. Dado el continuo incremento en las tasas de infección por VIH entre mujeres y entre hombres que tienen sexo con hombres (HSH),2,3 es necesario fortalecer los programas actuales para el uso del condón y crear otros métodos de barrera que optimicen el uso y las opciones en la prevención.

¿qué métodos están disponibles?

Actualmente, tanto el condón femenino (Reality) como el masculino son utilizados para prevenir VIH/ETS y embarazos no deseados.4,5 El condón femenino, hecho a base de plástico poliuretano, también es utilizado en las relaciones anales receptivas a pesar de no haber sido diseñado para ese propósito.6 La esponja, el diafragma y el capuchón cervical son a menudo utilizados con espermicidas y bloquean el cuello del útero para impedir la concepción. A pesar de que los estudios han demostrado que los métodos que bloquean el cuello del útero (cerviz) pueden a su vez prevenir algunas ETS7, no hay investigaciones que demuestren que previenen el VIH. Las barreras dentales son unas películas de látex utilizadas para en el sexo oral-anal y oral-vaginal. Los espermicidas (gelatinas, cremas, espumas o películas que se introducen en la vagina) asisten en la prevención de embarazos. Uno de los espermicidas más utilizados, el Nonoxynol 9 (N-9), recientemente se sometió a estudios para comprobar su efectividad respecto al VIH. Un estudio con trabajadoras sexuales en Tailandia, Sudáfrica, Costa de Marfil y Benin; asignó aleatoriamente quienes usarían 5.5 mg de N-9 y quienes usarían un placebo – la crema vaginal humectante “Replens.” Los resultados preliminares demostraron que hubo una mayor cantidad de nuevas infecciones entre el grupo que usó el N-9 que entre el grupo del placebo.8 En Agosto del 2000, el CDC hizo una recomendación en contra del uso de N-9 como único método para prevenir el VIH.9 Este mismo estudio documentó los efectos dañinos de una dosis relativamente alta de N-9 sobre la infección del VIH. El N-9 se utiliza como lubricante de condones en escalas mucho menores. El impacto de dosis en baja escala aún se desconoce.

¿por qué necesitamos métodos alternos al condón masculino?

Los condones masculinos son muy eficaces para prevenir VIH/ETS y embarazos. Generalmente lo que limita la efectividad de los condones son fallas por parte del usuario más que las del producto mismo. Por ejemplo, el colocarse el condón después de haber iniciado el contacto genital, el no desenrollarlo totalmente, ó el no usarlo en todo acto sexual son fallas. Algunos no usan condones porque les reduce la sensibilidad, otros los consideran un obstáculo para la intimidad. Los condones masculinos requieren de la negociación con el hombre para su uso. Las opciones controladas por mujeres o parejas receptoras pueden ser utilizadas en situaciones en las que la negociación del uso de condón se dificulta, como en las relaciones de abuso, donde las cuestiones económicas, como costo del condón, son un pretexto para no usarlo10 o cuando la pareja que penetra se rehusa a usarlo5. Los métodos de prevención del VIH/ETS controlados por la mujer ofrecen una forma de autopoder11 y son vitales dado el incremento de mujeres infectadas por la epidemia del VIH, especialmente en los países en vías de desarrollo. Finalmente, no existe un método de barrera que le permita a la mujer protegerse del VIH y al mismo tiempo poder embarazarse. El que se desarrolle un método que separe el control de la natalidad de la prevención de ETS es una consideración importante para muchas mujeres.2

¿cuáles son los obstáculos ?

Los métodos de barrera pueden ofrecer protección contra el VIH/ETS, sin embargo no son una alternativa para todo mundo. A pesar del bajo costo de algunos métodos, los precios de otros no son tan accesibles (como el de los condones femeninos). La mayoría de los métodos de barrera requieren ser aplicados antes de cada acto sexual, lo cual dificulta el uso constante. Es posible que no protejan en contra de aquellas ETS que se transmiten por medio del contacto con la piel como el herpes y el Virus del Papiloma Humano (VPH). Los productos que resultan complicados o que requieren de cierta limpieza o almacenamiento, se vuelven inaccesibles para algunas personas. Las barreras que se introducen en la vagina requieren de que la persona se familiarice con su cuerpo y sienta cómoda haciéndolo. Con el diafragma y el capuchón cervical es un médico quien debe tomar la medida adecuada para cada persona. Algunas personas son sensibles a ciertos químicos ó materiales, como quienes presentan alergias al latex. Estas limitaciones se están considerando para el desarrollo de nuevas barreras.

¿qué son los microbicidas?

Los microbicidas son barreras químicas de aplicación tópica para prevenir la transmisión del VIH/ETS que aún se encuentran en proceso de desarrollo y bajo pruebas de ensayo para asegurar su eficacia como método alterno. Quizá serán presentados en forma de gelatinas, cremas, espumas o películas para introducirse en la vagina o el recto. Las investigaciones se están enfocando en crear productos que destruyan o inmovilicen gérmenes o virus por medio de mecanismos como romper las membranas externas de las células de los patógenos, o proveer un recubrimiento a las paredes de la vagina o el recto, ó inhibir la inserción del VIH en las células, lo que previene la reproducción del mismo. Los estudios han demostrado que existe una demanda potencial de microbicidas a nivel nacional y mundial para las mujeres. Estudios realizados con mujeres y con HSH demostraron que hay personas dispuestas a participar en estudios clínicos para probar la eficacia de estos productos.

¿qué se está haciendo?

Actualmente, el condón masculino es el método de prevención más completo que existe. Deben continuar las campañas de prevención en las que se optimice el uso del condón mientras se consiguen otras alternativas. Las labores de prevención podrían ser más efectivas para ciertas poblaciones si se incluyera el tema del condón y del VIH en las campañas de prevención de embarazos y ETS. Algunas clínicas de ETS y de planificación familiar promueven con mucho éxito el uso del condón para prevenir el VIH/ETS. Se están investigando nuevos métodos de barrera como los diafragmas deshechables, alternativas de escudos cervicales, capuchones, esponjas y condones femeninos y masculinos. También se están desarrollando nuevos materiales incluyendo varias clases de plástico y silicón.2 De igual importancia es examinar el potencial para adaptar y probar productos ya existentes en la prevención del VIH; los cuales al ya haber sido aprobados por la FDA (Food and Drug Administration) no tendrían un proceso tan largo de pruebas.

