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Mexican immigrants

What are the HIV prevention needs of Mexican immigrants in the US?

Why do Mexicans migrate?

The most common motivation for Mexicans to move to the US is economic, followed by a desire to reunite with spouses, parents or other immediate family, particularly among women and children. However, for some an additional important reason to leave Mexico is the need to find a new social space where they can redefine their sexual and gender identities.^1,2 This phenomenon–labeled “sexual migration”–is known to happen among Mexican women and among men who are sexually attracted to other men (MSM). Sexual migration is of particular interest in terms of HIV risk. Contrary to what is often assumed, the population of Mexicans who move to the US is considerably diverse. Mexicans are from cities and rural areas, poor and middle-class, undocumented and legal immigrants, monolingual and bilingual. Some emigrate permanently or come for a short period and then return to Mexico.

Who is at risk for HIV infection?

There are an estimated 3 to 6 million Mexican undocumented residents in the US, and most of them live in California and Texas.³ Many Mexicans frequently travel back and forth over the border. One-fourth of the AIDS cases in Mexico are among persons who have spent prolonged periods in the US.⁴ AIDS statistics in Mexico report a slight trend toward the “ruralization” of AIDS that might be linked to male migration to the US.⁵ The limited data on HIV infection in Mexicans living in the US suggests that the groups that have been most greatly affected are MSM, heterosexuals-some of whom have injecting drug user (IDU) partners-and IDUs. Of the US AIDS cases reported in 2000 among persons born in Mexico, 44% were among MSM, 14% among heterosexuals, 9% among IDUs, and 3% among MSM IDUs.⁶ The cause of transmission was not known for 29% of cases.

What puts them at risk?

Different subgroups of Mexicans living in the US confront different challenges in terms of HIV risk. Among other factors, such challenges depend on 1) how their identities and behaviors (sexual and drug-related) change after moving to the US; 2) their access to health services, appropriate HIV education, and condoms; 3) norms about safe sex and drug use in their new communities; 4) the nature of their relationships with sexual partners in the US and in Mexico; and 5) the degree to which they experience racism, discrimination, and poverty in the US. One study of 374 young Latino MSM in the San Diego/Tijuana region found high rates of HIV: 19% in Tijuana, Mexico and 35% in San Diego, CA.⁷ In Tijuana, only half had ever received HIV prevention information and less than half had ever been tested for HIV. Young MSM in Tijuana were more likely to report sex with females and injection drug use than young MSM in San Diego. In San Diego, young MSM were more likely to report unprotected sex with men. HIV risk also exists among heterosexual Mexican migrants, especially among male urban day laborers and those working in agriculture. Often these men come without a spouse and are young, lonely, and isolated, making them likely to seek sex. In addition, they often are not well educated, speak little English, and have limited access to healthcare, making it difficult for them to receive HIV prevention messages⁸. Some of these men engage in sex work, regularly have unprotected sex with female sex workers, or have spouses in Mexico with whom they use no condoms.⁹ Many married Mexican women, whether they are living in the US or in border towns, or living in Mexico with a spouse who migrates to the US, believe strongly in marital fidelity and have negative beliefs about condom use. In one study, many women acknowledged that men who spend long periods of time away from home are at risk for HIV, but most believed that it did not pertain to their marriages or their spouses.¹⁰ Both younger and older women said they did not want to know about any extra-marital affairs their spouses may have had, and did not want to infer infidelity by using condoms.

Does acculturation affect HIV risk?

Research is somewhat contradictory about whether HIV risk increases or decreases as immigrants adopt norms and values of mainstream communities in the US. Some studies argue that acculturation is protective because it promotes individuality, self-esteem and self-empowerment. Others argue that acculturation increases HIV risk because immigrants adopt sexual and drug-related behaviors that were not part of their more conservative, previous worldviews. What is clear is that immigrants change over time in the US, that the changes are complex, and that they have to be taken into account when designing HIV prevention programs for immigrant populations.

What’s being done?

Few HIV prevention programs for Mexican immigrants currently exist, although the number of programs is increasing. In addition, cooperation between the Mexican and American governments in addressing HIV/AIDS has increased. In San Francisco, CA, Hermanos de Luna y Sol has been designed to address the HIV prevention needs of Latin American MSM who have migrated to the US. The program deals with the common history of oppression among Latino gay men, social support, and community and emotional issues around sex and sexuality. This program explicitly ties HIV prevention to other developmental and identity-related needs in ways that contextualize safe sex in the participants’ larger lives. In El Paso, TX, prevention case management services (PCMS) are provided in a large homeless shelter serving undocumented immigrants. PCMS uses a holistic approach to address homelessness, being HIV+, an IDU, a sex worker, or a partner of any of the above. The program concentrates on survival needs first, providing referrals for housing, food banks and medical and mental health treatment. PCMS also locates clinics to give free Pap smears to undocumented women. The Promotoras de Salud Project, sponsored by the Farmworker Justice Fund and Centro de Salud Familiar la Fe, trains farmworker women as health educators or promotoras to provide counseling and education about HIV prevention, care and services in their communities. The promotoras link farmworker women with healthcare facilities, often accompanying the women and interpreting for them. They also provide condoms and emotional support for women using them.

What needs to be done?

Prevention programs for immigrant Mexicans need to contextualize HIV risk in the lives of participants in order to ensure that potential safety measures are relevant and that participants can strategize realistic ways of adopting them. Programs should address the challenges of being a Mexican immigrant living in the US; experiences of racism and homophobia; and barriers that may be imposed by poverty and social marginality. These factors may influence sexual and drug-related behaviors. In addition to prevention programs in US cities with large concentrations of Mexicans, such as Los Angeles, CA and Chicago, IL, border cities such as Ciudad Juárez and Tijuana, Mexico, El Paso, TX, and San Diego, CA are key locations for HIV prevention efforts. Similarly, there is a need for programs focusing on rural areas that attract Mexican migrant workers. Access to basic needs such as healthcare, housing, and jobs, may help reduce HIV risk in Mexican immigrant populations. Culturally-relevant educational and training materials in Spanish, as well as educational programs tailored for the needs of specific subgroups of immigrants, are also needed. HIV surveillance must be improved to understand the scope of HIV among both documented and undocumented immigrants. Because many Mexicans travel back and forth between the US and Mexico, bi-national cooperation is key in addressing these issues. Fostering participation of Mexican immigrants in HIV Prevention Community Planning is key to further identifying effective prevention interventions, and to expanding funding and availability of prevention services for this population.

