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In an effort to equip community and institutional leaders from the health professions with the skills and knowledge to sustain community-campus partnerships, we are pleased to provide you with a copy of Partnership Perspectives-a magazine designed to foster greater awareness of critical issues impacting upon partnerships between communities and health professions schools. Partnership Perspectives is an informational resource drawing upon the diverse perspectives of leaders representing higher education, such as health professions institutions, 4-year undergraduate level universities and community colleges, health policy organizations, and civic groups. The purpose of Partnership Perspectives is to bring to the forefront the wide range of issues and perspectives that shape and influence the development of community-campus partnerships across the country. Partnership Perspectives brings to its readers a new look into the impact of partnerships and relationship building in our changing society. The goals of Partnership Perspectives are to:

• showcase thought provoking articles that address efforts to improve and promote community health, education and development through innovative approaches and best practices.
• promote a diverse range of multidisciplinary perspectives from within the community and educational sectors.
• advance new thinking and awareness about health and its connection to community and economic development.
•  highlight ways in which communities and educational institutions value each other’s assets and strengths to collaborate and improve community health together.
• promote the CCPH principles of community-campus partnerships

Instrument: SECope Scoring: Included in the article. Reliability or validity: Johnson MO, Neilands TB. Coping with HIV Treatment Side Effects: Conceptualization, Measurement, and Linkages. AIDS and Behavior. 2007 Jul;11(4):575–85.SECope_measure.pdf

Qué necesitan los usarios de drogas en la prevención del VIH?

¿están los usuarios de drogas que no se inyectan a riesgo de infectarse?

Si. A pesar del alto riesgo de transmisión del VIH al compartir jeringas, la relación que existe entre el VIH y el uso de drogas va mucho mas allá del tema de las jeringas. Las personas adictas al alcohol, al “speed” y a la cocaína-crack, los “poppers” o cualquier otra droga no inyectada, están más propensos que aquellos que no usan drogas a ser portadores del VIH y a convertirse en seropositivos. Aún aquellos personas que no usan drogas intravenosas están mas propensas a participar en actividades sexuales de alto riesgo.¹ Muchos de los usuarios de drogas intravenosas (UDIs) primordialmente usan otras drogas no inyectadas. Cuando un UDI porta el VIH, compartir jeringas puede ser el factor de mayor riesgo, pero el uso de drogas no inyectadas, puede además propiciar conductas de riesgo. Por ejemplo, en un estudio de clientes en programas de tratamiento con “Methadone” que presentaban conductas de alto riesgo, se descubrió que los de mayor riesgo de infectarse con el VIH eran los que usaban cocaína-crack.² Al hacer una encuesta a heterosexuales en programas de tratamiento de alcohol en San Francisco, CA se encontraron tasas de infección del 3% entre hombres no UDIs y no homosexuales y del 4% entre mujeres no UDIs. Estas tasas resultan considerablemente altas en comparación con otra encuesta a una población similar en la que los resultados fueron del 0.5% entre hombres y el 0.2% entre mujeres.³ Un estudio realizados a hombres homosexuales de la ciudad de Boston, MA encontró una estrecha relación entre el uso de inhalantes o “poppers” y la infección del VIH. Los hombres que tuvieron sexo anal bajo los efectos del inhalante estaban 4.2 veces más propensos a ser VIH positivos que los que no estaban bajo estos efectos al tener sexo anal.⁴ La cocaína-crack siempre ha estado estrechamente ligada con la transmisión del VIH. Al realizarse un estudio entre jóvenes adultos de 3 vecindarios urbanos que fumaban crack y que nunca se habían inyectado drogas, se obtuvieron tasas de infección del 15.7%. Los más propensos a tener la infección eran las mujeres que habían accedido a tener sexo sin protección a cambio de drogas o dinero y los hombres que tuvieron sexo anal con otros.⁵

¿por qué están a mayor riesgo?

