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What works best in sex/HIV education?

why sex/HIV education?

Sex and HIV education programs have multiple goals: to decrease unintended pregnancy, to decrease STDs including HIV and to improve sexual health among youth. In 2005, almost two-thirds (63%) of all high school seniors in the US had engaged in sex, yet only 21% of all female students used birth control pills before their last sex and only 70% of males used a condom during their last sexual intercourse.¹ In 2000, 8.4% of 15-19 year old girls became pregnant, producing one of the highest teen pregnancy rates in the western industrial world.¹ Persons aged 15-24 had 9.1 million new cases of STDs in 2000 and made up almost half of all new STD cases in the US.³ There are numerous factors affecting adolescent sexual behavior and use of protection. Some of these factors have little to do with sex, such as growing up in disadvantaged communities, having little attachment to parents or failing at school. Other factors are sexual in nature, such as beliefs, values, perceptions of peer norms, attitudes and skills involving sexual behavior and using condoms or contraception.⁴ It is these sexual factors that sex/HIV education programs can potentially affect, thereby impacting behavior. Sex/HIV education programs alone cannot totally reduce sexual risk-taking, but they can be an effective part of a more comprehensive initiative.

do sex/HIV education programs work?

Yes. Some sex/HIV education programs delay initiation of intercourse, reduce the frequency of sex, reduce the number of sexual partners and increase use of condoms or other forms of contraception. Also, research indicates that sex/HIV education programs–even those that encourage condom and contraceptive use–do not increase sexual activity. In a recent review, almost two-thirds of the programs evaluated within the US significantly improved one or more of these behaviors. The results were even more positive in developing countries. Thus, many programs are effective, but others may not be and communities should implement either those programs that have been demonstrated to be effective or those programs that incorporate common characteristics of effective programs.⁵

can effective programs be replicated?

Yes. Several curricula have been implemented and evaluated up to five times in different states and consistently produced positive changes in sexual behavior when implemented as designed. One of them was even replicated in more than 80 CBOs and found to be effective.⁶ However, when the curricula are greatly shortened, when condom lessons are cut, or when programs designed for the community are implemented in the classroom, they are less likely to significantly change behavior.

which curricula are most likely to significantly change behavior?

• In a randomized trial of young women, SiHLE (sistering, informing, healing, living, and empowering) significantly increased condom use, reduced the pregnancy rate and reduced the STD rate.⁷
• In four different studies, Reducing the Risk delayed the initiation of sex and/or increased condom use for up to 18 months.^8,9
• In a randomized trial, Safer Choices delayed sex among some youth and increased condom and contraceptive use among sexually active youth over a 31 month period.¹⁰
• Finally, in multiple randomized trials, Making Proud Choices¹¹ and Becoming a Responsible Teen¹² increased condom use for at least one year.

These and other effective programs share 17 characteristics that contribute to their success. Characteristics are divided into development, the curriculum itself, and implementation.

how are effective programs developed?

Effective programs can be developed by teams of people with backgrounds in psychosocial theory, adolescent sexual behavior, curriculum design, community culture and/or teaching sex/HIV education. They review local data on teens’ sexual behavior, pregnancy rates and STD rates and often conduct focus groups with teens and interviews with adults. Using a logic model framework, they identify the behaviors they want to change, the risk and protective factors affecting them and activities that would change them. They then design activities consistent with community values and resources and finally pilot-test and revise the curricula.

what do effective curricula look like?

Effective curricula really focus on reducing unintended pregnancy, STD/HIV or both. They do this by emphasizing the consequences of unintended pregnancy, STDs or HIV, and the risk of experiencing them; by giving a very clear message about sexual behavior; and by discussing situations that might lead to sex and how to avoid or get out of those situations. Particularly important are the behavioral messages. Effective curricula most commonly emphasize that abstinence is the safest and best approach and encourage condom/contraceptive use for those having sex. Sometimes other values, such as being proud, being responsible, respecting yourself, sticking to your limits and remaining in control, are also emphasized, and are clearly linked to particular behaviors. Effective curricula incorporate activities, instructional methods and behavioral messages that are appropriate to the youths’ culture, developmental age, gender and sexual experience. All actively involve youth to help them personalize the information.

