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Can Healthcare Workers Help in HIV Prevention?

revised 4/99

Are healthcare providers important in prevention?

Yes. Healthcare providers have many opportunities to help foster the behavior changes needed to stem the spread of HIV infection. In the US in 1996, the average adult visited a physician 3 times a year. Overall, 82% of visits were in physician offices and 10% in emergency departments.¹ Visits with healthcare providers or other encounters with the healthcare system are “teachable moments”-opportunities for discussing sexual and drug-use risks in a manner relevant to individual patients’ lives. Healthcare providers in environments with large numbers of high-risk patients such as emergency departments, sexually transmitted disease (STD) clinics, methadone maintenance clinics and prison or jail clinics, can be crucial for HIV prevention. For example, men, women and adolescents who have been incarcerated have high rates of HIV, STDs and tuberculosis, as well as substance abuse problems, and would benefit from preventive information and medical services.² In a nationwide survey of adults, only 20% of patients had discussed HIV risks with their doctors in the previous five years. Only 21% of those who did talk to a physician said the physician initiated the discussion. And only 23% of those who reported a behavioral risk for HIV had spoken to their physician about AIDS.³

What are barriers to discussing HIV?

HIV prevention requires the ability to talk about sexuality and drugs in an open manner, which may be uncomfortable. Healthcare providers need training in initiating discussions, negotiating awkward moments, responding to fears and expectations, encouraging patient feedback and being empathic. Ways to help foster these skills include instructors acting as patients for role-play and videotaped feedback on clinical performance.⁴ Lack of time can be a huge barrier to discussing HIV risks for healthcare providers. Many hospitals, clinics and health maintenance organizations (HMOs) require healthcare providers to address prevention in many other areas such as diet and exercise, smoking, depression, diabetes, heart disease and cancer. With a limited amount of time allotted each patient, healthcare providers may feel there is not enough time to also discuss sensitive issues such as sexuality and drug use.

What can healthcare providers do?

Assessing HIV risk behaviors should be a standard part of new patient intake. In-depth AIDS prevention education is not necessary for each and every patient. However, healthcare providers should ask all patients about condom use, number of sexual partners, sexual orientation and injection drug use to assess a patient’s risk for HIV. These quick questions may lead to longer discussions and counseling about safer sex or drug use practices. Healthcare providers who don’t have the time or comfort for these discussions can refer patients to toll-free hotlines or community-based public health programs. Healthcare providers can provide HIV counseling and testing to patients who request it, and recommend testing to patients at high risk for HIV. These include patients with STDs, especially adolescents, injection drug users (IDUs), women whose partners may be IDUs and patients who are unsure of their partner’s HIV status.⁵ Helping patients get into drug treatment can be an effective HIV prevention tool. Healthcare providers can have a profound effect on patients’ lives by showing an interest in drug-using patients and encouraging willing patients to enter a drug or alcohol treatment program. Because relapse is common in treating addictions, healthcare providers should use a non-judgmental attitude.⁶ Healthcare providers who work with HIV+ patients can help prevent HIV transmission by assessing patients’ risky sexual and needle-use behaviors and counseling them to reduce those unsafe behaviors.⁷ This is especially important with the advent of more effective treatments for HIV. For example, HIV+ patients may believe that if they have a low or undetectable viral load, they cannot transmit HIV. Opportune moments for counseling are: at diagnosis, at onset of symptoms and when beginning drug treatment.⁸

Can treatment promote prevention?

Yes. Diagnosing and treating STDs such as syphilis and gonorrhea can help protect against HIV transmission. Early detection and treatment of STDs can be crucial, as STD infections make it easier to both get HIV and transmit it to others. In areas and populations with high rates of STDs and low rates of HIV infection, treating STDs is an effective means to prevent HIV infection.⁹ In recent years, great advances have been made in preventing HIV transmission from mother to infant. Healthcare providers should offer HIV testing to all pregnant women. Treating HIV+ mothers and their babies with AZT has been shown to reduce transmission by two-thirds. HIV+ mothers should also be counseled on the risk of breastfeeding and provided with alternates to breast milk if needed.¹⁰ Post-exposure prophylaxis (PEP) is a method for potentially preventing HIV transmission by administering AZT and other anti-HIV drugs within 72 hours of an accidental exposure to HIV. Studies of occupational PEP have found that HIV transmission can be prevented by post-exposure treatment, and PEP is now recommended by the Centers for Disease Control and Prevention (CDC) for occupational exposure among healthcare workers.¹¹ PEP is currently being piloted for exposure via sexual or drug use activities, including sexual assault. The CDC has not yet endorsed this due to lack of research data directly from drug and sexual exposure.¹²

What’s being done?