Probablemente sean múltiples las razones por las que el riesgo a contraer el VIH sea mayor entre las personas que usan o abusan de las drogas. Estas razones varían mucho y dependen del tipo de drogas y el ambiente que les rodea. Por ejemplo, es posible que aquellos que usan crack experimenten diferentes niveles de riesgo que los que abusan del alcohol. Entre los usuarios de drogas no inyectadas, contraer el VIH no ocurre a causa del solo hecho de usar drogas sino por tener sexo sin protección. Recientemente, los observadores han encontrado un asociación entre la infección del VIH, el uso intenso del crack, y la práctica del sexo oral sin protección entre las prostitutas. Esto puede ser atribuido a la poca higiene bucal y al daño que sufre la boca al usar las pipas en las que fuman crack, a la alta frecuencia del sexo oral y al uso inconsistente del condón.⁶ En San Francisco, CA, los hombres homosexuales que abusan de las drogas identificaron una serie de factores que les dificultaba las relaciones sexuales seguras, entre ellas: la desinhibición percibida ocasionada por el alcohol u otras drogas, la adquisición de los patrones existentes que relacionan al sexo con las drogas (especialmente entre las anfetaminas y el sexo anal), la baja auto-estima, la falta de seguridad y la falta de poder (percibida).⁷ Se cree que el hecho de tener relaciones sexuales bajo los efectos del alcohol o drogas es lo que les expone a riesgo de contraer el VIH. Cabe mencionar que el riesgo se hace aún más latente cuando ocurren relaciones sexuales mixtas dentro de estos grupos.⁸ La mayoría de las personas que participan en programas de tratamiento de drogas o de alcohol escogen parejas sexuales que pertenecen al mismo círculo. Estas pueden ser personas que se han inyectado, han intercambiado sexo por drogas o dinero, que han sido víctimas de algún trauma, o han estado en la cárcel. Estas poblaciones pueden poseer tasas de VIH mucho más altas, acrecentando así las posibilidades de transmisión del virus.

¿cuáles son los obstáculos?

Para la cultura de la sociedad Americana, el sexo y las drogas van de la mano. Para muchas personas homosexuales, o no, el método más eficaz para hacer amistades es en los bares o cantinas. Hace falta la conversación franca y abierta acerca de la homosexualidad en las escuelas, hogares y en el medio noticioso. Esta falta de communicación puede ocasionar una mayor inhibición frente a la sexualidad las cuales se liberan al usar drogas o alcohol. Muchas veces, las metas de prevención del VIH y de los programas de tratamiento de drogas son contradictorias. Muchos de estos programas creen que los participantes deben cortar las drogas al unísono, el programa de los 12 pasos está a favor de la abstinencia sexual durante la etapa rehabilitadora. Por otro lado, muchos programas de prevención cuyo objetivo es el de promover la reducción del riesgo por medio del sexo seguro, advierten que hay posibilidades de una recaída. Es posible que estos conceptos contradictorios sean un obstáculo al tratar integrar las intervenciones de prevención del VIH en los programas para el tratamiento de drogas.

¿qué se está haciendo?

El programa “New Leaf” (previamente conocido como “18th Street Services”) en San Francisco, CA, ofrece programas de rehabilitación a hombres bisexuales y homosexuales y un componente sobre el sexo seguro. Al evaluar este estudio se encontró poca diferencia entre aquellos que recibieron la parte del sexo seguro y los que recibieron solo la rehabilitación, aunque en ambos grupos se observó una reducción en el nivel de riesgo sexual. Reclutar y mantener a los clientes en rehabilitación se puede considerar como un método efectivo en las tareas de prevención; agregar un componente sobre sexo seguro puede ayudar un poco más. Algunos programas ofrecen información sobre sexo seguro sin tomar en cuenta el uso de las drogas. En “Juegos, Sexo y Videos”, un programa para enfermos mentales desamparados de la ciudad de Nueva York, los hombres sugirieron pegar un condon en las pipas, esto les ayuda recordar a usar el condón aún cuando los encuentros sexuales son a menudo rápidos y en público. Estos tambien compiten entre ellos para ver quien le pone un condón a una banana más rápido (sin romperlo) lo cual les enseña a usar el condón en situaciones comprometidas. El programa les permite tratar temas sexuales sin ser juzgados por ello, reduciendo en gran parte las conductas sexuales de alto riesgo.¹⁰ Muchos usuarios de drogas reciben el tratamiento después de haber sido arrestados, entonces se les ofrece como alternativa al ir a la cárcel o mientras están en la prisión. El sistema correccional de Delaware ha instituido un programa Terapeútico Comunitario (TC) dentro de las cárceles y otro para los que están bajo libertad condicional. Este programa residencial en el que no se permiten drogas incluye: rehabilitación, educación en grupo impartida por miembros del grupo en cuestión, consejería y servicios sociales. Los participantes resultaron estar menos propensos a tener una recaída o a quedar arrestados nuevamente, además de reportar bajos niveles de conductas de riesgo.¹¹

¿qué queda por hacer?