• To increase basic knowledge about risks of teen sex and methods of avoiding intercourse or using protection, effective programs can use: short lectures, class discussions, competitive games, skits or videos and flip charts or pamphlets.
• To address risk, programs can use: data on the incidence or prevalence of pregnancy or STD/HIV among youth and their consequences, class discussions, HIV+ speakers, and simulations such as the STD handshake.
• To change individual values and peer norms about abstinence and condom use, programs can use: clear behavioral messages, forced choice value exercises, peer surveys/voting, peer role plays, discussions of effectiveness of condoms and visits to drug stores or clinics where condoms are sold or distributed.
• To build skills to help avoid unwanted or unprotected sex and insist on and use condoms or contraception, programs can use: role playing including describing the skills, modeling the skills and repeated individual practice role playing the skills.
• To use condoms properly, youth can practice opening the package and putting a condom over their fingers, or talking through all the steps for using condoms.

how are effective programs implemented?

When effective programs are implemented, they typically obtain necessary support from appropriate authorities, select educators with desirable traits and train them, implement activities to recruit and retain youth if needed, and implement the curricula with fidelity. Programs can be effective with either adult or peer educators.

what needs to be done?

Policy makers should fund and encourage the implementation of sex/HIV education programs that have been demonstrated to be effective. If a new program is used, it should have the common characteristics of effective programs. Untested programs should be evaluated for effectiveness. Although programs should be implemented everywhere, they especially should be implemented in the locations and among populations where youth are at highest risk for HIV, STDs and unplanned pregnancy. In order for evidence-based sex/HIV education programs to be implemented broadly, they should have support from appropriate authorities such as directors of youth-serving organizations, school districts, principals and teachers. Staff or teachers conducting programs should be trained and supported to implement programs with fidelity. This includes allowing enough time in the classroom or organization to deliver the program.

Says who? 1. Centers for Disease Control and Prevention. Youth risk behavior surveillance – United States, 2005. Surveillance Summaries. June 9, 2006. 2. Alan Guttmacher Institute. U.S. teenage pregnancy statistics: Overall trends, trends by race and ethnicity and state-by-state information. New York: The Alan Guttmacher Institute, 2004. 3. 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. 4. Kirby D, Lepore G, Ryan J. Sexual risk and protective factors: Factors affecting teen sexual behavior, pregnancy, childbearing and sexually transmitted disease: Which are important? Which can you change? Washington DC: National Campaign to Prevent Teen Pregnancy. 2005. 5. Kirby D, Laris BA, Rolleri L. Sex and HIV education programs for youth: Their impact and important characteristics. Washington DC: Family Health International, 2006. 6. Jemmott III, JB. Effectiveness of an HIV/STD risk-reduction intervention implemented by nongovernmental organizations: A randomized controlled trial among adolescents. Presented at the American Psychological Association Annual Conference. Washington DC: August, 2005. 7. DiClemente RJ, Wingood GM, Harrington KF, et al. Efficacy of an HIV prevention intervention for African American adolescent girls: a randomized controlled trial. Journal of the American Medical Association. 2004;292:171-179. 8. Kirby D, Barth RP, Leland N, et al. Reducing the risk: Impact of a new curriculum on sexual risk-taking. Family Planning Perspectives. 1991;23:253-263. 9. Hubbard BM, Giese ML, Rainey J. A replication of Reducing the Risk, a theory-based sexuality curriculum for adolescents. Journal of School Health. 1998;68:243-247. 10. Kirby DB, Baumler E, Coyle KK, et al. The “Safer Choices” intervention: its impact on the sexual behaviors of different subgroups of high school students. Journal of Adolescent Health. 2004;35:442-452. 11. Jemmott JB, Jemmott LS, Fong GT. Abstinence and safer sex: A randomized trial of HIV sexual risk-reduction interventions for young African-American adolescents. Journal of the American Medical Association. 1998;279:1529-1536. 12. St. Lawrence JS, Brasfield TL, Jefferson KW, et al. Cognitive-behavioral intervention to reduce African American adolescents’ risk for HIV infection. Journal of Consulting and Clinical Psychology. 1995;63:221-237. *All websites accessed July 2006

