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How Do HIV, STD and Unintended Pregnancy Prevention Work Together?

Why is it important?

HIV is a sexually transmitted disease (STD). HIV, other STDs (such as gonorrhea, syphilis, herpes, chlamydia and trichomoniasis), and unintended pregnancy are all adverse consequences of sexual behavior. If someone is at risk for unintended pregnancy or common STDs, that means they are engaging in an activity that could also put them at risk for HIV. In addition, these STDs may increase the likelihood of HIV acquisition. STDs are the most frequently reported diseases in the US. Every year in the US, about 12 million new cases of STDs occur, 3 million of them among teenagers.¹ In 1996, for the first time in the US, the number of AIDS deaths decreased. However, new cases continue to occur, and the largest proportionate increase in AIDS incidence in 1996 occurred among men and women who acquired AIDS through heterosexual contact (28% increase for men, 23% for women).² Over half of the 6.4 million pregnancies in the US in 1988 were unintended (56%). As many of those pregnancies ended in abortion (44%) as in birth (43%).³ In 1996, over half a million young women under age 20 gave birth, and two-thirds of those were unintended.⁴ Unintended pregnancy has great personal and social consequences.

Do STDs affect HIV?

Absolutely. First, an HIV- person who has an STD is 2- to 5-times more susceptible to HIV acquisition because the lesions and immune response associated with STDs make it easier for HIV to enter the body. Second, an HIV+ person who has an STD can be more infectious and more easily transmit HIV to an uninfected partner. Third, an HIV+ person may be more likely to acquire other STDs. This “epidemiological synergy” may be responsible for the explosive growth of HIV in some populations.⁵ Many research studies have shown the connection between HIV and STDs. A study in Malawi found that HIV+ men with gonorrhea had concentrations of HIV in their semen eight times higher than HIV+ men who did not have another STD. After treatment for the STD, HIV concentration in semen decreased to levels not significantly different from pre-STD levels. This suggests that STDs increase the infectiousness of HIV, and that detecting and treating STDs in HIV+ persons may help prevent HIV transmission.⁶ Clients at urban STD clinics in Miami, FL who had at least two HIV tests were found to have high rates of HIV and syphilis. Among clients tested twice, 10% acquired syphilis and 4% HIV in the interval. African-Americans accounted for 77% of HIV seroconversions and the rate was highest in women, especially 15-19 year olds. The majority of HIV infections were acquired heterosexually. A total of 18% of all seroconversions were associated with syphilis acquired between two HIV tests.⁷

Are STD and HIV prevention connected?

Yes and no. While the epidemics of STD and HIV have grown in parallel, prevention efforts to combat the adverse consequences of sexual behavior have not always worked in tandem. In the US HIV epidemic, heterosexual transmission is an increasing cause of infection, and people of color and younger people are increasingly infected. This is also true of STDs in the Southeast and selected large cities across the US, where syphilis, gonorrhea and HIV epidemics clearly overlap, especially among young African-American women.⁸ HIV prevention efforts may be more effective among certain populations if condom use and HIV are addressed together with STD or pregnancy prevention. Young people are much more likely to know someone who has had an STD or an unintended pregnancy than they are to know someone with HIV. HIV prevention programs, as well as family planning and STD clinics, might create a more effective and realistic message by putting all three together-HIV, STDs and unintended pregnancy-and saying condoms can protect against all three.^9,10

What’s working?

In rural Tanzania, a community-level program focused on improving diagnosis and treatment of STDs as means to prevent HIV infection. The program included training existing health center staff in STD management, ensuring availability of effective antibiotics for STDs, and providing periodic outreach to educate on STDs and increase health care use. Individuals in the intervention communities had lower HIV incidence (by about 40%) compared to persons in non-intervention communities.¹¹ Project RESPECT was a randomized HIV counseling and testing program conducted at STD clinics in five cities in the US with high HIV seroprevalence. The program evaluated whether interactive counseling is more effective than informational messages in reducing risk behaviors and preventing HIV and other STD transmission. The program found relatively little difference between 4-session and 2-session interactive counseling interventions, but found lower rates of new STDs, including HIV, among those groups compared to groups that only received information. Reported condom use increased across all groups. Project RESPECT demonstrated that brief risk-reduction counseling strategies can be effectively conducted in busy public clinic settings, and that counseling interventions can change STD rates in high-risk populations.¹² An HIV prevention program was implemented at an STD clinic in the South Bronx, NY, due to the clinic’s access to large numbers of high-risk men and women. The program was designed to have minimal disruption on clinical services while providing culturally-appropriate counseling. Patients had access to either a video on condom use in English or Spanish, or both the video and an interactive group session. Patients were given coupons for free condoms at a pharmacy several blocks from the clinic. Clients who saw the video were more likely to redeem coupons than those who did not, and clients who saw the video and participated in group sessions were even more likely to redeem coupons.¹³ People of Color Against AIDS Network (POCAAN) in Seattle, WA found that because of the stigma of HIV, prevention educators were not always successful at reaching at-risk populations, especially young African-American and Latino males ages 13-35. In 1990 POCAAN decided to educate about STDs and sexual health since these messages were more acceptable to the target population. The program uses street outreach and presentations in various settings such as juvenile facilities, middle and high schools, ESL classes and drug treatment centers. They offer referral vouchers that ensures clients will be seen at an STD clinic and that it will be free. In addition, POCAAN continually updates and educates its staff about STDs and works hard to integrate STD prevention messages into all its HIV-related activities.¹⁴

What still needs to be done?

It is time to further integrate STD, HIV and unintended pregnancy efforts, both on a programmatic and a research level. Wherever and whenever feasible, HIV prevention behavior change programs, STD clinics, family planning clinics and primary care facilities need to incorporate all three-HIV, STDs and unintended pregnancy-in their education, testing, counseling and treatment services.¹⁰ Research on HIV, both clinical and behavioral, needs to include the effects of STD and pregnancy. Although funding for HIV, STDs and family planning have traditionally been separate, government agencies and foundations need to provide funds for improved coordination or integration. Workers in STD, HIV and family planning should be cross-trained. Community Planning Groups should consider STD and unintended pregnancy prevention plans as well in areas where the epidemiology warrants. A comprehensive HIV prevention strategy uses many elements to protect as many people at risk for HIV as possible. As funding for social services grow more scarce, it is important to not pit STDs and unintended pregnancy against HIV in the fight for money, but to adopt new approaches to fight these overlapping epidemics.

Says who?

1. Eng TR, Butler WT, eds. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC : National Academy Press; 1997. 2. Centers for Disease Control and Prevention. Update: trends in AIDS incidence-United States, 1996 . Morbidity and Mortality Weekly Report. 1997;46:861-867. 3. Forrest JD . Epidemiology of unintended pregnancy and contraceptive use . American Journal of Obstetrics and Gynecology. 1994;170:1485-1489. 4. Centers for Disease Control and Prevention. State-specific birth rates for teenagers-United States, 1990-1996 . Morbidity and Mortality Weekly Report. 1997;46:837-842. 5. Wasserheit JN. Epidemiological synergy. Interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases . Sexually Transmitted Diseases. 1992;19:61-77. 6. Cohen MS, Hoffman IF, Royce RA, et al. Reduction of concentration of HIV-1 in semen after treatment of urethritis: implications for prevention of sexual transmission of HIV-1 . The Lancet. 1997;349:1868-1873. 7. Otten MW, Zaidi AA, Peterman TA, et al. High rate of seroconversion among patients attending urban sexually transmitted disease clinics . AIDS. 1994;8:549-553. 8. St. Louis ME, Wasserheit JN, Gayle HD. Editorial: Janus considers the HIV pandemic-harnessing recent advances to enhance AIDS prevention . American Journal of Public Health. 1997;87:10-12. 9. Cates W. Sexually transmitted diseases and family planning. Strange or natural bedfellows, revisited . Sexually Transmitted Diseases. 1993;20:174-178. 10. Stein Z. Family planning, sexually transmitted diseases, and the prevention of AIDS-divided we fail? American Journal of Public Health. 1996;86:783-784. 11. Grosskurth H, Mosha F, Todd J, et al . Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomized controlled trial . The Lancet. 1995;346:530-536. 12. Kamb ML, Bolan G, Zenilman J, et al. Does HIV/STD prevention counseling work? Results from a multi-center randomized trial. Presented at 12th Meeting of the International Society of Sexually Transmitted Diseases Research, Seville, Spain. 1997.