Los programas diseñados en base al género son necesarios, especialmente los que tratan las necesidades de la mujer usuaria de drogas. La mujer más que el hombre, es más vulnerable al daño físico ocasionado por el alcohol y a eventos traumáticos asociados con el uso de substancias o drogas.¹² Otros de los programas necesarios son los que cumplen con las necesidades de la población homosexual (hombre y/o mujer). Los programas de prevención para los usuarios de drogas requieren ser integrados en los servicios existentes. Las agencias que proveen tratamiento y los reclusorios necesitan entrenamiento y la autoridad para exigir que la prevención del VIH forme parte de sus programas. Las agencias que financian estos programas deberán incrementar los fondos y exigir la extensión de los programas de rehabilitación e incluir la prevención del VIH. Los programas preventivos no deben partir de las causantes, es decir, que no es necesario que los programas se basen en la creencia de que el abuso de las drogas conlleva a conductas de alto riesgo. Un programa de prevención completo y eficaz utiliza múltiples elementos para proteger a la mayor cantidad de personas a riesgo posible. Es urgente implementar programas para los usuarios de drogas debido a la alta incidencia en el VIH y a las conductas de alto riesgo.

¿quién lo dice? 1. Leigh BC, Stall R. Substance use and risky sexual behavior for exposure to HIV. American Psychologist. 1993;48:1035-1045. 2. Grella CE, Anglin MD, Wugalter SE. Cocaine and crack use and HIV risk behaviors among high-risk methadone maintenance clients . Drug and Alcohol Dependence. 1995;37:15-21. 3. Avins AL, Woods WJ, Lindan CP, et al . HIV infection and risk behaviors among heterosexuals in alcohol treatment programs . Journal of the American Medical Association. 1994;271:515-518. 4. Seage GR, Mayer KH, Horsburgh CR, et al. The relation between nitrite inhalants, unprotective receptive anal intercourse, and the risk of human immunodeficiency virus infection . American Journal of Epidemiology. 1992;135:1-11. 5. Edlin BR, Irwin KL, Faruque S, et al. Intersecting epidemics – crack cocaine use and HIV infection among inner-city young adults . New England Journal of Medicine. 1994;331:1422-1427. 6. Wallace JI, Bloch D, Whitmore R, et al. Fellatio is a significant risk activity for acquiring AIDS in New York City street walking sex workers. Presented at the Eleventh International Conference on AIDS, Vancouver BC; 1996. Abs #Tu.C.2673. 7. Paul JP, Stall R, Davis F. Sexual risk for HIV transmission among gay/bisexual men in substance-abuse treatment . AIDS Education and Prevention. 1993;5:11-24. 8. Fullilove MT, Fullilove RE, Smith M, et al. Violence, trauma and post-traumatic stress disorder among women drug users . Journal of Traumatic Stress. 1993;6:533-543. 9. Renton A, Whitaker L, Ison C, et al. Estimating the sexual mixing patterns in the general population from those in people acquiring gonorrhoea infection: theoretical foundation and empirical findings. Journal of Epidemiology and Community Health. 1995;49:205-213. 10. Stall RD, Paul JP, Barrett DC, et al. Substance abuse treatment lowers sexual risk among gay male substance abusers. Presented at Eleventh International Conference on AIDS, Vancouver, BC; 1996. Abs #We.C.3490. Contact: Ron Stall, 415/597-9155. 11. Susser E, Valencia E, Torres J. Sex, games and videotapes: an HIV-prevention intervention for men who are homeless and mentally ill. Psychosocial Rehabilitation Journal. 1994;17:31-40. Contact: Ezra Susser, 212/960-5763. 12. Martin SS, Butzin CA, Inciardi JA. Assessment of a multistage therapeutic community for drug-involved offenders . Journal of Psychoactive Drugs. 1995;27:109-116. Contact: Steve Martin, 302/831-2091-fax. 13. el-Guebaly N. Alcohol and polysubstance abuse among women . Canadian Journal of Psychiatry. 1995;40:73-79. 14. Stall R, Leigh B. Understanding the relationship between drug or alcohol use and high risk sexual activity for HIV transmission: where do we go from here ? Addiction. 1994;89:131-134.

Preparado por Ron Stall, PhD, Robert Fullilove, EdD, Traducción Romy Benard-Rodríguez Enero 1997. Hoja Informativa 21S.

What is the role of male condoms in HIV prevention?

revised 01/05

do condoms work?

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

what are the advantages?

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

what are the disadvantages?

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

how are they used?

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

what are concerns?

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

what works?

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

what needs to be done?

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

Says who?

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

Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © January 2005, University of California