Healthcare providers need access to training and medical updates. One program trained rural healthcare providers in HIV/AIDS information, how to conduct risk assessments, advances in treatments, and sensitivity to diverse populations. The most effective training was achieved with a self-study booklet which helped increase prevention, early intervention and health promotion among rural health care providers. This booklet is now available free of charge on the Internet. Interactive teleconference training and personal training from visiting educators were also effective.¹³ Healthcare providers need to address the multiple needs of patients. In Bangalore, India, the Well Woman Clinic was established as part of an HIV control program. Poor women, especially commercial sex workers, had been underserved, had high rates of STDs and were at high risk for HIV. Because women are conditioned to ignore or tolerate health problems, patients at the Clinic are automatically screened for STDs without having to admit to any symptoms.¹⁴ Healthcare providers need to take advantage of community-based services. Children’s Hospital Los Angeles teamed with community-based prevention organizations to provide an integrated care model for youth with and at high risk for HIV infection. The model offers a general medical clinic for youth and psychosocial services such as counseling and case management. Peer educators also conduct extensive street outreach where high-risk youth congregate. The program developed a computerized referral system for local youth services available on the Internet.¹⁵

Will enhancing healthcare providers’ involvement be enough?

Enhancing healthcare providers’ involvement is only one aspect of a broad prevention policy. A comprehensive HIV-prevention strategy uses multiple elements to protect as many people at risk of HIV infection as possible. HIV prevention is not a “one-shot” effort; it is an ongoing process that demands the involvement of many sectors of society. This includes the physicians, nurses, health educators, therapists, dentists and other healthcare providers to whom people look for advice on how to stay healthy.

Says who?

1. Schappert SM. Ambulatory care visits to physician offices, hospital outpatient departments, and emergency departments: United States, 1996 . Vital and Health Statistics. 1998;134:1-37. 2. Hammett TM, Gaiter JL, Crawford C. Reaching seriously at-risk populations: health interventions in criminal justice settings . Health Education and Behavior. 1998;25:99-120. 3. Gerbert B, Bleecker T, Bernzweig J . Is anybody talking to physicians about acquired immunodeficiency syndrome and sex? A national survey of patients. Archives of Family Medicine. 1993;2:45-51. 4. Epstein RM, Morse DS, Frankel RM, et al. Awkward moments in patient-physician communication about HIV risk. Annals of Internal Medicine. 1998;128:435-442. 5. American Medical Association. Physician Guide to HIV Prevention. June 1996. 6. Herman M, Gourevitch MN. Integrating primary care and methadone maintenance treatment: implementation issues . Journal of Addictive Diseases. 1997;16:91-102. 7. Gerbert B, Brown B, Volberding P, et al. Physicians’ transmission assessment and counseling practices with their HIV-seropositive patients. AIDS Education and Prevention. In press. 8. Gerbert B, Love C, Caspers N et al. “ Making all the difference in the world”: how physicians can help HIV-seropositive patients become more involved in their healthcare . AIDS Patient Care and STDs. 1999;13:29-39. 9. Centers for Disease Control and Prevention. HIV prevention through early detection and treatment of other sexually transmitted diseases-United States . Morbidity and Mortality Weekly Report. 1998;47(RR-12):1-25. 10. Centers for Disease Control and Prevention. Update: perinatally acquired HIV/AIDS-United States, 1997 . Morbidity and Mortality Weekly Report. 1997;46:1086-1092. 11. Centers for Disease Control and Prevention. Management of health-care worker exposures to HIV and recommendations for postexposure prophylaxis . Morbidity and Mortality Weekly Report. 1998;47(RR-7):1-33. 12. Centers for Disease Control and Prevention. Management of possible sexual, injecting drug-use, or other non-occupational exposure to HIV, including considerations related to antiretroviral therapy . Morbidity and Mortality Weekly Report. 1998;47(RR-17):1-14. 13. Martin SJ. HIV/AIDS prevention, early intervention and health promotion: results of training for rural health care providers. Presented at the 9th National AIDS Update Conference, San Francisco, CA. March 19, 1997. 14. Baksi CM, Harper I, Raj M. A `Well Woman Clinic’ in Bangalore: one strategy to attempt to decrease the transmission of HIV infection . International Journal of STDs & AIDS. 1998;9:418-423. 15. Schneir A, Kipke MD, Melchior LA, et al. Children’s Hospital Los Angeles: a model of integrated care for HIV-positive and very high risk youth. Journal of Adolescent Health. 1998;23(2Suppl):59-70. Computerized referral system:www.caars.net

Prepared by Pamela DeCarlo*, Barbara Gerbert, PhD** and the Center for Health Improvement and Prevention Studies** *CAPS, **Division of Behavioral Sciences, UCSF April 1999. Fact Sheet #6ER

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 1999, University of California

What Is the Role of Counseling and Testing in HIV Prevention?

why is C&T important?

HIV counseling and testing (C&T) is an important part of a continuum of HIV prevention and treatment services. C&T is one of the main times when a comprehensive individual risk assessment is taken, making it the best opportunity for accurate referrals to more intensive services. C&T is also one of the primary entry points into prevention and other services. C&T uses short, client-centered counseling that can be effective in increasing condom use and preventing sexually transmitted diseases (STDs).¹ Knowing one’s HIV status, whether HIV- or HIV+, is key to preventing the spread of HIV and accessing counseling and medical care. It is estimated that one-fourth of all HIV+ persons in the US do not know they’re infected.² A survey of young men who have sex with men (MSM), found that 14% of young Black MSM were HIV+. Among those, 93% were unaware of their infection, and 71% reported it was unlikely they were HIV+.³ Recently, the Centers for Disease Control and Prevention (CDC) announced an initiative aimed at expanding C&T in the US.⁴ Their Strategic Plan for 2005 strives to decrease by 50% the number of people who don’t know their HIV status.⁵ If this goal is met by 2010, an estimated 130,000 new HIV infections may be prevented, saving over $18 billion.⁶

how is C&T done?

