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Risk Behavior and Health Care for HIV+ Injection Drug Users (INSPIRE Study)

These instruments were used to measure the effectiveness of the multisite INSPIRE Study (known as VOICE in San Francisco) and cover medication use and adherence, health care utilization, substance abuse, injection behavior, sexual behavior, partner relationships, and more. Instruments:

Scoring: N/A Reliability and/or validity: Purcell DW, Metsch LR, Latka M, Santibanez S, Gómez CA, Eldred L, Latkin CA, INSPIRE Study Group. Interventions for seropositive injectors—research and evaluation: an integrated behavioral intervention with HIV-positive injection drug users to address medical care, adherence, and risk reduction. J Acquir Immune Defic Syndr. 2004 Oct 1;37 Suppl 2:S110–8.

Resource

Needle exchange programs (NEP)

Does HIV Needle Exchange Work?

revised 12/98

Why do we need needle exchange?

More than a million people in the US inject drugs frequently, at a cost to society in health care, lost productivity, accidents, and crime of more than $50 billion a year.¹ People who inject drugs imperil their own health. If they contract HIV or hepatitis, their needle-sharing partners, sexual partners and offspring may become infected. It is estimated that half of all new HIV infections in the US are occurring among injection drug users (IDUs)². For women, 61% of all AIDS cases are due to injection drug use or sex with partners who inject drugs. Injection drug use is the source of infection for more than half of all children born with HIV.³ Injection drug use is also the most common risk factor in persons with hepatitis C infection. Up to 90% of IDUs are estimated to be infected with hepatitis C, which is easily transmitted and can cause chronic liver disease. Hepatitis B is also transmitted via injection drug use.⁴ Needle exchange programs (NEPs) distribute clean needles and safely dispose of used ones for IDUs, and also generally offer a variety of related services, including referrals to drug treatment and HIV counseling and testing.

Why do drug users share needles?

The overwhelming majority of IDUs are aware of the risk of the transmission of HIV and other diseases if they share contaminated equipment. However, there are not enough needles and syringes available and even these are often not affordable to IDUs. Getting IDUs into treatment and off drugs would eliminate needle-related HIV transmission. Unfortunately, not all drug injectors are ready or able to quit. Even those who are highly motivated may find few services available. Drug treatment centers frequently have long waiting lists and relapses are common. Most US states have paraphernalia laws that make it a crime to possess or distribute drug paraphernalia “known to be used to introduce illicit drugs into the body.”⁵ In addition, ten states and the District of Columbia have laws or regulations that require a prescription to buy a needle and syringe. Consequently, IDUs often do not carry syringes for fear of police harassment or arrest. Concern with arrest for carrying drug paraphernalia has been associated with sharing syringes and other injection supplies.⁶ In July 1992, the state of Connecticut passed laws permitting the purchase and possession of up to ten syringes without a prescription and making parallel changes in its paraphernalia law. After the new laws went into effect, the sharing of needles among IDUs decreased substantially, and there was a shift from street needle and syringe purchasing to pharmacy purchasing.⁷ However, even where over-the-counter sales of syringes are permitted by law, pharmacists are often unwilling to sell to IDUs, emphasizing the need for education and outreach to pharmacists.

What’s being done?

Around the world and in more than 80 cities in 38 states in the US, NEPs have sprung up to address drug-injection risks. There are currently 113 NEPs in the US. In Hawaii, the NEP is funded by the state Department of Health. In addition to needle exchange, the program offers a centralized drug treatment referral system and a methadone clinic, as well as a peer-education program to reach IDUs who do not come to the exchange. Rates of HIV among IDUs have dropped from 5% in 1989 to 1.1% in 1994-96. From 1993-96, 74% of NEP clients reported no sharing of needles, and 44% of those who did report sharing reported always cleaning used needles with bleach.⁸ Harm Reduction Central in Hollywood, CA, is a storefront NEP that targets young IDUs aged 24 and under. The program provides needle exchange, arts programming, peer-support groups, HIV testing and case management and is the largest youth NEP in the US. Over 70% of clients reported no needle-sharing in the last 30 days, and young people who used the NEP on a regular basis were more likely not to share needles.⁹

Does needle exchange reduce the spread of HIV? Encourage drug use?

It is possible to significantly limit HIV transmission among IDUs. One study looked at five cities with IDU populations where HIV prevalence had remained low. Glasgow, Scotland; Lund, Sweden; New South Wales, Australia; Tacoma, WA; and Toronto, Ontario, all had the following prevention components: beginning prevention activities when levels of HIV infection were still low; providing sterile injection equipment including through NEPs; and conducting community outreach to IDUs.¹⁰ A study of 81 cities around the world compared HIV infection rates among IDUs in cities that had NEPs with cities that did not have NEPs. In the 52 cities without NEPs, HIV infection rates increased by 5.9% per year on average. In the 29 cities with NEPs, HIV infection rates decreased by 5.8% per year. The study concluded that NEPs appear to lead to lower levels of HIV infection among IDUs.¹¹ In San Francisco, CA, the effects of an NEP were studied over a five-year period. The NEP did not encourage drug use either by increasing drug use among current IDUs, or by recruiting significant numbers of new or young IDUs. On the contrary, from December 1986 through June 1992, injection frequency among IDUs in the community decreased from 1.9 injections per day to 0.7, and the percentage of new initiates into injection drug use decreased from 3% to 1%.¹² Hundreds of other studies of NEPs have been conducted, and all have been summarized in a series of eight federally funded reports dating back to 1991. Each of the eight reports has concluded that NEPs can reduce the number of new HIV infections and do not appear to lead to increased drug use among IDUs or in the general community.^13-15 These were the two criteria that by law had to be met before the federal ban on NEP service funding could be lifted. This is a degree of unanimity on the interpretation of research findings unusual in science. Five of the studies recommended that the federal ban be lifted and two made no recommendations. In the eighth report the Department of Health and Human Services decided that the two criteria had been met, but failed to lift the ban. The Congress has since changed the law, continuing to ban federal funding for NEPs, regardless of whether the criteria are met.