¿cuáles son los próximos pasos?

Desarrollar métodos de barrera alternos debe ser la prioridad entre científicos públicos y privados. Con más de 50 microbicidas en vías de investigación quizá uno saldrá al mercado para el 2005. Los grupos que han sido claves en la lucha para despertar el interés y atención por los microbicidas deben continuar abogando por tener métodos de barrera accesibles. A pesar de que el gobierno Estadounidense incrementó los fondos destinados a los microbicidas, en el año fiscal 1998 el porcentaje para la investigación de éstos fue sólo del 1% del presupuesto de los Institutos Nacionales de Salud de Investigación de SIDA La solución para prevenir el SIDA y las ETS no es sencilla. La prevención requiere un trabajo continuo a muchos niveles incluyendo aumentar el acceso a los productos y desarrollar alternativas para la prevención y tratamientos más fuertes. Los métodos de barrera son una parte integral de estos métodos de prevención alternos y deben desarrollarse a su máxima capacidad.

¿quién lo dice? 1. Feldblum P, Joanis C. Modern barrier methods: effective contraception and disease prevention. Family Health International. 1994. 2. The Population Council and International Family Health. The case for microbicides: a global priority . 2000. 3. Microbicides: a new weapon against HIV. American Foundation for AIDS Research (AmFAR) Report. www.amfar.org . 4. Pinkerton SD, Abramson PR. Effectiveness of condoms in preventing HIV transmission . Social Science and Medicine. 1997;44:1303-1312. 5. Elias CJ, Coggins C. Female-controlled methods to prevent sexual transmission of HIV . AIDS. 1996;3:S43-51. 6. Gibson S, McFarland W, Wohlfeiler D, et al. Experiences of 100 men who have sex with men using the REALITY condom for anal sex . AIDS Education and Prevention. 1999;11:65-71. 7. Rosenberg MJ, Davidson AJ, Chen JH, et al. Barrier contraceptives and sexually transmitted diseases in women: a comparison of female-dependent methods and condoms . American Journal of Public Health. 1992; 82:669-674. 8. UNAIDS. Nonoxynol-9 not effective microbicide, trial shows. Search continues for effective product, UNAIDS chief says. UNAIDS Press Release, June 13, 2000. Gayle H. Dear Colleague. Centers for Disease Control and Prevention. August 4, 2000. 10. Abdool Karim Q, Abdool Karim SS, Soldan K, et al. Reducing the risk of HIV infection among South African sex workers: socioeconomic and gender barriers . American Journal of Public Health. 1995;85:1521-1525. 11. Gollub EL. The female condom: tool for women’s empowerment . American Journal of Public Health. 2000;90:1377-1381. 12. Heise L. Topical microbicides: new hope for STI/HIV prevention. Center for Health and Gender Equity (CHANGE). Takoma Park, MD. 13. Darroch JE, Frost JJ. Women’s interest in vaginal microbicides . Family Planning Perspectives. 1999;31:16-23 14. Hammet TR, Mason TH, Joanis CL, et al. Acceptability of formulations and application methods for vaginal microbicides among drug-involved women: results of product trials in three cities . Sexually Transmitted Diseases. 2000;27:119-126. 15. Gross M, Buchbinder SP, Celum C, et al. Rectal microbicides for U.S. gay men: are clinical trials needed? Are they feasible? Sexually Transmitted Diseases. 1998;39:55-61. 16. Kamb ML, Fishbein M, Douglas JM Jr, et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. Project RESPECT Study Group . Journal of the American Medical Association. 1998;280:1161-1167. 17. Harrison PF. A new model for collaboration: the alliance for microbicide development . International Journal of Gynecology and Obstetrics. 1999;67:S39-S53.

Preparado por Beth Freedman, MPH, Nancy Padian, PhD, CAPS/ARI Traducción: Romy Benard-Rodríguez, Revisión: Maricarmen Arjona, CAPS Abril 2001. Fact Sheet #39S

Resource

Jóvenes HSH

¿Qué necesitan los hombres jóvenes que tienen sexo con hombres para la prevención del VIH?

revisado 4/01

¿están en riesgo de contraer VIH?

Sí. En los EEUU más de la mitad de los casos nuevos de VIH/SIDA en hombres de 13 a 24 años, ocurren por contacto sexual entre hombres.1 Varios estudios encontraron que del 26% -50% de los hombres jóvenes que tienen sexo con hombres reportó haber tenido relaciones sexuales recientes sin protección, muchas de las cuales se dieron con parejas de estatus de VIH desconocido o diferente al del entrevistado.2-4 El índice de conductas de riesgos que toman los jóvenes HSH también se ha incrementado.5 El término de hombres jóvenes que tienen sexo con hombres (jóvenes HSH) se refiere a todo aquel menor de 30 años que se identifique como gay/bisexual, así como a quien no se identifique como tal pero que practique el sexo con otro hombre Un gran número de jóvenes HSH urbanos está infectado con VIH. Un estudio con participantes entre los 15 y 22 años en siete ciudades (Baltimore, Dallas, Los Angeles, Miami, Nueva York, El Area de la Bahía de San Francisco y Seattle) reveló una alta prevalencia (número total de infecciones existentes) general del 7%, que varía entre 2% y 12% entre subgrupos. El 82% de los jóvenes VIH+ no sabían que estaban infectados antes participar en éste estudio.6 Los jóvenes HSH de raza no blanca (no caucásicos), especialmente los afroamericanos, están siendo mayormente afectados por el VIH. En el estudio mencionado arriba, el 14% de los afroamericanos resultaron VIH+ comparado con un 3% de asiáticos, 3% de caucásicos, 7% de hispanos y un 13% de hombres de razas mezcladas (o “mixtas” como se les denomina en EEUU).6

¿por qué corren riesgos los jóvenes HSH?