C&T has three distinct components: risk assessment and counseling before the blood or oral sample is taken, testing of the sample, and counseling and referral with the test results.⁷ C&T can be confidential-a person’s name is recorded with the test results-or anonymous-no name is recorded with the test. Publicly funded HIV C&T takes place in testing centers, community health clinics, community-based organizations, outreach programs, mobile vans, STD and family planning clinics and local health departments, among other venues. Although public health workers are trained in C&T procedures, most HIV testing in the US occurs in private doctors’ offices. Many people prefer being tested as part of a routine check-up, instead of public health sites. However, testing in private venues does not offer anonymity, and patients who get tested as part of routine medical care may not receive adequate counseling or referrals.⁸ Other venues also test for HIV, such as emergency rooms, jails/prisons, military recruitment sites and Job Corps. HIV testing in the US is mandatory to get some insurance and medical benefits, apply for some jobs, join the military, give blood or enter the US as an immigrant. HIV testing is compulsory for federal prison inmates and sex offenders in some states.

what about rapid testing?

The standard testing method for the past 20 years has been a needle blood draw. In the past 10 years, a mouth swab (OraSure) that tests cells from inside the cheek has also been available. Results are sent to a lab for the ELISA test and a Western Blot to confirm an initially positive result, with an average wait of 1-2 weeks between sample collection and the provision of results. With this method, many persons don’t return for their test results, and nationally 31% of persons who test HIV+ don’t return to find out their results.⁴ Rapid testing is now available with a finger stick (OraQuick). With this method, results are known in 20 minutes, eliminating the need for a return visit for results. However, if a client’s tests is reactive, he receives a preliminary positive result. A second blood test (needle draw or OraSure) is required to confirm the result with a standard Western Blot. Final confirmation still takes 1-2 weeks. National data indicate that with rapid testing, 95% of clients who received a preliminary positive result returned for their confirmatory results.⁹ Rapid testing will change the way C&T is conducted, although clients can still opt to get their results later. Because the client needs to wait for 20 minutes for the results, the counselor takes the blood early in the session and has a “captive audience” for risk assessment and counseling. Test counselors can conduct the blood test themselves, or a separate staff person can do the finger stick and read results. Counseling with rapid testing can be more intense and client-focused due to the immediacy of getting results. It is hoped that rapid testing will dramatically increase the number of persons who know their results.

what makes good C&T?

Good C&T depends on counselors who are properly trained and have enough experience. Counselors must protect the confidentiality of client information, obtain informed consent before testing and provide effective counseling services and appropriate referrals. Counselors should establish relationships with key service agencies to make sure the referrals they give clients reflect their needs, priorities, culture, age, sexual orientation and language. C&T counselors should be evaluated regularly to assure quality and be provided with support and ongoing training.⁷ With rapid testing, counselors need different training as they can be both the counselor and the lab. Rapid testing requires stable temperatures, adequate lighting, and careful attention to detail. Also, rapid testing is not rapid counseling. Counselors need to work closely with clients to develop a reasonable risk reduction step and to make sure their clients are actually ready to receive the test results. It is also important to obtain a second blood sample for confirmation if a client tests positive.¹⁰

what’s being done?

The Department of Public Health (DPH) in Florida made a deliberate effort to improve their C&T services and increase the number of people who know they are HIV+. State funded testing sites targeted venues with high-risk persons, including CBOs, prisons/jails and outreach settings. They also began using OraSure for testing in the field. In 2002, the DPH reported a 2% seropositive rate for blood draws and 3.2% for OraSure. In jails they found a 3.6% seropositive rate. They also used partner counseling and referral services (PCRS) and in 2002, 80% of HIV+ people gave names of partners, 64% of partners were located and counseled, and 13% of partners who tested were HIV+.¹¹ In Minneapolis, MN, rapid testing was offered at a variety of agencies serving primarily African American clients. Venues included drug treatment programs, homeless shelters, teen clinics, sex offender groups and halfway houses. Almost all (99.7%) of clients received their test results and counseling, and 95% reported they would rather have a finger stick than a blood draw.¹² Wisconsin’s AIDS/HIV Program wanted to increase the number of high-risk persons accessing testing. In the early 90s, tests jumped from 6000 per year to between 20,000-30,000. The number of high-risk persons tested, however, remained the same while seroprevalence rates dropped from 3.5% to 0.5%. In the late 90s, the program shifted its philosophy from one of public education to case finding. Publicly funded sites were reduced from 126 to 55 serving the greatest percentage of high-risk persons and persons of color. In one year, the seroprevalence rate improved to .75%, the number of low-risk persons tested decreased 42%, high-risk persons tested increased 6%, and testing among persons of color improved 18%.¹³

what is the future of C&T?