Is needle exchange cost-effective?

Yes. The median annual budget for running a program was $169,000 in 1992. Mathematical models based on those data predict that needle exchanges could prevent HIV infections among clients, their sex partners, and offspring at a cost of about $9,400 per infection averted.¹⁶ This is far below the $195,188 lifetime cost of treating an HIV-infected person at present.¹⁷ A national program of NEPs would have saved up to 10,000 lives by 1995.¹³

What must be done?

Efforts to increase the availability of sterile needles must be a part of a broader strategy to prevent HIV among IDUs, including expanded access to drug treatment and drug-use prevention efforts. Although the US federal government has acknowledged that NEPs¹⁵ reduce rates of HIV infection and do not increase drug use rates, it still refuses to provide funding for NEPs. Therefore, advocacy activity at the state and local community level is critical. However, the federal government should play a more active role in advocating for NEPs publicly, even if it doesn’t fund them. States with prescription laws should repeal them; those with paraphernalia laws should revise them insofar as they restrict access to needles and syringes. Local governments, Community Planning Groups and public health officials should work with community groups to develop comprehensive approaches to HIV prevention among IDUs and their sexual partners, including NEPs and programs to increase access to sterile syringes through pharmacies.

Says who?

1. Rice DP, Kelman S, Miller LS. Estimates of economic costs of alcohol and drug abuse and mental illness, 1985 and 1988 . Public Health Reports. 1991;106:280-92. 2. Holmberg SD. The estimated prevalence and incidence of HIV in 96 large US metropolitan areas . American Journal of Public Health. 1996;86:642-654. 3. CDC. HIV/AIDS Surveillance Report . 1998;9:12. 4. Alter MJ, Moyer LA. The importance of preventing hepatitis C virus infection among injection drug users in the United States . Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 1998; 18(Suppl 1):S6-10. 5. Gostin LO, Lazzarini Z, Jones TS, et al. Prevention of HIV/AIDS and other blood-borne diseases among injection drug users: a national survey on the regulation of syringes and needles . Journal of the American Medical Association. 1997;277:53-62. 6. Bluthenthal RN, Kral AH, Erringer EA, et al. Drug paraphernalia laws and injection-related infectious disease risk among drug injectors. Journal of Drug Issues. (in press). 7. Groseclose SL, Weinstein B, Jones TS, et al. Impact of increased legal access to needles and syringes on practices of injecting-drug users and police officers-Connecticut, 1992-1993 . Journal of Acquired Immune Deficiency Syndromes. 1995;10:82-89. 8. Vogt RL, Breda MC, Des Jarlais DC, et al. Hawaii’s statewide syringe exchange program . American Journal of Public Health. 1998;88:1403-1404. 9. Kipke MD, Edgington R, Weiker RL, et al. HIV prevention for adolescent IDUs at a storefront needle exchange program in Hollywood, CA. Presented at 12th World AIDS Conference, Geneva, Switzer-land. 1998. Abstract #23204. 10. Des Jarlais DC, Hagan H, Friedman SR, et al. Maintaining low HIV seroprevalence in populations of injecting drug users . Journal of the American Medical Association. 1995;274:1226-1231. 11. Hurley SF, Jolley DJ, Kaldor JM. Effectiveness of needle-exchange programmes for prevention of HIV infection . Lancet. 1997;349:1797-1800. 12. Watters JK, Estilo MJ, Clark GL, et al. Syringe and needle exchange as HIV/AIDS prevention for injection drug users . Journal of the American Medical Association. 1994; 271:115-120. 13. Lurie P, Drucker E. An opportunity lost: HIV infections associated with lack of a national needle-exchange programme in the USA . Lancet. 1997;349:604-608. 14. Report from the NIH Consensus Development Conference. February 1997. 15. Goldstein A. Clinton supports needle exchanges but not funding. Washington Post. April 21, 1998:A1. 16. Lurie P, Reingold AL, Bowser B, et al. The Public Health Impact of Needle Exchange Programs in the United States and Abroad . Prepared for the Centers for Disease Control and Prevention. October 1993. 17. Holtgrave DR, Pinkerton SD. Updates of cost of illness and quality of life estimates for use in economic evaluations of HIV prevention programs . Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 1997;16:54-62.

Prepared by Peter Lurie, MD MPH*,** and Pamela DeCarlo** *Public Citizen’s Health Research Group **CAPS Updated December 1998. Fact Sheet #5Er

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]. © December 1998, University of California

Resource

Superinfection

What do we know about HIV superinfection?

revised 5/06

what is dual infection, co-infection, superinfection?