Says who?

1. Hogdagneu-Sotelo P. Gendered transitions: Mexican experiences of immigration. University of California Press: Berkeley, CA, 1994. 2. Cantú, L. Border crossings: Mexican men and the sexuality of migration. Doctoral Dissertation. University of California, Irvine, 1999. 3. Lowell BL, Suro R. How many undocumented: the numbers behind the US-Mexico migration talks. Report by the Pew Hispanic Center. March 2002 4. Rangel G, Lozada R. Factores de riesgo de infección por VIH en migrantes mexicanos: el caso de los migrantes que llegan a la Casa del Migrante “Centro Escalabrini y Ejército de Salvación. El Colegio de la Frontera Norte, ISESALUD/COMUSIDA. 5. Magis-Rodríguez C et al. La situación del SIDA en México a finales de 1998. Enfermedades Infecciosas y Microbiológicas. 1998; 18, 6: 236-244. 6. CDC. HIV AIDS Surveillance Report. 2001. Volume 12, No.2 https://www.cdc.gov/hiv/library/reports/hiv-surveillance-archive.html.Ruiz JD. HIV prevalence, risk behaviors and access to case among young Latino MSM in San Diego, California, and Tijuana, Mexico. Presented at the Binational Conference on HIV/AIDS. Oakland, CA, 2002. 8. Bronfman N, Moreno L. Perspectives on HIV/AIDS prevention among immigrants on the US-Mexico border. In: Mishra S, Conner R, Magaña R (eds) AIDS crossing borders: The spread of HIV among migrant Latinos. Westview Press: Boulder, CO, 1996. 49-76. 9. Organista KC, Organista PB. Migrant laborers and AIDS in the United States: A review of the literature. AIDS Education and Prevention. 1997; 9:83-93. 10. Hirsch JS, Higgins J, Bentley ME, et al. The social constructions of sexuality: marital infidelity and sexually transmitted disease-HIV risk in a Mexican migrant community. American Journal of Public Health. 2002; 92:1227-1237 11. Flaskerud JH, et al. Sexual practices, attitudes, and knowledge related to HIV transmission in low income Los Angeles Hispanic women. The Journal of Sex Research. 1996: 33:343-353. 12. Marín BV, Flores E. Acculturation, sexual behavior, and alcohol use among Latinas. International Journal of the Addictions. 1994; 29:1101-1114 13. Díaz RM. Latino gay men and HIV. New York and London: Routledge. 1998. prevention.ucsf.edu/uploads/projects/hlsindex.php 14. Moore EF. Sub-culturally competent HIV prevention case management on the Mexican-American border. Presented at the National AIDS Prevention Conference, Atlanta, GA. 1999. Abs#659. 15. Hernández A. Promovision/ USMBHA: Proyecto para fortaleces la capacidad de la comunidad en la prevención del VIH/SIDA. Presented at the United States-Mexico Border Health Association (USMBHA) Conference, Las Cruces, New Mexico. 2001. https://www.hhs.gov/about/agencies/oga/about-oga/what-we-do/international-relations-division/americas/border-health-commission/index.html 16. US-Mexico Border Health Association. The State of Latinos in HIV Prevention Community Planning. 2002. Prepared by Héctor Carrillo, DrPH and Pamela DeCarlo, CAPS April 2003. Fact Sheet #48E Special thanks to the following reviewers of this Fact Sheet: María Chaparro, Frank Galvan, Apolonia Hernández, Barbara Marin, Octavio Vallejo.

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 2003, University of California

Resource

Redes sexuales

¿Cómo afectan las redes sexuales a la prevención del VIH/ETS?

¿qué son las redes sexuales?

El comportamiento de riesgo no es suficiente para explicar por qué algunas personas y comunidades (más que otras) siguen infectándose por el VIH y otras enfermedades de transmisión sexual (ETS). Las redes ayudan a explicar cómo dos personas pueden tener la misma conducta riesgosa y sin embargo una puede tener un riesgo mucho mayor de contraer o de transmitir el VIH. Las redes sexuales son grupos de personas interconectadas sexualmente. El número de personas en la red, la centralidad de las personas de alto riesgo, el porcentaje de relaciones monógamas y el número de “enlaces” que cada individuo tiene con los otros, son todos determinantes de la rapidez con la cual el VIH y las ETS pueden ser transmitidas por la red.¹ Las redes sexuales son distintas a las redes sociales, aunque muchas veces se traslapan.

¿cómo afectan las redes en la transmisión?

Las diferentes maneras de elección de parejas afectan la rapidez de propagación del VIH y las ETS. Por definición, las personas exclusivamente monógamas no forman parte de ninguna red sexual. Si ambas personas son VIH-negativas, permanecerán así. Los monógamos seriales son personas que terminan una relación antes de pasar a la próxima. Si tienen sexo sin protección, corren más riesgo de contraer el VIH o una ETS que las personas exclusivamente monógamas. El riesgo de las parejas anteriores puede afectar a las parejas posteriores. En las relaciones concurrentes, se tiene más de una pareja sexual en el mismo periodo y se tienen relaciones sexuales con una y otra alternativamente; lo cual aumenta la probabilidad de transmisión, pues las parejas anteriores pueden ser infectadas por las parejas posteriores. Además, las relaciones concurrentes pueden servir como “puntos o nodos” que conectan a todas las personas de la red en una densa agrupación, creando redes ampliamente conectadas que facilitan la transmisión. Las parejas concurrentes también pueden conectar a cada una de sus agrupaciones y redes respectivas. La concurrencia por sí sola puede generar una epidemia aunque el número promedio de parejas sea relativamente reducido. Las dos redes representadas arriba demuestran que no solo importa la conducta de riesgo sino también de la configuración del riesgo. Cada red tiene 8 personas (círculos) interconectadas que forman 9 relaciones. Dos personas tienen 3 parejas cada una, y las otras seis tienen 2 parejas cada una, pero la transmisión será menos eficiente en la red A y la prevención será más difícil en la red B. En la red A, a tan sólo dos pasos de la persona índice, la mitad de los integrantes de la red se pueden infectar mientras que la mitad puede permanecer libre de infección; en la B, a dos pasos todos pueden resultar infectados menos la persona situada al extremo derecho. Para evitar la exposición de la mitad de la población de la red A, es necesario cortar un solo enlace, mientras que en la red B se deberán cortar tres enlaces. En otras palabras, cuando se trata de una epidemia, el destino de las personas depende de la estructura de su red sexual.³

¿cuáles son los conceptos clave?