Desgraciadamente, no existe una respuesta sencilla. Las razones por las que ocurre el sexo desprotejido son complejas y múltiples.3,7 La adolescencia y el inicio de la edad adulta comúnmente se caracterizan por la experimentación sexual y el consumo de drogas. Aunque la mayoría de los jóvenes HSH llegará a practicar ciertas conductas de riesgo, sólo un pequeño porcentaje tomará riesgos constantemente. Muchos jóvenes luchan con tensiones personales, interpersonales y sociales que pueden limitar su capacidad de protegerse. Para algunos jóvenes HSH [en los EEUU] existen factores individuales capaces de impulsarles a tener sexo desprotegido, por ejemplo: sentimientos de invulnerabilidad ante el VIH, altos niveles de optimismo por los medicamentos antivirales, percepción de que el sexo desprotegido es más placentero que el sexo protegido, depresión o tristeza, conflicto con la identidad sexual o racial [que frecuentemente se ven como separadas y parte de dos comunidades diferentes] y consumo de alcohol o drogas (como cristal/speed, poppers).8 Proteger su salud no es necesariamente la preocupación principal del joven HSH como lo son las motivaciones interpersonales de querer sentirse parte de algo, querer compañía y tener intimidad. Además, existen otros factores interpersonales que pueden contribuir al sexo desprotegido como no saber comunicar o negociar relaciones sexuales más seguras con una pareja sexual. Los jóvenes HSH con pareja son más propensos que los solteros al sexo desprotejido.4 Los factores sociales también pueden influir en los riesgos que toman los jóvenes HSH. Muchos jóvenes se sienten aislados o rechazados por las fuentes de tradicionales de apoyo como la familia, la escuela o la comunidad religiosa.9 La homofobia, el racismo y la pobreza también ponen en riesgo a estos jóvenes. Algunos jóvenes HSH (especialmente los indigentes) luchan con preocupaciones diarias como evitar la violencia, buscar un lugar dónde vivir o conseguir comida. Estas preocupaciones inmediatas pueden opacar la necesidad de protegerse al inyectarse drogas y al tener sexo. Los jóvenes HSH tienen pocos lugares públicos dónde reunirse. Los bares gay y las areas públicas de encuentro o “de ligue” son sitios visibles y accesibles que ofrecen anonimato para el joven que intenta explorar su identidad sexual. Estos sitios están asociados con niveles altos para la toma de riesgos pues tienen una alta tensión sexual. Además, la escena del bar al enfatizar el consumo de alcohol, crea un escenario ideal para los encuentros sexuales bajo la influencia del mismo. Se ha encontrado que todo esto contribuye consistentemente al sexo desprotegido.10 Poco se sabe del papel de la Internet en la vida de éstos jóvenes y cómo la utilizan para obtener apoyo social, conocer nuevas amistades, tener encuentros sexuales, y conseguir pareja.

¿qué se ha hecho?

El proyecto Mpowerment es una intervención de múltiples niveles por y para jóvenes gay. Ellos mismos se encargan del programa. Debido a que el VIH puede ser un tema poco atractivo para muchos jóvenes HSH, el proyecto se concentra en sus intereses y preocupaciones sociales. Ellos coordinan y planean actividades que les permiten crear una comunidad más fuerte y más saludable en la que el sexo protegido sea la norma aceptada mutuamente. Al participar, los jóvenes del proyecto reducen sus tasas de sexo anal desprotegido con parejas casuales y con novios.3 Mpowerment ha comprobado su eficacia como intervención para la prevención del VIH. Ofrece adiestramientos a agencias comunitarias y un manual sobre cómo replicar éste modelo.11 La organización COLOURS en Filadelfia ofrece grupos de apoyo, adiestramiento de pares y manejo de casos individuales para jóvenes de raza no blanca. Tienen promotores que asisten a los bares y clubes de sexo frecuentados por adultos HSH de raza no blanca y ofrecen condones y consejería a jóvenes que se relacionan con una pareja mayor. También promueven programas para el tratamiento del alcohol y drogas dirigidos a jóvenes HSH.12 La Asociación Americana de Psicología (APA sus siglas en inglés) ha implementado el proyecto Healthy Schools for Gay and Lesbian Students (escuelas sanas para estudiantes gay y lesbianas) que imparte adiestramiento a psicólogos, consejeros, enfermeras y trabajadoras sociales de las escuelas para que puedan trabajar exitosamente con estudiantes gay, lesbianas y bisexuales. La meta es crear un ambiente escolar más hospitalario y que la educación sobre prevención de VIH toque temas importantes para ellos/as.13 “Chico Chats”, un programa del proyecto STOP AIDS en San Francisco, imparte una serie de talleres intensivos durante un mes. Los participantes llegan a conocerse mientras que entablan conversaciones conducidas por un moderador sobre temas como identidad, imagen corporal, relaciones de pareja y cómo todo ésto se vincula con el VIH. Un componente clave de los talleres es aprender las técnicas sobre organización y movilización comunitaria. Los participantes formaron un grupo activista llamado ¡Ya Basta! Diseñaron un video y un taller que examina los temas del silencio sexual y la forma de “salir del closet” en el contexto de las familias latinas. El video está siendo presentado a la comunidad latina de San Francisco.14

¿qué más se necesita?