• Contact: Mary Kamb (404) 639-2080.

13. O’Donnell LN, San Doval A, Duran R, et al. Video-based sexually transmitted disease patient education: its impact on condom acquisition . American Journal of Public Health. 1995;85:817-822

• Contact: Lydia O’Donnell, Education Development Center, (617) 969-7100 X2368.

14. US Conference of Mayors. Sexual Health and STDs: an avenue to HIV prevention services. AIDS Information Exchange. 1995:12:6-8.

Contact: Kevin Harris (206) 322-7061 x233.

Prepared by Pamela DeCarlo* and Nancy Padian PhD** *CAPS, **UCSF Department of Obstetrics, Gynecology and Reproductive Sciences

December 1997. Fact Sheet #31E

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 AIDS Clearinghouse at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © December 1997, University of California

How Can Service Providers and Researchers Collaborate in HIV Prevention?

Why collaborate?

“Research on HIV prevention—no matter how good—does not stop HIV infection. HIV behavioral research can only stop HIV infection when results of the research can be used to make applied programs better.”¹ -Jeff Kelly

Everyone working in HIV prevention wants to know that their efforts make a difference towards halting the spread of HIV. When researchers and community-based organizations (CBOs) collaborate, the outcome can be better community programs and better science, resulting in improved HIV prevention. Researchers need to learn about how health education and community organizing programs function in order to evaluate or create interventions that are feasible in real world settings. They also need to gain access to research participants (clients of CBOs) and disseminate research findings in the most useful way. Working with CBOs and their clients can improve research.”² The mission of most CBOs is program delivery, not evaluation. CBOs may need to collaborate with a researcher when using tested interventions, evaluating ongoing programs and incorporating theory into intervention design. Working with researchers can improve programs.”³ Federal, state, local and private funders are increasingly requiring CBOs both to use theory in designing programs and to evaluate their programs.

What does collaboration involve?

Researchers and service providers can work together in many ways and the degree of collaboration can vary. Collaboration can be a simple act that is not very time consuming, such as CBOs getting help with questions on a survey or researchers learning more about client populations. Even if the relationship between a researcher and service provider is limited, there are ways to bring the expertise of all participants together and optimize outcomes of their joint work. Collaboration can also be relatively complex and time- and resource-intensive. Service providers and researchers may collaborate on program evaluation, program design, data analysis or research. Typically, these collaborations involve 1) selecting the researcher and CBO partner; 2) developing a relationship; 3) deciding on a research or programmatic question; 4) conducting the research or evaluation; 5) analyzing and interpreting the data; and 6) disseminating the findings.”⁴ The last step in the collaboration would involve developing programs based on the research findings.

What are barriers to collaboration?

Collaboration can be understood as a cross-cultural experience: a meeting of the culture of research and the culture of CBOs. Researchers and providers have distinct work cultures including norms, incentives, jargon, sense of time, resources, training, education, and expectations, that are often at odds with each other.”⁵ For example, CBO staff often must respond to clients with immediate needs. Researchers, on the other hand, often work on 2-5 year grants with more long-term objectives. While their common goal may be slowing the epidemic, each has different contributions and strategies for achieving that end. Often CBOs mistrust researchers. Researchers are seen as “using” the CBO, collecting data with no return of information and taking all of the credit.”⁶ Service providers often see researchers as over-resourced. For example, CBO staff may be paid far less than the researchers they collaborate with. On the other hand, researchers are often frustrated by the fast pace, limited staff time and lack of prioritization of research activities found in CBOs. An inherent power imbalance exists when researchers and CBOs work together on research projects. Researchers are often seen as “experts” by virtue of their academic degree. The expertise of CBO staff—knowledge of the community, understanding how interventions work and access to the population—is often overlooked and undervalued by researchers.

What’s being done?

One simple yet vital method of collaboration is making sure that data collected by the researcher is available to CBOs to use. The University of British Columbia in Canada conducted a large-scale study of health care and community resources used by persons living with HIV/AIDS. After the study, they hired a Community Liaison Researcher to work with CBOs to jointly determine their information needs, and conduct tailored analyses of the large and valuable database for use in CBO programs.”⁷ Another more complex method of collaboration involves working together from the beginning to develop programs. The San Francisco AIDS Foundation (SFAF) wanted to understand why gay/bisexual men were continuing to become HIV-infected. They initiated a collaboration with CAPS, UCSF to conduct qualitative research among high-risk men. SFAF and research staff met weekly to discuss the research question, design the instrument and discuss the transcripts. This led to the agencies collaboratively developing and evaluating two interventions and a media campaign. The programs, Gay Life and Black Brothers Esteem, are ongoing.”⁸ Collaborations often require a solid infrastructure for support. In San Francisco, CA, the CAPS collaboration initiative provided funding, training, supervision, technical assistance and researcher pairing for CBOs to conduct program evaluation. This initiative was jointly funded through the university and private funders. CBOs developed research questions and conducted evaluation with the aid of researchers. Findings were disseminated through public forums and a special issue of a journal. This collaborative model has been replicated across the US.”⁹

What are best practices?

Although collaborating can be a resource and labor-intensive activity, the benefits for the CBO, researcher and the field of HIV prevention are worth the investment. The following recommendations can help ensure a successful experience:^10,11

• Choose CBO or researcher partners carefully. Interview several different individuals or agencies. Always ask for and check references.
• Establish buy-in, input and ownership from agency staff and directors.
• Define roles and responsibilities clearly and repeatedly.
• Plan and budget for time for CBO-researcher communication and meetings.
• Address conflict when it arises.
• Allow flexibility to modify or change the scope of research.
• Expect staff turnover and allow time to orient and train new staff.
• Support agencies to build capacity before engaging in outcome research. Formative, descriptive and theory-development research are useful; outcome evaluation is not always the best choice for new interventions or new CBOs.
• Build a safety net into the research design. If you are evaluating a new intervention, make sure to include alternative research questions from the start.
• Plan for community dissemination strategies throughout all stages of research.
• Jointly monitor for research quality control.
• Secure adequate resources and support for intervention and evaluation time.

What supports collaboration?

There are some recent initiatives that support collaborative work, including federal, foundation and university grants. Funders, however, still need to set aside money for researchers and CBOs to work together, and the requirement for this should be structured into the grant.”¹² This way, much-needed program funds aren’t diverted into research. Local and state health departments can help by matching CBOs and researchers and then fostering the collaboration. In addition to requiring adequate funding, collaboration requires time, energy and commitment. Without support for these basic requirements, the ultimate goal of collaboration—more effective HIV prevention—will not be achieved.

Says who?