Prepared By Douglas Kirby PhD, ETR Associates September 2006 . Fact Sheet #10ER Special thanks to the following reviewers of this Fact Sheet: Forrest L. Alton, Suzan Boyd, Karin Coyle, Glenn Dodd, Polly Edwards, Erin Johnson, Barbara Richardson-Todd, John Santelli, William Smith, Katherine Suellentrop, Mary Martha Wilson, Paulina Zamudio. Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © September 2006, University of California

¿qué necesitan las personas transgénero de masculino a femenino (MAF) para prevenir el VIH?

¿qué significa ser transgénero?

Transgénero es un término amplio que se refiere a las personas que no pueden o no quieren conformarse con las normas sociales asociadas a su sexo físico.¹ Estas personas poseen una identidad, expresión o comportamientos que no se relacionan tradicionalmente con su sexo de nacimiento. Las personas transgénero tienen diferentes grados o niveles de “transformación genérica” y viven conforme al género que han escogido autoidentificándose ya sea como: mujeres, hombres, transmujeres, transhombres, transexuales sin operarse, transexuales preoperadas, transexuales operados u operadas (reasignación sexual quirúrgica) o transvestistas, entre otras identidades. Estos términos varían según la región y la época. Esta hoja informativa se concentra en las personas transgénero de Masculino a Femenino (MAF) debido a que tienen mayores índices de riesgo de infección por VIH que las de Femenino a Masculino.

¿tienen riesgos las MAF?

Sí. Las MAF tienen un alto riesgo de infección por VIH. En 1997 las tasas de infección de MAF en San Francisco fueron de un 35% y de un 22% en 1998 en Los Angeles.^2,3 Un estudio realizado en Atlanta con trabajadoras sexuales MAF encontró que un 68% eran VIH positivas.4 Las tasas de infección entre las MAF continúan en aumento. Se estima que el porcentaje de nuevas infecciones varía entre el 3% y el 8% anual.^3,5 Las MAF Afroamericanas tienen un índice de infección más alto que otros grupos étnicos y raciales.^2-5 El uso de drogas inyectables también es común entre las MAF y eso las pone aún más a riesgo. En un estudio realizado en San Francisco, el 18% de las participantes respondieron que habían usado drogas inyectables durante los últimos seis meses y la mitad de éstas compartieron sus jeringas.² Las MAF pueden también inyectarse hormonas para afeminar sus cuerpos. El riesgo de infección por el uso de hormonas inyectadas varía regionalmente. En Nueva York se reporta un riesgo mayor que en San Francisco debido a las diferencias en el acceso a las hormonas y a jeringas apropiadas.^2,6 En San Francisco, los programas de intercambio de jeringas ofrecen jeringas adecuadas para la inyección de hormonas y clínicas ofrecen terapia hormonal gratis o de bajo costo.

¿qué pone a las MAF en riesgo?

La transfobia o sea la estigmatización social generalizada hacia las MAF, aumenta enormemente su riesgo de infección. Esta intensa estigmatización las marginaliza socialmente y redunda en que se les niegue oportunidades de educación, empleo y vivienda.^7,8 También les crea múltiples barreras para el acceso a los servicios de salud. Esta marginalización disminuye la autoestima de las MAF, incrementa la probabilidad de que se prostituyan para sobrevivir y reduce sus posibilidades de practicar sexo protegido.⁹ Todo esto se refleja en las altas tazas de MAF de infección por el VIH y otras enfermedades de transmisión sexual, uso de drogas e intentos de suicidio. Las MAF tienen relaciones sexuales principalmente con hombres y de forma anal receptiva, lo cual, también aumenta su riesgo.^2,3,10 Algunas MAF que son trabajadoras sexuales no usan condones si sus clientes les ofrecen más dinero;8 sin embargo, algunos estudios han demostrado que la mayoría de las prácticas sexuales sin protección no ocurren con sus clientes sino con sus parejas.³

¿cuáles son las barreras a la prevención?

