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What is the role of male condoms in HIV prevention?

revised 01/05

do condoms work?

Yes. The condom is one of the only widely available and highly effective HIV prevention tools in the US.¹ When used consistently and correctly, latex male condoms can reduce the risk of pregnancy and many sexually transmitted infections (STIs), including HIV by about 80-90%^1-6. Condoms, including female condoms, are the only contraceptive method that is effective at reducing the risk of both STIs and pregnancy. When placed on the penis before any sexual contact, the male condom prevents direct contact with semen, sores on the head and shaft of the penis and discharges from the penis and vagina. Condoms thus should effectively reduce the transmission of STIs that are transmitted primarily through genital secretions such as gonorrhea, trichomoniasis, chlamydia, hepatitis B and HIV.^1-6 Because condoms only cover the penis, they provide less protection from STIs primarily transmitted through skin-to-skin contact such as genital herpes, syphilis, chancroid and genital warts. Abstinence, mutual monogamy between uninfected partners, reducing the number of sexual partners and correctly and consistently using condoms during intercourse are all essential to slowing the spread of HIV/STIs.⁷ Condom effectiveness depends heavily on the skill level and experience of the user. Appropriate education, counseling and training on partner negotiation skills can greatly increase the ability of a person to use a condom correctly and consistently.²

what are the advantages?

Accessibility. Using condoms does not require medical examination, prescription or fitting. Condoms can be bought at drug stores, grocery stores, vending machines, gas stations, bars and the internet, and are distributed free at many STI and HIV clinics. Sexual enhancement. Using condoms can help delay premature ejaculation. Lubricated condoms can make intercourse easier and more pleasurable for women. And condoms do away with the “wet spot” left by semen leakage after sex. Using condoms helps reduce anxiety and fears of pregnancy and STIs so that men and women can enjoy sex more. Protect fertility. Some STIs can affect a woman’s ability to get pregnant; condoms can protect against some STIs and therefore help reduce the risk of infertility.⁸

what are the disadvantages?

Lack of cooperation. Women cannot directly control whether a condom is used and have to rely upon male cooperation. When men refuse, condom use may be impossible. Physical problems. Many men and their partners complain that condoms reduce sensitivity. Proper condom use requires an erect penis. Some men cannot consistently maintain an erection so condom use becomes difficult. Trying different kinds of condoms (such as thinner condoms) and using water-based lubricant can help increase sensation. Embarrassment. Some men and women may be embarrassed to buy condoms at a store, or take free condoms from a clinic. Others may be embarrassed to suggest or initiate using condoms because they perceive condom use implies a lack of trust or intimacy.⁹

how are they used?

The most important key messages for condom use are quite simple: 1) Use a new condom every time, with every act of intercourse, if there is a risk of pregnancy or STIs. 2) Before penetration, carefully unroll the condom onto the erect penis, all the way to the base. Put it on before the penis comes in contact with the partner’s vagina or anus. 3) After ejaculation (while the penis is still erect), hold the rim of the condom against the base of the penis during withdrawal.^2,10 Even with adequate training and access to condoms, people won’t always use condoms perfectly. In the real world, people may fall in love, or make mistakes, or get drunk or simply decide not to use condoms. Having sex under the influence of alcohol and/or drugs greatly increases the chances of condom non-use, misuse and failure.¹¹

what are concerns?

Condom education/distribution in schools. Although schools can be an important source of information on HIV/STIs, only 2% of public schools have school-based health centers, and only 28% of those make condoms available to students.¹³ In 2000, persons aged 15-24 had 9.1 million new cases of STIs and made up almost half of all new STI cases in the US. 47% of US high school students have had sexual intercourse.¹⁵ Condom breakage and slippage (condom failure). Condom quality has been improving¹⁶ and for most users condom failure is relatively rare. About 4% of condoms break or slip off.² However some persons report much higher rates. In one study, gay men who were unemployed and reported amphetamine and/or heavy alcohol use were more likely to report condom failure. Men who were frequent users of condoms and used lubricant reported less failure¹¹. Counseling and education on condom use can greatly reduce condom failure.² Effectiveness of N-9. Condoms lubricated with the spermicide nonoxynol-9 (N-9) often cost more, have no proven protective advantage over condoms without N-9, have a shorter shelf life and might be harmful if used excessively. Many manufacturers have discontinued N-9 condoms.^2,16

what works?

The following programs have been documented as effective by the Centers for Disease Control and Prevention, and are currently being replicated nationwide.¹⁷ Training on condom use and negotiation. The SISTA Project is a social skills training intervention for African American women designed to increase their comfort with and use of condoms. In small group sessions, women learn sexual assertion skills and proper condom use and discuss cultural and gender triggers that affect condom negotiation. Homework activities involve their male partners. Participants reported more condom use.¹⁸ Changing community norms. The Mpowerment Project is a community-level program developed by and for young gay men that increases peer support and acceptance for safer sex. Peer-led M-groups use a gay-positive and sex-positive approach to teach men negotiation and condom use and train and motivate them to conduct informal outreach with their friends. Participants reported decreased rates of unprotected anal intercourse.¹⁹ Combining HIV prevention with STI and unintended pregnancy prevention.The VOICES/VOCES program was implemented in an STI clinic and uses culturally-specific videos and skills building to increase condom use and negotiation among African American and Latino/a heterosexuals. The program is bilingual and includes education about different types of condoms and condom distribution. Participants reported more condom use and fewer repeat STIs.²⁰

what needs to be done?

Better marketing and increased accessibility to condoms is needed in the US. Although condom use has increased in the past decade, there are still unacceptably high rates of STIs among sexually active adolescents and young adults and among gay men, two populations that are also at increased risk for HIV. New approaches to condom promotion are needed, ideally before the onset of sexual activity. For adolescents to use them, condoms must be easily and anonymously accessible, widely available and low cost. Distributing free condoms can also help increase condom use.²¹ To effectively address HIV prevention, all persons should have accurate and complete information about different prevention options. But the emphasis needs to be different for different groups. For example, while young people who have not started sexual activity need information and access to condoms, the first priority should be to encourage abstinence and delay of sexual intercourse. When targeting those at highest risk for HIV, the first priority should be to encourage correct and consistent condom use along with avoiding high-risk behaviors and partners.⁷ Are condoms foolproof? No. Neither are seat belts, helmets, abstinence pledges or vaccines. But in the real world we drive to work, vaccinate our children, and hope to get through the day unscathed. No public health strategy can guarantee perfect protection. The real question is not are condoms 100% effective, but how can we more effectively use condoms and other approaches to help reduce the risk of disease.

Says who?