1. Kelly JA, Somlai AM, DiFranceisco WJ, et al. Bridging the gap between the science and service of HIV prevention: transferring effective research-based HIV prevention interventions to community AIDS service providers . American Journal of Public Health. 2000;90:1082-1088. 2. Schensul JJ. O rganizing community research partnerships in the struggle against AIDS . Health Education & Behavior. 1999; 26:266-283. 3. Holtgrave DR, Qualls NL, Curran JW, et al. An overview of the effectiveness and efficiency of HIV prevention programs . Public Health Reports. 1995;110:134-146. 4. Harper GW, Salinan DD. Building collaborative partnerships to improve community-based HIV prevention research: The university-CBO collaborative partnership (UCCP) model. Journal of Prevention & Intervention in the Community. 2000;19:1-20. 5. Gomez C, Goldstein E. The HIV prevention evaluation initiative: a model for collaborative and empowerment evaluation. In: The Empowerment Evaluation: Knowledge and Tools for Self-Assessment and Accountability . Fetterman, Wandersman and Kaftarian, eds. Sage Publications, 1995. 6. Perkins DD, Wandersman A. “You’ll have to overcome our suspicions”: the benefits and pitfalls of research with community organizations. Social Policy. 1990;21:32-41. 7. James S, Hanvelt R, Copley T. The role of the Community Liaison Researcher- returning research to the community. Presented at the AIDS Impact Conference, Ottawa. July 15-18, 1999. 8. Bey J, Durazzo R, Headlee J, et al. Prevention among african american gay and bisexual men. Presented at the 8th International AIDS Conference, Durban, South Africa. Abst# WePeD4523. 9. Haynes Sanstad K, Stall R, Goldtsein E, et al. Collaborative Community Research Consortium: a model for HIV prevention. Health Education & Behavior. 1999;26:171-184. 10. Goldstein E, Freedman B, Richards A, et al. The Legacy Project: lessons learned about conducting community-based research. Published by the AIDS Research Institute, University of California San Francisco, Science to Community series. 2000. prevention.ucsf.edu/uploads/bibindex.php . 11. Acuff C, Archambeault J, Greenberg B, et al. Mental health care for people living with or affected by HIV/AIDS: A practical guide. Published by the Research Triangle Institute. 1999. #6031. 12. DiFranceisco W, Kelly JA, Otto-Salaj L. Factors influencing attitudes within AIDS service organizations toward the use of research-based HIV prevention interventions . AIDS Education and Prevention. 1999;11:72-86. Resources: Behavioral and Social Science Volunteer Program (BSSV) American Psychological Association 750 First Street, N.E. Washington, D.C., 20002-4242 202/218-3993 Fax: 202/336-6198 e-mail: [email protected] https://www.apa.org/topics/hiv-aids HIV Community-Based Research www.cbrc.net Loka Institute PO Box 355 Amherst, MA 01004 413/559-5860 https://centerhealthyminds.org/programs/loka-initiative 

PREPARED BY Ellen Goldstein MA*, Beth Freedman MPH*, Dan Wohlfeiler MPH** *CAPS, **STD Prevention Training Center April 2001. Fact Sheet #40E

Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. ©April 2001, University of California

What is the role of acute HIV infection in HIV prevention?

What is acute infection?

Acute HIV infection refers to the first stage of infection, the time immediately after a person is infected and before an antibody response to the infection develops. The second stage of infection is seroconversion, when a person develops HIV-specific antibodies. During acute HIV infection, there are high levels of virus since the antibody response has not yet developed.^1,2 Determining acute HIV infection is critical for HIV prevention efforts. Conventional HIV tests do not detect acute infection, yet it is estimated that almost half of new HIV infections may occur when a person with acute infection unknowingly transmits HIV.³ There is no defined acute retroviral syndrome since there are many different symptoms associated with acute HIV infection. After an incubation period of 1 to 3 weeks, about 50% of persons with acute HIV infection develop headaches, sore throat, fever, muscle pain, anorexia, rash, and/or diarrhea.⁴ The symptoms are generally mild and may span anywhere from days to weeks. It is easy to overlook or miss the signs of acute HIV infection. Half of persons who are acutely infected will never notice any symptoms. Also, the symptoms of acute retroviral syndrome are similar for other common illnesses such as infectious mononucleosis and influenza, which means acute HIV infection often goes undiagnosed.⁴

How is acute infection detected?

Acute infection cannot be detected by most routinely used HIV tests. Conventional HIV tests detect HIV-specific antibodies in blood or oral fluids that are produced by the immune system during seroconversion. Therefore, a person who was infected very recently will receive an HIV-negative result using conventional HIV tests. Nucleic acid amplification testing (NAAT) can detect acute HIV infection by looking for the presence of the virus.⁵ Because NAAT is expensive to use for each individual specimen, many testing sites are combining HIV-negative blood specimens for testing. This NAAT pooling strategy makes screening for acute HIV infection feasible in settings with low disease incidence but high testing volume.⁶ Blood specimens with initial HIV-negative antibody results can be routinely screened using the pooled NAAT strategy to detect acute HIV infection. If a client has an HIV-negative antibody test but a positive NAAT result for the virus, it is important to have them come back to the clinic for follow-up counseling and repeat testing to confirm HIV infection.

How does it affect prevention?

The only way for persons to know that they are HIV+ and take precautions to prevent transmission is to be tested for HIV. However, with most routinely used HIV tests, it may take two months or more after initial infection to receive an HIV+ result. These two months are critical for HIV prevention: it is estimated that almost half of HIV transmissions occur when a person is in this acute HIV infection phase. During acute infection, there are high levels of HIV virus in the body,^2,3 and high viral load has been shown to be associated with increased risk of HIV transmission.⁷ If persons are at greatest infectivity during acute infection, it is likely that many persons are transmitting HIV unknowingly during this time. An acutely infected person who receives an HIV-negative antibody test result could be engaging in recommended HIV prevention practices, such as disclosing their status and only having sex or sharing injection equipment with HIV-negative persons, and yet still be transmitting HIV. Persons with acute HIV infection may benefit from enhanced counseling focused on immediate risk reduction strategies and clarification about the conflicting test results. They should also be offered disclosure assistance and partner testing and counseling.⁸

Can acute infection be treated?

Treating HIV during the acute infection stage may boost the immune system and slow the progression of HIV disease. One study followed HIV+ persons who started highly active antiretroviral treatment (HAART) in the acute infection stage. These persons had significantly better viral load and CD4 counts, compared to HIV+ persons who began HAART at a later stage.⁹ Guidelines for treating HIV infection usually recommend that HIV+ persons who are asymptomatic and have low viral loads and strong CD4 counts should wait to begin HAART.¹⁰ It is possible that initiating treatment during acute infection may be beneficial. However, starting HIV medications is a major decision: there are many side effects and toxicities and there are currently no long-term studies on the effectiveness of treatment for acute infection.¹¹

What’s being done?

North Carolina has instituted the Screening and Tracing Active Transmission (STAT) program to identify and manage new HIV infections. As a part of STAT, all tests at publicly funded sites that return HIV-negative using standard testing are re-tested with NAAT. In 2003, NAAT detected an additional 23 cases of HIV infection, a 3.9% increase in the rate of HIV case identification. All 23 persons with acute infection were notified, 21 began HIV medical care, and 48 of their sexual partners received HIV testing, risk reduction counseling and referrals.⁶ In 2003, the San Francisco Department of Public Health began to screen for acute HIV infection among persons seeking HIV counseling and testing at the city STD clinic. In 2004, 11 cases of acute HIV infection were detected, reflecting an increase in HIV case detection of 8.8%. Program staff performed contact tracing and partner management for all persons newly diagnosed HIV+.^8,12 At a hospital Urgent Care Center in Boston, MA, all patients who had symptoms of a viral illness and who reported risk factors for HIV infection were tested for acute HIV infection. Most patients (68%) agreed to be tested for HIV even though they came to the hospital with unrelated concerns. Of 499 patients tested in 2000, 5 had acute HIV infection and 6 had chronic infection. Of the 5 patients with acute HIV infection, 4 returned for their test results, were seen by an HIV physician or nurse and began antiretroviral therapy.¹³

What needs to be done?

