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How does childhood sexual abuse affect HIV prevention?

What is childhood sexual abuse?

Childhood sexual abuse may be defined in many ways, but this fact sheet refers to unwanted sexual body contact prior to age 18, the age of consent to engage in sex. CSA is a painful experience on many levels that can have a profound and devastating effect on later physiological, psychosocial and emotional development. CSA experiences can vary with respect to duration (multiple experiences with the same perpetrator), degree of force/coercion or degree of physical intrusion (from fondling to digital penetration to attempted or completed oral, anal or vaginal sex). The identity of the perpetrator–ranging from a stranger to a trusted figure or family member–may also impact the long-term consequences for individuals. To distinguish CSA from exploratory sexual experimentation, the contact should be unwanted/coerced or there should be a clear power difference between the victim and perpetrator, often defined as the perpetrator being at least 5 years older than the victim. Many more children are sexually abused than are reported to authorities.¹ Estimates of the prevalence of CSA in the US are about 33% for females under the age of 18 and 10% in males under 18 years of age.² Men are significantly less likely than women to report CSA when it occurs.³ CSA is more likely to occur in families under duress. Children are at risk for CSA in families that experience stress, poverty, violence and substance abuse and whose parents and relatives have histories of CSA.

Does CSA affect HIV risk?

Yes. Because childhood and early adolescence are critical times in a person’s sexual, social and personal development, CSA can distort survivors’ physical, mental and sexual images of themselves. These distortions, combined with coping mechanisms adopted to offset the trauma of CSA, can lead CSA survivors into high-risk sexual and drug-using behaviors that increase the likelihood of HIV infection.⁴ Persons who experience CSA may feel powerless over their sexuality and sexual communication and decision-making as adults because they were not given the opportunity to make their own decisions about their sexuality as children or adolescents. As a result, they may engage in more high-risk sexual behavior, be unable to refuse sexually aggressive partners and have less sexual satisfaction in relationships. CSA survivors may have difficulties forming attachments and long term relationships and may dissociate from their feelings, resulting in having multiple sexual partners, “one night stands” and short-term sexual relationships. Adults who perceive positive aspects of their own CSA (such as gaining attention) may also use sex as a soothing or comforting strategy, which can lead to promiscuity and compulsive sexual patterns.⁵ The effects of CSA may be different for adult men and women. Female survivors of CSA may have lower condom self-efficacy with partners, use condoms less frequently, exhibit more sexual passivity and attract or be attracted to overly controlling partners.⁶ Male survivors of CSA may experience higher levels of eroticism, exhibit aggressive, hostile behavior and victimize others.⁷ Adults with CSA histories may use dissociation and other coping efforts to avoid negative thoughts, emotions and memories associated with the abuse. One of the most common dissociation methods is alcohol and drug abuse. A study of men and women with a history of substance abuse found that 34% had experienced CSA. CSA survivors with substance abuse problems were more likely than substance abusers who had not experienced CSA to exchange sex for money or drugs, have an HIV+ or high-risk partner and not use condoms.⁸ Sexual revictimization can also influence high-risk sexual behavior. One study of African American and white women found that CSA survivors who experience revictimization as adults had more unintended pregnancies, abortions, STDs and high-risk sexual behaviors than those who experienced only CSA.⁹

What’s being done?

There are many resources for CSA survivors, but few programs exist to reduce HIV-related sexual and drug-using risk behaviors and increase psychological well being. Most of these programs focus on women; there are even fewer programs for male CSA survivors. Good-Touch/Bad-Touch is a comprehensive child abuse prevention intervention designed for pre-school and kindergarten through sixth grade students. The program uses a variety of materials to teach children prevention skills including personal body safety rules, what abuse is and what action to take if threatened.¹⁰ The Children’s Medical Center in Dallas, TX, provides HIV/STD prevention for young female sexual abuse victims at a child abuse clinic. Adolescent females between 12 and 16 years old receive one-on-one evaluation and personalized education from an adolescent-focused HIV/STD counselor. Providing sensitive counseling close to the time of recognition of abuse can be a good method for prevention education.¹¹ At Stanford University, CA, a trauma-focused group therapy intervention seeks to reduce HIV risk behavior and revictimization among adult women survivors of CSA. The groups focus on survivors’ memories of CSA to see if this helps increase safer behaviors and reduce stress. The women also receive case management.¹² The Visiting Nurse Service of New York offers comprehensive in-home services to HIV-infected families. The children in these families are at high risk for repeating the histories and behaviors of their parents, including HIV infection, substance abuse, sexual abuse and mental illness. The program provides home-based interventions that include play therapy, health and safe sex education, family and individual counseling, relapse prevention for the parent and drug awareness and prevention for the children. Helping the child deal with anger and resentment towards the parent lessens the likelihood that their anger will be displaced on themselves, thus repeating the behavior of the parent. Supporting each family member is key to breaking the cycle of HIV and abuse in these families.¹³ At the University of California, Los Angeles, and King-Drew University, CA, a psychoeducational intervention aims to increase healthy behavior and decrease HIV risk behaviors in HIV+ women with histories of CSA. Women are taught communication and problem-solving tools and link CSA experiences to past and current areas of risk.¹⁴

What needs to be done?

Although dealing with CSA may seem like a daunting task for many HIV prevention programs, there are a variety of usable approaches to address CSA in adults. Programs can: include questions on abuse during routine client screening, reassess clients over time, provide basic education on the effects of CSA and offer referrals for substance abuse and mental health services. Program staff need basic training and support to help cope with the effects of CSA counseling and the relative high prevalence in certain populations.¹⁵ Persons who are likely to interact with CSA survivors such as medical and other health professionals, religious and peer counselors, including alcohol, substance abuse and rape counselors, and probation officers need to be educated on the effects of CSA on sexual and drug risk behaviors. They also need training on how to recognize symptoms of CSA and how to address these issues or provide appropriate referrals for treatment. Professionals should look beyond CSA symptoms and inquire about other childhood experiences that may have been problematic. CSA survivors often are forced to contend with other types of abuse and a dysfunctional family environment. A poor family environment may set the tone for abuse to occur and leave the survivor with little support to cope with the experience.

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Says who?