Dual infection is when a person is infected with two or more strains of HIV. That person may have acquired both strains simultaneously from a dually infected partner or from multiple partners. A different strain of the virus is one that can be genetically distinguished from the first in a “family” or phylogenetic tree. Acquisition of different HIV strains from multiple partners is often called co-infection if all the virus strains were acquired prior to seroconversion, that is, very early before any HIV infection is recognized. Acquisition of different HIV strains from multiple partners is called superinfection if the second virus is acquired after seroconversion when the first virus strain already has been established.¹ Superinfection and re-infection mean the same thing. Dual infections can be sequentially expressed, which can make co-infection look like superinfection. Sequentially Expressed Dual Infections (SEDI) may occur because immune responses against the predominant virus may allow other virus strains in the body to be expressed. Random shifts in evolving virus populations can also occur, which could look like superinfection even though dual infection was present from the beginning.

why does superinfection matter?

Superinfection is a concern because it may be a way for someone who is HIV+ to acquire drug resistance, and it may lead to more rapid disease progression.^2,3 Research on when superinfection may or may not occur could identify types of immune responses that may protect against infection. This could guide the development of HIV vaccines. People who are HIV+ and have HIV+ partners often ask about superinfection. Public health officials need information about superinfection in order to craft messages that help people understand the possible risks of unprotected sexual intercourse among HIV+ persons, without creating undue anxiety that could undermine rewarding relationships between HIV+ persons and disclosure of HIV status with prospective new partners.

does superinfection occur?

Many scientists believe that superinfection can occur. Research in monkeys has indicated that superinfection with viruses like HIV can occur.^4,5 Sixteen people with SEDI (apparent superinfection) have been reported in the scientific literature, including injection drug users in Asia, women in Africa, and men in Europe and the US. Laboratory analysis in some of these reports suggested that the second virus that appeared in these individuals was not present earlier in the course of infection, which suggests superinfection. The sensitivity of these laboratory assays is limited, and source partners have not been identified, so there is no way to know for sure when the second virus was acquired.

who is at highest risk?

Ninety-five percent of apparent superinfection cases have occurred during the first three years of infection.^6-9 Studies have found evidence of superinfection in 2 to 5% of persons in the first year of infection. Intermittent treatment in acute or recent HIV infection may prolong superinfection susceptibility.^10-11 In contrast, studies in persons with longer term infection have found no evidence of superinfection. One study found no cases after 1,072 person-years of observation.¹² Another found none after 215 person-years of observation among intravenous drug users.¹³ A third found none after 233 person-years and 20,859 exposures through unprotected sex.¹⁴ It is possible that people with very low viral load in their blood may be more susceptible to superinfection. Low viral load in the blood can occur during combination antiretroviral therapy or in “healthy non-progressors.” Antiviral immune responses and viral interference is lower in persons with low viral load, so superinfection may occur more frequently.¹⁵ More research is needed to know for sure.

is it bad to have more than one virus?

Dual infection can have a harmful effect on the health of HIV+ persons. Superinfected individuals may have higher viral loads and lower CD4 counts, which causes more rapid disease progression.^2,3 Disease progression can accelerate after a second virus appears.¹ Superinfection may also affect treatment of HIV, as it increases the likelihood of drug resistance.¹⁶ HIV+ persons with dual infection may not respond as well to available antiretroviral medication due to resistant strains.

what don’t we know?

There is a lot we still do not know about superinfection. First of all, we need to be more sure whether superinfection actually occurs between HIV+ persons. A definitive case of superinfection has not been documented, which would require that the timing of the second infection be traced to initiation of a relationship with a new sexual partner. Second, we need to understand how and when superinfection occurs. Among researchers some consensus is developing about the idea that HIV+ persons in early infection–and particularly the first year of infection–may be at higher risk for superinfection than HIV+ persons with chronic infection.¹⁷ We also should determine whether persons with suppressed viral load on treatment are susceptible to superinfection. Third, we need to know how to protect against superinfection. If superinfection is rare, or if it only happens in recent infection, it is important to determine what mechanisms make an HIV+ person immune to acquiring a second virus. It would be important to know if exposure to different viral strains may provide protective immunity against superinfection.¹⁸ Lastly, we must continue to provide up-to-date scientific data on superinfection, its causes and consequences to HIV+ persons and healthcare professionals who work with them.

what can we recommend right now?

Counseling about superinfection should be based on understanding the individual’s sexual relationships. Before providing advice about superinfection, the counselor should know whether the individual is in a continuing relationship with another HIV+ partner, whether the person routinely seeks out other HIV+ partners for unprotected sex, and whether there is disclosure of HIV status with prospective partners. This background should inform the discussion about the risks and benefits of sex among HIV+ partners. If the counselor does not have time to consider these personal issues, it would probably be best to simply say that “There is not enough information available about superinfection. If superinfection occurs at all, it probably occurs in the first few years after infection. After that, it may be rare.” Even less is known about superinfection as a result of sharing needles, although it is reasonable to expect that the same pattern of initial high risk followed by low risk during chronic infection may occur. However, because intravenous drug users are at high risk of hepatitis C infections from sharing needles, efforts to obtain clean needles through needle exchange should always be emphasized. Interested persons should be referred to on-going research studies so that important gaps in information can be filled.¹⁹ People with multiple sexual partners, or partners with multiple partners, should be counseled regarding the risks of other sexually transmitted infections. Vaccination for hepatitis B and periodic testing for syphilis is warranted.

Says who?