Acute HIV infection is hard to detect and often goes undiagnosed.¹⁴ Primary care physicians and healthcare workers at emergency rooms, urgent care and STD clinics need education and training on symptoms of acute HIV infection.¹⁵ Clinicians with patients who show signs of viral illness such as influenza or mononucleosis should conduct quick risk assessments for HIV risk and provide referrals to testing and counseling sites as needed. More HIV testing and counseling sites need to test for acute infection, especially in high prevalence areas and high risk settings such as STD clinics. To accomplish this, resources for training, technical assistance and funding need to increase for agencies that provide acute HIV infection testing. State and federal reimbursement protocols, as well as public and private insurance, need to be changed to encourage the use of NAAT. Identifying persons with acute HIV infection can be an effective HIV prevention strategy, as it focuses on persons at greatest risk for transmission. Persons with acute infection may need enhanced post-test counseling, including referrals to: medical care; social services such as substance abuse and mental health treatment when appropriate and prevention programs for HIV+ persons. Acute infection is also a crucial time for identifying sex and drug use partners and offering disclosure assistance services such as partner notification, counseling, testing and referrals.^2,16

Says who?

1. Pilcher CD, Eron JJ, Galvin S, et al. Acute HIV revisited: new opportunities for treatment and prevention . Journal of Clinical Investigation. 2004;113:937-945. 2. Pope M, Haase AT. Transmission, acute HIV-1 infection and the quest for strategies to prevent infection . Nature and Medicine. 2003;9:847-852. 3. Wawer MJ, Gray RH, Sewankambo N, et al. Rates of HIV-1 transmission per coital act, by stage of HIV-1 infection, in Rakai, Uganda . Journal of Infectious Diseases. 2005;191:403-409. 4. Schacker T, Collier AC, Hughes J, et al. Clinical and epidemiologic features of primary HIV infection . Annals of Internal Medicine. 1996;125:257-264. 5. Quinn TC, Brookmeyer R, Kline R, et al. Feasibility of pooling sera for HIV-1 viral RNA to diagnose acute primary HIV-1 infection and estimate HIV incidence . AIDS. 2000;14:2751-2757. 6. Pilcher CD, Fiscus SA, Nguyen TQ, et al. Detection of acute infections during HIV testing in North Carolina . New England Journal of Medicine. 2005;352:1873-1883. 7. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. New England Journal of Medicine. 2000;342:921-929. 8. Klausner J, Kohn R, Nieri G, et al. A comprehensive HIV surveillance & disease control program in a sentinel site: San Francisco municipal STD clinic, 2004. Presented at the National HIV Prevention Conference, Atlanta, GA, 2005. Abst # W0-L0405. 9. Hecht F, Wang L, Collier A, et al. Outcomes of HAART for acute/early HIV-1 infection after treatment discontinuation. Presented at the 12th Conference on Retroviruses and Opportunistic Infections. 2005. Abst# 568. 10. Department of Health and Human Services. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Oct 2005. 11. Geise R, Maenza J, Celum CL. Clinical challenges and diagnostic approaches to recognizing acute human immunodeficiency virus infection . American Journal of Medicine. 2001;111:237-238. 12. Truong HM, McFarland W, Kellogg T, et al. Detection of acute HIV infection among STD clinic patients in San Francisco. Presented at the 13th Conference on Retro-viruses and Opportunistic Infections. 2006. Abst #914. 13. Pincus JM, Crosby SS, Losina E, et al. Acute human immunodeficiency virus infection in patients presenting to an urban urgent care center . Clinical Infectious Diseases. 2003;37:1699-1704. 14. Kuo AM, Haukoos JM, Witt MD, et al. Recognition of undiagnosed HIV infection: an evaluation of missed opportunities in a predominantly urban minority population . AIDS Patient Care and STDs. 2005;19:239-246. 15. Hightow L, MacDonald P, Boland M, et al. Missed opportunities for the diagnosis of acute infection: room for improvement. Presented at the 12th Conference on Retroviruses and Opportunis-tic Infections. 2005. Abst# 565. 16. Centers for Disease Control and Prevention. HIV transmission among black college student and non-student men who have sex with men– North Carolina, 2003 . Morbidity and Mortality Weekly Report. 2004;53:731-734.

Prepared by Hong-Ha M. Truong, PhD, MS, MPH*; Christopher D. Pilcher MD** *CAPS, *Gladstone Institute of Virology and Immunology, **University of North Carolina Chapel Hill January 2006 . Fact Sheet #59E Special thanks to the following reviewers of this Fact Sheet: Michael Busch, Andrew Forsyth, Karlissa Foy, Sabine Kinloch-de Loes, Mario Legault, Elizabeth Londoño, Willi McFarland, Jon Pincus, Elisabeth Puchhammer-Stöckl, Kathleen Sikkema. 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 2006, University of California

¿Qué necesitan las mujeres jóvenes para la prevención del VIH?

¿corren riesgo las mujeres jóvenes?

Sí. Una de cada cinco personas con VIH en EE.UU. es menor de 25 años. El 40% de estos jóvenes son mujeres con un total de 10,111 jovencitas en EE.UU. viviendo con VIH.¹ Los patrones de infección entre las jóvenes son muy diferentes a los de los jóvenes. Las jovencitas representan una mayoría de un 57% de todos los casos de VIH entre personas de 13 a 19 años de edad, en contraste con el 35% de los casos entre personas de 20 a 24 años.¹ Entre las jóvenes VIH+, predominan desproporcionadamente las afroamericanas, que componen casi las tres cuartas partes (69%) de las mujeres jóvenes viviendo con VIH. El 23% de éstas son blancas, el 6% son latinas y las asiáticas/de las islas del Pacífico, y las indígenas/nativas de Alaska componen el 1% respectivamente.¹ No se ha realizado suficiente investigación sobre las razones por las cuales las jóvenes afroamericanas en particular tienen tasas tan altas de VIH y de otras enfermedades transmitidas sexualmente (ETS). Las desigualdades económicas y sociales aumentan su vulnerabilidad a la infección por VIH. El racismo estructural (que conduce a la discriminación en el empleo, la vivienda, los salarios y las oportunidades educativas) puede promover su riesgo de contraer el VIH.²

¿qué las pone en riesgo?