Para ser eficientes, los programas para jóvenes HSH deberán considerar el contexto de sus vidas y los factores individuales, interpersonales y sociales que los pone en riesgo. Una educación integral sobre salud y sexualidad debe dirigirse tanto a los que se identifican como gay o bisexual como a los que no lo hacen. Desgraciadamente, muchos programas escolares tienen un enfoque en la reproducción o la abstinencia hasta el momento del matrimonio, marginando aún más a los jóvenes HSH. Hay una necesidad urgente de crear programas de prevención y bienestar para jóvenes HSH de raza no blanca. Los programas existentes para hombres mayores HSH de raza no blanca también deben estar disponibles para los jóvenes. Estos programas deben incluir los temas de la sexualidad, identidad gay, cultura, etnicidad, racismo, homofobia, pobreza y violencia. Los programas deben considerar las necesidades de prevención de VIH para jóvenes que son VIH+ y VIH-. Es necesario prestar especial atención a la forma de llegar a los jóvenes HSH marginados como los indigentes, los trabajadores sexuales o los que están bajo el sistema de justicia criminal. Es posible que ellos no se identifiquen a sí mismos como gay o bisexuales y que sus necesidades inmediatas sean la comida y un techo. Se necesitan programas que promuevan el apoyo para jóvenes HSH y los incluyan directamente en la planificación e implementación de los mismos; por ejemplo crear lugares seguros donde los jóvenes puedan socializar y tengan acceso a servicios, implementar programas escolares que instruyan sobre la sexualidad y necesidades de gay y bisexuales; promover mayor aceptación del joven HSH en las escuelas, familias, comunidades religiosas, la comunidad gay en general y en las comunidades de razas no blancas.15 La homofobia social puede impedir la implementación de programas de prevención para jóvenes HSH y puede desalentarles para que utilicen los servicios de prevención.16 La política no debe interferir con los servicios de prevención para jóvenes HSH. Dirigir mensajes de prevención y ofrecer servicios a estos jóvenes son respuestas adecuadas ante la grave amenaza que enfrenta la salud pública. Si no se toma acción inmediata muchos más hombres perderán sus vidas a causa del VIH.

¿quién lo dice?

  1. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report . 2000;12.
  2. Molitor F, Facer M, Ruiz JD. Safer sex communication and unsafe sexual behavior among young men who have sex with men in California. Archives of Sexual Behavior. 1999;28:335-343.
  3. Kegeles SM, Hays RB, Pollack LM, et al. Mobilizing young gay and bisexual men for HIV prevention: a two-community study . AIDS. 1999;12:1753-1762.
  4. Hays RB, Kegeles SM, Coates TJ. Unprotected sex and HIV risk-taking among young gay men within boyfriend relationships . AIDS Education and Prevention. 1997;9:314-329.
  5. Ekstrand ML, Stall RD, Paul JP et al. Gay men report high rates of unprotected anal sex with partners of unknown or discordant HIV status . AIDS. 1999;13:1525-1533.
  6. Valleroy LA, MacKellar DA, Karon JM et al. HIV prevalence and associated risks in young men who have sex with men . Young Men’s Survey Study Group. Journal of the American Medical Association. 2000;284:198-204.
  7. Strathdee SA, Hogg RS, Martindale SL et al. Determinants of sexual risk-taking among young HIV-negative gay and bisexual men . Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 1998;19:61-66.
  8. Choi KH, Kumekawa E, Dang Q et al. Risk and protective factors affecting sexual behavior among young Asian and Pacific Islander men who have sex with men: Implications for HIV prevention . Journal of Sex Education & Therapy. 1999;24:47-55.
  9. Beeker C, Kraft JM, Peterson JL, et al. Influences on sexual risk behavior in young African-American men who have sex with men. Journal of the Gay and Lesbian Medical Association. 1998;2:59-67.
  10. Greenwood GL, White EW, Page-Shafer K, et al . Correlates of heavy substance use among young gay and bisexual men: The San Francisco Young Men’s Health Study . Drug and Alcohol Dependence. 2001:61:105-112.
  11. CDC. Compendium of HIV prevention interventions with evidence of effectiveness . 1999.
  12. The COLOURS Organization, Inc . Philadelphia, PA. 215/496-0330.
  13. Clay RA. Healthy Schools project hoped to ease discrimination . APA Monitor. 1999;30.
  14. The STOP AIDS Project . Q Action, ¡Ya Basta! San Francisco, CA. 415/865-0790 x303.
  15. 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. 200;12:5-26.
  16. Stokes JP, Peterson JL. Homophobia, self-esteem, and risk for HIV among African American men who have sex with men . AIDS Education and Prevention. 1998;10:278-292.

Preparado por Pilgrim Spikes MPH, Phd, Bob Hays PhD, Greg Rebchook PhD, Susan Kegeles PhD; Traducción Romy Benard y Maricarmen Arjona CAPS Septiembre 2001. Hoja Informativa 8SR

Resource

Latina/os

What Are U.S. Latinos’ HIV Prevention Needs?

revised 4/02

Are Latinos at risk for HIV?

HIV continues to be a major health threat for Latinos in the US, many of whom are disadvantaged due to racism, economic disparities and language barriers. Latinos in the US (including residents of Puerto Rico) are disproportionately affected by HIV, accounting for 18% of total AIDS cases while comprising 14% of the US population.1 The majority of AIDS cases among the Latino population in 2000 were concentrated among those born in the continental US (35%) and Puerto Rico (25%), followed by those born in Mexico (13%), Central or South America (8%) and Cuba (2%). An additional 18% were reported from Latinos with unknown place of birth (15%) or born elsewhere (3%).2

What puts Latinos at risk?

Latinos in the US include a diverse mixture of racial and ethnic groups and cultures. Latinos share common factors with other ethnic groups that increase vulnerability to HIV, such as discrimination,3 poverty, lack of information, substance use and negative attitudes toward condoms. AIDS case rates and risk behaviors among Latinos in the US vary by region. In the Northeast and along the eastern seaboard, where many Latinos from Puerto Rico live, Latino rates are up to three times higher than the national average.4 In this region, the main risk for transmission is injection drug use, believed to be fueled by the concentration of heroin availability. By comparison, in the West and Southwest, the majority of AIDS cases occurs among men who have sex with men (MSM), although cases are also high among injection drug users (IDUs) in certain areas. In 2000, 47% of AIDS cases among Latino men were attributed to sex with men, 33% to injection drug use, and 14% to sex with women. In the same year, 65% of AIDS cases among Latina women were attributed to sex with men, and 32% to injection drug use.1 Thus, among both male and female Latinos, as with most other groups, unprotected sex with an HIV+ man is the most common route for becoming infected with HIV, followed by the sharing of an unclean syringe/needle with an HIV+ person. HIV risk dynamics among immigrant and migrant Latinos can be more complex than among US born Latinos, as they are dealing with conflicting cultural norms while trying to adjust to life in a new country. For some, this results in higher risk; for others, lower risk. Levels of acculturation, poverty, employment, migrant labor conditions and connection to traditional Latino values can influence HIV risk.6

What are barriers to prevention?