1. Scientific evidence on condom effectiveness for STD prevention. Report from the NIAID. July 2001. 2. Warner L, Hatcher RA, Steiner MJ. Male Condoms. In: Hatcher RA, Trussel J, Stewart F, et al, editors. Contraceptive Technology. New York: Ardent Media Inc. 2004:331-353. 3. Holmes KK, Levine R, Weaver M. Effectiveness of condoms in preventing sexually transmitted infections. Bulletin of the World Health Organization. 2004;82:454-461. 4. Weller S, Davis K. Condom effectiveness in reducing heterosexual HIV transmission. Cochrane Database Systematic Review. 2002;(1):CD003255. 5. Hearst N, Chen S. Condom promotion for AIDS prevention in the developing world: is it working? Studies in Family Planning. 2004;35:39-47. 6. CDC. Male latex condoms and STDs. 7. Halperin DT, Steiner MJ, Cassell MM, et al. The time has come for common ground on preventing sexual transmission of HIV. Lancet. 2004;364:1913-1915. 8. Ness RB, Randall H, Richter HE, et al. Condom use and the risk of recurrent pelvic inflammatory disease, chronic pelvic pain, or infertility following an episode of pelvic inflammatory disease. American Journal of Public Health. 2004;94:1327-1329. 9. Miller LC, Murphy ST, Clark LF, et al. Hierarchical messages for introducing multiple HIV prevention options: promise and pitfalls. AIDS Education and Prevention. 2004;16:509-25. 10. ASHA. The right way to use a male condom. 1/30/05. 11. Stone E, Heagerty P, Vittinghoff E, et al. Correlates of condom failure in a sexually active cohort of men who have sex with men. Journal of AIDS. 1999;20:495-501. 12. McElderry DH, Omar HA. Sex education in the schools: what role does it play? International Journal of Adolescent Medical Health. 2003;15:3-9. 13. Santelli JS, Nystrom RJ, Brindis C, et al. Reproductive health in school-based health centers: findings from the 1998-99 census of school-based health centers. Journal of Adolescent Health. 2003;32:443-451. 14. Weinstock H, Berman S, Cates W. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspectives in Sexual and Reproductive Health. 2004;36:6-10. 15. Youth risk behavior surveillance–US, 2003. Morbidity and Mortality Weekly Report. 2004;53:1-98. 16. Condoms: extra protection. Consumer Reports. Feb 2005. 17. https://www.cdc.gov/hiv/effective-interventions/index.html 18. DiClemente RJ, Wingood GM. A randomized controlled trial of an HIV sexual risk reduction intervention for young African-American women. Journal of the American Medical Association. 1995;274:271-276. 19. Kegeles SM, Hays RB, Pollack LM, et al. Mobilizing young gay and bisexual men for HIV prevention: a two-community study. AIDS. 1999;13: 1753–1762. 20. O’Donnell CR, O’Donnell L, San Doval A, et al. Reductions in STD infections subsequent to an STD clinic visit: using video-based patient education to supplement provider interactions. Sexually Transmitted Diseases. 1998;25:161–168. 21. Cohen DA, Farley TA. Social marketing of condoms is great, but we need more free condoms. Lancet. 2004;364:13. Prepared by Markus Steiner PhD* and Pamela DeCarlo** *Family Health International, **CAPS January 2005. Fact Sheet #2ER Special thanks to the following reviewers of this Fact Sheet: Barb Adler, Daniel Bao, Willard Cates, Bill Cayley Jr, Rick Crosby, Scott Dougherty, Ralph DiClemente, Paul Feldblum, Steve Gibson, Daniel Halperin, Norman Hearst, Mary Hoban, John James, Doug Kirby, Andrzej Kulczycki, Kay Stone, Koray Tanfer, Lee Warner, Dan Wohlfeiler.

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 2005, University of California

What are men who have sex with men’s (MSM) HIV prevention needs?

What do MSM need?

Men who have sex with men (MSM) are not a single homogenous group, but represent a wide variety of people, lifestyles and health needs. From middle class gay men, to homeless runaways, to injection drug users (IDUs) to incarcerated men, MSM have many different identities and associated risks for HIV and other infectious diseases. MSM refers to any man who has sex with a man, whether he identifies as gay, bisexual or heterosexual. Despite success in changing sexual behaviors, MSM continue to be disproportionately affected by HIV/AIDS. MSM account for the largest percentage of persons with AIDS in the US (53%), even as the percentage of AIDS cases among IDUs (25%) and heterosexuals (10%) has increased.1 In 1997, the prevalence rate of HIV for MSM in 4 urban communities was 17% overall, 29% for African-American MSM and 40% for MSM-IDUs.2 HIV is not an issue that exists by itself, but is woven into many aspects of men’s lives. Risk for HIV is embedded in many other core issues such as dating and intimacy, sexual desire and love, as well as alcohol and recreational drug use, homophobia, abuse and coercion, racism and self-esteem.3 HIV prevention programs must be informed by of all these elements

Sexual health

There is not enough sexuality education for young people in the US, and almost no samegender sexuality education. Like many teenagers, young MSM may only learn about sex through distorted media or pornographic images. In general, men in today’s society are pressured to prove their manhood through sexual activity and aggressiveness, while women receive messages on moderation and caretaking. Given this, many MSM face additional challenges learning about dating, intimacy and forming relationships, or about desire, sexual functioning and arousal. Discomfort with one’s sexuality and identity can lead to sexual risk taking.4 In Minnesota, “Man-to-Man: Sexual Health Seminars” are based on the sexual health model. This model assumes that if MSM are more sexually literate, comfortable and competent, they are more likely to be able to reduce risk in the context of sexual behaviors and relationships. The program uses comprehensive sexuality education, cultural specificity and empirical research to help MSM reduce HIV risk long-term. The program was effective in reducing internalized homonegativity and unprotected anal intercourse.5 HIV is not the only sexual health concern for MSM. Other sexually transmitted diseases (STDs) such as herpes and genital warts can negatively affect health and sexuality. Several states have seen an increase in drug-resistant gonorrhea among MSM, making it more difficult to treat.6

Homophobia, racism and self esteem

Homophobia and racism are prevalent in the US. Internal and external homophobia and racism can lead to low self-esteem, which can lead to increased risk behavior such as sexual aggression, difficulty negotiating safer sex, and drug or alcohol abuse. MSM of color are disproportionately affected by many social and health-related ills such as HIV. African American and Latino MSM are more likely than their White counterparts to engage in high-risk activities and to be HIV-infected. Social and cultural factors may limit the ability of MSM of color to protect themselves from HIV. A study of Latino gay men in urban centers found that men who reported high-risk behavior also reported significantly higher rates of financial hardship, experiences of racism and homophobia, incidence of domestic violence and a history of coercive childhood sexual abuse.7 Hermanos de Luna y Sol, an HIV prevention intervention for Latino gay/bisexual men in San Francisco, CA, deals with the common history of oppression among Latino gay men, including issues of homophobia, machismo, sexual abuse, racism and separation from family and culture.8 In Washington, DC, US Helping US (UHU) is a multi-modal prevention program for Black MSM that addresses the psychological and emotional stress that they may experience as racially and sexually oppressed minorities. UHU provides mental health services, community building and anti-homophobia social marketing.9