Número de parejas: Los programas se pueden enfocar en las personas con el mayor número de enlaces en la red. Con respecto al VIH/ETS, esto sugiere que además de promover el uso de condones, los programas deben identificar a las redes con un alto número de parejas desprotegidas. La difusión aleatoria amplifica la transmisión: La infección se propaga con más rapidez cuando la formación de parejas se hace aleatoriamente.⁴ Cuando las parejas se eligen por compartir ciertas características (como edad, grupo étnico o clase socioeconómica), es posible que la enfermedad no llegue a transmitirse a todos los subgrupos. Cuando la elección se realiza en forma aleatoria o anónima, la enfermedad se puede transmitir más rápidamente entre todos los grupos. Grupos centrales: Los integrantes del grupo central tienen un comportamiento de riesgo alto, contribuyen desproporcionadamente a la transmisión del VIH/ETS y pueden alimentar una transmisión sostenida. Centralidad: El grado de centralidad de una persona VIH+ dentro de la red tiene una influencia profunda sobre las tasas de transmisión en la comunidad. En Colorado Springs, CO, un análisis de redes reveló que las personas VIH+ tenían niveles altos de conducta riesgosa pero se situaban en la periferia de las redes de riesgo.⁵ Esta configuración de red puede haber explicado los niveles relativamente reducidos del VIH. En contraste, las personas VIH+ en la ciudad de Nueva York, NY ocupaban posiciones centrales dentro de sus redes de uso de jeringas compartidas y de riesgo sexual, lo cual ayudó a explicar los elevados niveles de infección observados entre ellas.⁶

¿pueden las redes sexuales ayudar a explicar diferencias raciales en las tasas de VIH/ETS?

Sí. Las redes sexuales y la selección de parejas ayudan a explicar las diferencias raciales en las tasas de VIH y ETS. Por ejemplo, aunque no se arriesguen más que los caucásicos los hombres afroamericanos gay y bisexuales, parecen infectarse mucho más rápidamente.⁷ De la misma manera, los hombres asiáticos gay y bisexuales reportan niveles parecidos de riesgo pero se infectan con menos frecuencia.⁸ Un estudio nacional demostró que los afroamericanos heterosexuales se infectaban con ETS casi cinco veces más rápidamente que los caucásicos después de controlar los factores de riesgo individuales. Las infecciones transmitidas sexualmente permanecen en las poblaciones afroamericanas porque la elección de parejas se hace en forma más segregada que en otros grupos. Además, los afroamericanos “no centrales” (con pocas parejas sexuales) son más propensos a elegir parejas sexuales “centrales”. En cambio, los caucásicos no centrales tienden a elegir parejas no centrales.⁹

¿qué intervenciones influyen en las redes?

Notificación de pareja: Muchos departamentos de salud pública han desarrollado técnicas sumamente confidenciales y confiables de notificación de parejas y, mediante el análisis de redes, han aprendido a rastrear “subiendo” por la cadena de transmisión hacia el transmisor en lugar de “bajar” por la cadena hacia las parejas infectadas.¹⁰ Esto les permite identificar a los transmisores y remitirlos a servicios de tratamiento y de asesoramiento sobre la prevención del VIH y las ETS. Formulación de mensajes: Además de la promoción del uso de condones y la consejería, se pueden difundir mensajes específicos en los medios de comunicación para fomentar la fragmentación de la red, lo cual se hace promoviendo la monogamia serial (“una pareja la vez”) en lugar de tener parejas concurrentes. Diálogo comunitario: Las organizaciones comunitarias (OC) pueden ser clave para facilitar el diálogo sobre las preguntas difíciles acerca de las redes en la comunidad: ¿Cómo deben las comunidades equilibrar las libertades sexuales de todos (incluyendo las personas de alto riesgo) con la salud y el futuro de la comunidad entera? ¿Qué normas comunitarias y culturales contribuyen a la formación de redes sexuales riesgosas? Las OC también deben distinguir entre los tradicionalmente definidos “grupos de riesgo” y aquellos individuos de más alto riesgo, con el fin de canalizar recursos hacia estos últimos. Lugares que facilitan el intercambio sexual de parejas: En muchos ambientes, la identificación de parejas puede ser imposible. Sin embargo, es posible que al focalizar lugares en donde las redes de alto riesgo se mezclan sexualmente con las de bajo riesgo, los promotores de la prevención del VIH y las ETS puedan reducir la transmisión. Por ejemplo, muchos hombres con sífilis informan haber conocido a parejas en internet y lugares de comercialización sexual.^11,12 Los trabajadores de intervenciones contra el VIH y las ETS deben priorizar la colaboración con los gerentes de baños públicos y de clubes sexuales y con los proveedores de servicios de internet para negociar sus papeles respectivos en la promoción de conductas más seguras. En San Francisco, CA, los educadores de SIDA y los propietarios de clubes sexuales establecieron una serie de normas compartidas para reducir las prácticas riesgosas en los clubes.¹³ En los Países Bajos, el sitio en internetwww.dateguide.nl para hombres gay que buscan pareja proporciona a quien entre al sitio una educación interactiva sobre cómo protegerse en el sexo.¹⁴

¿qué queda por hacer?

Al principio de la epidemia, el análisis de redes ayudó a explicar algunos de los aspectos más importantes del SIDA así como sus causas, y puede ser útil todavía en las colaboraciones entre organizaciones, comunidades e investigadores para fomentar la formación de redes sexuales que impidan la transmisión del VIH y las ETS.¹⁵ Hace tiempo que se sabe y se entiende que algunos individuos contribuyen mucho más a la transmisión del VIH y las ETS que otros. No darle importancia a este hecho y al papel de las redes sexuales en alimentar la epidemia impide nuestra capacidad para desacelerar la transmisión del VIH y las ETS.

¿quién lo dice?