The social and political climate in the US today poses serious problems for effective HIV prevention in Latino communities. Racial and ethnic discrimination, anti- immigrant attitudes, policies on mandatory testing for immigrants, and fear of deportation for undocumented immigrants can prevent many Latinos from receiving and accessing adequate resources and services for HIV prevention, including HIV counseling and testing. Traditionally in Latino cultures, sex and sexuality are not discussed. For some Latina women, this sexual silence dictates that they should not know about or talk to men about sex because it suggests promiscuity. Therefore, their ability, comfort and success in insisting on condom use with male partners may be limited. Sexual silence can prevent MSM from discussing their sexual preference, instilling low self-esteem and personal shame. In addition, the lack of parental discussions and education regarding sex and condoms seems to contribute to the disproportionate number of unintended pregnancies, sexually transmitted diseases and HIV cases among Latino youth.9 Injection drug use is one of the main risk factors for HIV transmission, yet many IDUs do not have access to clean needles and drug treatment. Access is even more difficult for monolingual, immigrant Latino IDUs who may not use needle exchange sites or other public services due to lack of knowledge and fear of being recognized or deported.

How does culture affect prevention?

Familismo is a traditional Latino commitment to family and a central support to family members. Familismo can be a powerful incentive in helping heterosexual Latino men reduce unprotected sex with casual partners outside of primary partnerships. However, for many Latino MSM, familismo and homophobia can create conflict because families may perceive homosexuality as wrong. MSM are forced to separate their sexual identity from their family life, leading to low self-esteem and personal shame.8 Machismo may lead men to view sex as a way to prove masculinity. This can mean that frequency and type of sex are most often determined by men, leaving women in fear of violence or abandonment if they resist male sexual advances.7Machismo may also be used as an excuse for unprotected sex.

What’s being done?

Prevention Point Philadelphia, in collaboration with other AIDS organizations, operated a full service needle exchange site from a van that traveled to an area with many shooting galleries. The van offered needle exchange, oral HIV testing, bilingual social service and drug treatment referrals and medical care. The van reached many homeless, Spanish-speaking Puerto Rican IDUs who were regular shooting gallery users. Many of them had never accessed preventive medical care or social services. In San Antonio, TX, a three-session small group intervention was offered to English-speaking Mexican-American women who had a sexually transmitted disease (STD). The intervention sought to help women recognize their risk for HIV and other STDs, make a plan to change and then build skills to help reduce those risks. The intervention significantly reduced rates of subsequent STDs.11 Hermanos de Luna y Sol, is an ongoing intervention for Latino gay/bisexual men at Mission Neighborhood Health Center in San Francisco, CA, based on empowerment education and social support. The program provides outreach, six structured discussion sessions and ongoing support to maintain behavior change. Sessions deal with the common history of oppression among Latino gay men, social support and community and emotional issues around sex and sexuality. The impact of AIDS and HIV transmission are discussed in the final two sessions. The program has been successful in recruiting men and increasing condom use among participants.12 Mujeres Unidas y Activas is a community education, organizing and advocacy project created by and for Latina immigrant and refugee women in San Francisco, CA. The project includes components such as information meetings, friendship circles, workshops and advocacy. Although the project was not developed to specifically target HIV risk behaviors, women who attended up to nine types of activities showed increases in sexual communication comfort, were less likely to maintain traditional sexual gender norms and reported changes in decision-making power.13

What still needs to be done?

Latinos are concerned about the HIV epidemic and are motivated to learn and to teach their children about prevention.14 Providers and social service agencies should capitalize on this by providing Spanish-language or bilingual education and services such as anonymous and confidential HIV testing. Incorporating HIV prevention messages into general health services, Spanish media and religious settings would decrease stigma and increase access to HIV prevention programs. As Latinos, we must attempt to break the silence around sexuality in our communities and overcome homophobia. Latinos can encourage healthy sexuality by discussing gender role expectations, teaching children about sexuality and accepting diversity in our own community. Programs can build upon the protective aspects of Latino culture and emphasize resiliency. Larger societal factors such as poverty, racism and homophobia must also be addressed in order to reduce their impact on risk behavior.

Says who?

1.Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, Midyear Edition. 2001;13. https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html  2. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, Year End Edition. 2000;12. https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html  3. Díaz RM, Ayala G. Social discrimination and health: the case of Latino gay men and HIV risk. National Gay and Lesbian Task Force. 4. Kaiser Family Foundation. Key Facts: Latinos and HIV/AIDS. November 2001. 5. Klevens RM, Díaz T, Fleming PL, et al. Trends in AIDS among Hispanics in the United States, 1991-1996. American Journal of Public Health. 1999;89:1104-1106. 6. Organista K, Carrillo H, Ayala G. HIV prevention with Mexican migrants: review, critique and recommendations. Journal of Acquired Immune Deficiency Syndrome. 2004;37:S227-39 7. Gómez CA, Marín BV. Gender, culture and power: barriers to HIV prevention strategies for women. The Journal of Sex Research. 1996;33:355-362. 8. Díaz RM. Latino Gay Men and HIV: Culture, Sexuality and Risk Behavior. New York: Routledge Press, 1998. 9. The National Campaign to Prevent Teen Pregnancy. Whatever Happened to Childhood? The Problem of Teen Pregnancy in the United States. 1997. 10. Porter J, Perez G. Taking it to the street: shooting gallery needle exchange site for drug injectors at highest risk for HIV. Presented at the International Conference on AIDS, Geneva, Switzerland; 1998. Abst #33402. 11. Shain RN, Piper JM, Newton ER, et al. A randomized, controlled trial of a behavioral intervention to prevent sexually transmitted disease among minority women. New England Journal of Medicine. 1999;340:93-100. 12. Hermanos de Luna y Sol. Contact: 415/552-1013 x296 13. Gómez CA , Hernandez M, Faigeles B. Sex in the New World: An Empowerment Model for HIV Prevention among Latina Immigrant Women. Health Education & Behavior. 1999;26:200-212. 14. Kaiser Family Foundation. Latinos’ View of the HIV/AIDS Epidemic at 20 Years: Findings from a National Survey. 2001. 15. Ortiz-Torres B, Serrano-Garcia I, Torres-Burgos N. Subverting culture: promoting HIV/AIDS prevention among Puerto Rican and Dominican women. American Journal of Community Psychology. 2000;28:859-881. 16. Raj A, Amaro H, Reed E. Culturally tailoring HIV/AIDS prevention programs: Why, when and how. In: Kazarian & Evans (Eds) Handbook of Cultural Health Psychology. San Diego: Academic Press, 2001; 195-239.