Alcohol and recreational drug use

The prevalence of drug use is higher among MSM than among heterosexuals,10 although decreases recently have been noted in all alcohol and drug use categories except amphetamines.11 In many areas of the US, gay bars--often sex-charged environments where alcohol and drugs are prevalent--are the only venues for MSM to meet and socialize with each other. Drug use may vary greatly by region and subculture. Substance use puts MSM at risk for HIV for several reasons: 1) MSM-IDUs are at risk if they share infected injection equipment; 2) substance use is associated with high risk sexual behavior; 3) background HIV prevalence rates are higher for MSM-IDUs and MSM who abuse drugs but do not inject, increasing the likelihood of transmission.12 Substance use can serve as a trigger or an excuse for unprotected sex. Some MSM have trouble having sex without getting high first; others prefer having sex while high, believing recreational drugs increase their libido. For some MSM, drug use provides a sense of community and bonding at gay clubs and circuit parties. A survey of MSM who attend circuit parties found that serodiscordant unprotected anal sex was more likely to occur among men who used amphetamines (speed), Viagra and amyl nitrites (poppers).13 For many MSM-IDUs, drug use, rather than sexual orientation, forms their personal identity. Many MSM-IDUs identify as heterosexual. Too often MSM-IDUs are missed in prevention programs that target MSM but leave out IDUs, or programs that target IDUs but don’t address sexual orientation. MSM-IDUs have high rates of HIV infection, high frequency of unprotected sex and high rates of poverty, addiction and its related social and physical ills.12 The Stonewall Project in San Francisco, CA is a harm reduction program for MSM who use speed. The project provides education and assistance and has been successful at reaching MSM of different sexual and social identities.14 Across the US, several cities have opened social centers for gay men where no alcohol is served and drugs are not allowed. One HIV prevention program for young gay men helps develop community centers where young men can socialize without alcohol.15

What is sexual risk?

The perception of sexual risk for HIV varies among MSM and may change from one sexual situation to another. Throughout the HIV epidemic, MSM have engaged in sophisticated decision-making about what they consider to be risky.16 Some men decide for themselves it is OK to not use a condom if they are the top (insertive partner), if they are having oral sex or if their or their partner’s viral load is undetectable. MSM may make these decisions because the scientific evidence of HIV risk is cloudy, or simply because they are comfortable with some level of risk. HIV prevention programs should help MSM to make realistic and healthy choices based on factual information. MSM have engaged in a hierarchy of strategies for maintaining safer sex that are fluid and context-dependent. Most MSM are able to manage sexual risk with effective strategies such as monogamy with concordant partners, consistent condom use with repeated testing, condom use outside of relationship or abstinence. Other MSM use strategies that are not known to be effective (see above paragraph). A small minority of MSM choose to engage in known risk activities such as unprotected anal intercourse without knowledge of partner serostatus. Unprotected anal intercourse between an HIV+ and an HIV- man remains the greatest risk for HIV transmission among MSM. This has proven to be the biggest challenge for HIV prevention. The intimacy of skin-to-skin contact during intercourse is a powerful and important draw. Many MSM feel their sexual identity, as well as the hard-won goals of gay sexual liberation, are based on having sex--including anal intercourse--in a free and unconstricted manner. A majority of MSM consistently manage sexual risk, yet there is little understanding or research of men who are largely safe, and how their values of nurturance and caretaking, ethics, hopes for collective survival, or relations with friends and community help support them. Only recently have HIV+ MSM been targeted with messages and programs featuring “prevention altruism” that make use of MSM’s strengths. HIV prevention efforts need broader, more emotionally-resonant concepts that build on what is good in MSM’s lives.17

Says who?

1. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report. 2000;12.
2. Catania JA, Osmond D, Stall RD, et al. The continuing HIV epidemic among men who have sex with men. American Journal of Public Health. in press.
3. 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. 2000;12:5-26.
4. Robinson BE, Bockting W, Rosser BRS, et al. The sexual health model: a sexological approach to long-term HIV risk reduction. Presented at the XIII International Conference on AIDS, Durban, South Africa, July 2000. Abst #ThPeD5613.
5. Rosser BRS, Bockting WO, Rugg DL, et al. A sexual health approach to long-term HIV risk reduction among men who have sex with men: results from a randomized controlled intervention trial. Presented at the XIII International Conference on AIDS, Durban, South Africa, July 2000. Abst #WePeD4718.
6. Altman LK. Gonorrhea shows its resistant side; disease control agency tells doctors of new recommendations. Milwaukee Journal Sentinel. October 2, 2000. p. 5G.
7. Diaz RD, Ayala G, Bein E. Social oppression, resiliency and sexual risk: findings from the national Latino gay men’s study. Presented at the National HIV Prevention Conference, Atlanta, GA, Aug 29-Sep 1, 1999. Abst#287
8. Díaz RM. Latino Gay Men and HIV: Culture, Sexuality, & Risk Behavior. NY:Routledge. 1998.
9. Simmons R. Towards developing a comprehensive program for effective HIV prevention among racially oppressed gay men, bisexuals and MSM. Presented at the XIII International Conference on AIDS, Durban, South Africa, July 2000. Abst #TuPeD3839.
10. Stall R, Wiley J. A comparison of alcohol and drug use patterns of homosexual and heterosexual men: the San Francisco men’s health study. Drug Alcohol Dependency. 1988;22:63-73.
11. Crosby M, Stall R, Paul J, et al. Alcohol and drug use patterns have declined between generations of younger gay/bisexual men in San Francisco. Drug and Alcohol Dependence. 1998;52:177-182.
12. Rhodes F, Deren S, Wood MM, et al. Understanding HIV risks of chronic drug-using men who have sex with men. AIDS Care. 1999;11:629-648.
13. Colfax G, Mansergh G, Vittinghoff E, et al. Drug use and high-risk sexual behavior among circuit party participants. Presented at the XIII International Conference on AIDS, Durban, South Africa, July 2000. Abst #TuPeC3422.
14. Stonewall Project. 415/502- 1999.
15. Kegeles SM, Hays RB, Pollack LM, et al. Mobilizing young gay and bisexual men for HIV prevention: a two-community study. AIDS. 1999;13:1753-1762.
16. Williams AM. Condoms, risk and responsibility. Presented at the HIV Prevention Summit, Half Moon Bay, CA, June 2000.
17. Nimmons D. In this together: the limits of prevention based on self-interest and the role of altruism in HIV safety. Journal of Psychology & Human Sexuality. 1998;10:75-87

Prepared by Michael Crosby PhD and Pamela Decarlo, CAPS December 2000

¿Qué necesitan las personas mayores de 50 en la prevención del VIH?

