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Healthy Oakland Teens Description and Explanation of Study Instrument

While you are setting up your equipment, getting the consent form, etc. take note of the surroundings for your field notes.

1. I’d like you to think back to the last time you got an HIV test. Take a minute to remember everything you can about it and then tell me the whole story. Starting from what led up to the test, why you went to get it, where it was done and then how you felt afterwards?

If they have never tested, skip to question # 6: Let interviewee describe the episode. Listen for answers to each of the following questions. Once interviewee's story is told, probe for any questions not answered. Content Areas for HIV Testing: Motivation: including why they decided to test, whether strictly voluntary, coerced or mandatory testing (prison, hospital), where they found out about testing/test site Location: Where was the test site? Procedures: Describe the actual test? (blood/Orasure) Who administered? How was the counseling? What was discussed in counseling? (Probe for discussion of risk behaviors, results, follow-up appointment) How did you feel after you left? Confidentiality: avoid using the words "confidential" or "anonymous" Were you concerned about privacy at all? (Probe for name or number given, familiar test site, familiar test counselor/administrator) Waiting Period: How was the waiting period? Tell me about any changes that occurred during this time period. Did you talk to anyone about HIV and/or the test during the waiting period? Results: When did you go back for results? IF didn’t get results ask why. If had another test where did get results, what was different this time? Where did you go for results? Who gave them? (probe for familiarity with results counselor) How was the result explained/presented to you? What were your results? Was this the result you were expecting? Why? How did you feel after receiving the results? What was discussed after you received the results? (probe for discussions around risk, 6 month window period, referrals given, IF NEGATIVE — ways to stay negative, any plans made to stay negative) Was talking to them useful/helpful? Did you just want to get out of there? Who did you share your results with? 2. How did this compare to other tests you’ve had, did you like it or not? Was it typical of other tests? 3. After this HIV test, did anything change in your life? (drug use, sex, views on risk) If yes, explain what changed. If NO ask: 4. Have you ever had an HIV test that caused you to change your beliefs or behaviors? If yes, please explain what changed. (Probe for what aspect of C&T caused the change; i.e. was it the risk assessment counseling, or receiving the test results) 5. Is there anything [else] that caused you to change your beliefs or behaviors? (i.e. drug use, sex, views on risk) If yes, please explain what it was, and what changed. 6. Have you ever thought about testing/or been approached about testing? What happened? How did you hear about it? Why did you decide not to test? What do you think would happen if you did test?

Now I’d like to ask you a few more general questions about HIV testing. If they have already discussed their testing pattern above skip 1,2 & 3. 1. How many times have you tested in your life? 2. How often do you test? 3. Do you test regularly? If so, why?

This next section is very general. We are just trying to get a sense of people’s everyday lives. 1. Describe yesterday. What did you do when you got up in the morning until you went to bed? Content Areas for Daily Life: Location(s) Who respondent interacted with during the day Drug Use Resources: eating, getting money Time frames (what time did they get up, what time to bed, etc.) 2. How, in any way, was this different from a typical day?

I have a couple general questions about drugs and then I’d like to ask you more specifically about the last time you used.1. What kinds of drugs do you use now? Probe for all drugs, including alcohol and those used sporadically 2. When do you use and how much? Ask for each drug mentioned above 3. Can you describe to me what happened the last time you used. Tell me the whole story from when it began until where you think it ended. I’d like to know who you were with, what you used, etc. Let interviewee describe the episode. Listen for answers to each of the following questions. Once interviewee's story is told, probe for any questions not answered. Content Areas for Drug Narrative: In this section we want to get at settings, people, and social and physical conditions which shape use; decisions and rules, spoken and tacit. Before Using: How were you feeling/What kind of mood were you in? What was going on at the time? Buying and preparing: Time and place. How were drugs procured? Who got them? Who paid? How did you get money for the drugs/buy in? If didn’t have money, how did you get your portion? Who was there? What are your relationships with these people? Who prepared drugs, how? How were drugs measured? Probe for using ONE syringe to divide up drugs into other syringes— was the loader’s syringe new or used; were receivers’ syringes new or used. Who or what determined how much each person got? Taking: How did you take the drugs (inject self, injected by another person, smoke, snort) Where did you get the (pipe, works)? Whose (rigs, pipe) did you use? Who went first (second, third, etc.) and why? Afterwards: How did you feel, what did you do afterwards? Did you need any other drugs to come down? 4. How, in any way, was this different from your usual experience using? 5. How does your drug use fit into your sex life? How does your drug use impact your sex life? Probe for drugs used before, during and after sex.