As rapid testing becomes more widely used, it is hoped that the number of people not returning for their test results will decrease. Rapid testing can allow for more targeted outreach to communities and persons at risk, as C&T occurs in venues that are more accessible and acceptable. Rapid testing should be implemented carefully to allow time for agencies to gain experience and clients to understand the new testing process. Greater efforts may be necessary to refer clients to effective services. Behavior change is a slow and difficult process, and many persons make changes incrementally. Linkages to other services and follow-up with clients may substantially increase the impact of the initial counseling. While training and quality assurance has traditionally centered on counseling in C&T, referrals may be the weakest part and need most improvement. Simply increasing the number of persons who know they are HIV+ will not slow the HIV epidemic sufficiently. As more persons in the US discover their HIV status, it is crucial to ensure that more prevention, social and treatment services are available both to HIV+ and HIV- persons. In addition to primary HIV prevention interventions, these should include access to quality drug and alcohol treatment, housing and employment services, STD testing and treatment, syringe exchange programs, quality medical care and adherence support to insure effective use of AIDS medications. Prepared by Steven R. Truax, PhD*, Pamela DeCarlo** *California State Office of AIDS, **CAPS

Says who?

1. Kamb ML, Fishbein M, Douglas JM,et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases. Journal of the American Medical Association. 1998;280:1161-1167. 2. Fleming P, Byers RH, Sweeney PA, et al. HIV prevalence in the United States, 2000. Presented at the 9th Conference on Retroviruses and Opportunistic Infections, Seattle, WA; February 24-28, 2002. 3. Centers for Disease Control and Prevention. Unrecognized HIV infection, risk behaviors and perceptions of risk among young black men who have sex with men – six US cities, 1994-1998. Morbidity and Mortality Weekly Reports. 2002;33:733-736. 4. Centers for Disease Control and Prevention. Advancing HIV Prevention: New Strategies for a Changing Epidemic – US, 2003. Morbidity and Mortality Weekly reports. 2003:52;329-332. https://pubmed.ncbi.nlm.nih.gov/12733863/  5. Centers for Disease Control and Prevention. HIV Prevention Strategic Plan Through 2005. www.cdc.gov/hiv/partners/ psp.htm 6. Holtgrave DR, Pinkerton SD. Economic implications of failure to reduce incident HIV infections by 50% by 2005 in the United States. Journal of Acquired Immune Deficiency Syndromes. 2003;33:171-174. 7. Centers for Disease Control and Prevention. Revised Guidelines for HIV Counseling, Testing, and Referral. Morbidity and Mortality Weekly Reports. 2001;50. 8. Haidet P, Stone DA, Taylor WC, et al. When risk is low: primary care physicians’ counseling about HIV prevention. Patient Education and Counseling. 2002;46:21-29. 9. Kassler WJ, Dillon BA, Haley C, et al. On-site, rapid HIV testing with same-day results and counseling. AIDS. 1997;11:1045-1051. 10. Fournier J, Morris P. Speed bumps and roadblocks on the road to rapid testing: a look at the integration of HIV rapid testing in an agency and community. Presented at the US Conference on AIDS, New Orleans, LA, 2003. 11. Liberti T. Florida’s HIV counseling, testing and referral program. Presented at the US Conference on AIDS, New Orleans, LA, 2003. 12. Keenan PA. HIV outreach in the African American community using OraQuick rapid testing. Presented at the National HIV Prevention Conference, Atlanta, GA. 2003. 13. Stodola J. Restructuring Wisconsin’s HIV CTR program: targeting CTR services. Presented at the US Conference on AIDS, New Orleans, LA, 2003.

January 2004. Fact Sheet #3ER Special thanks to the following reviewers of this Fact Sheet: Jena Adams, Barbara Adler, Chris Aldridge, Teri Dowling, Barbara Gerbert, Paul Haidet, Sydney Harvey, Willi McFarland, Patrick Keenan, Kathryn Phillips, Jim Stodola, Brenda Storey, Ed Wolf.

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 2004, University of California

What are the HIV Prevention Needs of Young Men Who Have Sex with Men?

revised 4/01

Are young MSM at risk for HIV?

Yes. Over half of all the reported HIV and AIDS cases among males aged 13-24 in the US were due to male-male sexual contact.¹ Various studies found that 26% to 50% of young men who have sex with men (MSM) report recent unprotected anal intercourse, and much of this unprotected sex occurred with a partner of unknown or different HIV status.^2-4 Rates of sexual risk-taking among young MSM are also increasing.⁵ The term young MSM includes men who self-identify as gay or bisexual, as well as non-gay/bi-identified MSM under 30 years old.⁶ A large number of urban young MSM are already infected with HIV. A study of 15- to 22-year-old young MSM in seven cities (Baltimore, MD; Dallas, TX; Los Angeles, CA; Miami, FL; New York, NY; San Francisco Bay Area, CA and Seattle, WA) showed a high overall HIV prevalance: 7%, ranging from 2% -12%. Moreover, 82% of the HIV+ men had no idea they were HIV+ before this testing. Young MSM of color, especially African American men, are disproportionately impacted. In the multi-city study, 14% of the African Americans tested HIV+, compared to 13% among mixed race men, 7% among Hispanics, 3% among Asians and 3% among whites.⁶

Why do young MSM take risks?