¿están a riesgo las personas mayores?

Sí. En los EEUU más del 10% de todos los nuevos casos de SIDA ocurren entre personas mayores de 50 años.¹ En los últimos años, los nuevos casos de SIDA aumentaron más rápido entre personas de edad mediana y mayores que en personas menores de 40.² Si bien es cierto que muchas de estas personas con SIDA quedaron infectadas con el VIH a una edad más temprana, muchos se infectaron después de los 50. Es difícil determinar los índices de infección con VIH entre personas mayores, ya que son pocas las personas mayores de 50 a riesgo de contraer el VIH que se hacen la prueba de detección rutinariamente.³ A la mayoría de las personas mayores se les diagnostica el VIH a un estado muy avanzado de la enfermedad-cuando andan en búsqueda de algún tratamiento a causa de las enfermedades ocasionadas por el VIH.¹ Los casos de SIDA en personas mayores pueden no estar siendo reportados ya que los síntomas y las infecciones del VIH pueden coincidir con otras enfermedades relacionadas con la edad por lo tanto pasa desapercibida. La demencia ocasionada por el SIDA es muchas veces diagnosticada como el mal de Alzheimer, y los primeros síntomas del VIH coma la fatiga y la pérdida de peso pueden estar siendo interpretadas como el proceso natural del envejecimiento.⁴ Las personas mayores con SIDA se enferman y mueren más rápido que las más jóvenes. Esto se debe al diagnóstico tardío del SIDA y a la combinación de infecciones y otras enfermedades que posiblemente aceleran la progresión del SIDA. Además, las nuevas medicinas para tratar el VIH pueden interferir con el tratamiento médico de enfermedades crónicas previas.

¿qué los pone a riesgo?

Una de las falsas creencias más comunes en los EEUU es que las personas mayores ni tienen sexo ni usan drogas. Muy pocas campañas de prevención son dirigidas a personas mayores, y en la mayoría de los anuncios con mensajes educativos no aparecen personas mayores, lo cual les convierte en una población a riesgo e invisible.⁶ Esto ocasiona que las personas mayores estén generalmente menos informadas sobre el VIH que los más jóvenes y menos conscientes de como protegerse a si mismos de la infección. Esto es más real entre personas mayores usuarios de drogas inyectadas, los cuales componen el 16% de los casos de SIDA en mayores de 50 años. El mayor grupo de casos de SIDA entre personas mayores de 50 ocurre en hombres que tienen sexo con hombres. Los hombres gay/homosexuales mayores tienden a ser un grupo invisible dentro de esta comunidad y en los esfuerzos de prevención. Dentro de los factores que presentan los gay/ homosexuales mayores están: la arraigada homofobia, la negación del riesgo, el uso del alcohol y otras drogas, y los encuentros sexuales anónimos. ⁷ Las mujeres componen un mayor porcentaje de casos de SIDA a medida que aumenta la edad. A pesar de que solo el 6,1% de los casos de SIDA ocurre en mujeres de 50 a 59 años, el porcentaje se eleva a 13,2% en las de 60 a 69 años y a 28,7% en las mayores de 65 años de edad.⁸ Los cambios normales que aparecen con la edad tales como la falta de lubricación vaginal y el desgaste de las paredes vaginales pueden estar poniendo a mayor riesgo de infección con VIH a las mujeres mayores durante las relaciones sexuales.⁹

¿cuáles son las barreras en la prevención?

Pocos norteamericanos mayores de 50 a riesgo de contraer el VIH usan condones o se hacen la prueba de detección del VIH. En una encuesta a nivel nacional, de las personas mayores a riesgo de infectarse con VIH, un sexto estaba tan propenso a usar condones y un quinto a hacerse la prueba del VIH, que las personas de 20 a 30 años a riesgo de infección.³ Se desconocen los factores que influyen en el uso del condón en personas mayores. Pocas veces doctores y enfermeras consideran al VIH un riesgo entre pacientes mayores. Un estudio hecho a doctores, reveló que la gran mayoría de estos “raras veces” o “nunca” hacían preguntas sobre VIH/SIDA o discutían el tema de la reducción del riesgo con pacientes mayores de 50. Los doctores estuvieron mucho más propensos a “raras veces” o “nunca” preguntar a sus pacientes mayores de 50 sobre el factor de riesgo con relación al VIH (40%) que a pacientes menores de 30 (6.8%).¹⁰

¿en qué se diferencian?

Es necesario tomar en cuenta el aspecto cultural y generacional al diseñar campañas de prevención. A las personas mayores les puede resultar muy incómodo revelar a otros información sobre su comportamiento sexual o su uso de drogas. Esto puede interferir con la participación de personas mayores en grupos de apoyo.¹¹ Además, las personas mayores pueden creer que el condón ni es importante ni necesario, especialmente si la mujer ya pasó la etapa de la menopausia cuando ya no hay necesidad de protegerse para evitar un embarazo. Es posible que a estas personas les queden pocos amigos y que el círculo social que pudiera ofrecerles apoyo y cuidados sea reducido. Adicionalmente, es muy probable que ellos estén cuidando a otras personas, ya que cerca de un tercio de los pacientes con SIDA dependen de un familiar mayor para que les ayude en el aspecto económico, emocional y físico.¹²

¿qué se está haciendo?

El “Senior HIV Intervention Project (SHIP)” o “proyecto de intervención de VIH para mayores” en los condados de Dade, Broward y Palm Beach de la Florida capacita a personas mayores para hacer presentaciones de tipo educativo y conducir seminarios sobre sexo seguro en comunidades de jubilados. Estos educadores a su vez se reúnen con profesionales de la salud y trabajadores al servicio de personas mayores para informarles sobre el riesgo que este grupo encierra en cuanto al VIH.¹³ En seis centros para el cuidado de personas mayores de Chicago, Illinois, un programa utilizó “círculos de estudio”, los cuales fueron dirigidos por miembros del mismo grupo con el fin de alertar y aumentar el conocimiento sobre VIH entre los participantes. Los participantes presenciarion el video “The Forgotten Tenth” o “el 10% restante” e investigaron por cuenta propia como afecta el VIH en sus vidas: física política y economicamente. Luego compartieron lo aprendido en las reuniones subsecuentes. Al concluir el programa muchos de los participantes se convirtieron en educadores de SIDA.¹⁴ En la Florida se llevó a cabo un programma educativo sobre VIH en varios comedores para mayores. Basado en el “Modelo de Creencia de Salud”, el programa incluyó información básica y estadísticas sobre el VIH, instrucción sobre el uso del condón, información sobre las pruebas de detección, y el estudio de algunos casos de personas mayores con SIDA. Al final de esta sesión, los participantes reportaron un aumento en su conocimiento del SIDA y la susceptibilidad que estos perciben con respecto al VIH.¹⁵

¿qué queda por hacer?