Let me ask you a few general questions about your relationships. 1. Do you currently have a steady partner(s) (girlfriend, boyfriend, husband, wife, etc.)? If so, tell me about her/him or them? Individual characteristics of their partner. (age, gender, and ethnicity). Relationship with this partner (duration and nature of relationship, where/when/how met partner; main, casual, paying or exchange) Probe around past sexual experiences with this partner. What attracted you to her/him? What did you like about her/him? (if appropriate)

Now I would like to ask some personal questions about your sexual behavior. We realize that this is a very personal subject, but your answers are very important to our research. Your answers will remain completely confidential and remember names will not be attached to any of this information. 1. I would like to talk about the last time you had sex with someone without a condom. When was that? NOTE: This includes when a condom broke and when there was dipping. 2. Could you think back now and try to remember as much as you can about that time, and tell me the story of how it happened? Try to remember when it happened, who you were with, what you were doing and how you felt. Let interviewee describe the episode. Listen for answers to each of the following questions. Once Interviewee's story is told, probe for any questions not answered. Content Areas for Sexual Interactions: Sexual partner: Individual characteristics of this sex partner. (age, gender, and ethnicity). Relationship with this partner (duration and nature of relationship, where/when/how met partner; main, casual, paying or exchange) Past sexual experiences with this partner What attracted you to him/her? (if appropriate) Before Sex: What was going on at that time? How did it happen? (When did it happen?, who initiated?, where were you?) How were you feeling? (Were you expecting to have sex? Did either one of you talk about it first? What were you hoping to get out of it?) Sexual Events: What happened? (types of sex: anal, oral, vaginal, mutual masturbation, digital, etc.) What determined the kinds of sex you had? (active vs. passive roles, verbal vs. nonverbal c communication, payment, consent, etc.)  How did you make a decision to NOT use a condom?/Why didn’t you use condoms? Birth control method of any kind used Using (Drugs): Drugs or alcohol used by you or this sex partner before, during or after having sex. (Injected drugs/non-injected drugs/alcohol; levels of intoxication) What did using have to do with this sexual encounter? (sex/drug exchanges, drugs enhancing sex, sex enhancing drug, etc.) HIV/AIDS: Issue of HIV ever discussed (Your status? Partner’s status? If so, how? Before or after sex?) If not discussed, then what did you believe (or assume)? Before or after sex? How did knowing or not knowing your partner’s HIV status affect having sex this time. After Sex: Thinking back over this particular experience, is there anything that you would have wanted to happen differently? Tell me about that. Generalizability - Typical or unusual compared to most of other sexual interactions Relationship potential - Someone you wanted to see again? To have sex with again? 3. How was this different from your usual experience having sex without a condom? 4. How was this different from the last time you had sex WITH a condom? 5. Thinking about when you have sex in general, what makes it easier to use condoms/protection with your partners? (Probes: nature of relationship; how long they knew their partner; serostatus) 6. Thinking about when you have sex in general, what are some of the reasons you haven’t used condoms/protection? 7. How are these situations (using a condom verses not using a condom) different. 8. How is having sex with your "steady partner" (whatever term interviewee uses) different from having sex with others, such as casual partners, one-night stands or tricks?

¿Qué debe hacerse para prevenir el VIH en los hombres negros?

Elaborado por Bob Haas y Barbara Green-Ajufo, DrPH, MPH

¿Quiénes son los hombres negros?

En los Estados Unidos, los hombres negros son descendientes de las diversas etnias de la diáspora africana. Son amigos y familiares: padres, abuelos, esposos, novios, hermanos, tíos, hijos, sobrinos y primos. Son colegas, profesionales y obreros. Tienen diferentes orientaciones sexuales, profesan diversas creencias religiosas y hablan diferentes idiomas, entre otras particularidades demográficas.

¿Es un riesgo el VIH para los hombres negros?