Unfortunately, there are no simple answers to this question. The explanations for unsafe sex are complex and multi-faceted.^3,7 Adolescence and young adulthood are often characterized by experimentation and exploration of sexuality and drug using. While most young MSM will engage in some HIV risk behaviors at some point in their lives, only a small percentage are consistent risk takers. Many young MSM struggle with individual, interpersonal and societal stressors that may interfere with their ability to protect themselves.⁸ For some young MSM, individual factors can lead to unsafe sex, such as: feeling invulnerable to HIV; having high levels of optimism about HIV antiviral medications; perceiving that unsafe sex is more pleasurable than safer sex; being depressed or sad; having conflicting allegiance with either their racial or sexual identity; and using alcohol or other drugs (e.g. speed/crystal, poppers).⁸ Protecting one’s health is not necessarily a young MSM’s top concern. Interpersonal motivations may be more pressingwanting to fit in, to find companionship and intimacy. However, interpersonal issues can also contribute to unsafe sex, such as finding it difficult to communicate or negotiate safer sex with a sexual partner. Young MSM who are in a relationship are more likely to have unsafe sex than single young MSM.⁴ Societal factors may also influence the risk-taking of young MSM. Many young MSM find themselves isolated or rejected by traditional sources of support like family, school, or religious community.⁹ Homophobia, racism and poverty also place young MSM at risk. Some young MSM, especially those living on the street, are struggling with daily needs like avoiding violence, finding a place to live, or obtaining food. These pressing needs may overshadow the concern for safer sex and injection practices. Young MSM have few public places to meet each other. Gay bars and public cruising areas are some of the more visible and accessible places, offering anonymity for young men exploring their sexual identity. These venues are also associated with high levels of risk-taking. They are highly sex-charged and the bar scene’s emphasis on alcohol sets the stage for engaging in sex while intoxicated. This is consistently found to contribute to unsafe sex.¹⁰ Little is known about the Internet’s role in the lives of young MSM, including how young MSM use the Internet to obtain social support, make new friends, find romantic partners, and/or cruise for sex.

What’s being done?

The Mpowerment Project is a multilevel, sex- and gay-positive, peer-based intervention in which young men take charge. Because HIV may not be particularly compelling for many young MSM, the project focuses on young MSM’s social concerns. The young men plan and coordinate activities to create a stronger and healthier community for themselves in which safer sex becomes the mutually accepted norm. Participants in the Project have reduced rates of unprotected anal intercourse with casual partners and boyfriends. Mpowerment, proven effective as an HIV prevention intervention, provides CBOs with training and a manual for replication.¹¹ The COLOURS Organization in Philadelphia, PA targets young MSM of color with support groups, peer educator training and individual case management. They do street outreach at sex clubs and bars frequented by MSM of color, providing condoms and counseling to young MSM who partner with older men. They also promote gay-friendly drug and alcohol treatment services for young MSM.¹² The American Psychological Association has implemented the Healthy Schools Project for Lesbian and Gay Students. The Project trains school psychologists, counselors, nurses and social workers to work effectively with gay, lesbian and bisexual students. The goal is to make schools a friendlier environment for these students and make HIV prevention education more relevant to them.¹³ “Chico Chats,” a program of the STOP AIDS Project in San Francisco, CA, consists of a one-month intensive series of workshops. Participants get to know each other while engaging in facilitated conversations about body image, relationships and identity and how these issues relate to HIV. Learning community organizing and mobilization techniques is a key component of these workshops as well. Participants formed an activist group called ¡Ya Basta! (Enough Already) and designed a video and workshop examining the issues of sexual silence and coming out in Latino families. The video is being shown throughout Latino communities in San Francisco.¹⁴

What else needs to happen?

Effective programs for young MSM must address the context of their lives and the individual, interpersonal and societal factors that put them at risk. Comprehensive health and sexuality education must target both those who identify as gay or bisexual and those who do not. Unfortunately, many school-based programs focus on reproduction or abstinence until marriage, further marginalizing young MSM. There is an urgent need to create prevention and wellness programs specifically for young MSM of color. Existing programs for older MSM of color should also be accessible to young MSM. These programs should address issues of sexuality, gay identity, culture, race/ethnicity, racism, homophobia, poverty and violence. Programs must also consider the HIV prevention needs of both HIV positive and HIV negative young MSM. Special attention is necessary to reach marginalized young MSM, such as those who are homeless, engaged in commercial sex work or involved with the criminal justice system. These young men may not identify as gay or bisexual, and may have immediate needs for food and shelter to address. Programs are needed that foster support for young MSM and involve them directly in planning and implementation. Support might encompass creating safe places for young MSM to socialize and access services, developing school-based sexuality and gay-awareness programs and helping young MSM advocate for greater acceptance by schools, families, religious communities, the gay community at large and communities of color.¹⁵ Societal homophobia may impede implemention of prevention programs for young MSM and may discourage young MSM from accessing prevention services.¹⁶ Political concerns must not be allowed to interfere with HIV prevention services for young MSM. Targeting young MSM with HIV prevention messages and services is an appropriate response to a grave public health threat. Unless action is taken quickly, we will lose many young men to HIV.