1. Potterat JJ, Muth SQ, Brody S. Evidence undermining the adequacy of the HIV reproduction number formula. Sexually Transmitted Diseases. 2000;27:644-645. 2. Morris M. Sexual networks and HIV. AIDS. 1997;11:S209-216. 3. Klovdahl AS, Potterat JJ, Woodhouse D, et al. HIV infection in a social network: A progress report. Bulletin de Methodologie Sociologique. 1992;36:24-33. 4. Laumann EO, Gagnon J, Michael R, Michaels S. The Social Organization of Sexuality. Chicago: The University of Chicago Press, 1994. 5. Rothenberg RB, Potterat JJ, Woodhouse DE, et al. Social network dynamics and HIV transmission. AIDS. 1998;12:1529-1536. 6. Friedman SR, Neaigus A, Jose B, et al. Sociometric risk networks and risk for HIV infection. American Journal of Public Health. 1997;87:1289-1296. 7. Centers for Disease Control and Prevention. HIV Incidence Among Young Men Who Have Sex With Men—-Seven U.S. Cities, 1994-2000. Morbidity and Mortality Weekly Report. 2001;50:440-444. 8. Choi KH, Operario D, Gregorich S, et al. Age and race mixing patterns of sexual partnerships among Asian men who have sex with men: implications for HIV transmission and prevention. AIDS Education and Prevention. 2003;15:S53-65. 9. Laumann EO, Youm Y. Racial/ethnic group differences in the prevalence of sexually transmitted diseases in the United States: a network explanation. Sexually Transmitted Diseases. 1999;26:250-61. 10. Ghani AC, Ison CA, Ward H, et al. Sexual partner networks in the transmission of sexually transmitted diseases. An analysis of gonorrhea cases in Sheffield, UK. Sexually Transmitted Diseases. 1996;23:498-503. 11. Klausner JD, Wolf W, Fischer-Ponce L, et al. Tracing a syphilis outbreak through cyberspace. Journal of the American Medical Association. 2000;284: 447-449. 12. Williams LA, Klausner JD, Whittington WL, et al. Elimination and reintroduction of primary and secondary syphilis. American Journal of Public Health. 1999;89:1093-1097. 13. Wohlfeiler D. Structural and environmental HIV prevention for gay and bisexual men. AIDS. 2000;14:S52-S56. 14. Harternik P, van Berkel M, van den Hoek K, et al. e-Dating: a developing field for HIV prevention. Published by the Dutch AIDS Fund. www.dateguide.nl 15. Auerbach DM, Darrow WW, Jaffe HW, et al. Cluster of cases of the acquired immune deficiency syndrome. Patients linked by sexual contact. American Journal of Medicine. 1984;76:487-92.

Preparado por Dan Wohlfeiler*, John Potterat. *UCSF Traducción Rocky Schnaath Septiembre 2003. Hoja Informativa 50S

Resource

Utilizando la ciencia

¿Cómo se utiliza la ciencia en la prevención del VIH?

¿es necesaria la ciencia? Sí. Aunque la ciencia de la prevención por si sola no ofrece la respuesta, esta posee algunas piezas críticas del rompecabezas de la prevención. La ciencia en conjunto con la experiencia de algunas agencias en el manejo de clientes además de reforzar el programa sirve de inspiración y guía para hacer un mejor uso de los escasos fondos que enfrentan los programas de prevención. Esta hoja informativa intentará abordar algunos de los elementos básicos que ofrecen las ciencias de la prevención, su significado, y su implicaciones en la práctica. Actualmente, es un requisito usar la ciencia de la prevención en muchas áreas. En 1994, el CDC cambió radicalmente su criterio para designar los programas que serían subsidiados. El CDC recomienda que los Grupos de Planificación Comunitaria (CPGs por sus siglas en Inglés) tomen en cuenta la epidemiología, la evaluación, las teorías científicas del comportamiento, descubrimientos y la metodología en la creación de estos programas.¹ La ciencia aplicable a la prevención del VIH puede dividirse en cinco categorías generales: la ciencia de la epidemiología, la ciencia conductual básica, la ciencia básica del cambio conductual, la ciencia de la intervención y la metodología de la evaluación. la epidemiología La epidemiología es el estudio de los casos de infección u otras enfermedades dentro de la población. Nos informa sobre la cantidad de nuevos casos de infección con VIH, la subpoblación afectada, y las que pueden llegar a infectarse. La epidemiología conductual puede indicar la frecuencia de las conductas de riesgo.² La epidemiología local puede servir de mucho a los planificadores de programas de prevención ya que les permite identificar la comunidad y las conductas de riesgo que necesitan ser tratadas. Esto a su vez puede ser muy útil para hacer mejor uso de los recursos limitados. El departamento de salud y el CDC pueden ayudar recopilando datos de los diferentes grupos poblacionales.³ la ciencia conductual básica Los elementos básicos de esta ciencia exploran la influencia que los factores sociales, culturales y conductuales ejercen sobre las personas. Esto nos permite entender el porque las personas se exponen al riesgo y porque sigue en aumento la cantidad de infectados con VIH. El estudio de la sexualidad es un elemento clave que ayuda a entender los cambios en las conductas riesgo con relación al sexo y facilita la tarea del diseño del programa.⁴ No señala exactamente lo que habrá de hacerse, sino que sugiere diferentes formas de pensar en cuanto a los elementos que el programa debe tener. Por ejemplo, recientemente se descubrió una estrecha relación entre el abuso sexual a temprana edad y las conductas de riesgo en la adultez.⁵ Con estos antecedentes, los planificadores del programa pueden agregar preguntas sobre abuso sexual a temprana edad para asesorar las necesidades del caso. Se puede también agregar un segmento sobre abuso infantil a las intervenciones con sesiones educativas múltiples o crear programas para los que fueron abusados y/o capacitar al personal sobre el tema del abuso sexual. la ciencia de los cambios de conducta La teoría del cambio conductual nos brinda un marco de ideas sobre como y por que ocurren estos cambios de conducta que exponen a las personas a riesgo de contraer el VIH. Para lograr mantener unidos cada uno de los componentes del modelo al diseñar una intervención puede ayudar usar las Teorías de cambio conductual.⁶ Por ejemplo, la teoría de Paulo Freire sobre la Educación Popular propone que el alumno y el maestro aprendan el uno del otro.⁷ Si se usa esta teoría, un programa puede reemplazar las lecturas por discusiones de grupo. De esta forma la intervención se hace más fuerte puesto que las personas adquieren por si mismas el poder o la responsabilidad que les permitirá cambiar el ambiente que les rodea. la ciencia de la intervención La ciencia de la intervención analiza los componentes más eficaces del programa e identifica los programas que han logrado un cambio en ciertas poblaciones. Por ejemplo, en un estudio reciente, las personas que estaban a mayor riesgo no asistieron a los talleres de sexo seguro. Un programa para hombres gay/bisexuales de Portland, OR, hizo su campaña en bares, organizando eventos comunitarios y reuniones en casas, y ofreciendo talleres de sexo seguro. Mientras la mayoría de los hombres asistió a la mayor parte de las actividades, pocos asistieron a los talleres.⁸ El estudio científico del programa indicó que la mayoría de los hombres atraídos por el programa eran jóvenes los que presentaban mayor riesgo o los hombres que reportaron sexo anal sin protección.⁸ Las intervenciones que intentan trabajar con poblaciones de alto riesgo pueden obtener la atención de esta audiencia con un programa a nivel comunitario intensivo, innnovador, que ofrezca actividades sociales y consejería, con una estructura no complicada. la metodología de la evaluación La evaluación estimula el pensamiento crítico en el proceso del diseño de la intervención y no necesariamente debe ocurrir al final de la intervención. Una buena evaluación genera información acerca de las necesidades que tiene el grupo a ser intervenido, el tipo de servicios necesarios, el impacto del programa y los resultados del mismo. Esto a la vez que permite conocer la opinión del cliente, les brinda la oportunidad a los proveedores del servicio de ajustar el programa para aumentar su efectividad.⁹ Por ejemplo, el Centro de Salud Tri-City de Fremont, CA, encuestó a jóvenes de la calle para evaluar la efectividad del programa en cuanto a los talleres educativos y a la forma de atraer a los necesitados. En base a la opinión de los jóvenes, el Tri-City reemplazó los talleres con horas establecidas por un servicio disponible a cualquier hora. Este nuevo servicio ofreció educación sobre VIH, apoyo en áreas tales como la deserción escolar, el desempleo, el abuso de drogas, las relaciones abusivas y como vivir con el VIH.¹⁰ ¿cómo se obtiene el acceso a la ciencia? No se requiere un nivel de educación avanzado para comprender la ciencia de la prevención. Existen algunas organizaciones que interpretan y resumen los resultados de la investigación a un lenguaje claro y conciso. La función de los CPGs es la de incorporar la ciencia de la prevención en todos sus planes, los cuales están disponibles a través de los departamentos de salud estatales y locales.¹¹ Las universidades locales son un excelente punto de contacto en cuanto a la asistencia con las investigaciones.¹² Pertenecer a listas de envío por correo y a Boletines Informativos especializados en las ciencias de la prevención puede ser un recurso invaluable.¹³ ¿qué queda por hacer? Estrechar aún más los esfuerzos de los investigadores y de los proveedores de servicio: 1) Los investigadores deben compartir datos reveladores con los CBO locales, con el CDC y con el departamento de salud pública. También es necesario ejercer una participación activa en los CPG. 2) Los CBO locales deben ser más agresivos y pro-activos haciendo uso de la información que existe fuera de las agencias. 3) Los departamentos de salud pública estatales y el CDC deben reconocer y poner en práctica su papel de traductores de esta ciencia. 4) Los Institutos Nacionales de Salud, el CDC y las Fundaciones Privadas deberán integrar la ciencia en los programas de prevención y proveer los fondos para este fin.¹⁴ El uso de la ciencia en la aplicación del servicio es un campo especializado. La mayoría de los investigadores no están capacitados para aplicar sus proyectos de investigación en el mundo real. Así como la mayoría de los proveedores de servicio no están capacitados para aplicar los métodos de investigación. Un programa de prevención completo utiliza muchos elementos para proteger del VIH a la mayor cantidad de personas posible. Si logramos acortar la distancia entre la ciencia y la práctica de la prevención , nos aseguraríamos que nuestros esfuerzos no van a ser en vano y haremos la diferencia en la lucha contra el VIH.