Muchas mujeres encuentran obstáculos estructurales que las hacen vulnerables al VIH, pero las jóvenes se enfrentan a otras barreras específicas. Las desigualdades sociales y económicas, la violencia y su posición social como persona joven, en combinación con la vulnerabilidad particular de la mujer joven, ponen a las jovencitas en un riesgo considerable de contraer el VIH. Más de la mitad de todos los casos de VIH entre mujeres jóvenes no se atribuye a ningún riesgo identificado (ellas reportan un riesgo desconocido o ninguno), lo cual indica que ellas no se dan cuenta de que se exponen al VIH. De los casos de VIH reportados entre mujeres jóvenes con un riesgo identificado, el 37% se debe al contacto heterosexual y el 7% al uso de drogas inyectables.¹ El 22% de los niños en EE.UU. vive en familias con ingresos por debajo del índice de pobreza, casi el doble de la tasa de pobreza de cualquier otro país industrializado. La pobreza contribuye a crear un ambiente de alto riesgo para las mujeres jóvenes, por ejemplo, la falta de vivienda o la necesidad de tener sexo a cambio de dinero o alojamiento.³ El VIH y otras ETS se transmiten más fácilmente del hombre a la mujer joven que a la mujer mayor, pues los órganos genitales de la joven aún se encuentran en desarrollo. Durante la juventud, el aparato genital tiene sólo una capa delgada de células, la cual no se convierte en barrera gruesa (con la formación de capas adicionales) sino hasta un poco después de los 20 años de edad.⁴ Las mujeres jóvenes tienen tasas altas de ETS. Una ETS activa puede facilitar la transmisión del VIH. En EE.UU., las mujeres de 15-19 años de edad tienen las tasas más altas de gonorrea y clamidia. Las afroamericanas de 15-19 años tienen tasas de gonorrea 24 veces mayores que las jóvenes blancas.⁵ Aunque las mujeres jóvenes usuarias de drogas inyectables (UDI) no se inyecten más que los hombres jóvenes UDI, es más frecuente que ellas compartan jeringas y equipos de preparación de drogas. Entre mujeres la práctica de compartir materiales de inyección de drogas con su pareja sexual es un factor clave en el aumento del riesgo al inyectarse.⁶ La cuarta parte (26%) de los jóvenes gays, lesbianas, bisexuales y transexuales son corridos de su casa al revelar su sexualidad. La vida en la calle pone a las mujeres jóvenes en peligro de contraer el VIH al exponerlas a la violación, al sexo por sobrevivencia y al uso de drogas inyectables.⁷ Haber sufrido abuso y trauma físico y sexual en el pasado aumenta la vulnerabilidad al uso riesgoso de drogas y a la actividad sexual sin protección. Un estudio de jóvenes UDI en Vancouver, Canadá encontró que quienes eran VIH+ tendían a: ser mujeres, haber sufrido abuso sexual, tener sexo a cambio de drogas, inyectarse diariamente heroína y haber tenido muchas parejas sexuales.⁸ Las adolescentes (de 13 a 19 años de edad) VIH+ son más propensas que las VIH- a tener parejas sexuales mayores y a un uso infrecuente de condones ellos.⁹ Tener un compañero sexual mayor ofrece beneficios aparentes y reales para las mujeres jóvenes, tales como la seguridad económica y emocional, la capacidad de salir de su situación de vivienda actual, y el respeto de sus compañeras. Los compañeros mayores también pueden presentar un riesgo, pues es más probable que ellos hayan tenido varias parejas sexuales y por lo tanto estén infectados por VIH u otra ETS. Ellos también son menos propensos a usar condones.¹⁰

¿qué es lo que ayuda en la prevención?

La prevención del VIH entre mujeres jóvenes abarca mucho más que el VIH, y deberá tomar en cuenta el contexto social y económico de la vida de estas jóvenes. La base de una prevención del VIH bien pensada, consiste en apoyar a las jóvenes para que sean agentes del bienestar y del cambio en su propia vida y en su comunidad. La familia y la comunidad son sistemas de apoyo importantes que pueden proteger a las jovencitas contra el riesgo del VIH. Por ejemplo, un estudio reveló que las jóvenes afroamericanas que participan en organizaciones sociales de la comunidad negra son menos propensas a participar en actividades sexuales riesgosas y más propensas a hablar con sus padres sobre la sexualidad y el VIH.¹¹

¿qué se está haciendo al respecto?

El Center for Young Women’s Development (Centro para el Desarrollo de la Mujer Joven) es una organización dirigida por mujeres jóvenes en San Francisco, CA. que promueve la autosuficiencia, la seguridad comunitaria y la defensa de los derechos de la juventud entre chicas de 14 a 18 años de edad que están involucradas en los sistemas de justicia juvenil o de crianza temporal, o que han vivido en la calle. El centro les brinda empleo, liderazgo y capacitación para que ellas orienten a otras personas en su comunidad. Una vez que tengan los conocimientos y la oportunidad de capacitar a otros, es más probable que estas mujeres jóvenes incorporen estas habilidades a su propia vida.¹² Sisters for Life (Hermanas de por Vida), en Washington, DC, es un programa de mentoras para afroamericanas de 9-14 años de edad en tres comunidades de vivienda pública en Alexandria, VA. El programa fortalece las habilidades prácticas de las jovencitas al apoyar sus esfuerzos por llegar a ser adultas sanas y responsables que eviten la infección por VIH, el uso de drogas y alcohol y las ETS. Sisters for Life promueve tanto los logros académicos como el amor propio y la autoestima. El programa abarca el VIH/SIDA en forma indirecta, centrándose en apoyar a las muchachas como jóvenes en vías de maduración y en enfocar las conductas de alto riesgo dentro del contexto más amplio de la vida de cada jovencita.¹³ De Madre a Hija: Protegiendo Nuestra Salud, es una iniciativa intergeneracional de prevención del VIH entre mujeres latinas. Este programa piloto se destina a las madres hispanohablantes de adolescentes. Su enfoque es ayudar a las participantes a mejorar la comunicación madre-hija por encima de barreras generacionales y culturales, aumentar sus conocimientos sobre el sexo y su confianza para hablar del tema, entender los riesgos para la salud, examinar actitudes sobre los papeles masculinos y femeninos y aumentar las habilidades tanto de las madres como de las hijas para reducir riesgos.¹⁴

¿qué queda por hacer?

“Quiero hablar en mi propio idioma y saber que me entenderán.” (Nelly Valesco, 10/16/76 – 10/06/96) Las jóvenes deben ser incluidas en la planificación, diseño y puesta en práctica de los programas de prevención del VIH. Para tener buenos resultados, la prevención del VIH entre mujeres jóvenes deberá realizarse dentro del contexto social y económico en el cual ellas se infectan. Ya que muchas veces ellas tienen desventajas económicas y sociales, las oportunidades educativas y de capacitación laboral son componentes importantes de los programas de prevención. Los programas de prevención del VIH que involucren y fortalezcan a la comunidad pueden lograr cambios positivos. Estos programas deben incorporar información sobre la buena comunicación y la negociación (especialmente con hombres mayores), la salud general y reproductiva, así como ayuda para superar los efectos del trauma o abuso y otras necesidades de salud mental. La prevención del VIH entre las mujeres jóvenes debe incluir acceso o referencias a servicios de prevención y tratamiento de ETS, prevención del embarazo e intercambio de jeringas. Es necesario ofrecer programas para las jóvenes con quienes es difícil establecer contacto y que pueden correr un mayor riesgo de contraer el VIH. Éstos servicios deben ofrecerse en lugares fuera de la escuela, tales como albergues para jóvenes, centros comerciales, centros de detención y centros recreativos o comunitarios. El VIH y otras ETS dejan de ser una gran amenaza para las mujeres jóvenes cuando ellas han adquirido las destrezas y se les han ofrecido oportunidades de apoyarse a sí mismas.

¿quién lo dice?

1. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report. US HIV and AIDS cases reported through June 2001 Midyear edition. 2002;13(1). 2. Zierler S, Krieger N. Reframing women’s risk: social inequalities and HIV infection. Annual Review of Public Health. 1997;18:401-436. 3. Prilleltensky I, Nelson G. Promoting Child and Family Wellness: Priorities for Psychological and Social Interventions. Journal of Community Applied and Social Psychology. 2000;10:86. 4. Reid E, Bailey M. Young Women: Silence, Susceptibility and the HIV Epidemic. UNDP HIV and Development Programme, Issue Paper No. 12, 2001. 5. Division of STD Prevention. Sexually Transmitted Disease Surveillance, 1996.Atlanta, GA: U.S. Dept. of Health and Human Services, Centers for Disease Control and Prevention, 1997. 6. Evans JE, Hahn JA, Page-Shafer K, et al. Gender differences in sexual and injection risk behavior among active young injection drug users in San Francisco(The UFO Study) (in press). 7. Clifton CE. The young and the restless. Positively Aware. March/April 2001. 8. Miller CL, Spittal PM, LaLiberte N, et al. Females experiencing sexual and drug vulnerabilities are at elevated risk for HIV infection among youth who use injection drugs. Journal Of Acquired Immune Deficiency Syndromes. 2002;30:335-341. 9. Sturdevant MS, Belzer M, Weissman G, et al. The relationship of unsafe sexual behavior and the characteristics of sexual partners of HIV infected and HIV uninfected adolescent females. Journal of Adolescent Health. 2001;29:S64-71. 10. Harper GW, Bangi AK, Doll M, et al. Older male sex partners present increased HIV risk for low-income female adolescents: economic, social and cultural influences. Presented at the International Conference on AIDS, July 2002,Barcelona, Spain. #ThPeE7789. 11. Crosby RA, DiClemente RJ, Wingood GM, et al. Participation by African-American adolescent females in social organizations: associations with HIV-protective behaviors. Ethnicity and Disease. 2002;12:186-192. 12. Center for Young Women’s Development. www.cywd.org 13. AIDS Action Committee. What Works in HIV Prevention for Youth. Chapter 4: What Is Working in Local Communities. 2001.https://aac.org/  14. Gómez CA, Gómez-Mandic C. Intergenerational HIV Prevention Initiative forLatina Women. Presented at the UCSF Center for AIDS Prevention Studies Conference. April, 2002.

Preparado por Sonja Mackenzie, MS, CAPS

Traducción Rocky Schnaath Octubre 2002. Hoja Informativa 45S

Marin, Barbara VanOss; Gomez, Cynthia A.; Tschann, Jeanne M. Public Health Reports v108, n6 (Nov-Dec, 1993):742-750

COPYRIGHT U.S. Department of Health and Human Services 1993 Effective and culturally appropriate strategies for promoting condom use within the Hispanic community in the United States are needed urgently because of Hispanics' high prevalence of infection with human immunodeficiency virus (HIV) and other sexually transmitted diseases (STD). Hispanics are overrepresented disproportionately in statistics on STD and acquired immunodeficiency syndrome (AIDS). HIV infection is currently the sixth leading cause of death among Hispanic adults, although it is not among the first 10 causes of death among non-Hispanic whites. The already high levels of HIV infection in the Hispanic community mean that rates will increase unless successful preventive measures, such as the promotion of condom use, are employed more effectively. HIV risk behavior is difficult to change. In one study, despite individual counseling of patients following HIV testing, 23 percent of those STD seronegative and 15 percent of those STD seropositive had a new exposure to STD in less than 12 months following counseling. To create effective and culturally appropriate promotion campaigns for condom use by Hispanics at risk, the beliefs, attitudes, and behaviors that are associated with consistent condom use for the community need to be better identified and understood. Most of the information about condom use among Hispanics has come from studies of married women. Those studies focused on simple demographic predictors of condom use behavior, rather than identification of complex psychological mechanisms that could improve the understanding and effectiveness of condom promotion efforts. Studies of condom use rarely distinguish between use with a primary sexual partner and use with a secondary sexual partner, despite the many differences in those relationships that could affect the likelihood or ability to use condoms. We designed a study of condom use by Hispanics with a sample of sufficient size and representation to assess predictors of the frequency of condom use by men with their secondary female sexual partners and to assess differences among specific Hispanic subgroups, as for example, Puerto Ricans and Mexican Americans.

Sampling. The 1991 telephone survey employed a modified Mitofsky- Waksberg sampling technique to identify Hispanic household in nine States that had concentrations of Hispanics ranging from 5 percent to 38 percent in the Northeast (NY, NJ, MA, and CT) and Southwest (CA, AZ, CO, NM, and TX). Hispanics in those States comprise 77 percent of all Hispanics in the country. In the first stage of sampling, 143,984 telephone number hundred- series groups were randomly generated from working telephone area codes and prefixes for the 9 States. A hundred-series group consists of an area code, plus a 3-digit prefix, plus the next 2 digits, plus all 100 possible combinations of numbers for the last 2 digits. Computer matching of Spanish surnames with telephone directory information identified 27,574 hundred-series groups (19 percent) that contained at least 1 Spanish- surnamed household. We did not sample hundred-series groups with no listed Spanish surnames, because we assume that the number of Hispanic households would be extremely low. Subsequently, 12,078 telephone numbers were randomly generated from those 27574 hundred-series groups by a stratification procedure that oversampled the hundred series with the most Spanish surnames to increase the probability of reaching Hispanic households. Because the Northeast has a smaller Hispanic population that the Southwest, higher sampling fractions also were assigned to the Northeast to allow for reliable extrapolation of results to all Hispanics in that area. Calls to the 12078 numbers produced 372 Hispanic households, although not all households include an eligible respondent. In the second stage of sampling, the hundred-series groups in which those 372 Hispanic households appeared were treated as Primary Sampling Units, and additional telephone numbers from these groups were computer generated. Hundred-series groups were noted in which at least 1 additional Hispanic household was identified in the first 20 numbers called. Those hundred-series groups were called at a higher rate to increase the probability of finding eligible Hispanics. We made at least six attempts during various days and hours to reach unanswered telephone numbers. Procedures. The screening procedure involved identifying the ethnicity, sex, and age of household members. Potential respondents were asked "Do you, or any of the members of your household, consider yourselves to be Latinos or Hispanics?" An eligible Hispanic respondent in the household was selected randomly, using the Kish method. Interviews were bilingual men and women. Prior experience of the telephone survey research organization that conducted the interviews had indicated that Hispanic women have difficulty answering questions on sexuality if interviewed by a man. Accordingly, the survey procedures called for only women to interview women respondents. Interviewers were experienced and received specific training on how to ask the question used in this project. Respondents were interviewed in the language of their choice. Interviews were conducted between March and July of 1991.

Instrument. The survey instrument was based on more than 100 open- ended interview and 2 focus groups with Hispanics in San Francisco, held to identify Hispanic men's perceptions of the consequences of condom use with primary and secondary sexual partners, difficulties with condom use, and normative aspects of condom use. The instrument was developed originally in Spanish and a back-translation procedure was used to assure that the English version was equivalent in meaning. Both the Spanish and English versions were pretested with at least 20 persons. The final version of the interview required an average of 24 minutes to complete. Most interview questions had four or five-level Likert-type response scales. The reported reliabilities were for the sample of 361 Hispanic men, reporting 1 or more secondary female sexual partners, who responded to the question on condom use with a secondary partner or partners. Frequency of using and carrying condoms. The extent of condom use with a secondary sexual partner was assessed by the question, "When you had sex with someone other than your wife or primary partner in the last 12 months, how often did you use condoms?" The extent of carrying condoms was assessed by the question, "How often do you carry a condom with you?" Each item was recorded using a five-point response scale from "always" to "never." Self-efficacy to use condoms. Four questions were developed to assess perceived ability to use condoms:

• "Would you be able to refuse sex if you partner didn't want you to use a condom?"
• "Would you use condoms even if you had to stop to buy them or look for them?"
• "Would you use condoms even if you had been drinking or using drugs?" and,
• "Would you be able to use a condom with a secondary partner?"