1. Green AH. Overview of child sexual abuse. In SJ Kaplan (ed.), Family violence: A clinical and legal guide. Washington, DC: American Psychiatric Press. 1996;73-104. 2. Finkelhor D. The international epidemiology of child sexual abuse. Child Abuse & Neglect. 1994;18:409-417. 3. Roesler TA, McKenzie N. Effects of childhood trauma on psychological functioning in adults sexually abused as children. Journal of Nervous and Mental Disease. 1994;182:145-150. 4. Prillo KM, Freeman RC, Collier C, et al. Association between early sexual abuse and adult HIV-risky behaviors among community-recruited women. Child Abuse & Neglect. 2001;25:335-346. 5. Paul, J. Understanding childhood sexual abuse as a predictor of sexual risk-taking among men who have sex with men: The Urban Men’s Health Study. Child Abuse & Neglect. 2001;125:557-584. 6. Watkins B, Bentovim A. The sexual abuse of male children and adolescents: a review of current research. Journal of Child Psychology & Psychiatry & Allied Disciplines. 1992;33:197–248. 7. Wyatt GE, Guthrie D, Notgrass CM. Differential effects of women’s child sexual abuse and subsequent revictimization. Journal of Consulting and Clinical Psychology. 1992;60:167-173. 8. Morrill AC, Kasten L, Urato M, et al. Abuse, addiction and depression as pathways to sexual risk in women and men with a history of substance use. Journal of Substance Abuse. 2001;13:169-184. 9. Wyatt GE, Myers HF, Williams JK, et al. Does a history of trauma contribute to HIV risk for women of color? Implications for prevention and policy. American Journal of Public Health. 2002;92:1-7. 10. Harvey P, Forehand R, Brown C, et al. The prevention of sexual abuse: Examination of the effectiveness of a program with kindergarten-age children. Behavior Therapy. 1988;19:429-435. 11. Squires J, Persaud DI, Graper JK. HIV and STD prevention counseling for adolescent girls seen in a child abuse clinic. Presented at the 14th International AIDS Conference, Barcelona, Spain. 2002. Abst # TuPeF5249. 12. Group Interventions to Prevent HIV in High Risk Women.www.med.stanford.edu/school/ Psychiatry/PSTreatLab/TraumaStudy.php 13. Mills R, Samuels KD, Bob-Semple N, et al. Breakin the cycle: multigenerational dysfunction in families affected with HIV/AIDS. Presented at the 14th International AIDS Conference, Barcelona, Spain. 2002. Abst #. ThPeE7828. 14. Wyatt GE, Myers H, Longshore D, et al. Examining the effects of trauma on HIV risk reduction: the women’s health intervention. Presented at the International Conference on AIDS, Barcelona, Spain. 2002. Abst# WePeF6853. 15. Paul JP. Coerced childhood sexual episodes and adult HIV prevention. FOCUS. 2003;18:1-4

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Prepared by Gail Wyatt PhD, Tamra Loeb PhD, Inna Rivkin PhD, Jennifer Carmona PhD, Dorothy Chin PhD, John Williams MD, Hector Myers PhD, Douglas Longshore PhD and Charlotte Sykora PhD UCLA Women’s Health Project September 2003. Fact Sheet #52E Special thanks to the following reviewers of this Fact Sheet: Ruth Kelley, Jay Paul, Elizabeth Radhert.

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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]. © September 2003, University of California

How does HIV prevention work on different levels?

what are levels?

HIV prevention is not just about changing individual behavior. Many other factors also influence HIV transmission, such as relationships with family and friends, community norms, access to health care and local laws. Working on different levels means addressing all these factors through multiple approaches: individual, couple/family, community, medical and legal.¹ HIV prevention programs for injecting drug users (IDUs) in the US have included interventions on many different levels. These programs have incorporated interventions such as: intensive street outreach to educate IDUs, drug treatment, syringe exchange, community-building and empowerment efforts and adherence programs for HIV+ IDUs. Where these efforts are in place, rates of HIV among IDUs have remained stable.¹ Prevention efforts addressing multiple levels have reversed HIV epidemics in Uganda and Thailand, and averted an epidemic in Senegal. Senegal, for example, used prevention programs on the individual level (HIV counseling and testing), community level (HIV education in schools, condom promotion among sex workers), medical level (treatment of sexually transmitted diseases [STDs]), and structural/political level (mobilizing religious and political leaders to talk openly about HIV) to maintain one of the lowest rates of HIV infection in Sub-Saharan Africa.³

individual level

Many prevention programs help individuals change risky behavior. Project EXPLORE was a randomized trial of an individually-based counseling intervention for men who have sex with men. EXPLORE recognized that different men experience different individual, interpersonal and situational factors associated with risk. The program tailored the intervention to each man’s needs. Ten counseling modules used motivational interviewing to assess risk behavior, enhance sexual communication, understand substance use and recognize triggers to unsafe sex.⁴ Project RESPECT was a randomized HIV counseling trial conducted at STD clinics in five cities in the US with high HIV seroprevalence. The program evaluated whether interactive counseling is more effective than informational messages in reducing risk behaviors and preventing HIV and other STDs. The program found relatively little difference between 4- and 2-session interactive counseling interventions, but found lower rates of new STDs among the interactive counseling groups compared to groups that only received information. Reported condom use increased in all groups, with significantly greater protection among those in interactive counseling.⁵

couple/family level

The Visiting Nurse Service of New York offers comprehensive in-home services to families affected by HIV, substance abuse, sexual abuse and mental illness. The children in these families are at high risk for repeating the histories and behaviors of their parents. The program provides home-based interventions that include play therapy, health and safe sex education, family and individual counseling, relapse prevention for the parent and drug awareness and prevention for the children. Helping children deal with anger and resentment towards their parents lessens the likelihood that their anger will be displaced on themselves, thus repeating the behavior of the parent. Supporting each family member is key to breaking the cycle of dysfunction in these families.⁶ Interventions that promote safer sexual behaviors for both members of a couple can also be important. Project Connect was a six-session relationship-based intervention for women in a heterosexual relationship. Women attended separately or with their partners. The sessions emphasized communication, negotiation and how gender roles affect relationship dynamics. Project Connect helped decrease risky behaviors for couples receiving the intervention together and for couples where the woman attended alone.⁷