1. Smith DM, Richman DD, Little SJ. HIV superinfection . Journal of Infectious Diseases. 2005;192:438-444. 2. Gottlieb GS, Nickle DC, Jensen MA, et al. Dual HIV-1 infection associated with rapid disease progression . The Lancet. 2004;363:610-622. 3. Grobler J, Gray CM, Rademeyer C, et al. Incidence of HIV-1 dual infection and its association with increased viral load set point in a cohort of HIV-1 subtype c-infected female sex workers . Journal of Infectious Diseases. 2004;190:1355-9. 4. Otten RA, Ellenberger DL, Adams DR, et al. Identification of a window period for susceptibility to dual infection with two distinct human immunodeficiency virus type 2 isolates in a Macaca nemestrina model . Journal of Infectious Diseases. 1999;180:673-84. 5. Fultz PN, Srinivasan A, Greene CR, et al. Superinfection of a chimpanzee with a second strain of human immunodeficiency virus . Journal of Virology. 1987;61:4026-4029. 6. Angel JB, Hu YW, Kravcik S, et al. Virological evaluation of the ‘Ottawa case’ indicates no evidence for HIV-1 superinfection . AIDS. 2004;18:331-334. 7. Smith DM, Wong JK, Hightower GK, et al. Incidence of HIV superinfection following primary infection . Journal of the American Medical Association. 2004;292:1177-1178. 8. Hu DJ, Subbarao S, Vanichseni S, et al. Frequency of HIV-1 dual subtype infections, including intersubtype superinfections, among injection drug users in Bangkok, Thailand . AIDS. 2005;19:303-308. 9. Grant R, McConnell J, Marcus J, et al. High frequency of apparent HIV-1 superinfection in a seroconverter cohort. 12th Conference on Retroviruses and Opportunistic Infections. 2005. Abst #287. 10. Altfeld M, Allen TM, Yu XG, et al. HIV-1 superinfection despite broad CD8+ T-cell responses containing replication of the primary virus . Nature. 2002;420:434-439. 11. Jost S, Bernard M, Kaiser L, et al. A patient with HIV-1 super-infection . New England Journal of Medicine. 2002;347:731-736. 12. Gonzales MJ, Delwart E, Rhee SY, et al. Lack of detectable human immunodeficiency virus type 1 superinfection during 1072 person-years of observation . Journal of Infectious Diseases. 2003;188:397-405. 13. Tsui R, Herring BL, Barbour JD, et al. Human immunodeficiency virus type 1 superinfection was not detected following 215 years of injection drug user exposure . Journal of Virology. 2004;78:94-103. 14. Grant R, McConnell J, Herring B, et al. No superinfection among seroconcordant couples after well-defined exposure. International Conference on AIDS, Bangkok, Thailand, 2004. Abst #ThPeA6949. 15. Marcus J, McConnell J, Liegler T, et al. Highly divergent viral lineages in blood DNA appear frequently during suppressive therapy in persons exposed to superinfection. 13th Conference on Retroviruses and Opportunistic Infections. 2006. Abst #297. 16. Smith DM, Wong JK, High-tower GK, et al. HIV drug resistance acquired through superinfection . AIDS. 2005;19:1251-1256.16. Gross KL, Porco TC, Grant RM. HIV-1 superinfection and viral diversity. AIDS. 2004;18:1513-1520. 17. Gross KL, Porco TC, Grant RM. HIV-1 superinfection and viral diversity . AIDS. 2004;18:1513-1520. 18. McConnell J, Liu Y, Kreis C, et al. Broad neutralization of HIV-1 variants in couples without evidence of systemic superinfection. 13th Conference on Retroviruses and Opportunistic Infections. 2006. Abst #92. 19. HIV+ persons who have HIV+ partners residing or visiting San Francisco can call the Positive Partners Study 1-415-734-4878.

Prepared by Robert M. Grant MD, J. Jeff McConnell MA Gladstone Institute of Virology and Immunology, UCSF May 2006 . Fact Sheet #56ER Special thanks to the following reviewers of this Fact Sheet: Jonathan Angel, Michael Carter, Mark Cichocki, Eric Delwart, Keith Folger, Geoffrey Gottlieb, Luc Perrin, Travis Porco, Peter Shalit, David Spach, Carolyn Williamson, Zenda Woodman. 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]. © May 2006, University of California

Resource

Structural interventions

What is the role of structural interventions in HIV prevention?

What are structural interventions?

Most HIV prevention interventions deal with individuals, one by one. Many of these interventions have been very successful. However, they often require a lot of staff time and reach a limited number of persons. Furthermore, those who do receive interventions may face pressures to continue high-risk behaviors from their peers who do not receive the intervention. Structural interventions change or influence social, political, or economic environments in ways that help many people all at onceperhaps without their even knowing it.¹ The term “structural interventions” means many things. Structural interventions include programs that change legal environments (often with community pressure or input) to make safer behavior easier, such as allowing syringes to be sold over the counter. They can also target the immediate social context of sexual or injection behaviors by changing the physical or normative environments within which they occur. Examples include Thai brothels that require condom use or European public health safer injection rooms. Structural interventions also include programs to reduce or abolish income inequality, racism, and other inequities and oppressions which create vulnerability to HIV/AIDS.

What structures create risk?

How can we know what social, political or economic structures or processes need changing? Generally, we learn this by studying naturally-occurring variation among areas or groups, or naturally-occurring experiments in which conditions change for reasons other than HIV-related interventions. Studies of naturally-occurring variation have shown that: 1) poor countries are more likely to have generalized HIV epidemics; 2) countries with more income inequality have higher HIV rates; 3) policies matter: localities where syringes can be bought legally have lower rates of HIV prevalence and incidence among injection drug users (IDUs).² Studies of natural experiments indicate that: 1) otherwise-positive social and political transitions like the end of apartheid in South Africa in the 1990s, the break-up of the Soviet Union in the 1990s, and the ending of the dictatorship in Indonesia in the late 1990s were followed by large HIV outbreaks; 2) wars cause the spread of HIV, STDs, prostitution, rape, sexual bondage and high-risk substance use and lead to increased numbers of sexual partners and rates of sexual partner change.³

Why structural interventions?