El VIH representa una crisis de salud para los hombres negros, sin importar su edad o su orientación sexual. En el 2015, el 33% de las infecciones por el VIH en los Estados Unidos fueron en hombres negros. El VIH se diagnostica en hombres negros ochos veces más que en hombres blancos y dos veces más que en hombres hispanos que no son negros. El riesgo de infección por el VIH en hombres negros es alto relativo a la población masculina en general. De cada 20 hombres negros, uno será diagnosticado con VIH. De no revertirse las tendencias actuales, esta prevalencia continuará. [2-4] Las estadísticas a continuación muestran la probabilidad en hombres negros de ser diagnosticados con VIH durante su vida.

• Hombres que tienen sexo con hombres (HSH): hombres negros (1/2); población masculina en general (1/6)
• Personas que se inyectan drogas: hombres negros (1/9); población masculina en general (1/36)
• Hombres heterosexuales: hombres negros (1/86); población masculina en general: 1/473

Entre los HSH, incluidos homosexuales y bisexuales, los hombres negros que tienen sexo con hombres (HNSH) tienen la mayor probabilidad de ser diagnosticados con el VIH (39% en 2015). [5] Los HNSH jóvenes corren un riesgo aún más alto. De todos los HNSH que fueron diagnosticados con el VIH en 2015, un 75% tenía menos de 34 años—con proporciones iguales para jóvenes de 13 a 24 años (37.7%) y jóvenes de 25 a 34 años (37.3%). [6]

Varias investigaciones han demostrado que los HNSH no suelen practicar más actos sexuales riesgosos (sexo anal sin condón o tener varias parejas) que los hombres de otros grupos raciales o étnicos. Sin embargo, tienen mayor probabilidad de ser diagnosticados con el VIH, sin importar la edad. [7-10] Según un estudio, el VIH es nueve veces más común entre los jóvenes negros que tienen sexo con hombres que entre los jóvenes blancos que tienen prácticas sexuales semejantes. [7]

La demanda y conciencia sobre la Profilaxis Pre-Exposición (PrEP)—un tratamiento biomédico eficaz—es menor entre HNSH que entre HSH blancos, por lo que se les receta menos. [11] De todas las recetas para PrEP en los Estados Unidos entre enero y septiembre de 2015, un 74% fue para blancos, un 12% para latinos y sólo un 10% para afro-americanos. [12]

¿Cuáles son los factores de riesgo del VIH para los hombres negros?

Muchos factores influyen en el riesgo para el VIH en los hombres negros.

Estigma y discriminación: Es menos probable que los hombres negros que han experimentado estigma o discriminación usen PrEP como medida preventiva [13] o revelen que viven con el VIH. [14] Además, los hombres que han experimentado traumas relacionados con la discriminación por ser gay, negro o por vivir con el VIH, suelen tener más sexo anal sin protección. [15]. Se ha demostrado que las altas tasas de infección por el VIH, las actitudes racistas de parte de los homosexuales no negros, las redes sociales y los ambientes en los que se relacionan los homosexuales estigmatizan y aislan a los HNSH de los demás HSH. [16]

Disparidades en el continuo del cuidado para el VIH: Por la discriminación histórica hacia la población negra por parte de los sistemas de salud, los hombres negros suelen acudir menos a los servicios médicos. [17] Por consiguiente, es más probable que los HNSH, comparados con HSH blancos, no conozcan su estado serológico, sean diagnosticados tardíamente y descuiden su cuidado y tratamiento médico. [18-19]

Pobreza: Por la discriminación y el reducido acceso y retención en educación de calidad, prevalece más el desempleo o el subempleo en hombres negros que en hombres blancos. [20] Por ello, las posibilidades de vivir en la pobreza son mayores para los hombres negros, lo que también tiende a reducir el acceso a servicios médicos de calidad. [20] Las tasas de VIH aumentan de 3 a 5.5 veces de acuerdo con el incremento de la pobreza de un barrio (menos de 10% en barrios con nivel de pobreza bajo y más de 30% en barrios con nivel de pobreza alto). [21-22] Para las personas negras que viven con VIH, la pobreza está asociada a una menor vinculación en el cuidado médico para el VIH. [23]