Prepared by Cynthia Gómez, PhD, CAPS April 2002. Fact Sheet #17ER Special thanks to the following reviewers of this Fact Sheet: Hortensia Amaro, George Ayala, Jaime Calderón-Soto, Alejandra Cano, Dennis De Leon, José Ramón Fernandez-Peña, Francisco Gonzales, Barbara Marín, Kurt Organista, Prisci Quijada, Carlos Soles, Carlos Velazquez, Luis Villanueva.

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. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © September 2001, University of California

Resource

Sexual networks

How do sexual networks affect HIV/STD prevention?

What are sexual networks?

Focusing on risk behavior alone does not explain why some persons and communities continue to be infected with HIV and other sexually transmitted diseases (STDs) more than others. Networks help explain why persons can have the same risk behavior and yet one may have a much greater risk of contracting or transmitting HIV. Sexual networks are groups of persons who are connected to one another sexually. The number of persons in a network, how central high-risk persons are within it, the percentage in monogamous relationships and the number of “links” each has to others all determine how quickly HIV/STDs can spread through a network.1 Sexual networks are distinct from, but often overlap with social networks.

How do networks affect transmission?

The different ways persons select partners affect how quickly HIV/STDs can spread. Exclusively monogamous persons are, by definition, not part of a sexual network. If both are HIV-negative they remain so. Serial monogamists are persons who go from relationship to relationship one at a time. If they have unprotected sex, they have a higher risk of HIV/STDs than exclusively monogamous persons. Earlier partners’ risk may affect later partners. Concurrent relationships involve having more than one sexual partner in a given period and going back and forth between them. This increases the probability for transmission because earlier partners can be infected by later partners. Further, they can serve as “nodes”, connecting all persons in a dense cluster, creating highly connected networks that facilitate transmission. Concurrent partners can connect each of their respective clusters and networks as well. Concurrency alone can fuel an epidemic even if the average number of partners is relatively low. The two networks above show that what matters is not simply risk behavior, but risk configuration. Each has 8 persons (circles) connected into 9 relationships. Two persons each have 3 partners, and the other six each have 2 partners. Yet transmission will be less efficient in network A, and prevention will be more difficult in network B. In A, in just two steps from the index person, half the network can be infected and half spared; in B, two steps can result in everyone being infected except for the person on the extreme right. In A, sparing half the population from exposure requires cutting one bridge, while in B, it requires cutting three bridges. In a word, for epidemics, the network structure is destiny.3

What are key concepts of networks?

Number of partners. Programs can focus on persons with the largest number of ties to others in a network. With HIV/STDs, this suggests that in addition to promoting condom usage, programs seek to identify those with a high number of unprotected partners. Random spread broadens transmission. An infection spreads quickest when partnering is random.4 When partners select one another within groups such as age, ethnicity, class, religion or other characteristics, diseases may not spread to all subgroups. When partnering is anonymous or random, a disease can spread more quickly through all groups. Core groups. Core group members have high levels of risky behaviors. They contribute a disproportionate share of HIV/STDs, and can fuel sustained transmission. Centrality. How central an HIV+ person is to a network deeply influences transmission rates in a community. In Colorado Springs, CO, network analysts found that HIV+ persons had high levels of risk behavior but were located in peripheral areas of risk networks.5 This network configuration may have explained the relatively low HIV transmission levels. In contrast, HIV+ persons in New York City, NY occupied central positions within their needle-sharing and sexual risk networks, which helped explain the high observed levels of infection.6

Can sexual networks help explain racial differences in HIV/STD rates?

Yes. Sexual networks and partner selection help explain racial differences in HIV/STD infection rates. For example, African American gay and bisexual men may take no more risk than white men, but appear to get infected much faster.7 In the same way, Asian American gay and bisexual men report similar risk levels but get infected at lower rates.8 In one national study, it was shown that heterosexual African-Americans were getting infected with bacterial STDs at rates almost five times faster than whites after controlling for individual level risk factors. Sexually transmitted infections remain in African American populations because their partner choices are more segregated than other groups. In addition, non-core African-Americans (with few partners) are more likely to choose “core” sexual partners. 9

What interventions influence networks?

Partner notification. Many public health departments have developed highly confidential and sound techniques of partner notification and, through network analysis, have learned to trace “up” the chain of transmission to the transmitter rather than “down” the chain to those infected.10 This allows transmitters to be identified for treatment and HIV/STD prevention counseling. Message development. In addition to promoting condom use and counseling, media messages can be tailored to encourage network fragmentation by encouraging serial monogamy (“one partner at a time”) rather than overlapping partners. Community dialogue. Community-based organizations (CBOs) can play a key role in facilitating community dialogue about difficult questions about networks: How should communities balance sexual freedoms of all–including those at highest risk–with the health and future of their entire community? What community and cultural norms contribute to risky sexual networking? Additionally, CBOs should distinguish between traditionally-defined “risk groups” and those individuals with the very highest levels of risk to focus resources on them. Addressing venues which facilitate partner mixing. In many settings, identification of partners may be impossible. However, by focusing on venues which facilitate sexual mixing between members of both high- and low-risk networks, HIV/STD prevention workers may be able to reduce transmission. For example, many men with syphilis report meeting partners over the internet and in commercial sex venues.11,12 Working with bathhouse and sex club managers and internet service providers to negotiate respective roles in promoting safer behaviors should be a priority for HIV/STD intervention workers. In San Francisco, CA, AIDS educators and sex club owners developed a shared set of guidelines to reduce risky behavior in the clubs.13 In the Netherlands, the gay dating internet site www.dateguide.nl provides interactive safer sex education for every man as he logs on.14

What still needs to be done?