The self-efficacy score was the mean of the four items on a four- point yes-no response scale with higher scores meaning higher efficacy (alpha = 0.55). Those with greater self-efficacy to use condoms were expected to use them more consistently with secondary partners that did those who scored lower. Negative beliefs about condoms. Sixteen items measured beliefs about the consequences of using condoms. Beliefs included "the condom might break," "the condom might come off inside your partner," and "you would feel less sexual pleasure." Responses were "yes" "probably yes," "probably no," and "no" (alpha = 0.70). Depression scale. Ten of the 20 items of the Center of Epidemiologic Studies Depression Scale (CES-D) were selected for the questionnaire, based on their factor loading for Hispanics (alpha = 0.88). The items measure sadness in the 7 days prior to the interview and have been shown to assess depression in community samples. We expected those men who reported the most depressive symptoms to report more risky behaviors than those who reported the least depressive symptoms. The scale score was a continuous variable ranging from 0 to 30, with high scores meaning more depressive symptoms. Sexual comfort. Three items were used to assess sexual comfort: being naked in front of a partner, having sex with the lights on, and having sex with a new partner. The sexual comfort score was the mean of the three items on a four-point scale ranging from "very comfortable" to "very uncomfortable" (alpha = 0.62). Persons with high levels of sexual comfort have been shown to exhibit sexual behavior that is more self-protective than persons with low levels of sexual comfort. Number of friends using or carrying condoms. Two items assessed the proportion of the respondent's close friends who carried condoms and used them with secondary partners, a measure of perceived normative condom use behavior among peers. Responses ranged on a five-point scale from "almost all" to "almost none." Myths about HIV transmission. A measure of beliefs about the casual transmission of HIV was computed by adding responses to three items, such as the likelihood of getting HIV from using public toilets. Total scores could range from 3 to 12, with higher scores representing less accurate beliefs. Demographics. Age, education, marital status, and ethnic origin were determined for each respondent. Acculturation. Acculturation, the process by which a person learns a new culture, was assessed using four language-related items. That scale has been previously shown to have good reliability and validity. Mean scores ranged from 1 to 5, with higher scores indicating more use of English, hence higher levels of acculturation (alpha = 0.90). Other variables. Positive attitude toward condom use with a secondary partner was measured with a six-level Likert-type scale ranging from "dislike a lot" to "like a lot." Knowing someone with HIV infection or AIDS and previous use of condoms to prevent disease were assessed through single items with "yes" or "no" responses.

Ordinary least squares regression with all variables entered simultaneously was used to identify predictors of frequency of condom use with secondary female sexual partners. The analysis was conducted for the 361 Hispanic men who reported more than 1 female sexual partners in the previous 12 months. Additional regressions were conducted to identify predictors of selected variables that were significantly related to frequency of condom use in the initial analysis. The results are reported as betas, a standardized regression coefficient reflecting the association between the predictor and the outcome, taking into account all other variables in the equation. Thus, effects of all psychosocial variables are adjusted for the demographic variables of ethnicity (Puerto Rican, Dominican, Mexican, or other Hispanic), age, marital status, education, income, and acculturation. All analyses were unweighted, because analysis indicated that sampling probability weights were uncorrelated (P > 0.20) to any of the outcome variables. Predictor variables showed low correlation between them, with the highest correlation of 0.32 between acculturation and education. Acculturation had a small correlation with several demographic variables, but most psychological predictor variables were uncorrelated.

Response rate. A response rate in survey sampling may be defined as the ration of the number of questionnaires completed for eligible elements to the number of eligible elements in the sample. The response rate was calculated by multiplying the proportion of households screened for eligibility by the proportion of eligible respondents who completed the interview. As in all telephone samples, certain telephone numbers (for example, those of businesses, facsimile machines, and nonhouseholds) were not eligible for enumeration. After those were eliminated, the age and sex of the adults in the household were determined for 67.1 percent of eligible telephone numbers (households or undetermined status). Also 86.4 percent of those contacted, and who met the survey criteria, provided complete interview. Multiplying those two proportions, a response rate of 58.0 percent for the entire sample was obtained. That rate compares well with other telephone surveys, since only six call-back attempts could be made because of budget constraints. Only 4.2 percent of eligible Hispanics refused to be interviewed. Another 4.7 percent broke off interviews before completion. The remaining 4.7 percent of eligible Hispanics who did not provide completed interviews were persons who could not be contacted after the initial contact.

Sample. There were 361 Hispanic men ages 18--49 years who reported having a secondary female sexual partner in the 12 months prior to the interview, including 5 men who also reported 1 for more male sexual partners. Those 361 men were 37 percent of all Hispanic men interviewed. Demographic characteristics of the 361 men are shown in table 1. More than two-thirds were unmarried, almost half were younger than 25 years, more than two-thirds had a high school diploma or better, more than half had incomes of $20,000 or less, and the men were evenly distributed by acculturation categories. Because of purposeful oversampling in the Northeast, almost 40 percent of the sample were either Puerto Rican or Dominican, with an equal percentage of Mexican origin, compared with the 1990 census, in which more than 60 percent of Hispanics were of Mexican origin. Hispanic men with a secondary female sexual partner were more likely than those with a single partner to be unmarried, ages 18--24 years, less acculturated, and living in the northeastern United States (data not shown). In the unweighted analyses, 60.1 percent of the 361 men reported "always" using condoms with secondary partners in the 12 months before the interview. Analysis weighted by sampling probability adjusted the prevalence of consistent condom use downward to 49.0 percent. The results of the least squares regression analysis are shown in table 2. Six variables were identified as the best combination of predictors of frequency of condom use with a secondary partner among the 361 Hispanic men reporting a secondary female sexual partner. Those variables were greater frequency of carrying condoms, higher self-efficacy to use condoms, positive attitude toward condom use with a secondary partner, having friends who used condoms with a secondary partner, personally knowing a person with AIDS or HIV, and fewer depressive symptoms. The multiple R for that equation was 0.588, which means those predictors account for a substantial proportion (35 percent) of the variance in frequency of condom use with secondary partners. Table 3 presents the results of separate regression analyses of three significant predictors of secondary condom use: carrying condoms, attitude toward condom use with a secondary partner, and self-efficacy to use condoms. We were able to explore those variables in more detail because we had additional predictors for each. Frequency of carrying condoms was predicted by the variables of having a positive attitude toward carrying condoms, having used condoms to prevent disease, being unmarried, having friends who carried condoms, knowing a person with AIDS or HIV, having greater sexual comfort, and having lower levels of acculturation. Together they account for 34 percent of the variance of that measure.

A more positive attitude toward condom use with a secondary partner was significantly predicted by lower acculturation, more sexual comfort, fewer depressive symptoms, less negative beliefs about the consequences of condom use with a secondary partner, and having ever used condoms. Together they explain 14 percent of the variance of that variable. High levels of sexual comfort, having ever used condoms, and fewer negative beliefs about the consequences of condom use with a secondary partner were significantly related to self-efficacy to use condoms with a secondary partner, explaining 28 percent of the variance of that variable.