community level

Community-level programs can reach large numbers of people and can therefore be cost-effective. The Mpowerment Project promoted a norm of safer sex among young gay men through a variety of social, outreach and small group activities designed and run by young men themselves. They found that young men engaging in unsafe sex who were unlikely to attend workshops were more likely to be reached through outreach activities such as dances, movie nights, picnics and volleyball games. Rates of unprotected anal intercourse fell from 40% to 31% after the intervention.⁸ A community-level intervention with ethnically-diverse adolescents living in low-income housing, uses skills training, modeling, peer norm and social reinforcement to reduce sexual risk. Using social events and peer leaders nominated for training and team building, the program attracted neighborhood youth. The peer leaders developed small media prevention messages and planned community-wide events. Workshops for parents were also offered. The community intervention was shown to be more effective in delaying onset of first intercourse than education or skills building only.⁹

medical level

In the past few years, various medical approaches have been shown to be effective in HIV prevention. For example, antiretroviral drugs used to treat HIV have also been used to help prevent mother to child transmission (MTCT) of HIV, and to prevent transmission after accidental exposures (post-exposure prophylaxis or PEP). Neither of these approaches completely prevents transmission, but MTCT can reduce the risk of transmission by one half to two-thirds. Similarly, because antiretroviral drugs can greatly reduce the viral load in HIV+ persons, it is possible that widespread use could decrease the sexual transmission of HIV.³ Children’s Hospital Los Angeles teamed with community-based prevention organizations to provide an integrated care model for youth with and at high risk for HIV infection. The model offered a general medical clinic for youth and psychosocial services such as counseling and case management. Peer educators also conducted extensive street outreach where high-risk youth congregate. The program developed a computerized referral system for local youth services available on the Internet.¹¹

policy/legal level

HIV infection is closely linked to and often fueled by structural factors such as poverty, discrimination and lack of power for women. The Center for Young Women’s Development is a peer-run organization in San Francisco, CA that promotes self-sufficiency, community safety and youth advocacy among young women aged 14-18 who are involved in the juvenile justice, foster care systems and/or have lived on the streets. The Center provides employment, leadership and training for young women to educate others in their community. Equipped with the knowledge and opportunity to train others, young women are more likely to incorporate these skills into their own lives.¹² Political and legislative factors can also hamper HIV prevention. For example, there is currently a ban on federal funding for needle exchange programs in the US. Connecticut addressed the problem of access to clean needles through a program that 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. Needle sharing dropped from 52% before the new laws to 31% after implementation, street purchase fell from 74% to 28%, and pharmacy purchase rose from 19% to 78%.¹³

what have we learned?

Prevention is more than a single program or intervention. A comprehensive HIV prevention strategy addresses multiple levels to protect as many people at risk for HIV as possible. We should learn from and promote the effectiveness of HIV prevention programs already in place, as well as continue to evaluate these programs.

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Says who?

1. Kelly JA, Kalichman SC. Behavioral research in HIV/AIDS primary and secondary prevention: recent advances and future directions. Journal of Consulting and Clinical Psychology. 2002;70:629-639. 2. Vlahov D, Des Jarlais DC, Goosby E, et al. Needle exchange programs for the prevention of human immunodeficiency virus infection: epidemiology and policy. American Journal of Epidemiology. 2001;154:S70-77. 3. Valdiserri RO, Ogden LL, McCray E. Accomplishments in HIV prevention science: implications for stemming the epidemic. Nature Medicine. 2003;9:881-886. 4. Chesney MA, Koblin BA, Barresi PJ, et al. An individually tailored intervention for HIV prevention: Baseline data from EXPLORE study. American Journal of Public Health. 2003;93:933-938. 5. Kamb ML, Fishbein M, Douglas JM Jr, et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. Project RESPECT Study Group. Journal of the American Medical Association. 1998;280:1161-1167. 6. Mills R, Samuels KD, Bob-Semple N, et al. Breakin’ the cycle: multigenerational dysfunction in families affected with HIV/AIDS. Presented at the 14th International AIDS Conference, Barcelona, Spain. 2002. Abst #ThPeE7828. 7. El-Bassel N, Witte SS. Gilbert L, et al. The efficacy of a relationship-based HIV/STD prevention program for heterosexual couples. American Journal of Public Health. 2003;93:963-969. 8. Hays RB, Rebchook GM, Kegeles SM. The Mpowerment Project: community-building with young gay and bisexual men to prevent HIV1. American Journal of Community Psychology. 2003;31:301-312. 9. Sikkema KJ, Hoffmann RG, Brondino MJ, et al. Outcomes of a community-level intervention among adolescents in inner-city housing developments. Presented at the International Conference on AIDS, Barcelona, Spain. July 2002. Abst# WeOrD1276. 10. Fuchs J, Colfax G. A shot or a pill: exploring biomedical approaches to HIV prevention. Focus. 2004;19:1-4. 11. Schneir A, Kipke MD, Melchior LA, et al. Children’s Hospital Los Angeles: a model of integrated care for HIV-positive and very high risk youth. Journal of Adolescent Health. 1998;23(2Suppl):59-70. Computerized referral system:www.caars.net 12. Center for Young Women’s Development. www.cywd.org 13. 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.

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Prepared by The Center for AIDS Prevention Studies, University of California, San Francisco July 2004. Fact Sheet #1ER 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]. © July 2004, University of California

What are rural HIV prevention needs?

are rural populations at risk?

Over the years, rural areas, which represent roughly 20% of the US population, have consistently reported 5-8% of all US HIV cases.¹ Yet certain rural areas and populations are disproportionately affected—the South and African Americans in particular. There may not be an epidemic of rural HIV/AIDS cases but there are troubling hot spots. The South comprises 68% of all AIDS cases among rural populations.² In 2000, the rate of new AIDS diagnoses was three times higher for the South than for other rural areas in the US.3 In certain areas of the South, the rate of HIV/AIDS diagnoses is almost as high in rural areas as in urban areas.³ African American men and women represent 50% of rural AIDS cases, Whites 37%, Latinos 9% and American Indian/Alaska Natives 2%.² African Americans and Latinos are disproportionately affected by HIV in rural areas: In the Northeast, African Americans and Latinos each represent 1% of the rural population, but 25% and 20% of the AIDS cases, respectively.³ Most rural AIDS cases (75%) occur among men.² However, rates among rural women are increasing, particularly among African American women. Heterosexual transmission accounts for most cases among rural women, whereas injection drug use is the most common transmission category for urban women.² Among rural men, men who have sex with men (MSM) comprise approximately 60% of rural AIDS cases and injecting drug users (IDUs) about 20%.2 In 2000, in the rural South, 28.5% of men were infected through heterosexual contact.³

what are rural challenges?