¿quién lo dice? 1. Valdiserri RO, Aultman TV, Curran JW. Community planning: a national strategy to improve HIV prevention programs. Journal of Community Health. 1995;20:87-100. 2. Rothman KJ. Modern Epidemiology. Boston, MA: Little, Brown and Company; 1986. 3. Si desea encontrar información con datos epidemiológicos los puede encontrar por estado y por ciudad (ciertas) en la internet: http://hivinsite.ucsf.edu/InSite?page=li-12-01#S2X  4. Kelly JA, Kalichman SC. Increased attention to human sexuality can improve HIV-AIDS prevention efforts: key research issues and directions. Journal of Consulting and Clinical Psychology. 1995;63:907-918. 5. Jinich S, Stall R, Acree M, et al. Childhood sexual abuse predicts HIV risk sexual behavior in adult gay and bisexual men. Presented at the 11th International Conference on AIDS, Vancouver, BC. 1996. Abstract Mo.D.1718. 6. Valdiserri RO, West GR, Moore M, et al. Structuring HIV prevention service delivery systems on the basis of social science theory. Journal of Community Health. 1992;17:259-269. 7. Wallerstein N. Powerlessness, empowerment, and health: implications for health promotion programs. American Journal of Health Promotion. 1992;6:197-205. 8. Hoff CC, Kegeles S., Acree M, et al. Gay men at highest risk are best reached through outreach in bars and community events. Presented at the 11th International Conference on AIDS, Vancouver, BC. 1996. Abstract Tu.D.360. 9. San Francisco HIV Prevention Plan. Report prepared by the San Francisco HIV Prevention Planning Council and the Department of Public Health AIDS Office. 1996. 10. Carver LJ, Harper GW. Responding to the HIV prevention needs of suburban street youth. Presented at the 11th International Conference on AIDS, Vancouver, BC. 1996. Abstract Th.D.4921. 11. Para mayor información sobre su Grupo Comunitario local o estatal, póngase en contacto con Lynne Greabell de NASTAD (202) 434-8090. 12. Un directorio de universidades está disponible en la internet en: https://en.wikipedia.org/wiki/List_of_state_and_territorial_universities_in_the_United_States

CDC (800) 458-5231 (www.cdc.gov/nchstp/hiv_aids/dhap.htm)
American Psychological Association (202) 336-6042
National Minority AIDS Council (202) 483-6622
National Association of People With AIDS (202) 898-0414
Academy for Educational Development (202) 884-8700
National Alliance of State and Territorial AIDS Directors (202) 434-8090
Council of State & Territorial Epidemiologist (770) 458-3811
The US Conference of Mayors (202) 293-7330
GMHC Education Department (212) 807-7517 (www.gmhc.org)
UCSF Center for AIDS Prevention Studies https://prevention.ucsf.edu/
Rural Prevention Center (812) 855-1718 https://rcap.indiana.edu/

14. Goldstein E, Wrubel J, Faigeles B, et al. Is research important for non-governmental organizations in the United States? Presented at the 11th International Conference on AIDS, Vancouver, BC. 1996. Abstract Th.C.4779.