Trauma sexual: Las tasas de asalto y abuso sexual son altas en HSH y están vinculadas a un mayor riesgo de infección por el VIH. Un 39% de los HSH en el estudio EXPLORE reportaron haber sufrido abuso sexual durante su niñez; y era más probable que los participantes negros en ese estudio hubieran tenido una historia de asalto sexual que no la hubieran tenido. [24-25]

Enfermedades transmitidas sexualmente (ETS): La presencia de ETS incrementa la probabilidad de transmitir o de contraer el VIH. ETS y tasas altas del VIH en la población negra incrementan la probabilidad de transmisión del VIH. [27-29]

Redes sociales y sexo con hombres de su raza: Las altas tasas del VIH en HNSH y la preferencia por tener relaciones con hombres de su propia raza incrementan la probabilidad de tener una pareja sexual que vive con el VIH. El análisis de varios estudios mostró que al menos un 29% de los HNSH en redes sexuales viven con el VIH; dentro de estas redes, el 47% de los hombres que viven con el VIH desconocen que son portadores del virus. [30]    

¿Qué se está haciendo?

Los resultados de las investigaciones realizadas con hombres negros de diversas edades, orientaciones sexuales y estados serológicos que se detallan a continuación han demostrado reducir las prácticas sexuales de riesgo y han incrementado la participación en el cuidado médico. [31]

Intervenciones comparativas aleatorizadas: Dos estudios "Muchos hombres, muchas voces"(Many Men Many Voices) y "Hermano a hermano" (Brother to Brother) demuestran que existe una relación positiva ya sea entre la reducción del número de instancias de sexo anal sin protección con parejas casuales, el número de cualquier acto sexual anal insertivo sin protección, número de parejas sexuales masculinas, y/o una mayor probabilidad de hacerse la prueba del VIH.

Intervenciones de encuestas pre-post o repetidas: Los HNSH que participaron en las intervenciones "D-up! Connect with Pride", "BRUTHAS", "Motivational Interviewing (MI)" y "Special Projects of National Significance (SPNS)" reportaron mejores resultados que los hombres cuya participación en estas intervenciones fue limitada o nula. Dichos estudios mostraron ya sea una reducción de sexo anal sin protección en diferentes momentos durante la intervención, una reducción de las instancias de sexo anal sin protección con la pareja principal, una reducción en el número de parejas sexuales, más uso del condón con la pareja principal, menos número de encuentros con prácticas sexuales riesgosas con parejas femeninas y/o una reducción de tener sexo bajo la influencia de drogas.

Diferentes estudios también registran un incremento en el apoyo social y la autoestima y disminución de la soledad, así como una mayor probabilidad de hacerse la prueba y consejería para el VIH, regresar a buscar los resultados de la prueba del VIH, y menos citas médicas perdidas. Un estudio demostró que entre más tiempo dedicaban los participantes a las reuniones de manejo de caso, más tiempo dedicaban también al cuidado médico para el VIH.

Estudio mixto de pre-post y grupo de control: Los hombres jóvenes de color que participaron en la intervención denominada STYLE (Strength through youth livin' empowered) reportaron un 83% de retención en el cuidado médico; asimismo, su probabilidad de asistir a sus visitas médicas era mayor que para los que no participaron (2.58, 95% CI 1.34-4.98).

¿Qué falta por hacer?

La prevención del VIH en hombres negros no debe enfocarse solamente en las prácticas sexuales de alto riesgo sino también en los factores sociales y estructurales. Hacen falta políticas sanitarias que prevengan nuevas infecciones, que ayuden a entender las disparidades de transmisión del VIH que existen entre la población blanca y negra y que esclarezcan el papel de las intervenciones estructurales.[32-33] Necesitamos combinar intervenciones biomédicas con intervenciones de comportamiento; entender que las particularidades de los diferentes grupos requieren abordajes distintos; reducir la transmisión de ETS; tener en cuenta circunstancias traumáticas; reducir las barreras estructurales y de acceso; y considerar la intersección de las condiciones de salud y condiciones sociales.

Es también urgente tener en cuenta el estigma y las huellas invisibles que deja. Exposiciones de datos deben integrar el contexto, la perspectiva de la comunidad y explicaciones comprehensivas. Deben desarrollarse estrategias que ayuden a las parejas y a los familiares a escuchar cuando su ser querido revela que es homosexual o que vive con el VIH. También es necesario aplicar ampliamente intervenciones exitosas en aquellas áreas donde las tasas del VIH en los hombres negros son más altas.