In rural areas, HIV prevention and intervention programs have lagged behind urban programs, due to stigmatization of HIV and high risk groups, geographic factors and low overall HIV rates. These three factors combine to make it difficult, financially and practically, to implement rural HIV prevention programs.⁴ Geographic isolation can hinder access to preventive services for rural residents who have limited access to transportation. Rugged topography and long distances between towns can mean traveling several hours for medical care or social services. This can result in services that are not tailored to specific population needs and delays in delivery of services.⁵ In addition, isolation can lead to difficulty finding sexual partners and might lead to riskier behaviors when sexual encounters do occur. One study found that rural men are more likely to have sex on their first date than urban men, possibly due to long travel distances and concern that the next chance may be a long time away.⁶ A powerful stigma remains associated with both HIV/AIDS and homosexuality. Rural MSM may avoid stigma, social hostility and expected violence by hiding their sexuality and assimilating into the heterosexual culture. Rural venues where MSM openly socialize are scarce, resulting in some men seeking sex partners in public sex environments, through the Internet and by regularly traveling to higher seroprevalence areas.⁴ Rural residents are more likely to live in poverty and less likely to have health insurance than urban residents.⁷ Without insurance, rural residents are less likely to seek medical care or social services. Rural areas have fewer healthcare providers with HIV expertise and rural HIV+ patients are less likely than urban patients to be on antiretroviral therapy.⁸ There is limited funding for and access to substance abuse treatment services. Poverty can also increase individual risk such as exchanging sex for money, shelter or drugs. In one study, Black women reported the most common reason for engaging in high risk behaviors was financial dependence on male partners.⁹

what puts rural populations at risk?

As with all populations, HIV risk depends not on where you live, but on whether you have unprotected sex or share needles with an HIV+ partner, and whether you have access to care, education and prevention services. Rates of sexual partner change and concurrent relationships (having more than one sexual partner at a time) increase the risk of transmission of HIV. A study of rural African Americans with heterosexually transmitted HIV found that more than half had multiple partners, 40% had concurrent partners and 87% believed that their partner had sex with others during their relationship. Concurrency was associated with smoking crack cocaine and incarceration of a sex partner.¹⁰ Drug abuse is often seen as an urban problem, but it poses a significant problem in rural areas, methamphetamine in particular.¹¹ One report showed that rural youth are more likely to become substance abusers than urban youth: eighth graders in rural towns are 59% more likely than urban eighth graders to use methamphetamines.¹² Substance abuse contributes to risky behaviors such as engaging in unprotected sex, having multiple partners, sharing needles or exchanging sex for drugs.

what’s being done?

The Strong African American Families (SAAF) program is a 7-week prevention intervention designed for African American mothers and their 11-year-old children in rural Georgia. SAAF sought to strengthen parenting skills that would in turn promote positive self-pride and positive sexual body image in their children to help lower their sexual risk behaviors. Mothers reported an increase in targeted parenting behaviors, which increase self pride in their children. Youth reported less intention and willingness to engage in risky behaviors, and a reduction in risky sexual behavior.¹³ The Wyoming Rural AIDS Prevention Project (WRAPP) piloted an Internet-based intervention for rural MSM that used conversations between an “expert” HIV+ gay man and an “inexperienced” HIV- gay man to deliver basic HIV education and behavior change strategies. The 2 modules lasted 20 minutes and featured dialogues, interactive activities and graphics. Men who participated in the intervention reported increases in knowledge, safer sex outcome expectancies and self-efficacy.¹⁴ In rural Arkansas, collaboration between a CBO, the Department of Corrections, the Health Department and Addiction Treatment and Recovery Centers, helped to identify and recruit HIV+ clients engaging in risky sexual and drug-using behaviors. These clients enrolled in the Healthy Relationships Intervention and reported decreased unprotected sex and increased disclosure to family, friends and partners.¹⁵ In Mississippi, the Mobile Medical Clinic van travels to rural areas where people are at highest risk for HIV and syphilis, specifically focusing on African Americans. So that they are not seen as the “VD van,” they offer glucose, blood pressure and cholesterol screening. Before the clinic enters a community, they arrange for a local sponsoring organization, like a church or community representative, to ensure that there is support in the community for their presence. They have partnered with local agencies to perform clinical breast exams, PAP smears and dental sealant applications in youth.¹⁶

what needs to be done?

Because resources are limited in rural areas, prevention activities need to be targeted to populations at highest risk, including women and men who have sex with men, African Americans and Latinos, young persons, and alcohol and drug users. Recent immigrants and migrant workers may also be at high risk, especially along the US/Mexico border.⁴ It is critical to expand and improve care for HIV+ persons in rural areas and provide prevention education in medical settings. Rural healthcare providers need better training and support on HIV clinical care, delivering prevention messages, assessing risk behavior and cultural sensitivity and confidentiality issues.

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Says who?