Preparado por Pamela DeCarlo y Ellen Goldstein, Traducción Romy Benard-Rodríguez Septiembre 1997. Hoja Informativa 25S.

Resource

Rapid testing

How is rapid testing used in HIV prevention?

why rapid testing?

It is estimated that 25% of all HIV+ persons in the US do not know they’re infected.¹ Taking an HIV antibody test and knowing one’s HIV status are key to preventing the spread of HIV. Many persons who test HIV+ can access counseling, prevention education, support services and medical care to stay healthy and not progress to AIDS. HIV- persons can access counseling and education to remain HIV-. However, even when people choose to get tested, many never return for their results. In public test sites, up to 33% of clients who test HIV- and 25% who test HIV+ never return for their results.² The rapid HIV test is a new, FDA-approved approach to HIV testing that addresses these issues. Conventional HIV testing has been conducted with needle blood draws or mouth swabs which are sent to a laboratory for analysis. Clients need to return to the test site 1-2 weeks later to find out their results. With rapid tests, clients can take the test, receive counseling, and find out their results all in one visit. This can help increase the number of persons who get tested and reduce the number of persons who don’t return for their results.³ Many government and non-governmental agencies are moving toward rapid testing instead of conventional testing. The Centers for Disease Control and Prevention’s (CDC) Strategic Plan for 2005 seeks to increase the number of HIV+ persons who know their HIV status from 70% to 95%—using rapid testing is an integral part of the plan.1 In California, the goal is to have 80% of all state-funded HIV test sites use rapid tests by the end of 2006.⁴

how is rapid testing done?

Rapid testing uses a finger stick, blood draw or mouth swab to collect samples. The test counselor places the sample in a tube with chemicals to process it, and can read the results in about 20 minutes. Counseling and risk reduction planning with the client can take place during the waiting time, or can be done before or after sample collection. Within 20 minutes, most rapid tests will either be non-reactive—a negative test result—or reactive—a preliminary positive result. Currently, if a result shows preliminary positive, a second conventional blood or oral sample is required to confirm it. 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.⁵ There are currently four FDA-approved rapid HIV tests in the US: Reveal, OraQuick, Multispot and Uni-Gold.⁶ All tests are extremely accurate, with 99.6-100% sensitivity rates.⁷ Only two of the tests—OraQuick and Uni-Gold—are Clinical Laboratory Improvement Amendment (CLIA) waived. OraQuick Advance uses a mouth swab and can be performed in a wider range of settings and temperatures. Rapid testing can be done in most clinical offices and in a large number of non-traditional health care and outreach settings such as mobile vans, storefronts, shelters, bathhouses,⁸ labor and delivery clinics and emergency rooms. Testing in alternative venues can help increase testing among populations that are mobile or hard to reach, including migrant workers, homeless persons, adolescents and young adults.⁹ Rapid testing can change the way HIV testing is done. Most HIV test sites currently have counselors and separate phelobotomists who take the blood sample. With rapid testing, the test counselor can also take the sample and analyze it. However, in some rapid test sites, counselors do the consent and counseling and someone else still collects the sample.

is rapid testing rapid counseling?

No. One study found no difference in STD rates after counseling with rapid tests and conventional tests.¹⁰ Rapid tests still allow for plenty of counseling time. Counselors have about 20 minutes between taking a sample and receiving the results to provide focused and specific counseling about the client’s real risks and possible exposure to HIV. Rapid testing counseling can be more intense due to the immediacy of getting results.¹¹ Clients who receive a preliminary positive result and must return for their confirmation result may be more prepared to deal with their diagnosis. Clients often have had a week to think about what testing positive means and may be more emotionally prepared to listen to and digest referrals and options the counselors can provide.

can my agency/clinic offer it?

Agencies have several considerations to make before deciding to use rapid testing. The client flow will be different because counselors are involved with each client for longer periods of time than during conventional testing. Agencies have greater responsibility because they are handling blood or oral samples. To do this, most agencies must apply to the government for a CLIA certificate,¹² provide quality assurance, keep records and create documentation. If test counselors are also conducting the test, they may need training to collect and process samples, run controls and track the tests. They will also need in-depth knowledge of referral resources for issues that may emerge in new, more focused HIV counseling sessions. Counselors typically may have concerns about the new testing procedures and counseling initially. After they’ve been trained and have provided a number of counseling sessions, they become more comfortable and often say they wished they had become involved in HIV rapid testing sooner.¹³ In some clinical settings it is easier to implement rapid testing because healthcare workers are used to taking samples, running controls and using universal precautions. However, clinicians may not be used to counseling when testing for HIV,¹⁴ and may need training to develop stronger counseling skills and provide adequate referrals.

what’s being done?

The Metro Atlanta Women of Color Initiative (MAWOCI) brought rapid testing, prevention education and linkage to medical care to African American women in community settings such as churches, college campuses, homeless shelters and public housing. Staff were trained in HIV test counseling, rapid testing and condom demonstrations. To facilitate referrals, MAWOCI mapped local resources, forged alliances with agencies serving women of color and assessed capacity of HIV care doctors and clinics. More than 99% of women returned for confirmatory test results.¹⁵ The introduction of OraQuick in counseling and testing sites throughout the state of New Jersey resulted in an increased number of previously undiagnosed HIV cases as well as an increased number of patients receiving both their test results and posttest counseling. Within the first year, 10,429 patients received the rapid test. Of this group, 99.7% received their test results, compared to 65% before rapid testing.¹⁶ In Seattle, WA, the public health department routinely provides rapid testing to persons at high-risk in bathhouses, needle exchange sites and STD clinics. They made this decision after conducting research showing that more people received their test results with rapid testing and it was more cost-effective than conventional blood or oral fluid testing strategies.⁸ The Night Ministry in Chicago, IL, provides rapid testing in health outreach buses for homeless adults and youth and pregnant and parenting teens. The buses are staffed by a nurse, two HIV test counselors and a minister, and offer general health care, mental health services, STD and hepatitis C screening as well as coffee, cookies and condoms. For clients who test HIV+, the program offers bus cards, telephone calling cards and referrals to physicians experienced in providing HIV care.¹⁷

what is the future of rapid testing?