Structural interventions often address issues that seem to be unrelated to HIV. When people think about preventing HIV, they don’t normally consider eliminating income inequalities or stopping war. But these social, political and economic realities greatly influence high-risk behaviors. Issues that are not directly related to HIV often create conditions that encourage the spread of HIV, making structural interventions necessary. For example, the New York City government closed fire stations in poor minority sections of the city in the 1970s. As a result, uncontrolled fires destroyed many buildings. The social lives of building residents were severely traumatized. Great overcrowding took place in surrounding poor minority areas. Injection drug use (and later crack), alcoholism, sex trading, gangs and demoralization spread widelyfollowed later by outbreaks of STDs, HIV, tuberculosis and many other ills.⁴ The governments of wealthy countries, including the USA, as well as banks, corporations and other economic elites have aggressively pursued an organized global policy of social welfare cutbacks, privatization and competition. This has led many developing countries into massive debt, and increased income inequality and the growth of massive cities based around giant slums. Also, International Monetary Fund-imposed “structural adjustment programs” have forced large-scale cuts in health and education services in many African, Asian and Latin American countries. These policies and progams have greatly hampered these countries from providing effective prevention interventions and/or antiretroviral therapy or other medical care for their infected populations.^5,6

Examples of structural interventions

In many countries, sex workers have high rates of HIV and other STDs. Thailand and the Dominican Republic have instituted “100% condom” campaigns mandating that brothel owners enforce the use of condoms during all sex acts. These campaigns enlist the support of brothel owners and sex workers and, when possible, their customers. These programs have reduced HIV and STD transmission considerably by changing the immediate social context of sexual behaviors to reduce unprotected sex.^7,8 Most US states have laws that make it a crime to possess or distribute needles and many have laws that require a prescription to buy a needle and syringe. Consequently, IDUs often do not carry syringes for fear of police harassment or arrest. To address this on a legal level, the Connecticut legislature passed a partial repeal of needle prescription and drug paraphernalia laws. This resulted in dramatic reductions in needle sharing, and increases in pharmacy purchase of syringes by IDUs. Sharing dropped from 52% to 31% after the new laws, pharmacy purchase rose from 19% to 78%, and street purchase fell from 74% to 28%.⁹

How can we impact harmful policies?

It is not easy to avoid or end wars, urban development policies that hurt the poor and minorities and repressive sexual and drug policies that create underground environments. However, individuals and communities can make a difference. Grassroots or community-based movements are often a necessary step to larger structural interventions. The formation of such movements can sometimes be a structural intervention if this leads to changes in power relationships or group norms. “Chico Chats,” a program of the STOP AIDS Project in San Francisco, CA, offered workshops on community organizing and mobilization techniques. Participants formed an activist group called ¡Ya Basta! (Enough Already) and designed a video and workshop examining the issues of sexual silence and coming out in Latino families. The video is being shown throughout Latino communities in San Francisco.¹⁰ Community organizations and individuals began operating needle exchange programs (NEPs) in many states with high rates of HIV among IDUs. The NEPs were often illegal and unsupported. The people working at NEPs and other politically active groups worked with public officials to invoke “state of emergency” policies to allow NEPs to exist legally in many states.¹¹ Calcutta sex workers were aided by public health authorities to organize a community union that has enabled them to insist upon condom use. HIV prevalence among Calcutta sex workers has remained lower than in other Indian cities.¹²

What still needs to be done?

The relationship between structural factors such as economic, political and social marginalization and behaviors that place persons at risk for contracting or spreading HIV/AIDS and STDs cannot be ignored.^13,14 Nor can high-risk behaviors be seen as operating outside of social, political and economic contexts. A more focused discussion of these issues is sorely needed in HIV/AIDS circles. One way to reduce the likelihood of negative repurcussions when structural factors change, is to legally mandate that economic, urban development and foreign policy programs conduct scientific “HIV/AIDS impact statements.” A first step might be for HIV prevention agencies to produce and publicize such HIV/AIDS impact statements themselves.¹⁵ Funders need to take into account the broad range of activities that constitute HIV prevention. Many community-based organizations find themselves responding to all issues affecting HIV, including ones that may seem unrelated. Addressing these larger issues of war, poverty, restrictive laws and social inequalities such as racism and homophobia is a part of what many agencies do on a daily basis. Helping organize and support these efforts may lead to needed structural HIV prevention interventions.

Says who?