Says who?

1. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report . 2000;12.
2. Molitor F, Facer M, Ruiz JD. Safer sex communication and unsafe sexual behavior among young men who have sex with men in California. Archives of Sexual Behavior. 1999;28:335-343.
3. Kegeles SM, Hays RB, Pollack LM, et al. Mobilizing young gay and bisexual men for HIV prevention: a two-community study . AIDS. 1999;12:1753-1762.
4. Hays RB, Kegeles SM, Coates TJ. Unprotected sex and HIV risk-taking among young gay men within boyfriend relationships . AIDS Education and Prevention. 1997;9:314-329.
5. Ekstrand ML, Stall RD, Paul JP et al. Gay men report high rates of unprotected anal sex with partners of unknown or discordant HIV status . AIDS. 1999;13:1525-1533.
6. Valleroy LA, MacKellar DA, Karon JM et al. HIV prevalence and associated risks in young men who have sex with men . Young Men’s Survey Study Group. Journal of the American Medical Association. 2000;284:198-204.
7. Strathdee SA, Hogg RS, Martindale SL et al. Determinants of sexual risk-taking among young HIV-negative gay and bisexual men . Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 1998;19:61-66.
8. Choi KH, Kumekawa E, Dang Q et al. Risk and protective factors affecting sexual behavior among young Asian and Pacific Islander men who have sex with men: Implications for HIV prevention . Journal of Sex Education & Therapy. 1999;24:47-55.
9. Beeker C, Kraft JM, Peterson JL, et al. Influences on sexual risk behavior in young African-American men who have sex with men. Journal of the Gay and Lesbian Medical Association. 1998;2:59-67.
10. Greenwood GL, White EW, Page-Shafer K, et al . Correlates of heavy substance use among young gay and bisexual men: The San Francisco Young Men’s Health Study . Drug and Alcohol Dependence. 2001:61:105-112.
11. CDC. Compendium of HIV prevention interventions with evidence of effectiveness . 1999.
12. The COLOURS Organization, Inc . Philadelphia, PA. 215/496-0330.
13. Clay RA. Healthy Schools project hoped to ease discrimination . APA Monitor. 1999;30.
14. The STOP AIDS Project . Q Action, ¡Ya Basta! San Francisco, CA. 415/865-0790×303.
15. Seal DW, Kelly JA, Bloom FR, et al. HIV prevention with young men who have sex with men: what young men themselves say is needed . AIDS Care. 200;12:5-26.
16. Stokes JP, Peterson JL. Homophobia, self-esteem, and risk for HIV among African American men who have sex with men . AIDS Education and Prevention. 1998;10:278-292.

Prepared by Pilgrim Spikes MPH Phd, Bob Hays PhD, Greg Rebchook PhD, Susan Kegeles PhD, CAPS April 2001. Fact Sheet 8ER

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

¿Qué necesítan los sordos en la prevención del VIH?

¿están a riesgo de contraer el VIH?

Si. Se estima que en los EEUU existen de 7,000 a 26,000 personas carentes del sentido auditivo infectadas con el VIH.¹ Sin embargo, los Centros para el Control de Enfermedades (CDC por sus siglas en Inglés) actualmente no recopilan información acerca de los que padecen de sordera y VIH o SIDA. Maryland fue el primer estado en incluir preguntas relacionadas con el sentido auditivo en el área de consejería y al realizar pruebas de detección. En Maryland, el 4.3% de la población sorda padecen de la infección con VIH.² Existen cerca de dos millones de personas que no pueden oir, y una de cada 10 Norteamericanos padecen de problemas auditivos. Las personas que carecen del sentido auditivo han luchado por mucho tiempo por obtener igualdad en acceso a servicios sociales y médicos, educación y empleos. Actualmente en los EEUU, existe poca información sobre VIH y sordera, pocos servicios de prevención o tratamiento, y escasa investigación para los sordos.³

¿cuáles son los factores de riesgo?