¿Quién lo dice?

1. CDC. HIV among Afr. Americans. Feb 2017.

2. Gavett G. Timeline: 30 Yrs. of AIDS in Blk. Americans. KQED Frontline. Jul 10, 2012.

3. Hess K, et al. Est. lifetime risk of dx of HIV infect in the U.S. CROI 2016. Boston, abstract 52.

4. CDC. Lifetime risk of HIV dx. Feb 2016.

5. CDC. HIV in the U.S.: At A Glance. Dec 2, 2016.

6. CDC. HIV among Afr. Am. gay and bisexual men. Jul 2016.

7. Millett GA, et al. Greater Risk for HIV Infect of Blk MSM: Lit Rev. AJPH. Jun 2006;96(6):1007-19.

8. Millet GA, et al. Disparities in HIV Infect among Blk and Wht MSM: Meta-Analysis. AIDS. Oct 1 2007;21(15):2083-91.

9. Magnus M, et al. Elevated HIV Prev. Despite Lower Rates of Sexual Risk Behav among Blk MSM in DC. AIDS Patient Care STDS. Oct 2010;24(10): 615–22.

10. Maulsby C, et al. HIV among Blk MSM in the U.S.: Lit. Rev. AIDS and Behav Jan 2014;18(1):10-25.

11. Cohen SE, et al. Response to race and PH impact potential of PrEP in the U.S. J Acquir Immune Defic Syndr. Sep 1 2015;70(1):e33-e35.

12. Highleyman L. PrEP use rising in U.S. but large racial disparities remain. nam aidsmap. Jun 24, 2016.

13. Chaill S, et al. Stigma, med mistrust, and racism affect PrEP awareness and uptake in Blk compared to Wht MSM in Jackson, MS and Boston, MA. AIDS Care, 2017.

14. Overstreet NM, et al. Internalized stigma and HIV status disclosure among HIV-pos MSM. AIDS Care 2013;25 4, 466-471.

15. Fields EL, et al. Assoc. of Discrimination-Related Trauma with Sexual Risk among HIV-Pos Afr. Am. MSM. AJPH. May 2013;103(5):875-80.

16. Raymond HF, et al. Racial Mixing and HIV Risk among MSM. AIDS Behav Aug 2009;13(4):630-37.

17. Lisa Eaton, et al. Role of Stigma and Med Mistrust in Routine Hlth Care Engagement of MSM. AJPH. Feb 2015;105(2): e75–e82.

18. Levy ME, et al. Understand Structural Barriers to Accessing HIV Test & Prev Servs among Blk MSM in the U.S. AIDS Behav. 2014 May; 18(5): 972–996.

19. Christopoulos KA, et al. Link and Retention in HIV Care among MSM in the U.S. Clin Infect Dis. 2011 Jan 15; 52(Suppl 2): S214–S222.

20. Ethnic and Racial Minorities and SES. Factsheet. APA.

21. Alameda Co. CA eHARS data (2008-2012). Verbal communication with Nina Murgai, Dir, HIV/AIDS Surv Unit.

22. Wiewel EW, et al. Assoc bwt Neighborhood Poverty and HIV Dx among Males and Females in NYC, 2010-2011. PH Rep. Mar-Apr 2016;131(2):290-302.

23. Lechtenberg RJ, et al. Poverty, Race, Engagement: Diff Assoc with Retention in Care among PLWH in Alameda Co. UCSF CFAR HIV Hlth Disparities Symposium, Mar 24, 2017.

24. Mimiaga MM, et al. Child Sexual Abuse Assoc with HIV Risk–Taking Behav and Infect among MSM in the EXPLORE Study. J Acquir Immune Defic Syndr. 2009 Jul 1:51(3):340-348.

25. Millett GA, et al. Rev of HIV epidemics in Blk MSM across African diaspora. Lancet. Jul 28 – Aug 3;380(9839):411-23.

26. CDC. STDs and HIV – CDC Factsheet. Nov 17, 2015.

27. CDC. 2015 STDs Surveillance – STDs in Racial and Ethnic Minorities. Jan 23, 2017.

28. Scott HM, et al. Racial/ethnic and sexual behav disparities in rates of STIs, SF (1999-2008). BMC Pub Hlth. Jun 6, 2010;10:315.