1. Friedman SR, O’Reilly K. Sociocultural interventions at the community level.AIDS. 1997; 11:S201-S208. 2. Friedman SR, Perlis T, Lynch J, et al. Economic inequality, poverty, and laws against syringe access as predictors of metropolitan area rates of drug injection and HIV infection. 2000 Global Research Network Meeting on HIV Prevention in Drug-Using Populations. Third Annual Meeting Report. Durban, South Africa, July 5 -7, 2000. 147-149. 3. Hankins CA, Friedman SR, Zafar T, et al. Transmission and prevention of HIV and STD in war settings: implications for current and future armed conflicts.AIDS. 2002:16(17):2245-52. 4. Wallace R. Urban desertification, public health and public order: ‘planned shrinkage’, violent death, substance abuse and AIDS in the Bronx. Social Science and Medicine. 1990;31:801-813. 5. Lurie P, Hintzen P, Lowe RA. Socioeconomic obstacles to HIV prevention and treatment in developing countries: the roles of the International Monetary Fund and the World Bank. AIDS. 1995;9:539-546. 6. Farmer P. Infections and Inequalities: the Modern Plagues. University ofCalifornia Press: Los Angeles. 1999. 7. Celentano DD, Nelson KE, Lyles CM, et al. Decreasing incidence of HIV and sexually transmitted diseases in young Thai men: evidence for success of the HIV/AIDS control and prevention program. AIDS. 1998;12:F29-F36. 8. Roca E, Ashburn K, Moreno L, et al. Assessing the impact of environmental-structural interventions. Presented at the International AIDS Conference,Barcelona, Spain. 2002. Abst #TuPeC4831. 9. Groseclose SL, Weinstein B, Jones TS, et al. Impact of increased legal access to needles and syringes on practices of injecting drug users and police officers–Connecticut, 1992-1993. Journal of Acquired Immune Deficiency Syndromes.1995;10:82-89. 10. The STOP AIDS Project. Q Action, ¡Ya Basta! San Francisco, CA. 415/865-0790 x303 11. Gostin LO. The legal environment impeding access to sterile syringes and needles: the conflict between law enforcement and public health. Journal of Acquired Immune Deficiency Syndromes. 1998;18:S60-70. 12. Piot P, Coll Seck AM. International response to the HIV/AIDS epidemic: planning for success. Bulletin of the World Health Organization. 2001;79:1106-1112. 13. Diaz RM, Ayala G, Marin BV. Latino gay men and HIV: risk behavior as a sign of oppression. Focus. 2000;15:1-5. 14. Friedman SR, Aral S. Social networks, risk potential networks, health and disease. Journal of Urban Health. 2001;78:411-418. 15. Friedman SR, Reid G. The need for dialectical models as shown in the response to the HIV/AIDS epidemic. International Journal of Sociology and Social Policy. (in press).

Prepared by Sam Friedman*, Kelly Knight** *National Development and Research Institutes, ** CAPS January 2003. Fact Sheet #46E Special thanks to the following reviewers of this Fact Sheet: Abu Abdul-Quader, Sevgi Aral, Judith Auerbach, Kim Blankenship, John Encandela, Mindy Fullilove, Carl Latkin, Peter Lurie.

Resource

Hombres gays Latinos en los Estados Unidos

¿Qué necesitan los hombres Latinos gay para la prevención del VIH en EE.UU.?

Hoja informativa 28, marzo del 2012

¿Por qué enfocarnos en los hombres latinos gay?

El panorama siempre cambiante de los antecedentes demográficos de los latinos radicados en EE.UU. nos plantea retos singulares para resolver las disparidades de salud de esta población, especialmente con respecto a sus necesidades de prevención del VIH. Los latinos son el grupo etno-racial minoritario más numeroso y con mayor velocidad de crecimiento en EE.UU., con un crecimiento del 43% entre el 2000 y el 2010¹. Los datos también indican que los latinos son una de las poblaciones con aumento más rápido de riesgo de transmisión del VIH.

Los hombres latinos que tienen sexo con hombres (HSH o MSM por sus siglas en inglés^*) representan el 81% de las nuevas infecciones entre hombres latinos y el 19% de todos los HSH en general^2,3
Los latinos componen el 16% de la población de EE.UU. pero representan el 17% de las personas vivas con VIH/SIDA y el 20% de nuevas infecciones cada año³
Los jóvenes (13-29 años de edad) son el 45% de las nuevas infecciones de VIH entre los latinos MSM⁴

Estos datos señalan la necesidad de identificar las necesidades de salud culturalmente específicas de los hombres latinos homosexuales con el fin de crear intervenciones eficaces que respondan a las disparidades actuales de salud y eviten otras futuras. La Estrategia Nacional de EE.UU. contra el VIH/SIDA subraya la necesidad de programas de VIH que reduzcan las inequidades entre poblaciones minoritarias etno-raciales y sexuales⁵. Los hombres latinos gay tienen identidades multiculturales distintas que los ubican en ambas categorías priorizadas⁶.

¿Cuáles son los desafíos para la prevención?

La mayor parte del trabajo relacionado con los hombres latinos gay se ha basado en un modelo de salud sociocultural, que demuestra que las experiencias de discriminación social, definidas como racismo, homofobia y pobreza, son pronosticadores importantes de la salud mental a futuro.⁷Se ha comprobado que los trastornos de salud mental, como la angustia psicológica, aumentan el riesgo sexual y disminuyen la capacidad para elegir opciones sexuales sanas. Un estudio reciente de HSH latinos radicados en Nueva York y Los Ángeles⁸ informó que:

Más del 40% de los participantes reportaron experiencias de racismo y homofobia durante el último año
La baja auto estima y los reducidos niveles de apoyo social entre hombres latinos gay se asocian con tasas más altas de comportamientos de riesgo sexual, entre ellos el sexo anal sin protección
Los hombres que habían tenido experiencias tanto homofóbicas como racistas eran más propensos que los hombres que no reportaron discriminación alguna a participar en el sexo anal sin protección como la pareja receptiva, y también a tener atracones de consumo excesivo de alcohol

Las pruebas tardías (es decir, individuos que reciben un diagnóstico de SIDA durante el primer año después de tener un resultado positivo de la prueba del VIH) y la falta de acceso a un seguro médico también plantean desafíos para la prevención, el tratamiento y el cuidado del VIH.