Existen altos índices de abuso de substancias en la communidad sorda. Una de cada siete personas (1 de 7) que no oyen tiene una historia de abuso de sustancias versus una de cada diez (1 de 10) reportada por la población sin problemas auditivos.³ El abuso de las sustancias puede ser un factor de riesgo para contraer el VIH ya que reduce la inhibición y altera el juicio, lo cual puede conducir a conductas sexuales poco seguras. Compartir el equipo de inyección es otro de los riesgos de transmisión del VIH. Existe muy poca educación sobre el VIH o sobre sexualidad en las escuelas para sordos, especialmente en escuelas para adolescentes. Debido a esto, las personas sordas poseen un menor conocimiento y están menos concientes de los riesgos de transmisión del VIH, tratamiento y prevención. Si los niños sordos no aprenden sobre el VIH u otras enfermedades de transmisión sexual, no van a tener el vocabulario adecuado para hablar del tema entre ellos. Un estudio entre estudiantes de una escuela para sordos descubrió que los adolescentes del 9 al 12 grado tenían un conocimiento extremadamente limitado sobre el SIDA. Los estudiantes solamente acertaron 8 de la 35 preguntas básicas sobre SIDA.⁴ Los hombres sordos que tienen sexo con hombres pueden sufrir discriminación dentro de la comunidad de sordos. Por este motivo, los hombres sordos que tienen sexo con hombres esconden a menudo su identidad y pueden llegar a presentar comportamientos sexuales furtivos, anónimos y de mucho riesgo. Muchos hombres sordos que tienen sexo con hombres también desean tener relaciones con hombres no sordos, lo cual dificulta aún mas la comunicación sobre la práctica segura del sexo.³ Se ha descubierto que los niños discapacitados, incluyendo a niños sordos, están a mayor riesgo de sufrir abuso sexual tanto en la escuela como en el hogar. En un estudio a niños sordos y no sordos de un instituto de lenguaje se descubrió que el 54% de los varones sordos reportó abuso, comparado con el 10% reportado por los no-sordos. Las niñas sordas reportaron índices de abuso del 50% comparado con el 25% reportado por las niñas no sordas. El abuso sexual a temprana edad es un fuerte indicador de los comportamientos sexuales de alto riesgo, del abuso de sustancias, e infección con VIH en la edad adulta.⁶

¿cuáles son las barreras en la prevención?

Para la mayoría de las personas sordas en los EEUU, el Lenguaje Americano de Signos (ASL) es su primer idioma, Inglés o Español el segundo. El ASL es un lenguaje complejo de gestos y señales con su propia gramática y sintaxis. La única forma de comunicarse en ASL es cara a cara. El material escrito sobre VIH en ASL Gráfico disponible es escaso. Aunque algunas personas sordas pueden leer material escrito tales como los panfletos utilizados en la prevención del VIH, para algunas personas sordas con un nivel de Inglés o Español limitado, estos panfletos son ineficaces.⁷ La comunidad sorda es un grupo muy unido, esto a veces significa que así como se recibe un fuerte apoyo a veces lo que se recibe es una fuerte condena. La privacidad es muy importante en esta comunidad donde las noticias vuelan muy rápido. Muchas personas sordas prefieren ir solas a hacerse la prueba de detección del VIH y a recibir consejería totalmente oral ya que traer a un intérprete o ir a una clínica para sordos pone a riesgo su privacidad aunque también a la misma vez exponen la comunicación y la comprensión.⁸ El hacerse la prueba usando un equipo casero de detección del VIH tampoco ofrece la solución al problema de la privacidad ya que estas personas necesitan a un intérprete por medio del teléfono o a través de un intermediario para conocer los resultados.

¿qué puede ayudar en la prevención?

Conocer las áreas mas fuertes de esta comunidad puede ser muy útil en los esfuerzos de prevención. El hecho de que esta comunidad sea tan unida significa que existe un mayor grado de intimidad física y emociónal. La naturaleza visual del ASL requiere tratar temas como el sexo y el uso de las drogas abiertamente y con mucha franqueza. Cuando estos temas salen a la luz, las personas sordas a menudo se sienten mas cómodas al hablar del los temas, logrando al unísono un mayor entendimiento y una mejor negociación en cuanto al comportamiento seguro.⁸ Las instituciones para sordos deben tratar temas que tradicionalmente han estado tapados o que han sido tabú en esta comunidad, tales como el abuso de la drogas y el alcohol, el abuso sexual a temprana edad y la homofobia. En 1998, la Línea Nacional del SIDA del CDC envió más de un millar de cartas a escuelas estatales para sordos ofreciendo programas educacionales sobre SIDA para estudiantes sordos o con problemas auditivos. De éstas solamente 3 escuelas respondieron.:7

¿qué se está haciendo?

Un programa creado por el Centro de Salud Mental de la Universidad Gallaudet ofrece entrenamiento sobre VIH/SIDA a profesionales de salud mental que trabajan con la comunidad sorda, utilizando videos con subtítulos o leyendas, dibujos, actividades de grupo y modelos sobre como el VIH se adhiere a las células.⁹ En París, Francia, la Unidad Móvil de Prevención de SIDA (EMIPS) utilizó una variedad de programas para llevar el mensaje a los adolescentes sordos dentro y fuera de las escuelas para sordos. Un joven educador sordo visitó escuelas para sordos y presentó una intervención en lenguaje por señas. El programa creó varias anuncios públicos exponiendo las falsas creencias del riesgo que envuelve al VIH. El programa también abrió una clínica que no requiere de cita previa en la que el Doctor(a) se comunica por medio del lenguaje por señas. Sin embargo, la clínica no estuvo muy concurrida ya que estaba demasiado identificada con el SIDA. Cuando el programa abrió un centro de detección de VIH dentro de una clínica general se obtuvo mayor éxito.¹⁰ En Minnesota, el programa para personas que carecen o tienen dificultades auditivas que dependen de sustancias químicas y otras drogas ofrecen tratamiento para los adictos al alcohol y otras drogas en los EEUU y Canadá. El personal está capacitado específicamente para tratar a personas con problemas auditivos parcial o total y en tratar el abuso de sustancias, además, han desarrollado métodos terapeúticos sin problemas de comunicación. Por otra parte, el programa ofrece entrenamiento a estudiantes y profesionales que trabajan con personas sordas, tienen además un centro de recursos para diseminar material y proveen fondos para intérpretes que asisten a reuniones de AA/NA (Alcohólicos Anónimos/Narcóticos Anónimos).¹¹