La pobreza, la baja autoestima, la depresión, el rechazo, el aislamiento y la falta de poder son factores psicosociales que las propias MAF han citado como barreras para la reducción de riesgos respecto al VIH y al uso de drogas. Por ejemplo, muchas MAF dicen que el sexo sin protección reafirma su identidad con el género femenino y aumenta su autoestima.^10,11 Para muchas MAF asegurar empleo y vivienda es más imperante que prevenir el VIH. Estas necesidades deben ser atendidas para que los esfuerzos de prevención sean eficaces.¹¹ Muchas MAF no acuden a los servicios de prevención del VIH o de salud debido a la falta de sensibilidad de los proveedores de salud^11,12 o bien porque tienen miedo de ser descubiertas como transgénero.¹³ Debido a la transfobia, algunos programas de prevención para las MAF han tenido dificultades para alquilar un local.

¿qué se está haciendo?

El proyecto “Transgender Resources and Neighborhood Space (TRANS)” del Centro de Estudios para la Prevención del SIDA en San Francisco, CA, imparte talleres para las MAF sobre el abuso de drogas, el VIH, el sexo comercial, cómo cuidarse a sí mismas y cómo sobrevivir al medio. Ofrece también un centro donde las MAF pueden descansar, bañarse y socializar. Todas las actividades son facilitadas por promotores de salud. Este proyecto colabora con un programa de la agencia Walden House para que las MAF con adicción a las drogas se recuperen, el cual les ofrece una terapia más amplia, consejería, programas de mentores y adiestramiento sobre las destrezas indispensables para subsistir de acuerdo a las necesidades de las propias MAF.¹⁴ El Programa de Sexualidad Humana (PHS por sus siglas en inglés) de la Universidad de Minnesota desarrolló y evaluó un proyecto comunal para las MAF basado en el modelo de Creencias sobre la Salud (Health Belief) y en el erotismo del sexo con protección. Aunque fue bien recibido, las participantes reafirmaron la necesidad de una perspectiva más amplia que incorpore todos los aspectos de la salud ya que eran más importantes sus preocupaciones sobre el género que sobre el VIH. Ahora el PHS ofrece talleres sobre “Salud para todos los géneros” basados en un modelo de salud sexual que ubica los riesgos del VIH en el contexto de la vida de las participantes y toca temas como la estigmatización, los encuentros románticos, el desempeño sexual, el abuso de sustancias y la violencia. El programa combina la educación con el entretenimiento, y presenta a MAF que son celebridades y profesionales de la salud.¹⁵ El programa “Transgender Harm Reduction” en West Hollywood, CA, tiene promotores de salud y de alcance para MAF de alto riesgo que viven tanto en las calles como en los suburbios. También cuenta con talleres para desarrollar destrezas, mentoría y adiestramiento laboral. Los talleres incluyen temas sobre higiene y arreglo personal, legalización y documentación, cuidado de la salud y terapia hormonal y reducción del riesgo para contraer el VIH. El programa maneja de manera implícita la importancia de aumentar la autoestima para poder adoptar comportamientos más seguros.¹⁶ Desde 1993, “Gender Identity Support Services for Transgenders (GISST)” en Boston, MA, ha prestado servicios a las personas VIH- y VIH+. GISST provee educación sobre el SIDA, pruebas de VIH, tratamientos para evitar el consumo del alcohol y las drogas, consejería, adiestramiento laboral, destrezas para socializar, consejería sobre la aceptación social y la identidad de género. Patrocinan almuerzos sobre temas como la cirugía y las hormonas, con invitados especiales, videos o con personas transgénero que comparten sus experiencias.¹⁷

¿qué más hay por hacer ?