Key psychosocial predictors explained a substantial portion (35 percent) of the frequency of condom use with secondary sexual partners in the 12 months prior to the interview. More frequent condom use with secondary partners for these Hispanic men was associated with more frequently carrying condoms, greater self-efficacy to use condoms, having friends who also used condoms with secondary partners, a positive attitude toward condom use with a secondary partner, a lack of depressive symptoms, and personally knowing someone who had HIV and AIDS. The data suggest that behavioral factors, the social environment, culture, and psychological symptoms may play an important role in whether Hispanic men consistently use condoms with secondary sexual partners. Given the large proportion (almost 40 percent) of Hispanic men who reported multiple female partners in the previous year and the high prevalence of STD and HIV infection in the Hispanic community, those factors deserve careful consideration. Behavioral factors. Two behavioral factors emerged as particularly important in the study: carrying condoms and self-efficacy to use condoms. In the sample, carrying condoms appears to be an indicators of preparedness for safe sex with a secondary partner and also of greater experience with condoms. Health care providers who wish to increase Hispanic men's use of condoms with secondary sexual partners should focus specifically on increasing the behavior of carrying condoms. Self-efficacy to use condoms strongly predicted actual use with a secondary partner, and was in turn strongly predicted by prior use of condoms. That was not surprising, since feelings of self-efficacy generally are produced by practice. Health care providers in STD or family planning clinics, who see Hispanic male patients should teach techniques of proper condom use, such as avoiding the use of oil-based lubricants and leaving a reservoir for semen at the tip. Hispanic men should be encouraged to handle condoms and to practice putting on one before attempting to do so during a sexual encounter. Men should be asked to consider how to overcome related difficulties, such as having to stop to buy condoms or to look for them, using them even if they had been drinking or using drugs, and learning how to insist on condom use with a partner who does not want them to use one. These barriers to condom use with a secondary partner, which were the basis of the self-efficacy measure in the study, should be specifically discussed. Video presentations or self-instructional approaches should be developed that incorporate modeling of appropriate condom behaviors. When feasible, role playing and instructive feedback may be used to prepare men. The relationship between risky sexual behavior and the use of alcohol has been debated since it was first described. We found no relationship between the frequency of condom use and the use of drugs of alcohol before sex. However, self-efficacy to use condoms (which did predict greater condom use) included the perception that one could use condoms even after drinking or using drugs. Thus, actual frequency of alcohol or drug use before sex may be less important factors to assess for intervention than a person's perceived self-efficacy to use condoms, even under the influence of alcohol or drugs. Social environment. The social environment affects condom use. Three factors appear particularly important: marital status, personal knowledge of someone with HIV or AIDS, and having friends who use condoms with secondary partners. A substantial minority (18 percent) of the married Hispanic men in the sample had multiple female sexual partners in the prior year. Unmarried men, with no marital partner who might question condom carrying, were more likely to carry condoms than were married men. Other research has found the same association between condom carrying and marital status among Hispanic men. Personally knowing someone with HIV or AIDS was a predictor of more condom carrying and more use of condoms with a secondary partner. That suggests that health care providers should assess and emphasize a Hispanic man's personal vulnerability to HIV from sexual risk behaviors and previous STD. The results confirm the wisdom of many community programs that utilize persons with HIV to reach and motivate the community. Having friends who carry condoms and use them with secondary partners were circumstances predictive of both carrying and using condoms. That was not surprising, given the importance of normative influences on sexual behavior. The findings suggest the importance of mass media and community level approaches to condom promotion, as well as approaches to promote normative changes within subgroups. Increased availability of condoms in vending machines can reduce embarrassment associated with buying condoms and increase the perception that "everybody" uses condoms. Culture. Hispanic culture may contribute to high-risk sexual activity. One way is the common idea that sexuality is embarrassing and not to be discussed either with one's children or with one's sexual partner. In this study, comfort with sexuality was an important predictor of self-efficacy to use condoms, accounting for a substantial amount of the variance, as well as predicting greater frequency of condom carrying and a positive attitude toward condoms. Other research has found among Hispanic men an association between carrying condoms and sexual discomfort, measured as embarrassment in buying condoms. We measured sexual comfort as comfort with commonplace aspects of sexuality, such as being naked in front of a partner or having sex with lights on. Fisher and coworkers have shown that comfort with sexuality is associated with various sexual self-care behaviors, such as breast self-examination and engaging in behaviors to prevent STD. As hypothesized by Fisher, some persons who feel discomfort with sexuality may avoid sex entirely, but those who are uncomfortable yet have multiple partners will be less likely to plan for sex, including condom buying and using. Those who are comfortable may be more likely to engage in nonpenetrative and generally safer forms of sex. The issue of comfort with sexuality needs to be addressed in a culturally appropriate manner by health care providers. Initially, comfort with condom use should be the focus, emphasizing carrying condoms, practicing their use, and practical skills needed for their use. The patient's basic information, such as knowing the names for body parts and sexual acts, should not be assumed. A Hispanic man in one focus group wondered if oral sex ("sexo oral") meant "sex by the hour"; another thought a woman's vaginal lubrication meant she had "ejaculated;" and several believed masturbation causes physical harm. Further work on the components and amelioration of sexual discomfort clearly is needed among Hispanics. If anthropological research is correct in suggesting a dichotomy in many Hispanics' minds between "good" women (a wife or mother) and "bad" women (a prostitute or easy conquest), changing the concept that only "bad" women enjoy sex could lead to more enjoyable sex with one's primary partner. Work is needed on the relationships between the beliefs many Hispanic men hold about what it means to be a man (low perceptions of sexual control, associating positive values with sexual behavior risk- taking, and needs for multiple sexual partners) and the sexual behaviors that many Hispanic men demonstrate. Psychological symptoms. Depressive symptoms in the week before the interview were associated with low rates of use of condoms with secondary partners in the previous year and negative attitudes toward condom use with a secondary partner. While those findings might appear to be surprising, people who are depressed are less likely, for example, to be able to quit smoking and are more likely to relapse from methadone maintenance. Depressed persons may perceive themselves as having less to live for, thus evaluating risk behavior as unimportant, or they may be preoccupied with significant life problems that appear more important than an unprotected sexual encounter. For Hispanics, and possibly for other ethnic groups as well, health care providers and staff members of STD clinics may want to assess depressive symptoms to identify those patients who are more likely to have repeated STD exposures. Care providers can then design more comprehensive clinical interventions for them, focusing on depression prevention. Demographic variables. We found no differences in predictors of condom use with secondary partners between Hispanic men in the Northeast and Southwest United States or between ethnic subgroups, education, income, or age groups, despite having sufficient power to detect such differences. Thus, recommendations made in this report are not limited to a particular subgroup of Hispanic men. Less acculturated men were more likely than the more highly acculturated to carry condoms and to report a positive attitude toward condom use, although they were no more likely than more acculturated men to actually use them. Those positive attitudes and behaviors suggest that less acculturated Hispanic men are quite open to condom use with secondary partners. Certainly, in Latin America, condoms are seen as useful primarily outside primary relationships. The data have the usual limitations of sexual behavior research, being self-reports that could not practically or ethically be validated. They are also cross-sectional in nature, with current measures of psychosocial variables being used to predict reports of past behavior. Thus, while the study provides useful information about the associations between variables, conclusions should not be drawn about causation or prediction. The generalizability of the sample is limited by the lack of telephones in some Hispanic households, although the absence of effects for income on relationships found in the research suggests that the limitation may be minimal. Some potential respondents were lost because of our inability to make more than six followup calls to a telephone number because of cost factors. We were told by the interviews that some respondents broke off the interview, or refused to participate, because of their fundamentalist religious beliefs.

Programs and providers promoting condom use with secondary partners should attend to behavioral factors, the social environment, cultural issues, and psychological symptoms. Specifically, they should recommend that Hispanic men carry condoms; should teach specific skills, such as how to use condoms even under difficult conditions; should lower sexual discomfort by providing basic information about sex in a sex-positive climate; and should pay particular attention to those men who may be emotionally troubled. Emphasizing personal vulnerability to HIV, especially for men with STD, and pointing out that "most men" use condoms with secondary partners is useful.

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Dr. Marin and Dr. Gomez are with the Department of Epidemiology and Biostatistics and with the Center of AIDS Prevention Studies. Dr. Marin is an Associate Adjunct Professor and Dr. Gomez is an Associate Specialist. Dr. Tschann is Assistant Adjunct Professor with the Graduate Program in Health Psychology, Department of Psychiatry. Rolando Juarez, of the Center for AIDS Prevention Studies, provided date analysis services; Dr. Thomas Piazza, of the Survey Research Center, University of California, Berkeley, suggested the sampling approach. The telephone survey was carried out by Communication Technologies, Inc., San Francisco, whose interviews collected the data.