Ha existido una falta notable de interés por las personas mayores de 50 en los esfuerzos de prevención. Es necesario crear programas de prevención exclusivos para gente mayor. Los medios de comunicación y los carteles de anuncios necesitan contener temas e imágenes que se identifiquen con las personas mayores de 50 y promover a su vez la prueba de detección del VIH rutinariamente en personas mayores que viven a riesgo de infección. Es necesario investigar más a fondo el comportamiento de estas personas en relación al sexo y al uso de drogas, la progresión de la enfermedad y los tratamientos, y reclutar a personas mayores VIH+ para los estudios clínicos. El personal clínico y los proveedores de servicio para personas mayores, incluyendo a los cuidantes y el personal de asilo de ancianos, deben recibir educación sobre los comportamientos de riesgo y los síntomas del VIH en personas mayores. El personal clínico además, debe asesorar el riesgo y el uso de drogas más cuidadosamente en pacientes mayores de 50 y no asumir que los pacientes no participan en este tipo de actividades o que no hablan de ello. Las personas mayores carecen del apoyo y la educación que les permitiría asegurarse una vida tan satisfactoria como la que tenían antes de pasar los 50 años. Un programa de prevención completo, utiliza muchos elementos para proteger del VIH a la mayor cantidad de gente posible. Los adultos mayores de 50 consituyen un grupo especial que debería recibir mensajes preventivos tanto por el riesgo ocasionado por las conductas de riesgo como por el papel de liderazgo y de maestros que estos desempeñan para futuras generaciones.

¿quién lo dice?

1. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report . 1996;8:15. 2. HIV, AIDS, and older adults . Fact sheet prepared by the National Institute on Aging, National Institutes of Health. 3. Stall R, Catania J. AIDS risk behaviors among late middle-aged and elderly Americans. The National AIDS Behavioral Surveys . Archives of Internal Medicine. 1994;154:57-63. 4. Whipple B, Scura KW. The overlooked epidemic: HIV in older adults . American Journal of Nursing. 1996;96:22-28. 5. Skiest DJ, Rubinstien E, Carley N, et al. The importance of comorbidity in HIV-infected patients over 55: a retrospective case-control study . American Journal of Medicine. 1996;101:605-611. 6. Feldman MD. Sex, AIDS, and the elderly . Archives of Internal Medicine. 1994;154:19-20. 7. Grossman AH. At risk, infected, and invisible: older gay men and HIV/AIDS . Journal of the Association of Nurses in AIDS Care. 1995;6:13-19. 8. Ship JA, Wolff A, Selik RM. Epidemiology of acquired immune deficiency syndrome in persons aged 50 years or older . Journal of Acquired Immune Deficiency Syndromes. 1991;4:84-88. 9. Catania JA, Turner H, Kegeles SM, et al. Older Americans and AIDS: transmission risks and primary prevention research needs . Gerontologist. 1989;29:373-381. 10. Skiest DJ, Keiser P. Human immunodeficiency virus infection in patients older than 50 years. A survey of primary care physicians’ beliefs, practices, and knowledge . Archives of Family Medicine. 1997;6:289-294. 11. Nokes K, ed. HIV/AIDS and the older adult . Washington DC: Taylor & Francis;1996. 12. Ory MG, Zablotsky D. Notes for the future: research, prevention, care, public policy. In MW Riley, MG Ory, D Zablotsky, eds. AIDS In an Aging Society. New York, NY: Springer Publishing; 1989. 13. Senior HIV Intervention Project (SHIP). Contact: Lisa Agate (954) 467-4774. 14. Dill D, Huston W. AIDS education for older adults. Healthpro UIC. 1996;Fall:18-19. Contact: Rita Strombeck, HealthCare Education Associates (760) 323-4032. 15. Rose MA. Effect of an AIDS education program for older adults . Journal of Community Health Nursing. 1996;13:141-148. Contact: Molly Rose (215) 503-7567. Recursos: NY HIV Over 50 Task Force, Brookdale Center on Aging, Hunter College, 425 E 25th Street, New York, NY 10010, (212) 481-7594. Contact: Kathy Nokes,[email protected] American Association of Retired Persons (AARP), Social Outreach and Support (SOS), 601 E Street, NW, Washington, DC 20049, (202) 434-2260,http://www.aarp.org National Association on HIV Over Fifty (NAHOF), Midwest AIDS Training & Education Center, University of Illinois, 808 S. Wood Street m/c 779, Chicago. IL 60612, (312) 996-1426, [email protected] National Institute on Aging, https://www.ioaging.org/

Preparado por Pamela DeCarlo*, Nathan Linsk, PhD**, Traducción Romy Benard-Rodríguez* *CAPS, **National Association on HIV Over 50, Midwest AIDS Training & Education Center Abril 1998. Hoja Informativa 29S.

We Know What Works in HIV Prevention -Why Aren’t We Doing More of It?

What have we learned?

Fifteen years ago, the first AIDS cases were diagnosed among 5 gay men in Los Angeles, CA. Since then, AIDS has spread to over half a million people in the US and is the leading cause of death for all Americans aged 25-44. Fifteen years have also seen great leaps in understanding how to prevent the spread of HIV. But these fifteen years have not seen the widespread implementation of effective HIV prevention programs in the US. If we know what works, why aren’t we doing more of it? HIV prevention does not have to be perfect to be effective. Epidemiological models have shown that simply cutting rates of risky behavior in half can halt the epidemic.¹ The programs listed below are some of the interventions that have shown signs of success and should be replicated, even without 100% reduction in risk behavior.

What has shown signs of working?