The future is now. Outside of the US, rapid testing is widely used and confirmatory tests are also done with rapid test, eliminating any waiting period for persons who test HIV+. Manufacturers have been slow to seek approval for tests in the US because the FDA has strict policies about licensing new HIV tests. Rapid testing has been met with great enthusiasm in some areas and great trepidation in others. As federal and state governments increase requirements for rapid testing, resources for training, technical assistance and funding need to increase for the agencies that implement rapid testing. State and federal reimbursement protocols, as well as public and private insurance, need to be changed to encourage rapid testing.

Says who?

1. Centers for Disease Control and Prevention. HIV Prevention Strategic Plan Through 2005. https://www.cdc.gov/nchhstp/strategicpriorities/default.htm 2. Kendrick SR, Kroc KA, Withum D, et al. Outcomes of offering rapid point-of-care HIV testing in a sexually transmitted disease clinic. Journal of AIDS. 2005;38:142-146. 3. Sullivan PS, Lansky A, Drake A. Failure to return for HIV test results among persons at high risk for HIV infection: results from a multistate interview project. Journal of AIDS. 2004;35:511-518. 4. Dowling T. Outreach and prevention rapid HIV testing in non-clinical settings. Presented at the California Rapid Testing Conference. 2004. 5. Kassler WJ, Dillon BA, Haley C, et al. On-site, rapid HIV testing with same-day results and counseling. AIDS. 1997;11:1045-1051. 6. Reveal: www.reveal-hiv.com/  7. Branson BM. Point-of-care rapid tests for HIV antibodies. Journal of Laboratory Medicine. 2003;27:288-295. 8. Spielberg F, Branson BM, Goldbaum GM, et al. Choosing HIV counseling and testing strategies for outreach settings: a randomized trial. Journal of AIDS. 2005;38:348-355. 9. Ellen JM, Bonu S, Arruda JS, et al. Comparison of clients of a mobile health van and a traditional STD clinic. Journal of AIDS. 2003;32:388-393. 10. Metcalf CA, Douglas JM, Malotte CK, et al. Relative efficacy of prevention counseling with rapid and standard HIV testing: a randomized, controlled trial (RESPECT-2). Sexually Transmitted Diseases. 2005;32:130-138. 11. Rapid HIV antibody testing. HIV Counselor Perspectives. 2003; 12:1-8. 12. Centers for Medicare and Medicaid Services. How to apply for a CLIA certificate, including foreign laboratories.http://www.cms.hhs.gov/CLIA/06_How_to_Apply_for_a_CLIA_Certificate,_Inc…(Accessed 4/20/06) 13. Birkhead GS, San Antonio-Gaddy ML, Richardson-Moore AL, et al. Effect of training and field experience on staff confidence and skills for rapid HIV testing in New York state. Presented at the International Conference on AIDS, Bangkok, Thailand. 2004. Abst #MoPeE4103. 14. Tao G, Branson BM, Anderson LA, et al. Do physicians provide counseling with HIV and STD testing at physician offices or hospital outpatient departments? AIDS. 2003;17:1243-1247. 15. Thompson MA, Williams S, Williams K, et al. MAWOCI: a novel program providing transportable prevention education, rapid HIV testing, free CD4+ testing and linkage to medical care for women of color in Atlanta, GA. Presented at the 2003 National HIV Prevention Conference, Atlanta, GA. Abst #M1-G0502. 16. Cadoff EM. Rapid HIV testing increases detection rates and posttest counseling. Presented at the Annual Meeting of American College of Preventive Medicine. Feb 17, 2005. Poster 35. 17. Rapid HIV testing popular with Chicago CBO clients. AIDS Alert. February 2005. 18. Rapid testing for HIV: An issue brief. NASTAD HIV Prevention Update. September 2000.

PREPARED BY TOM DONOHOE* AND JAY FOURNIER *UCLA/PACIFIC AIDS EDUCATION AND TRAINING CENTER May 2005 . Fact Sheet #58E Special thanks to the following reviewers of this Fact Sheet: Bernard Branson, Marc Butlerys, Grant Colfax, Teri Dowling, Emily Erbelding, Shelley Facente, Keith Folger, Carol Galper, Cindy Getty, Patrick Keenan, Sally Liska, Rosa Solorio, Peter Shalit, Freya Speilberg, Deanna Sykes, Barbara Weiser. 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]. © May 2005, University of California

Resource

Family

What is the role of the family in HIV prevention?

Why families?

Families have great influence over a person, and that influence can last a lifetime. Even people who are no longer or never were in touch with their family are influenced by their absence. One half of all persons with HIV became infected during adolescence or early adulthood (ages 15-24). Working with families as early as possible in children’s lives helps solidify healthy behaviors and relationships, thus preventing risk before it happens. HIV prevention has traditionally focused on the individual and not the family. Yet families can have both positive and negative impact on sexual and drug using behaviors that put a person at risk for HIV. Families are important determinants of adolescent sexual behavior, can affect men and women as they “come out” as gay and lesbian and can affect injection drug users (IDUs) as they gain and lose ties to family throughout the years. For this fact sheet, families are defined as the people you grew up with: fathers, mothers, uncles, aunts, cousins, grandparents or foster parents. Many families have strong ties with the community as well, making the community a strong influence. We will not be discussing families of choice, such as intimate social networks.

How do families affect risk behavior?

Families can help protect themselves and their children from risky sexual and drug using behaviors. Family connectedness and parent child communication are key for ensuring healthy behaviors.¹ Likewise, when families are not connected and adolescents feel they can’t talk to the adults in their lives, there is a greater risk of unhealthy behavior. Adolescents who feel connected to their families and perceive their parents as caring are more likely to postpone their sexual debut, use contraception, have fewer pregnancies and fewer children.^2,3 Two key aspects of parenting that are influential to adolescents are their beliefs that their parents know who they spend time with, and know where they are when they’re not at home or at school.¹ In families with strong religious values and an emphasis on marriage and having children, young gay men can have a hard time coming out to their parents. Young men may fear that having a gay son could cause the family shame, or that they will disappoint their parents by not getting married and having children.⁴ This can lead to internalized shame and low self esteem which contribute to risky behavior. A child who grows up in a family where high stress, alcoholism, substance use and domestic violence are the norm, may repeat that behavior as an adult. Many alcohol and substance abusers have a family history of alcoholism and substance abuse and high levels of domestic violence. In addition, family members sometimes are the ones who give young people their first puff of marijuana, first taste of alcohol or first injection of drugs.⁵ Family childhood physical abuse, sexual abuse and neglect often lead to risky sexual behavior and drug use in adolescence and adulthood. One study of persons who left methadone maintenance found that 36% had experienced sexual abuse as a child, 60% physical abuse, 57% emotional abuse, 66% child physical neglect and 25% all four experiences. Persons with a history of childhood abuse reported more sexual partners and those with physical neglect were more likely to be HIV+.⁶

W hat puts families at risk?