At the beginning of the epidemic, network analysis helped explain some of the most important features of AIDS and helped explain its causes.15 It can still be useful now for agencies, communities, and researchers to work together to encourage sexual networks that discourage HIV/STD transmission. It has long been known and understood that some individuals contribute much more to the spread of HIV/STDs than others. Ignoring that fact, and ignoring the role of sexual networks in fueling the epidemic, hampers our ability to slow HIV/STD transmission.

Says who?

1. Potterat JJ, Muth SQ, Brody S. Evidence undermining the adequacy of the HIV reproduction number formula. Sexually Transmitted Diseases. 2000;27:644-645. 2. Morris M. Sexual networks and HIV. AIDS. 1997;11:S209-216. 3. Klovdahl AS, Potterat JJ, Woodhouse D, et al. HIV infection in a social network: A progress report. Bulletin de Methodologie Sociologique. 1992;36:24-33. 4. Laumann EO, Gagnon J, Michael R, Michaels S. The Social Organization of Sexuality. Chicago: The University of Chicago Press, 1994. 5. Rothenberg RB, Potterat JJ, Woodhouse DE, et al. Social network dynamics and HIV transmission. AIDS. 1998;12:1529-1536. 6. Friedman SR, Neaigus A, Jose B, et al. Sociometric risk networks and risk for HIV infection. American Journal of Public Health. 1997;87:1289-1296. 7. Centers for Disease Control and Prevention. HIV Incidence Among Young Men Who Have Sex With Men—-Seven U.S. Cities, 1994-2000. Morbidity and Mortality Weekly Report. 2001;50:440-444. 8. Choi KH, Operario D, Gregorich S, et al. Age and race mixing patterns of sexual partnerships among Asian men who have sex with men: implications for HIV transmission and prevention. AIDS Education and Prevention. 2003;15:S53-65. 9. Laumann EO, Youm Y. Racial/ethnic group differences in the prevalence of sexually transmitted diseases in the United States: a network explanation. Sexually Transmitted Diseases. 1999;26:250-61. 10. Ghani AC, Ison CA, Ward H, et al. Sexual partner networks in the transmission of sexually transmitted diseases. An analysis of gonorrhea cases in Sheffield, UK. Sexually Transmitted Diseases. 1996;23:498-503. 11. Klausner JD, Wolf W, Fischer-Ponce L, et al. Tracing a syphilis outbreak through cyberspace. Journal of the American Medical Association. 2000;284: 447-449. 12. Williams LA, Klausner JD, Whittington WL, et al. Elimination and reintroduction of primary and secondary syphilis. American Journal of Public Health. 1999;89:1093-1097. 13. Wohlfeiler D. Structural and environmental HIV prevention for gay and bisexual men. AIDS. 2000;14:S52-S56. 14. Harternik P, van Berkel M, van den Hoek K, et al. e-Dating: a developing field for HIV prevention. Published by the Dutch AIDS Fund. www.dateguide.nl 15. Auerbach DM, Darrow WW, Jaffe HW, et al. Cluster of cases of the acquired immune deficiency syndrome. Patients linked by sexual contact. American Journal of Medicine. 1984;76:487-92. Prepared by Prepared by Dan Wohlfeiler*, John Potterat *UCSF April 2003. Fact Sheet #50E Special thanks to the following reviewers of this Fact Sheet: Buzz Bense, Peggy Dolcini, Paul Etkind, Sam Friedman, Azra Ghani, Jed Herman, Ed Laumann, Virginia Loo, Robin Miller, Michael Samuel, Tom Valente, Russell Westacott.

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]. © April 2003, University of California

Resource

Using science

How Is Science Used in HIV Prevention?

Is science needed?

Yes. While prevention science will not give “the answer,” science fills in critical pieces of the prevention puzzle. Science used in conjunction with an agency’s experience with clients can strengthen, inspire, target, and best use limited resources in HIV prevention programs. This fact sheet will cover some of the basic elements of prevention science, what they mean, and their implications for service. Using science in prevention is now mandated in many areas. In 1994, the Centers for Disease Control and Prevention (CDC) radically changed how it makes prevention program awards. The CDC’s guidance recommends that HIV Prevention Community Planning Groups (CPGs) use epidemiology, evaluation and behavioral science theories, findings, and methodologies in developing programs.1 Science that is applicable to HIV prevention can be broken down into five general categories:

  • epidemiology,
  • basic behavioral science,
  • behavior change theory,
  • intervention science, and
  • evaluation methodology.

How is epidemiology useful?

Epidemiology is the study of the occurrence of infections or disease in a population. It can tell you how many people are newly infected with HIV, what subpopulations have been infected, and who might be expected to be infected by HIV in the future. Behavioral epidemiology can tell you about the frequency of risk behaviors.2 Using local epidemiology can help program planners target specific audiences and behavior risks that are most in need of prevention in their community. It can also help planners be more thoughtful about how to best use limited resources. Health departments and the CDC can help by collecting local data for all populations.3

How is behavioral science useful?

Basic behavioral science explores the social, behavioral and cultural influences that help explain why people put themselves at risk, and why people continue to get infected with HIV. Research on human sexuality is key to understanding how people change risky sexual behaviors and can help in program design.4 It does not tell service providers what to do, but can suggest new ways of thinking about program elements. For example, recent research has shown that childhood sexual abuse is a predictor for risky sexual behavior in adulthood.5 Knowing this, program managers can incorporate questions on early abuse into needs assessments, add a segment on childhood abuse to multi-session education interventions, develop new programs for adults who were abused and/or give special training to direct service staff on sexual abuse issues.

How is behavior change theory useful?

Behavior change theory provides a framework to ideas on why and how people change behaviors that put them at risk for HIV infection. Using behavior change theories can help when crafting an intervention, to support each component in a model as the intervention is designed.6,7 For example, Paulo Freire’s theory of Popular Education states that teachers and students should learn from one another.8 Using this theory, a program can use discussion groups as opposed to lectures. This format can strengthen the intervention by empowering people to personally develop their own solutions to change their environment.