The majority of the estimated 41,000 annual new HIV infections in the US are occurring among injection drug users (IDUs), their sexual partners, and their offspring.² We know what works to prevent the spread of HIV among IDUs: starting HIV prevention efforts when rates of HIV are still low, providing sterile injecting equipment through needle exchange programs and over-the-counter pharmacy sales, conducting community outreach to IDUs, and providing drug treatment on demand.³ In Tacoma, WA, where prevention efforts for IDUs began in 1988, the prevalence of HIV among IDUs has remained steady at 3-4%. In New York City, NY, where prevention efforts for IDUs met with early opposition, HIV among IDUs increased from 10% to more than 50% in five years.³ Connecticut implemented the ideal HIV prevention program: it cost the state nothing and was highly effective. A partial repeal of needle prescription and drug paraphernalia laws resulted in dramatic reductions in needle sharing, and increases in pharmacy purchase of syringes by IDUs. Sharing dropped from 52% to 31% after the new laws, pharmacy purchase rose from 19% to 78%, and street purchase fell from 74% to 28%.⁴ Gay and bisexual men account for a majority of total current HIV infections, and 25% of annual new infections in the US.² We know what intervention strategies work for gay and bisexual men: small group counseling and skills training, peer outreach, counseling and testing, hot lines, media programs, and community interventions. One effective program in several medium-sized towns trained the most popular people in social settings to deliver AIDS risk-reduction messages to friends and acquaintances in gay bars. As a result, fewer gay men practiced unprotected sex.⁵ Another successful program promoted a norm for safer sex among young gay men through a variety of social, outreach and small group activities such as dances, picnics, and volleyball games. As a result, rates of unprotected intercourse dropped from 40% to 31%.⁶ One fourth of all new HIV infections in the US occur in young people under the age of 22. We know what works for adolescents: effective sex education programs in schools. Although the popular belief is that teaching kids about sex will lead to promiscuity, in fact, the opposite is true. A comprehensive review of 23 school-based programs found that teens who received specific AIDS education were less likely to engage in sex, and those who did were more likely to have sex less often and use contraception.⁷ Sex education is most effective when it is begun before students have initiated sexual activity. A program in Oakland, CA, used peer educators to teach seventh graders about sexuality and HIV/AIDS. After one year, students in the program were less likely to initiate activities such as deep kissing, genital touching, and sexual intercourse.⁸ Voluntary HIV testing and treatment with AZT for HIV-positive pregnant women reduced the risk of maternal-fetal HIV transmission by two-thirds in clinical trials.⁹ Long-term effects on mother and child have yet to be determined.

How is prevention being held back?

The US government still bans the use of federal funds for needle exchange programs, even though six government-sponsored reports have shown that those programs help stop the spread of HIV and do not lead to increased drug use. Similarly, ten states and the District of Columbia still have laws requiring a doctor’s prescription to buy a syringe, even though four government-sponsored studies have recommended repealing those laws.¹⁰ Meanwhile, drug treatment centers frequently have long waiting lists, and fewer than 15% of IDUs in the US are in treatment at any given time.¹¹ In recent years, many states have passed laws that restrict sex education. For example, eight states require or recommend teaching that homosexuality is not an acceptable lifestyle, even though gay teens are at highest risk for HIV and most in need of education. Twenty-six states require abstinence instruction, even though a review of abstinence programs showed no proof of effectiveness in delaying the onset of intercourse.⁷ Only 14 of the 26 states also require sex education curricula to include information on contraception, sexually transmitted diseases and HIV.¹² Funding for HIV prevention has not always flowed where it is most needed. For example, in California in 1991, gay and bisexual men accounted for 88% of all AIDS cases, yet received only 5% of total state spending on prevention.¹³ Success preventing maternal-fetal transmission has prompted the federal government to recommend universal counseling and voluntary HIV testing to all pregnant women. However, getting tested does not guarantee treatment if a women should test positive. A study of publicly funded HIV test sites found that almost half of all clients had no health insurance, and racial minorities were more likely to be uninsured.¹⁴ Lack of insurance may block many women from preventive services such as prenatal care. Prevention programs that have been evaluated and shown to be effective are sometimes perceived as too complicated or expensive to work “in the field.” Researchers and service providers can collaborate to better understand how to adapt effective programs to different populations, and to determine the cost-effectiveness of programs.

What can we do?

The federal government needs to repeal the ban on funding for needle exchange programs. State governments need to repeal needle prescription and paraphernalia laws. Federal and state governments need to dramatically increase methadone maintenance programs, as well as drug treatment programs for cocaine and crack. State governments should pass laws requiring all children to receive explicit and age-appropriate sexuality, drug, and HIV/AIDS education in schools that includes discussions of homosexuality and contraception. State health departments and their Community Planning groups need to prioritize funding for prevention programs that more accurately reflect the epidemiology of HIV in their communities. Highest priority should be given to programs for populations with the greatest need: IDUs in and out of treatment; gay and bisexual men who are young, substance users, and men of color; female partners of IDUs; and high-risk youth. The federal government needs to ensure early access to care and treatment for those who test positive. New medications and therapies can be prohibitively expensive for those without health insurance. Recent advances in HIV treatment can dramatically lower the amount of HIV virus during early phases of infection, which may reduce the risk of transmission. In the future, good HIV treatment may be key for HIV prevention. A comprehensive HIV prevention strategy uses many elements to protect as many people at risk for HIV as possible. Prevention does not have to be perfect to make a difference. We know what works in HIV prevention. We need to apply that knowledge more completely, more fairly, and more consistently. Prepared by Thomas J. Coates, PhD and Pamela DeCarlo

Says Who?

1. Blower SM, McLean AR. Prophylactic vaccines, risk behavior change, and the probability of eradicating HIV in San Francisco . Science. 1994;265:1451-1454. 2. Holmberg SD. The estimated prevalence and incidence of HIV in 96 large US metropolitan areas . American Journal of Public Health. 1996;86:642-654. 3. Des Jarlais DC, Hagan H, Friedman SR, et al. Maintaining low HIV seroprevalence in populations of injecting drug users . Journal of the American Medical Association. 1995;274:1226-1231.

• Contact: Don Des Jarlais 212/387-3870 X3808.

4. Groseclose SL, Weinstein B, Jones TS, et al. Impact of increased legal access to needles and syringes on practices of injecting-drug users and police officers-Connecticut, 1992-1993 . Journal of Acquired Immune Deficiency Syndromes. 1995;10:82-89.

• Contact: Beth Weinstein 203/509-7800.

5. Kelly JA, St. Lawrence JS, Stevenson LY, et al. Community AIDS/HIV risk reduction: the effects of endorsements by popular people in three cities . American Journal of Public Health. 1992;82:1483-1489.

• Contact: Jeff Kelly 414/287-4680.

6. Hays RB, Rebchook, GM, Kegeles SM. The Mpowerment project: a community-level HIV prevention intervention for young gay and bisexual men . American Journal of Public Health. 1996;86:1-8.

• Contact: Susan Kegeles 415/597-9159.