29. Pathela P, et al. MSM have higher risk for newly dx HIV and syphilis compared with heterosexual men in NYC. J Acquir Immune Defic Syndr. Dec 1, 2011;58(4):408-16.

30. Hurt CB, et al. Invest Sexual Network of Blk MSM: Implications for Transmission and Prev of HIV Infect in U.S. J Acquir Immune Defic Syndr. Dec 1, 2012;61(4):515-21.

31. Maulsby C, et al. Rev of HIV Interv for Blk MSM. BMC Pub Hlth. 2013;13:625.

32. Peterson, JL, et al. Soc. discrimination and resiliency not assoc with differ in HIV infect in blk and wht MSM. JAIDS 2014:66;538-543.

33. Sullivan PS, et al. Understand racial HIV/STI disparities in blk and wht MSM. PLoS One 2014;9: e90514.

Gracias a Emily Arnold, Jesse Brooks, Lorenzo Hinojosa, Loren Jones, Micah Lubensky, Daryl Mangosing, Janet Myers, Nasheedah Bynes-Muhammad, Rob Newells, John Peterson, Greg Rebchook, Andrew Reynolds y Wilson Vincent por revisar esta hoja informativa. Agradecemos la reproducción y la difusión de esta hoja, siempre que sea de manera gratuita y que se cite a la University of California San Francisco.

©2017, University of CA. Preguntas y comentarios pueden enviarse a [email protected].

Esta publicación es un producto del Centro de Investigación sobre la Prevención con el apoyo de los Centros de Control y Prevención de Enfermedades (Cooperative Agreement Number 5U48DP004998).

Childhood sexual abuse may be defined in many ways, but this fact sheet refers to unwanted sexual body contact prior to age 18, the age of consent to engage in sex. CSA is a painful experience on many levels that can have a profound and devastating effect on later physiological, psychosocial and emotional development. CSA experiences can vary with respect to duration (multiple experiences with the same perpetrator), degree of force/coercion or degree of physical intrusion (from fondling to digital penetration to attempted or completed oral, anal or vaginal sex). The identity of the perpetrator–ranging from a stranger to a trusted figure or family member–may also impact the long-term consequences for individuals. To distinguish CSA from exploratory sexual experimentation, the contact should be unwanted/coerced or there should be a clear power difference between the victim and perpetrator, often defined as the perpetrator being at least 5 years older than the victim. Many more children are sexually abused than are reported to authorities. Estimates of the prevalence of CSA in the US are about 33% for females under the age of 18 and 10% in males under 18 years of age. Men are significantly less likely than women to report CSA when it occurs. CSA is more likely to occur in families under duress. Children are at risk for CSA in families that experience stress, poverty, violence and substance abuse and whose parents and relatives have histories of CSA.

CAPS and Centerforce, a community-based organization that has been providing services to prisoners and their families for thirty years, have been collaborating since 1993 to design and evaluate HIV prevention interventions for incarcerated men and their female partners. Our previous work with male prisoners includes the evaluation of a peer-led HIV education orientation for arriving prisoners; development and evaluation of a prerelease intervention for men leaving prison; development and evaluation of a health promotion intervention for HIV+ prisoners preparing for release;3 and a multi-site study to conduct formative research and develop and test an HIV, STD and hepatitis intervention for young men preparing for release from prison. Early in the course of these studies, men expressed a need for HIV prevention interventions specifically tailored for the needs of the women with whom they were in romantic and sexual relationships. In response, we conducted formative research with women visiting men imprisoned in a California state prison and we piloted a single session intervention designed for this population that was taught by a peer educator. Our formative work with women visiting incarcerated men indicated that it was feasible to engage women in intervention and research evaluation activities. However, a single-session intervention did not have a measurable effect on the HIV risk behavior of study participants. We decided to develop a multi-component intervention targeting the specific needs of women with incarcerated male partners. We designed and evaluated Health Options Mean Empowerment (HOME), an intervention to reduce HIV risk among women whose male partner was being released from state prison.