1. Steinberg S, Fleming P. The geographic distribution of AIDS in the United States: is there a rural epidemic? Journal of Rural Health. 2000;16:11-19. 2. Centers for Disease Control and Prevention. HIV/AIDS surveillance in urban and nonurban areas. Slide set. 3. Hall HI, Li J, McKenna MT. HIV in predominantly rural areas of the United States. Journal of Rural Health. 2005;21:245-253. 4. Williams ML, Bowen AM, Horvath KJ. The social/sexual environment of gay men residing in a rural frontier state: implications for the development of HIV prevention programs. Journal of Rural Health. 2005;21:48-55. 5. Castañeda D. HIV/AIDS-related services for women and the rural community context. AIDS Care. 2000;12:549-565. 6. Horvath KJ, Bowen AM, Williams ML. Virtual and physical venues as contexts for HIV risk among rural men who have sex with men. Health Psychology. 2006;25:237-242. 7. National Rural Health Association. HIV/AIDS in rural America: Disproportionate impact on minority and multicultural populations. July 2004. *https://www.ruralhealthweb.org/getattachment/Advocate/Policy-Documents/HIVAIDSRuralAmericapolicybriefApril2014-(1).pdf.aspx 8. Cohn SE, Berk ML, Berry SH, et al. The care of HIV-infected adults in rural areas of the United States. Journal of AIDS. 2001;28:385-392. 9. HIV transmission among Black women–North Carolina, 2004. Morbidity and Mortality Weekly Report. 2005;54:89-94. *https://npin.cdc.gov/publication/mmwr-hiv-transmission-among-black-women-north-carolina-2004 10. Adimora AA, Schoenbach VJ, Martinson FEA, et al. Concurrent partnerships among rural African Americans with recently reported heterosexually transmitted HIV infection. Journal of AIDS. 2003;34:423-429. 11. Kraman P. Drug abuse in America–Rural meth. Trends Alert. March 2004. *csg-web.csg.org/pubs/Documents/TA0403RuralMeth.pdf 12. The National Center on Addiction and Substance Abuse. No place to hide: Substance abuse in mid-size cities and rural America. New York, New York: Columbia University. January 2000. https://eric.ed.gov/?id=ED443618  13. Brody GH, Murry VM, Gerrard M, et al. The Strong African American Families Program: translating research into prevention programming. https://pubmed.ncbi.nlm.nih.gov/15144493/  14. Bowen A, Horvath K, Williams M. Randomized control trial of an Internet-delivered HIV knowledge intervention with MSM. Health Education and Research. In press. *www.wrapp.net 15. Smith AJ, Gaynor H. Advancing HIV prevention in rural Arkansas. Presented at the National HIV Prevention Conference, Atlanta, GA, 2005. Abstract #M1-C1802. *https://www.cdc.gov/hiv/effective-interventions/treat/healthy-relationships?Sort=Priority%3A%3Aasc&Intervention%20Name=Healthy%20Relationships  16. Prevention in rural communities: Mississippi’s Mobile Medical Clinic. NASTAD HIV Prevention Bulletin. March 2006. *All websites accessed May 2006

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Prepared by Anne Bowen PhD*, Alan Gambrell MPubAff**, Pamela DeCarlo*** *University of Wyoming, **WordPortfolio, Inc., ***CAPS May 2006 . Fact Sheet #26ER Special thanks to the following reviewers of this Fact Sheet: James Anderson, Janet Arno, Keith Bletzer, Lucy Bradley-Springer, Angeline Bushy, Irene Hall, Rachel Kachur, Bronwen Lichtenstein, Deborah Preston, David Seal, Dale Stratford, Craig Thompson, Mohammad Torabi, Eric Wright. 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 2006, University of California

What Are Women Who Have Sex With Women’s HIV Prevention Needs?

Are women who have sex with women at risk for HIV?

HIV risk for women who have sex with women (WSW), like for all people, varies depending on what they do. Some WSW may shoot drugs, have sex with men, trade sex for money or drugs, be victims of rape or abuse, have sex with many partners or have artificial insemination. It is important to remember that sexual identity and sexual behavior are not always similar; for example, women who identify as lesbian can also have sex with men, and not all WSW identify as lesbian or bisexual. In this fact sheet, the term “WSW” will cover all these categories, unless a more specific term or definition is offered. Among injection drug users, WSW have higher HIV rates than do women who have sex with men only. A study of female injection drug users (IDUs) in 14 US cities found that, compared to heterosexual women, women who had a female sex partner were more likely to share syringes, to exchange sex for drugs or money, to be homeless and to seroconvert.¹ Women who identify as lesbian or bisexual and have sex with men may be at high risk for HIV due to male partnering choices and low condom use. A study of lesbians and bisexual women in San Francisco, CA, found that 81% reported sex with men in the past 3 years. Of those women, 39% reported unprotected vaginal sex and 11% unprotected anal sex.² In a survey of lesbians and bisexual women in 16 small US cities, among women who were currently sexually active with a male partner, 39% reported sex with a gay/bisexual man and 20% sex with an IDU.³

Is female-to-female transmission possible?

From all we know, there is a small but still unspecified risk of HIV transmission associated with female-to-female sexual practices.⁴ HIV is found in vaginal fluids and menstrual blood, but the amount of virus has not been adequately measured. Female-to-female sex can include a variety of activities, and the risk relative to all activities is still not known. It is thought that oral sex alone poses a relatively low risk,⁴ and acts that may result in vaginal trauma, such as sharing sex toys without condoms or digital play with finger cuts or sharp nails, might pose higher risk. To date, there have been no studies that have rigorously examined female-to-female sexual acts or cunnilingus as a risk for HIV transmission, but there are a number of reported cases of transmission.⁵ Only one study has looked at HIV-discordant lesbian couples (where one woman is infected and the other isn’t). Although this study followed only 10 couples and only over a short period of time, they found no seroconversions.⁶

What are barriers to prevention?

Social, environmental and economic factors can be a barrier to prevention. WSW who are poor, drug addicted, lack adequate job training, are homeless or who fear violence may turn to prostitution or engage in sex with men for survival.⁴ Attention to more immediate concerns of food, housing and addiction often takes priority over future concerns of HIV infection. Expectations of heterosexuality and negative social or cultural attitudes towards homosexuality may serve to increase risk behaviors among some WSW. A study in San Francisco, CA, found that young lesbians engaged in high rates of alcohol and drug use, unprotected sex with men and sexual experimentation with young gay men as a way of coping with societal pressures.⁷ At-risk WSW are often invisible or not recognized within other groups such as crack-smokers and injection drug users, the homeless, commercial sex workers and prisoners. WSW who have sex with men may identify with different communities depending on the gender of their current sex partner. Prevention efforts should take this into account, and recognize that bisexual women may be most effectively reached through programs targeted to high risk heterosexual women.

What’s being done?