El temor social y la intolerancia hacia MAF limitan enormemente a muchas de ellas para que tengan una vida sana. Algunas ciudades y estados han decretado leyes contra la discriminación de personas transgénero para la vivienda y el empleo. Las entidades sin dichas legislaciones deben de considerar tenerlas. Estos cambios se han producido gracias al activismo y la intervención de las personas transgénero. Se debe desarrollar y evaluar programas de pares (peer based) para las MAF que incluyan: 1) trabajo de promoción de salud para las prostitutas que trabajan en las noches y las madrugadas; 2) programas de intercambio de jeringas apropiadas para la inyección de hormonas; 3) intervenciones individuales y grupales sobre las barreras psicosociales para la prevención del VIH. Contratar y adiestrar a MAF en programas de prevención, no sólo proveería una fuente de empleo muy necesitada, sino que ofrecería programas de prevención del VIH apropiados culturalmente.¹² Si la terapia hormonal se hace más accesible, se podría motivar a las MAF a que utilicen los servicios de salud, en los que a su vez, podrían obtener información para la prevención del VIH. Estas intervenciones pueden ser más eficaces si se combinan con programas de empleo, vivienda y educación. Los esfuerzos de prevención deben incluir a las parejas y amigos de las MAF. Las MAF no han sido incluidas en los sistemas de clasificación del VIH del CDC (Centro para el Control y Prevención de Enfermedades). Aparecen como hombres que tienen sexo con hombres o como mujeres heterosexuales. Se deben incluir categorías específicas para las personas transgénero en todos los formularios federales y locales para recaudar datos. Hay una necesidad enorme de adiestramientos sobre comunidad transgénero que sensibilicen a todos los proveedores de servicios públicos como médicos, enfermeras, personal de las clínicas (recepcionistas), la policía y los empleados de los servicios de emergencias (paramédicos, bomberos). Abogar para aumentar el acceso a servicios de salud y realizar investigaciones, trabajo político y educación que sean culturalmente apropiados, se han citado como factores que mejoran la salud de las personas transgénero.¹⁸

¿Quién lo dice?

1. Gender Education and Advocacy. Gender Variance: A Primer. 2001.
2. Clements-Nolle K, Marx R, Guzman R, et al. HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons in San Francisco: Implications for public health intervention. American Journal of Public Health. 2001;91:915-921.
3. Simon PA, Reback CJ, Bemis CC. HIV prevalence and incidence among male-to-female transsexuals receiving HIV prevention services in Los Angeles County (letter). AIDS. 2000;14: 2953-2955.
4. Elifson KW, Boles J, Posey E, et al. Male transvestite prostitutes and HIV risk. American Journal of Public Health. 1993;83:260-262.
5. Kellogg TA, Clements-Nolle K, McFarland W, et al. Incidence of Human Immunodeficiency Virus (HIV) among male-to-female transgendered persons in San Francisco. Journal of the Acquired Immune Deficiency Syndromes. in press.
6. McGowan CK. Transgender needs assessment. The HIV Prevention Planning Unit of the New York City Department of Health. December 1999.
7. Green J. Investigation into Discrimination against Transgendered People: A Report by the Human Rights Commission, City and County of San Francisco. 1994;1:8-10 & 43-52.
8. Nemoto T, Luke, D, Mamo L, et al. HIV risk behaviors among maleto-female transgenders in comparison with homosexual or bisexual males and heterosexual females. AIDS Care.1999;11:297-312.
9. Bockting WO, Robinson BE, Rosser BR. Transgender HIV prevention: a qualitative needs assessment. AIDS Care. 1998;10:505-525.
10. Boles J, Elifson KW. The social organization of transvestite prostitution and AIDS. Social Science and Medicine. 1994;39:85-93.
11. Clements-Nolle K, Wilkinson W, Kitano K. HIV Prevention and Health Service Needs of the Transgender Community in San Francisco. In W. Bockting & S Kirk editors: Transgender and HIV: Risks, prevention and care. Binghampton, NY: The Haworth Press, Inc. 2001; in press.
12. Feinberg L. Trans health crisis: for us it’s life or death. American Journal of Public Health. 2001;91:897-900.
13. Xavier J. The Washington Transgender Needs Assessment Survey. Administration for HIV & AIDS, District of Columbia Government. 2000.
14. UCSF CAPS, Health Studies for People of Color. Contact Joanne Keatley 415/476-2364.
15. Bockting WO, Rosser S, Coleman E. Transgender HIV prevention: a model education workshop. Journal of the Gay and Lesbian Medical Association. 2000;4:175-183. https://link.springer.com/article/10.1023/A:1026511822410 
16. Reback K, Lombardi EL. HIV risk behaviors of male-to-female transgenders in a communitybased harm reduction program. International Journal of Transgenderism. 1999;3:1+2.
17. Hope Mason T, Connors MM, Kammerer CA. Transgenders and HIV risks: needs assessment. Prepared by the Massachusetts Department of Public Health, HIV/AIDS Bureau. August 1995. GISST: 617/720-3413.
18. Lombardi E. Enhancing transgender health care. American Journal of Public Health. 2001;91:869-872.