7. Kirby D, Short L, Collins J, et al. School-based programs to reduce sexual risk behaviors: a review of effectiveness. Public Health Reports. 1994;109:339-360. 8. Ekstrand ML, Siegel D, Nido V, et al. Peer-led AIDS prevention delays initiation of sexual behaviors among US junior high school students. Presented at 11th International Conference on AIDS, Vancouver, BC. 1996.

• Contact: Maria Ekstrand 415/597-9160.

9. Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment . New England Journal of Medicine. 1994;331:1173-1180. 10. Lurie P, Drucker E. An opportunity lost: estimating the number of HIV infections due to the US failure to adopt a national needle exchange policy. Presented at 11th International Conference on AIDS, Vancouver, BC. 1996. 11. Wiley J, Samuel M. Prevalence of HIV infection in the USA . AIDS. 1989;3(Suppl. 1):71-78. 12. Sexuality Education in America: A State-by-State Review. Report prepared by the NARAL Foundation. Washington, DC: 1995. 13. Lee PR, Franks P, Haynes-Sanstad K, et al. HIV Prevention in California: HIV Education and Prevention Evaluation. Report prepared for the Office of AIDS, California Department of Health Services, 1993. 14. Valdiserri RO, Gerber AR, Dillon BA, et al. Clients without health insurance at publicly funded HIV counseling and testing sites: implications for early intervention . Public Health Reports. 1995;110:47-52.

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 AIDS Clearinghouse at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. ©1996, University of California

¿Cómo ayuda la evaluación en la prevención del VIH?

¿qué es la evaluación?

La mayoría de los proveedores de servicios de prevención del VIH realizan actividades periódicas de evaluación y recolección de datos, aunque tal vez no consideren que sea una evaluación. Tomar notas durante reuniones de manejo de casos de prevención, comentar las opiniones de los clientes sobre los servicios que han recibido, observar un sitio de intercambio de jeringas, tomar notas en juntas del personal: todos son ejemplos de la recolección “informal” de datos que sucede a diario. La evaluación provee sistemas para obtener datos, luego ayuda a los proveedores a entenderlos y aplicarlos en el trabajo. La evaluación puede profundizar los conocimientos de los proveedores, su entendimiento de los grupos poblacionales que sirven, aumentar la eficacia de los programas que ofrecen y las decisiones que se toman. La evaluación es una manera de identificar los puntos programáticos fuertes y débiles¹ y facilita que los programas obtengan los resultados que desean. También permite que los proveedores se responsabilicen ante las comunidades en que trabajan y ante las entidades que los financian. La evaluación puede integrarse en todas las fases de planificación y ejecución de una intervención.

• Antes (evaluación formativa, valoración de necesidades): Para entender el contexto de las vidas de los miembros de la comunidad y lo que los pone en riesgo, cómo evitan el riesgo o qué recursos necesitan para reducirlo y mantener la salud y el bienestar. Esto puede ayudar a darle forma al programa y proveer datos basales que ayuden a medir cualquier cambio.
• Durante (monitoreo y evaluación del proceso, control de calidad): Para averiguar exactamente qué sucede en la práctica y si el programa opera tal y como fue planeado; para documentar las interacciones con los participantes; para identificar los componentes que sirven mejor y para saber si el programa satisface las necesidades de los participantes. Esta información puede ayudar a desarrollar cambios al programa.
• Después (evaluación del impacto y los resultados): Para determinar si el programa tuvo algún efecto a corto y a largo plazo sobre los participantes, sus parejas y familias, sobre el personal del programa y la comunidad. En ese momento, el personal puede reevaluar los objetivos del programa y aprovechar los datos obtenidos para refinar más los programas.

¿por qué hay que evaluar?

La evaluación puede aumentar la eficiencia y la calidad de los programas. No sustituye la experiencia ni los conocimientos del personal pero sí puede brindar información complementaria. El uso de datos recolectados sistemáticamente para el diseño de una intervención o programa puede ayudar a tomar decisiones inteligentes sobre qué elementos incorporar y qué conductas, influencias y circunstancias de vida se deben tomar en cuenta.¹ La evaluación puede ayudar a las organizaciones a solicitar fondos con mayor éxito, claridad y precisión. Muchos financiadores requieren que los solicitantes demuestren que han pensado sistemáticamente en las intervenciones que brindan actualmente y las que proponen.² La evaluación también puede ayudar a identificar exactamente qué servicios benefician más a los participantes, lo cual permite que en vez de responder a toda convocatoria de financiación, se trabaje sólo en las que concretamente respondan a las necesidades de los participantes.¹

¿cuál es una buena pregunta de evaluación?

Las buenas preguntas de evaluación se derivan de objetivos programáticos bien formulados que sean realistas y medibles. Al diseñar actividades programáticas basadas en un resultado deseado (por ejemplo: realizar extensión comunitaria para aumentar el número de mujeres que reciben la prueba del VIH), es mucho más fácil articular la evaluación.⁴ Por el contrario, es difícil evaluar programas que carecen de dirección. El indicador de una buena pregunta de evaluación es que a uno le importe la respuesta. ¿Qué es más útil conocer: el número de condones repartidos en un mes, o lo que hacen los clientes después de recibirlos? Asimismo, una pregunta buena también debe poder ser respondida. Muchas organizaciones tal vez quieran saber si sus programas son eficaces, pero estas preguntas tan amplias requieren de más tiempo, dinero y personal de los que disponen. Por ejemplo, en vez de preguntar, “¿Hemos reducido las tasas de VIH entre los hombres homosexuales?” otra pregunta más útil y más fácil de contestar podría ser: “¿Han reducido su consumo de metanfetamina o aumentado su uso de condones los hombres que asistieron a nuestro programa de pláticas grupales?”

¿cuáles son las percepciones?

Una percepción común sobre la evaluación es qué ésta se usa únicamente por financiadores para “comprobar” el éxito o fracaso de los programas. No es de extrañar que muchas organizaciones desconfíen al respecto.^4,5 Sin embargo, la evaluación permite que los proveedores descubran por sí mismos qué funciona y qué no, qué ajustes se necesitan para mejorar el programa y si sus servicios están logrando cambios en las vidas de sus usuarios y en la comunidad. Otra percepción es que la evaluación “se le hace a” la organización por alguien ajeno a ésta, cuando en realidad puede incorporarse en la planificación programática con la participación plena de todos los miembros de la propia organización. Esto fortalece el proceso y asegura que los resultados se entiendan y se aprovechen. Los evaluadores, el personal de atención al público, los representantes de la comunidad o participantes del programa deben ser incluidos en todas las fases: el diseño de las preguntas de evaluación, la revisión de formularios o guías y las discusiones sobre resultados y puntos de acción.⁶

¿cómo se realiza la evaluación?