Prevention programs that focus specifically on WSW and HIV are still extremely limited, but the following projects have made a difference. The Lesbian AIDS Project (LAP) at GMHC in New York City, NY, provides multiple services to both HIV- and HIV+ WSW. LAP runs groups, safer sex workshops and a hotline. At-risk and HIV+ lesbians on staff provide education and outreach in the community including in women’s prisons and recovery settings.⁸ In San Francisco, CA, Lyon-Martin Women’s Health Services trained lesbians and bisexual women as peer educators to deliver safer sex information in women’s bars, dance clubs and sex clubs. Affectionately known as the “Safer Sex Sluts,” the peer educators are “dedicated to demolishing denial” by presenting skits, giving workshops and individual consultations and handing out condoms and lubricant.⁹ A community-based outreach project in Hollywood, CA, targeted street-based high-risk gay, bisexual, lesbian and transgender drug users. Based on a harm reduction model, the program provided support groups, peer counseling, referrals, prevention packages and hygiene kits.¹⁰ In Guatemala, a public space for lesbians, transvestites and gay/bisexual men opened to provide a safe environment for self-expression free of alcohol, sex and drugs. The Culture House sponsors creative workshops and classes in pottery, photography, literature, English and French, among others. They also sponsor conferences and round tables on issues such as violations of human rights, attitudes of the Catholic church towards gays and lesbians, staying HIV-negative and legal aspects of AIDS.¹¹

What still needs to be done?

Definitive research on sexual practices, sexual risks, partnering choices and demographic characteristics of WSW are needed. Effective HIV prevention for WSW must take into account their sexual identity as well as their sexual behavior and drug use activity. Distinguishing WSW by their sexual identity may be crucial in targeting prevention messages. Service providers and health care workers must be sensitized to the needs of WSW and be trained to conduct risk assessments that are not heterosexually biased. Many service providers assume that women who are HIV+ are exclusively heterosexual. If a woman says that she has had sex with a man, most will stop at that first question and don’t proceed to ask if she has also had sex with a woman. Likewise, if a woman reports injection drug use, many will not proceed to sexual behavior questions, assuming drug use is the main risk. This not only affects the care and education a WSW may receive, but also leads to poor documentation on risk behavior forms and inadequate reporting of WSW HIV rates. As a group, WSW have been invisible in the Centers for Disease Control and Prevention (CDC) HIV classification system. While categories of risk groups for men include men who have sex with men, injecting drug use and heterosexual¹² contact, among others, there is no category for WSW. Efforts to more clearly identify WSW within the CDC’s current surveillance system are underway.¹³ Information on the actual number of WSW among AIDS cases will bring to light the need for targeted prevention programs in this population. The most effective prevention message for WSW is still unclear. Some groups contend that we need to focus on what’s causing HIV risk for the majority of WSW—drug use and sex with men—rather than focus on issues of female-to-female transmission. Education and outreach should focus on cleaning or using new needles and using condoms for anal and vaginal sex with men, but a clearer message regarding female-to-female sex must also be established.¹⁴ It is unconscionable that after 15 years of the HIV epidemic, HIV+ women still don’t have accurate information about risk in order to know what to do or not do sexually with their female partners. A comprehensive HIV prevention strategy uses a variety of elements to protect as many people at risk as possible. Accurate information on female-to-female sexual transmission and HIV incidence, as well as what factors influence risk taking among WSW, will be key to protecting women who have sex with women.

---

Says who?

1. Young RM, Weissman G, Cohen JB. Assessing risk in the absence of information: HIV risk among women injection drug users who have sex with women. AIDS and Public Policy Journal. 1992;7:175-183.
2. Lemp GF, Jones M, Kellogg TA, et al. HIV seroprevalence and risk behaviors among lesbians and bisexual women in San Francisco. American Journal of Public Health. 1995;85: 1549-1552.
3. Norman AD, Perry MJ, Stevenson LY, et al. Lesbian and bisexual women in small cities-at risk for HIV? Public Health Reports. 1996;111:347-352.
4. Mays VM, Cochran SD, Pies C, et al. The risk of HIV infection for lesbians and other women who have sex with women: implications for HIV research, prevention, policy, and services. Women’s Health: Research on Gender, Behavior and Policy. 1996;2:119-139.
5. Kennedy MB, Scarlett MI, Duerr AC et al. Assessing HIV risk among women who have sex with women: scientific and communication issues. Journal of the American Medical Women’s Association. 1995;50:103-107.
6. Raiteri R. HIV transmission in HIV-discordant lesbian couples. Presented at the 11th International Conference on AIDS. Vancouver, BC. 1996. Abstract #Tu.C.2455.
7. Gómez CA, Garcia DR, Kegebein VJ, et al. Sexual identity versus sexual behavior: implications for HIV prevention strategies for women who have sex with women. Women’s Health: Research on Gender, Behavior and Policy. 1996;2:91-109.
8. Hollibaugh A. LAP Notes. Lesbian AIDS project at GMHC. 1994;2:12.
   • Contact: Io Cyrus, Lesbian AIDS Project (212) 337-3531
9. Stevens PE. HIV prevention education for lesbians and bisexual women: a cultural analysis of a community intervention. Social Science in Medicine. 1994;39:1565-1578.
   • Contact: Lani Ka’ahumanu (415) 821-3534.
10. Reback CJ, Watt K. Street drugs, street sex: community-based outreach to gay, bisexual, lesbian and transgender drug users. Presented at the 11th International Conference on AIDS. Vancouver, BC. 1996. Abstract #ThC4670,
    • Contact: Cathy Reback (213) 463-1601.
11. Martinez LF, Mayorga R, Lorenzana A, et al. The Guatemalan Gay/bisexual and Lesbian Culture House: alternative activities fostering self-esteem, behavioral changes, and AIDS prevention. Presented at the 11th International Conference on AIDS. Vancouver, BC. 1996. Abstract #ThD363.
12. Warren N. Out of the question: obstacles to research on HIV and women who engage in sexual behaviors with women. SIECUS Report. 1993;October/ November:13-15.
13. Centers for Disease Control and Prevention. Report on lesbian HIV issues meeting. Decatur, GA; April 1995.
14. Gorna R. Lesbian safer sex: alarmist or inadequate? Presented at the 11th International Conference on AIDS. Vancouver, BC. 1996. Abstract #ThD244.
    • Contact: (in England) Robin Gorna, Terrence Higgins Trust (011) 44-171-831-0330.

---

Prepared by Pamela DeCarlo and Cynthia Gómez, PhD January 1997. Fact Sheet #24E 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]. © January 1997, University of California

Estudio del Uso de Condones 1991 Entrevista Para Mujeres

HORA AL EMPEZAR LA ENTREVISTA: __________________

Muchas de las preguntas que le vamos a hacer son de índole sexual y es
 posible que se pueda sentir un poco incómoda. Le recuerdo que sus
 respuestas se guardarán completamente confidenciales y que me
 puede indicar cualquier pregunta que no quiera contestar.