Families that have problems often produce children who have problems. Stress, poverty, violence and substance abuse in families leads to less family cohesion, less communication and less tolerance. As a result, teens experience more abuse, neglect and risky drug use and sexual behavior. Neighborhoods with few job opportunities and high levels of drug use and violence have a negative impact on teenage sexual behavior.⁷ Work and feeling overworked can greatly affect family life. At every economic level, work-related stress negatively impacts family cohesion and communication. When parents have long work hours and feel burned out by their jobs, they don’t have enough time for themselves or their families.⁸

What’s being done?

The Collaborative HIV Prevention and Adolescent Mental Health Project is a family-based preventive intervention. The program is based on the needs of urban African American youth and their families living in neighborhoods with high HIV infection rates. It seeks to 1) address pre-adolescent behavior, 2) target specific child, parent, and family factors in preventing HIV risk exposure and 3) address high HIV infection rates through a family-based approach. The program offers multiple family groups, a pre-adolescent component, an adolescent component, and stresses the importance of community collaboration.⁹ Family to Family is a structural intervention that strengthens family functioning and the bonds that connect families to each other. Designed to address a broad range of social issues, the program seeks to increase family communication in a community with high rates of violence, drug abuse and HIV infection. The program uses family groups and life coping skills to address issues such as forgiveness, communication, responsibility, teamwork, family traditions, and household management.¹⁰ While many schools and community agencies have begun to offer risk reduction programs for gay/lesbian/bisexual/transgender (GLBT) youth, there are few programs to help GLBT children and their parents. Groups such as Parents, Families & Friends of Lesbians & Gays (PFLAG) offer support and education.¹¹ In San Francisco, CA, a coalition of agencies serving Latino gay and bisexual men started a media campaign to address family cohesion. In their research they found that women were overwhelmingly identified as a source of support: mothers, sisters, aunts and cousins. The campaign “Families Change, Families Grow/Las Familias Cambian, Las Familias Crecen,” used posters showing a mother hugging her adult son’s boyfriend with the caption, “Mom got to know my boyfriend, now there’s a place for him too.” Keepin’ it R.E.A.L.!, a program for adolescents and their mothers, works to increase parental knowledge about HIV and sexuality issues and increase comfort discussing these issues with their children. The program gave mothers and teens a chance to interact and bond, as well as gave mothers a chance to communicate with each other. Women in the program were more likely to talk to their adolescents about sex. School classes that give homework assignments for students to talk to their parents about sexual topics can be effective. The assignments are required, and parents don’t have to go anywhere, but can talk to their children at home.

What still needs to be done?

Families need support to increase communication and build strong bonds as early as possible. Many HIV prevention programs acknowledge that families play a large role in determining risk behavior, but few programs offer interventions for families. In addition to supporting persons who are already engaged in risky behaviors, programs should support family members so that risk behavior doesn’t have cause to start. To establish open communication and solidify family bonds, special care must be taken to encourage gay and lesbian youth to talk about their sexuality, especially in families with strong values regarding the importance of marriage and bearing children. Gays and lesbians are prohibited by law from marrying, may not wish to have children and are often prohibited from adopting children. Community institutions such as churches and schools can work with prevention programs to educate their members and instill tolerance and acceptance of diverse sexual identities. Too often, communities hardest hit by drug use, crime and poverty also have the highest rates of HIV and the lowest rates of family and community support. However, negative outside influences can often be overcome with the help of a strong family. Family strengthening programs, parenting centers and hotlines are needed. Well monitored recreational activities and community centers are also necessary so that parents can know their children will be safe when not at home.

Says who?

1. DiClemente RJ, Wingood GM, Crosby R, et al. Parental monitoring: Association with adolescents’ risk behaviors. Pediatrics. 2001;107:1363-1368. 2. Resnick MD, Bearman PS, Blum RW, et al. Protecting adolescents from harm: Findings from the National Longitudinal Study on Adolescent Health. Journal of the American Medical Association. 1997; 278:823-32. 3. Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy, Washington, DC: National Campaign to Prevent Teen Pregnancy, 2001. 4. Newman BS, Muzzonigro PG. The effects of traditional family values on the coming out process of gay male adolescents. Adolescence.1993;28:213-216. 5. Hampton RL, Senatore V, Gullotta TP, editors. Substance abuse, family violence and child welfare. Thousand Oaks, CA: Sage Publications; 1998. 6. Kang SY, Deren S, Goldstein MF. Relationships between childhood abuse and neglect experience and HIV risk behaviors among methadone treatment drop-outs. Child Abuse and Neglect. 2002;26:1275-1289. 7. Averett SL, Rees D, Argys LM. The impact of government policies and neighborhood characteristics on teenage sexual activity and contraceptive use.American Journal of Public Health. 2002; 92:1773-1778. 8. Gallinsky, E. Ask the children: A breakthrough study that reveals how to succeed at work and parenting. Quill Publications. 2000. 9. Madison SM, McKay MM, Paikoff R, et al. Basic research and community collaboration: Necessary ingredients for the development of a family-based HIV prevention program. AIDS Education and Prevention. 2000;12:281. 10. Fullilove RE, Green L, Fullilove MT. The Family to Family program: A structural intervention with implications for the prevention of HIV/AIDS and other community epidemics. AIDS. 2000;14S1:S63-S67. 11. PFLAG. www.pflag.org 12. Freedman B. Great HIV prevention campaigns are not just born. CAPS Exchange. 2000. prevention.ucsf.edu/uploads/CEsummer2000.pdf 13. DiIorio C, Resnicow K, Dudley WN, et al. Social cognitive factors associated with mother-adolescent communication about sex. Health Communications.2000;5:41-51. 14. Kirby D, Miller BC. Interventions designed to promote parent-teen communication about sexuality. New Directions for Child and Adolescent Development. 2002;97:93-110. Prepared by Lesley Green*, Bob Fullilove*, Pamela DeCarlo** *Community Research Group, Columbia University, **CAPS April 2003. Fact Sheet #49E Special thanks to the following reviewers of this Fact Sheet: Roberta Downing, Beth Freedman, Doug Kirby, Mary McKay, Lydia O’Donnell, Birdy Paikoff, Pam Woody.