¿qué queda por hacer?

Crear material educativo y buscar la forma de llegar a esta comunidad, no solo alrededor del tema del VIH o del SIDA también sobre temas tan amplios como la salud sexual y el uso de sustancias psicotrópicas. Las escuelas para sordos necesitan ofrecer educación sobre sexualidad y sobre el uso de sustancias y proveer consejería a niños y adolescentes que hayan experimentado abuso. Los programas para sordos deben tratar temas específicos de esta comunidad, tales como negociar el sexo seguro con una pareja no sorda, abogar por los servicios del cuidado de salud y derribar las barreras que impiden tratar el problema del abuso sexual y abuso de drogas. Los programas de prevención de VIH para personas sordas deben ser lo mas claro y visuales posibles. Los programas no deben ser diseñados a manera de presentación sólamente, deben además dedicar mayor tiempo a debatir el tema, incorporar actividades físicas, fotos, muñecos, manuales gráficos en ASL y videos con subtítulos.¹² Para poder llegar a las comunidades de sordos tanto investigadores como proveedores de servicios deben aprovechar los avances tecnológicos tales como los videos interactivos y la internet.¹³ Si bien es cierto que ya se han hecho esfuerzos a todo nivel para educar a la comunidad sorda sobre el tema del VIH/SIDA, todavía existen discrepancias sobre el tipo de información crucial que debe recibir la población que realmente lo necesita. Cada estado al igual que el CDC necesita añadir preguntas sobre discapacidades al recaudar datos estadísticos para poder determinar el alcance de la epidemia en la población sorda. Se necesitan más programas que ayuden a desarrollar un mayor conocimiento y disipar los mitos acerca de la transmisión del VIH y las conductas de riesgo de las personas sordas. Los pocos programas populares que existen deben ser evaluados y replicados en toda la nación.

¿quién lo dice?

1. Friess S. Silence = Deaf . Poz Magazine. April 1998. p.60-63. 2. Personal communication. Department of Health and Mental Hygiene, State of Maryland. 1999. 3. Peinkoffer JR. HIV education for the deaf, a vulnerable minority . Public Health Reports. 1994;109:390-396. 4. Baker-Duncan N, Dancer J, Gentry B, et al. Deaf adolescents’ knowledge of AIDS. Grade and gender effects . American Annals of the Deaf. 1997;142:368-372. 5. Sullivan PM, Vernon M, Scanlan JH. Sexual abuse of deaf youth . American Annals of the Deaf. 1987;132:256-262. 6. Johnsen L, Harlow L. Childhood sexual abuse linked with adult substance use, victimization, and AIDS-risk . AIDS Education and Prevention. 1996;80:44-57. 7. Campbell D. AIDS and the deaf community. ADVANCE for Speech-Language Pathologists & Audiologists. April 26, 1999; p.10-11. 8. Morrone JJ. Peer education and the deaf community. Journal of American College Health. 1993;41:264-266. 9. Sleek S. HIV/AIDS education efforts have missed deaf community. American Psychological Association Monitor. 1999. 10. Grivois L, Houette A. Outreach programs towards deaf people targeting prevention of AIDS. Presented at the 11th International Conference on AIDS, Vancouver, Canada. June 1996. Abst. #MoD240. 11. Program celebrates ten years. Steps to Recovery. Published by the Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals. Spring/Summer 1999. 12. Gaskins S. Special population: HIV/AIDS among the deaf and hard of hearing. Journal of the Association of Nurses in AIDS Care. 1999;10:75-78. 13. Lipton DS, Goldstein M, Wellington Fahnbulleh F, et al. The interactive video-questionnaire: a new technology for interviewing deaf persons . American Annals of the Deaf. 1999;141:370-378.

Recursos:

Línea Nacional del SIDA de los CDC, Servicio Para Sordos Y Personas Con Dificultad En Oír American Sexual Health Association https://www.ashasexualhealth.org/ 

PREPARADO POR BRYAN DETERMAN** NATASHA KORDUS** Y PAMELA DECARLO*** *CLINICA MONTROSE, HOUSTON, TX, **ESCUELA PARA SORDOS DE CALIFORNIA,***CAPS Agosto 2000. Hoja Informativa 36S.

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