Quisiera hacerle unas preguntas generales acerca del SIDA.  Sus respuestas
 pueden ser "sí" "probablemente sí," "probablemente no," o "no." 

1. Cree que es posible contraer el virus del SIDA de una picada o
 piquete de mosquito?  Diría que sí, probablemente
 sí, probablemente no, o no?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(06)

2. Cree que es posible contraer el virus del SIDA al sentarse en un
 baño público?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(07)

3. Cree que el SIDA es un problema sólo de los homosexuales y
 drogadictos?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(08)

4. Cree que es posible saber por la apariencia si una persona tiene el
 virus del SIDA?  

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(09)

5. Ha conocido personalmente a alguien que tuviera SIDA o estuviera
 infectado con el virus del SIDA?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	

			8    NO SABE	(10)

6. Con qué frecuencia le preocupa el que pudiera contagiarse
 del virus que causa el SIDA?

Diría que muy frecuentemente, frecuentemente, a veces, o nunca?
		(11)
	1   Muy	2   Frecuentemente	3   A veces	4   Nunca
	Frecuentemente

Ahora le voy a preguntar acerca de los preservativos o condones.  

7. Prefiere que usemos la palabra "preservativo" o "condón?"   

	1	PRESERVATIVO	2     CONDON 	(12)

	3	NO TIENE PREFERENCIA (USE "PRESERVATIVO")

Las siguientes preguntas se refieren al uso de los preservativos/condones. Si
 nunca los ha usado, de todas maneras nos interesan sus respuestas.

8. Cree que la vaselina es buena como crema o lubricante para los
 preservativos/condones?

	1    SI	0    NO   	8    NO SABE	(13)

9. Cree que hay que desenrrollar el preservativo/condón antes
 de ponérselo al  pene?

	1    SI	0    NO   	8    NO SABE			(14)

Ahora quisiera hacerle algunas preguntas acerca de sus experiencias con
 preservativos/condones y otras actividades sexuales.  Usaré la
 palabra "compañero sexual" para referirme a la persona con quien se
 tiene relaciones sexuales.  Esta información es muy importante para
 nuestro estudio.  Cada persona tiene diferentes experiencias sexuales, de
 modo que algunas preguntas pueden no serle relevantes.

10. Con qué frecuencia lleva preservativos/condones consigo?
  Diría que siempre, a veces, casi nunca, o nunca?

	1   Siempre	2   A veces	3   Casi nunca	4   Nunca	(15)

11. Alguna vez ha tenido relaciones sexuales con un compañero
 sexual que usó preservativos/condones?

	1    SI			(16)
	0    NO  [PASE A LA P.15]
	9    RA

12. Alguna vez ha usado preservativos/condones para evitar un
 embarazo?

	1    SI	0    NO   	9    RA	(17)

13. Alguna vez ha usado preservativos/condones para evitar
 enfermedades?

	1    SI	0    NO   	9    RA	(18)

14. Cómo consiguió los preservativos/condones?
[NO LEA LAS RESPUESTAS]

[MARQUE UNA SOLA RESPUESTA]

[SI LA ENTREVISTADA DA MAS DE UNA RESPUESTA, PREGUNTE DONDE LOS
 OBTUVO CON MAS FRECUENCIA E INDIQUE ESA RESPUESTA SOLAMENTE]

______ LOS COMPRO   PREGUNTE:	Dónde?

	1	FARMACIA O DRUG STORE
	2	BAÑO PUBLICO [VENDING MACHINES]
	3	SUPERMERCADO
	9	RA
				(19)
_____ SE LOS REGALARON	PREGUNTE:	Dónde? 

	4	EN UNA CLINICA
	5	EN LA CALLE
	6	UN AMIGO/PARIENTE
	7	UN COMPAÑERO SEXUAL
	8	EN OTRO LUGAR _____________
	9	RA

15. En las siguientes preguntas, hablaremos de un compañero sexual
 habitual que se refiere a una persona con quien usualmente se comparte la
 vida sexual y podría ser un esposo.  

Imagínese que tuviera relaciones sexuales con un esposo o
 compañero sexual habitual en los próximos 30 días,
 Con qué frecuencia cree que usaría
 preservativos/condones ese compañero?  Diría que
 siempre, más de la mitad de las veces, la mitad de las veces, menos
 de la mitad de las veces, o nunca?

[SI LA ENTREVISTADA DICE QUE NO ES APLICABLE, DIGA: "Aunque no sepa,
 conteste lo que se imagine."]

	1	Siempre	(20)
	2	Más de la mitad de las veces
	3	La mitad de las veces
	4	Menos de la mitad de las veces
	5	Nunca
	9	RA

16. Imagínese que tuviera relaciones sexuales con una persona que no
 es su compañero habitual en los próximos 30 días,
 Con qué frecuencia cree que usaría
 preservativos/condones esa persona? [SI LA ENTREVISTADA DICE QUE NO ES
 APLICABLE, DIGA: "Aunque no sepa, conteste lo que se imagine."]

	1	Siempre	(21)
	2	Más de la mitad de las veces
	3	La mitad de las veces
	4	Menos de la mitad de las veces
	5	Nunca
	9	RA

17. Durante los últimos 12 meses, o sea desde [ESTE MES] de
 1990, ha tenido relaciones sexuales alguna vez?

	1	SI	[PASE A LA P. 19]	0	NO 	[PASE A LA P.18]	(22)

	9	RA 	[PASE A LA P.18]

18. Durante los últimos cinco años ha tenido relaciones
 sexuales alguna vez?

	1	SI	[PASE A LA P. 19]	0	NO 	[PASE A LA P.26]	(23)

	9	RA 	[PASE A LA P.26]

19. Como ya se explicó algunas de las preguntas tal vez no son
 relevantes a usted. Si no tienen aplicación para usted por favor
 indíquelo.

Durante los últimos 12 meses, cuando tuvo relaciones sexuales con su
 esposo o compañero habitual, Con qué frecuencia
 usó preservativos/condones su compañero?
  Diría que siempre, más de la mitad de las veces, la
 mitad de las veces, menos de la mitad de las veces, o nunca?