How is intervention science useful?

Intervention science explores which components of programs are more effective and which programs work well in certain populations. For example, in a recent study, the riskiest people did not attend small group educational sessions. A program for gay/ bisexual men in Portland, OR conducted outreach in bars and at community events, home meetings, and safer sex workshops. While most men attended outreach activities, few men were likely to attend safer sex workshops.9 Scientific study of the program showed that outreach was most likely to reach the riskiest men-younger men and men who reported unprotected anal intercourse. Interventions aimed at high risk-taking populations can rely on intensive individual outreach/counseling and/or innovative, minimally structured community-level social activities to help draw their intended audience.

How is evaluation methodology useful?

Evaluation encourages critical thinking about the process of designing interventions, and should not only occur at the end of an intervention. Good evaluation produces information about needs, service use patterns, impacts and outcomes. It also gives a voice to clients’ experiences, and allows service providers to learn about their programs so that they can make necessary changes to increase their effectiveness.10 An agency can hire a consultant or researcher for evaluation, or can conduct its own evaluation. For example, Tri-City Health Center in Fremont, CA surveyed suburban street youth to evaluate the effectiveness of their program of outreach and educational workshops. In response to youth feedback, Tri-City cancelled their scheduled workshops and added a drop-in center providing HIV education as well as support in areas such as dropping out of school, joblessness, substance abuse, abusive relationships and living with HIV.11

How do people access science?

No one should need an advanced degree to understand prevention science. Several organizations exist to help translate and summarize research into understandable and usable forms. CPGs are directed to incorporate prevention science in their comprehensive plans, which are available through local and state health departments.12 Local universities (especially schools of public health and social work, departments of sociology, psychiatry/psychology, or anthropology) are an excellent contact for research assistance.13 Mailing lists and newsletters from organizations that specialize in prevention science and technical assistance can also be invaluable resources.14

What still needs to be done?

To more closely link the efforts of researchers and service providers: 1) Researchers should share findings with local CBOs and with the CDC and DPHs, as well as become active members of CPGs. 2) CBOs should be more aggressive and proactive in using information outside of their agencies. 3) State DPHs and the CDC should recognize and act upon their role as translators of science. 4) National Institutes of Health, the CDC and private funders should provide adequate funding for integrating prevention science into prevention programs. 5) CBOs and researchers should forge long term partnerships to conduct collaborative projects.15 Using science in service provision is a specialized field. Most scientists are not trained in the real world application of research. Likewise, most service providers are not trained in research methods. A comprehensive HIV prevention strategy uses many elements to protect as many people at risk for HIV as possible. By closing the gap between HIV prevention science and prevention practice, we can ensure that our best efforts won’t be wasted, and we can make a difference in the fight against HIV.

Says who?

  1. Valdiserri RO, Aultman TV, Curran JW. Community planning: a national strategy to improve HIV prevention programs. Journal of Community Health. 1995;20:87-100.
  2. Rothman KJ. Modern Epidemiology. Boston, MA: Little, Brown and Company; 1986.
  3. A database of epidemiological data for states and some cities is available on the Internet at: https://www.cdc.gov/hiv/basics/statistics.html
  4. Kelly JA, Kalichman SC. Increased attention to human sexuality can improve HIV-AIDS prevention efforts: key research issues and directions. Journal of Consulting and Clinical Psychology. 1995;63:907-918.
  5. Jinich S, Stall R, Acree M, et al. Childhood sexual abuse predicts HIV risk sexual behavior in adult gay and bisexual men. Presented at the 11th International Conference on AIDS, Vancouver, BC. 1996. Abstract Mo.D.1718.
  6. Valdiserri RO, West GR, Moore M, et al. Structuring HIV prevention service delivery systems on the basis of social science theory. Journal of Community Health. 1992;17:259-269.
  7. Herlocher T, Hoff C, DeCarlo P. Can theory help in HIV prevention? Fact sheet prepared by the Center for AIDS Prevention Studies, UCSF. August 1995.
  8. Wallerstein N. Powerlessness, empowerment, and health: implications for health promotion programs. American Journal of Health Promotion. 1992;6:197-205.
  9. Hoff CC, Kegeles S., Acree M, et al. Gay men at highest risk are best reached through outreach in bars and community events. Presented at the 11th International Conference on AIDS, Vancouver, BC. 1996. Abstract Tu.D.360.
  10. San Francisco HIV Prevention Plan. Report prepared by the San Francisco HIV Prevention Planning Council and the Department of Public Health AIDS Office. 1996.
  11. Carver LJ, Harper GW. Responding to the HIV prevention needs of suburban street youth. Presented at the 11th International Conference on AIDS, Vancouver, BC. 1996. Abstract Th.D.4921.
  12. For information on your local or state Community Planning group, please contact Lynne Greabell at NASTAD (202) 434-8090.
  13. A directory of universities is available here: https://www.usnews.com/best-colleges/rankings/national-universities
  14. CDC (800) 458-5231 (www.cdc.gov/nchstp/hiv_aids/dhap.htm)
    • American Psychological Association (202) 336-6042
    • National Minority AIDS Council (202) 483-6622
    • National Association of People With AIDS (202) 898-0414
    • Academy for Educational Development (202) 884-8700
    • National Alliance of State and Territorial AIDS Directors (202) 434-8090
    • Council of State & Territorial Epidemiologist (770) 458-3811
    • The US Conference of Mayors (202) 293-7330
    • GMHC Education Department (212) 807-7517 (www.gmhc.org)
    • The Center for AIDS Prevention Studies - https://prevention.ucsf.edu/ 
    • Rural Prevention Center (812) 855-1718 https://rcap.indiana.edu/ 
  15. Goldstein E, Wrubel J, Faigeles B, et al. Is research important for non-governmental organizations in the United States? Presented at the 11th International Conference on AIDS, Vancouver, BC. 1996. Abstract Th.C.4779.

Prepared by Ellen Goldstein and Pamela DeCarlo January 1997. Fact Sheet #25E

Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National AIDS Clearinghouse at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © January 1997, University of California