PREPARADO POR JOANNE KEATLEY, MSW* Y KRISTEN CLEMENTS-NOLLE, MPH**, TRADUCIÓN MATEO RUTHERFORD Y ROY ROJAS *CAPS, **SF DEPARTAMENTO DE SALUD PÚBLICA

Se autoriza la reproducción (citando a UCSF) mas no la venta de copias este documento. Para obtener copias llame al National Prevention Information Network al 800/458-5231 o visite https://prevention.ucsf.edu/ También disponibles en inglés. Comentarios o preguntas pueden dirigirse a: [email protected] ©Enero 2002, UCSF.

Sex and HIV education programs have multiple goals: to decrease unintended pregnancy, to decrease STDs including HIV and to improve sexual health among youth. In 2005, almost two-thirds (63%) of all high school seniors in the US had engaged in sex, yet only 21% of all female students used birth control pills before their last sex and only 70% of males used a condom during their last sexual intercourse. In 2000, 8.4% of 15-19 year old girls became pregnant, producing one of the highest teen pregnancy rates in the western industrial world. Persons aged 15-24 had 9.1 million new cases of STDs in 2000 and made up almost half of all new STD cases in the US. There are numerous factors affecting adolescent sexual behavior and use of protection. Some of these factors have little to do with sex, such as growing up in disadvantaged communities, having little attachment to parents or failing at school. Other factors are sexual in nature, such as beliefs, values, perceptions of peer norms, attitudes and skills involving sexual behavior and using condoms or contraception. It is these sexual factors that sex/HIV education programs can potentially affect, thereby impacting behavior. Sex/HIV education programs alone cannot totally reduce sexual risk-taking, but they can be an effective part of a more comprehensive initiative.

Sex and HIV education programs have multiple goals: to decrease unintended pregnancy, to decrease STDs including HIV and to improve sexual health among youth. In 2005, almost two-thirds (63%) of all high school seniors in the US had engaged in sex, yet only 21% of all female students used birth control pills before their last sex and only 70% of males used a condom during their last sexual intercourse. In 2000, 8.4% of 15-19 year old girls became pregnant, producing one of the highest teen pregnancy rates in the western industrial world. Persons aged 15-24 had 9.1 million new cases of STDs in 2000 and made up almost half of all new STD cases in the US. There are numerous factors affecting adolescent sexual behavior and use of protection. Some of these factors have little to do with sex, such as growing up in disadvantaged communities, having little attachment to parents or failing at school. Other factors are sexual in nature, such as beliefs, values, perceptions of peer norms, attitudes and skills involving sexual behavior and using condoms or contraception. It is these sexual factors that sex/HIV education programs can potentially affect, thereby impacting behavior. Sex/HIV education programs alone cannot totally reduce sexual risk-taking, but they can be an effective part of a more comprehensive initiative.

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