Las organizaciones pueden realizar la evaluación de muchas maneras. Una es capacitar al personal para que la efectúe o contratar a algún miembro del propio personal con experiencia en investigación para que se encargue de la evaluación y de los datos. Este método puede ser el más apto para una organización grande con muchos recursos. Por ejemplo, el equipo de evaluación del AIDS Project Los Angeles colaboró con la iniciativa Commercial Sex Venues (CSV) para diseñar y evaluar actividades de reducción de riesgos en nueve CSV en el condado de Los Ángeles. El personal del programa y el de evaluación diseñaron e implementaron conjuntamente investigaciones formativas, pre y postevaluaciones, formularios de extensión comunitaria, la evaluación del programa y una valoración anual de las necesidades de los usuarios. Los usuarios de los CSV reportaron una reducción en encuentros sexuales sin protección en el seguimiento realizado un año más tarde.⁷ Otro ejemplo es que la propia organización contrate a un evaluador externo para que realice este trabajo ya sea una sola vez o en forma continua. Este método puede resultar menos costoso que la contratación de personal de plantilla, puede promover la ejecución de algunos aspectos de la evaluación con recursos internos y puede ser visto por los financiadores como un proceso menos subjetivo que el realizado por un evaluador interno. Las experiencias de las organizaciones con los evaluadores externos han sido positivas y negativas. Estas evaluaciones suelen ser más exitosas cuando existe una colaboración fuerte; concordancia sobre los roles, responsabilidades y expectativas; y una solidaridad absoluta entre el evaluador y la organización. Al contratar a un evaluador, las organizaciones pueden buscar a un profesional con un historial de colaboración exitosa, amplia habilidad y experiencia de evaluación en ambientes de prestación de servicios y conocimientos o experiencia con la población beneficiada por el programa.⁸ Un tercer ejemplo es la colaboración entre una organización y un evaluador para desarrollar los métodos de evaluación y aumentar la capacidad de la organización. En Chicago, el HIV Prevention and Adolescent Mental Health Project (CHAMP), es una colaboración a largo plazo entre investigadores de la Universidad de Chicago, padres de familia, escuelas y organizaciones comunitarias. Conjuntamente han diseñado, implementado y evaluado este programa de prevención del VIH para jóvenes negros y sus familias. Iniciaron su colaboración en 1995 y la continúan hasta la fecha.⁹ Los Centros para el Control y Prevención (CDC siglas en inglés) han otorgado fondos para proyectos de fomento de capacidad (CBA en inglés) que integran las actividades de planificación, vigilancia y evaluación programática en las organizaciones. Una red nacional de proveedores CBA fomenta la capacidad organizacional, de prevención del VIH y de evaluación en organizaciones con usuarios asiáticos e isleños del Pacífico, latinos, indígenas americanos, nativos de Alaska y afroamericanos.¹⁰

¿qué queda por hacer?

Si no se le asignan tiempo y fondos concretos, la evaluación puede perderse en el mundo de los servicios a usuarios el cual gira en torno a las crisis. Se debe alentar a las organizaciones a promover un ambiente de aprendizaje junto con la provisión de servicios. Las organizaciones pueden incorporar en los perfiles de sus puestos el tiempo necesario para realizar la evaluación y pueden asignar al personal el tiempo necesario para comentar lo que han aprendido en reuniones periódicas. Los financiadores necesitan cubrir todos los gastos relacionados con la evaluación para que ésta cuente con suficiente personal. Con frecuencia se pasa por alto los costos del tiempo y capacitación del personal, el registro de datos, el análisis de datos y la redacción y divulgación del informe sobre los resultados de la evaluación. Es esencial difundir los resultados de la evaluación. El personal de la organización necesita redactar informes sobre los hallazgos y presentarlos en congresos regionales y nacionales. Los financiadores necesitan compartir informes con las organizaciones y con otros financiadores y sintetizar las lecciones aprendidas para todos sus financiados. Los departamentos de salud pueden organizar reuniones regionales para difundir resultados y fomentar vínculos entre organizaciones con necesidades de evaluación similares.

¿Quién lo dice?

1. Gandelman AA, DeSantis LM, Rietmeijer CA. Assessing community needs and agency capacity—an integral part of implementing effective evidence-based interventions. AIDS Education and Prevention. 2006;18:32-43. 2. Holtgrave DR, Gilliam A, Gentry D et al. Evaluating HIV prevention efforts to reduce new infections and ensure accountability. AIDS Education and Prevention. 2002;14SA:1- 3. Nu’Man J, King W, Bhalakia A, et al. A framework for building organizational capacity integrating planning, monitoring, and evaluation. Journal of Public Health Management and Practice. 2007;Suppl:S24-32. 4. Kegeles SM, Rebchook GM. Challenges and facilitators to building program evaluation capacity among community-based organizations. AIDS Education and Prevention. 2005;17:284-299. 5. Napp D, Gibbs D, Jolly D, et al. Evaluation barriers and facilitators among community-based HIV prevention programs. AIDS Education and Prevention. 2002;14:38-48. 6. Gilliam A, Davis D, Barrington T, et al. The value of engaging stakeholders in planning and implementing evaluations. AIDS Education and Prevention. 2002;14:5-17. 7. Mutchler M, Colemon L. A model for community-based participatory evaluation: Benefits, challenges and lessons of evaluating HIV prevention in commercial sex venues. Presented at the 2005 Nat’l HIV Prevention Conf, Atlanta, GA. #M3-D0601. 8. Center for AIDS Prevention Studies. Working Together: A Guide to Collaborative Research in HIV Prevention. 2001. 9. Baptiste DR, Paikoff RL, McKay MM, et al. Collaborating with an urban community to develop an HIV and AIDS prevention program for black youth and families. Behavior Modification. 2005;29:370-416. 10. Taveras S, Duncan T, Gentry D, et al. The evolution of the CDC HIV Prevention Capacity-building Assistance Initiative. Journal of Public Health Management & Practice. 2007;13S:S8-S15. Recursos Manuales

• A Buenas Preguntas… ¡Mejores Respuestas!: Un manual de investigación formativa, CAPS
• Evaluacion de Programas, NMAC
• Manual de Evaluación, Fundación W.K. Kellogg

Herramientas

• Caja de Herramientas Comunitarias

Preparado por Dara Coan,* Oscar Macias,* Janet Myers,** Kevin Khamarko*** *San Francisco Public Health Department, **CAPS, ***AETC Evaluation Center Traducción: Rocky Schnaath Abril 2008. Hoja de Dato #44SR