El 38% de los latinos se hacen la prueba en una etapa tardía de la enfermedad⁹.
En un estudio realizado en 21 ciudades grandes de EE.UU., el 46% de los HSH latinos que salieron positivos desconocían que estaban infectados con el VIH³.
En comparación con los blancos, los latinos VIH+ son más propensos a aplazar el cuidado por problemas como la falta de transporte y a demorar el inicio del cuidado médico después de ser diagnosticados⁹.
El 24% de los latinos que viven con VIH/SIDA no tienen seguro médico, en comparación con el 17% de los blancos; y sólo el 23% de los latinos VIH+ cuentan con un seguro médico privado, en contraste con el 44% de los blancos.

Las revisiones de investigaciones en hombres latinos gay y bisexuales también reportan que las influencias culturales y fuerzas socioeconómicas afectan al bienestar sexual. Por ejemplo, el estatus de residencia legal, el estigma relacionado con el VIH, el machismo, los patrones de inmigración y migración, el idioma, el estatus de seguro médico y el nivel de estudios son todos obstáculos asociados con los servicios y programas de prevención para el VIH^{11, 12}

¿Qué otros factores afectan al riesgo sexual y la capacidad para elegir opciones sanas?

Muchos hombres latinos gay afrontan situaciones socio sexuales únicas que los hacen vulnerables a la transmisión del VIH. Estudios realizados anteriormente con grupos de HSH, entre ellos hombres latinos gay, han documentado que varios factores están asociados con el riesgo sexual:

Selección serológica (elegir a la pareja sexual basándose en su condición percibida de VIH), posicionamiento serológico (selección de roles sexuales [activo o pasivo] según la condición percibida de VIH de cada pareja) y estereotipos y preferencias sexuales¹³
Consumo de alcohol y drogas (incluido el consumo de metanfetaminas y la inyección de drogas) así como tener antecedentes de ITS como sífilis y gonorrea^14,15
Tasas altas de sexo anal sin condón (“sexo a pelo”) y parejas múltiples¹⁶
Abuso sexual en la niñez y un contexto social de discriminación¹⁷

Definida como la adopción de las costumbres culturales de la sociedad mayoritaria, el trabajo sobre la aculturación sugiere que los latinos que son menos asimilados a la cultura mayoritaria de EE.UU. están protegidos por sus valores (sexuales) latinos tradicionales; y que la asimilación de los valores mayoritarios estadounidenses les sirve de barrera protectora porque les aumenta el sentido de individualismo y autodeterminación.¹⁸ Entender el papel que juegan los factores socioculturales nos ayuda a refinar la definición de la capacidad para elegir opciones sexuales sanas de los hombres latinos gay. El trabajo innovador que explora factores protectores entre hombres latinos gay señala que: Entre los latinos radicados en San Francisco, la prevalencia del VIH era mayor entre los latinos nacidos en EE.UU. que los nacidos en otro país, en contraste con Chicago donde sucedió lo contrario⁹

El involucramiento comunitario modera las conductas de riesgo²⁰
Trabajar como voluntario con organizaciones de VIH/SIDA puede reducir los estresores psicológicos²⁰

Dado que la mayoría de estos datos provienen de encuestas cuantitativas, se necesitan más estudios enfocados en la salud pública para examinar más a fondo el contexto de las situaciones sexuales en las cuales los hombres latinos gay se encuentran, así como los factores culturales y guiones sexuales²¹ que influyen en sus comportamientos de reducción de daños.

¿Qué se está haciendo al respecto?

Hermanos de Luna y Sol, un programa nacido en el Distrito de la Misión en San Francisco, CA es una intervención de prevención del VIH con una larga trayectoria enfocada en hombres inmigrantes latinos gay y bisexuales que hablan español. Basado en la educación sobre el empoderamiento y la fomentación del apoyo social, el programa ha logrado aumentar el uso de condones entre sus participantes²².
latinos D (basado en Queens, NY²³) y Somos latinos Salud (basado en Ft. Lauderdale, FL²⁴) son adaptaciones dinámicas y prometedoras del programa MPowerment, una eficaz intervención de VIH a nivel comunitario y basada en evidencias para hombres jóvenes gay y bisexuales²⁵.
SOMOS, un programa de prevención de VIH surgido de la comunidad y culturalmente sensible basado en la ciudad de Nueva York, ha mostrado reducir los comportamientos de riesgo y disminuir el número de parejas entre los hombres latinos gay²⁶.

Aun así, a pesar de estos programas y las recomendaciones de los CDC para resolver las disparidades de salud de los HSH latinos, la mayoría de las adaptaciones de intervenciones basadas en evidencias han sido versiones de programas establecidos que han sido traducidos lingüísticamente pero no necesariamente culturalmente.

¿Cuáles son las recomendaciones?

Honrar la diversidad dentro de las culturas latinas al momento de diseñar programas. Existen diferentes experiencias de eventos históricos, ambientes políticos, patrones inmigratorios y culturas regionales dentro de las comunidades latinas (por ejemplo, los chicanos en Los Ángeles, los “Nuyoricans” en Nueva York y los tejanos en San Antonio).
Realizar más investigaciones sobre las influencias estructurales y ambientales en la salud sexual de los hombres latinos gay, incluyendo temas relacionados con los latinos VIH+ indocumentados.
Entender que trabajar con una población no es lo mismo que tener competencia cultural. Incluir la participación latina no equivale a la provisión de servicios apropiados.
Cultivar la colaboración y empoderamiento de la comunidad gay latina logrando que los hombres latinos gay participen en los consejos locales que planifican la prevención y cuidado del VIH.
Crear programas que respondan a las necesidades particulares de los hombres latinos gay, tanto los inmigrantes como los nacidos en EE.UU. Suponer que todos los hombres latinos gay son hispanohablantes monolingües minimiza las necesidades de los hombres latinos gay biculturales (pero no necesariamente bilingües).
Reducir el estigma relacionados con la homosexualidad y el VIH en las comunidades latinas. Romper los silencios sexuales ayudará a promover la formación de una identidad sexual sana.
Colaborar con formuladores de políticas y entidades políticas interesadas para promover el acceso sostenible al cuidado de la salud.
Destacar las normas sociales y valores culturales que aumenten la capacidad para elegir opciones sexuales sanas. Enfocarse sólo en los factores de riesgo limita la identificación de nuevas percepciones y oportunidades para las intervenciones.
Fomentar programas que respondan al impacto del aislamiento y a la validación de la identidad. Disminuir los estresores que los hombres latinos gay encaran mejorará su bienestar general.

¿Quién lo dice?

1 US Census Bureau (2011). Overview of Race and Hispanic Origin: 2010 – U.S. Census Bureau. CDC Fact Sheet: HIV and AIDS among Latinos. https://www.cdc.gov/hiv/group/racialethnic/hispaniclatinos/index.html 3 CDC. (2008). HIV Surveillance in Men Who Have Sex with Men (MSM). https://npin.cdc.gov/publication/slide-set-hiv-surveillance-men-who-have-sex-men-msm-through-2017 4 Prejean J, et al. (2011). Estimated HIV Incidence in the United States, 2006-2009. PLoS ONE. 5 ONAP. (2010). National HIV/AIDS Strategy: Federal Implementation Plan. 6 Diaz, RM (1998). Latino gay men and HIV: culture, sexuality, and risk behavior. Routledge. 7 Díaz RM, et al. (2001). The impact of homophobia, poverty, and racism on the mental health of gay and bisexual Latino men: findings from 3 US cities. Am J Public Health. 91(6):927-932. 8 Mizuno Y, et al. (2011). Homophobia and Racism Experienced by Latino Men Who Have Sex with Men in the United States: Correlates of Exposure and Associations with HIV Risk Behaviors. AIDS Behav. [Epub ahead of print] 9 CDC. (2011). HIV Surveillance Report, Vol. 21. 10 RAND. (2011). HIV Cost and Services Utilization Study (HCSUS). http://www.rand.org/health/projects/hcsus.html.\ 11 Zea MC, et al. (2004). Methodological issues in research on sexual behavior with Latino gay and bisexual men. Am J Community Psychol. 31(3-4):281-291. 12 National Latino AIDS Awareness Day. HIV/ AIDS and Latino/ Hispanic men who have sex with men. 13 Rosenberg ES, et al. (2011). Number of casual male sexual partners and associated factors among men who have sex with men: results from the National HIV Behavioral Surveillance system. BMC Public Health. 25: 11-89. 14 CDC. (2010). HIV among Hispanics/ Latinos. https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-11-189 15 Balan IC, et al. (2009). Intentional Condomless Anal Intercourse Among Latino MSM Who Meet Sexual Partners on the Internet. AIDS Educ Prev. 21(1): 14-24. 16 Diaz RM et al. (2005). Reasons for stimulant use among Latino gay men in San Francisco: a comparison between methamphetamine and cocaine users. Journal of Urban Health. 82(Supp1): 71-78. 17 Arreola SG, et al. (2009). Childhood sexual abuse and the sociocultural context of sexual risk among adult Latino gay and bisexual men. Am J Pub Hlth. 99 Suppl 2:S432-8. 18 Abraído-Lanza AF, et al. (2005). Do healthy behaviors decline with greater acculturation? Implications for the Latino mortality paradox. Soc Sci Med. 61:1243–1255. 19 Ramirez-Valles J, et al. (2008) HIV Infection, Sexual Risk, and Substance Use among Latino Gay and Bisexual Men and Transgender Persons. American Journal of Public Health. 98: 1036-1042. 20 Ramirez-Valles J (2002). The proactive effects of community inolvment for HIV risk behavior: A conceptual framework. Health Education Research. 17(4): 389-403. 21 Carrillo H, et al. (2008). Risk across borders: Sexual contexts and HIV prevention challenges among Mexican gay and bisexual immigrant men. Findings and recommendations from the Trayectos Study (Monograph). San Francisco: UCSF and SFSU. . 22 Hermanas de Luna y Sol.https://prevention.ucsf.edu/research-project/hermanos-de-luna-y-sol 23 Latinos Diferentes. https://www.facebook.com/LatinosD. 24 Latinos Salud – Somos. http://www.Latinossalud.org 25 Mpowerment. http://mpowerment.org. 26 Vega MY, et al. (2011). SOMOS: evaluation of an HIV prevention intervention for Latino gay men. Health Educ Res. 26(3):407-418.

Preparado por Gabriel R. Galindo DrPH, UCSF Center for AIDS Prevention Studies Fact Sheet 28, March 2012 Agradecemos a los revisores de esta hoja informativa: Ana F. Abraido-Lanza, Sonya Arreola, Maricarmen Arjona, George Ayala, Alida Bouris, Hector Carrillo, Rafael Díaz, Lizette Rivera, Ramon Ramirez y Jesus Ramírez-Valles.

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 Francisco 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]. © July 2012, University of California