	1	Siempre	(24)
	2	Más de la mitad de las veces
	3	La mitad de las veces
	4	Menos de la mitad de las veces
	5	Nunca
	6	NO COMPAÑERO HOMBRE [PASE A LA P. 26]
	7	NO COMPAÑERO HABITUAL
	8	NO RELACIONES SEXUALES EN LOS ULTIMOS 12 MESES  [PASE A LA P. 26]
	9	RA

20. Durante los últimos 12 meses, cuando tuvo relaciones sexuales con
 algún hombre diferente de su esposo o compañero habitual,
 Con qué frecuencia usó preservativos/condones ese
 compañero?

	1	Siempre	(25)
	2	Más de la mitad de las veces
	3	La mitad de las veces
	4	Menos de la mitad de las veces
	5	Nunca
	7	NO COMPAÑERO CASUAL
	8	NO RELACIONES SEXUALES  [PASE A LA P. 26]
	9	RA

			BLANK	(26-28)

23. Durante los últimos 12 meses, Con cuántos
 hombres en total ha tenido relaciones sexuales?

	______  NUMERO DE HOMBRES [90  O MAS  = 90]	99	RA	(29-30)

SI LA RESPUESTA A LA PREGUNTA ANTERIOR ES  00, PASE A LA P. 26

24. Durante los últimos 12 meses, Con qué frecuencia
 tomó bebidas alcoholicas antes de tener relaciones sexuales?
   Diría que siempre, más de la mitad de las veces, la
 mitad de las veces, menos de la mitad de las veces, o nunca?

	1	Siempre	(31)
	2	Más de la mitad de las veces
	3	La mitad de las veces
	4	Menos de la mitad de las veces
	5	Nunca
	9	RA

25. Durante los últimos 12 meses, Con qué frecuencia
 usó drogas antes de tener relaciones sexuales?		

	1	Siempre	(32)
	2	Más de la mitad de las veces
	3	La mitad de las veces
	4	Menos de la mitad de las veces
	5	Nunca
	9	RA

26. Cree que va a tener relaciones sexuales en los próximos 30
 días?  Diría que sí, probablemente sí, probablemente no, o no?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(33)

27. Es posible saber de antemano si va a tener relaciones sexuales?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(34)

En las siguientes preguntas le voy a pedir sus opiniones acerca del uso de los
 preservativos/condones. Si nunca ha tenido relaciones sexuales o nunca ha
 usado un preservativo/condón por favor conteste imaginándose
 como se sentiría en cada caso.

28. Cree que el preservativo/condón es sólo para las
 relaciones sexuales de hombres con prostitutas?  Diría que
 sí, probablemente sí, probablemente no, o no?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(35)

29. Cree que es difícil encontrar donde comprar
 preservativos/condones?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(36)

	BLANK	(37)

31. Le pediría a un compañero sexual que usara un
 preservativo/condón aunque usted hubiera estado tomando bebidas
 alcohólicas o usando drogas?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(38)

32. Se sentiría capaz de pedirle a un compañero que
 usara un preservativo/condón si pensara que está teniendo
 relaciones sexuales con otra persona?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(39)

33. Se sentiría capaz de rehusarse a tener relaciones sexuales
 si su compañero no quisiera usar un preservativo/condón?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(40)

34. Imagínese que la próxima vez que tuviera relaciones
 sexuales su compañero usara un preservativo/condón.
  Sentiría usted menos placer sexual que si no lo usara?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(41)

35. Si su compañero sexual usara un preservativo/condón,
 durarían más tiempo las relaciones sexuales que si no
 lo usara?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(42)

36. Si su compañero sexual usara un preservativo/condón,
 Se sentiría culpable usted?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(43)

37. Si se usara un preservativo/condón, Sentiría una
 barrera emocional con su
	compañero sexual?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(44)

38. Cree que el preservativo/condón le produciría una
 sensación de ardor?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(45)

39. Cree que se interrumpiría el acto sexual al ponerse su
 compañero un preservativo/condón?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(46)

40. Cree que las relaciones sexuales serían más
 limpias que si no usara su compañero un preservativo/condón?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(47)

Continue imaginándose que la próxima vez que tuviera
 relaciones sexuales su compañero usara un preservativo/condón.

41. Cree que el preservativo/condón se le haría
 incómodo o apretado a su compañero sexual?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(48)

42.  Cree que podría quedarse el preservativo/condón
 dentro de usted?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(49)

43. Cree que el preservativo/condón podría romperse?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(50)

44. Si su compañero sexual usara un preservativo/condón,
 Cree que podría contraer cáncer usted?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(51)

45. Si su compañero sexual usara un preservativo/condón,
 Cree que quedaría embarazada?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(52)

		9   RA				

46. Si su compañero sexual usara un preservativo/condón,
 Se le haría más difícil eyacular o acabar que
 si no lo usara?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(53)

47. Si su compañero usara un preservativo/condón, Se
 le haría más difícil mantener una erección que
 si no lo usara?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(54)

En las siguientes preguntas, hablaremos de dos tipos de compañero
 sexual: el compañero sexual habitual y el compañero sexual
 casual.  Como ya le explicamos, compañero sexual habitual se refiere a
 una persona con quien usualmente se comparte la vida sexual.
  Compañero sexual casual se refiere a una persona poco conocida con
 quien uno tiene relaciones sexuales una o pocas veces.

48. Se sentiría capaz de pedirle a un compañero sexual
 habitual que use un preservativo/condón?

Diría que sí, probablemente sí, probablemente no, o no?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(55)

49. Se sentiría capaz de pedirle a un compañero sexual
 casual que use un preservativo/condón?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(56)

Imagínese que fuera a tener relaciones sexuales con un
 compañero sexual casual y que él usara un
 preservativo/condón

50. Cree que podría contraer una enfermedad venérea
 como sífilis o gonorrhea?
Diría que sí, probablemente sí, probablemente
 no, o no?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(57)

51.  Cree que podría contraer el virus que causa el SIDA si
 este compañero casual usara un preservativo/condón?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(58)

52. Si este compañero casual usara un preservativo/condón, se
 preocuparía usted menos de infectar a un compañero habitual
 con una enfermedad como sífilis, gonorrea o SIDA?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(59)

Imagínese que  la próxima vez que tenga relaciones sexuales
 con un compañero sexual habitual le pidiera que usara un preservativo/condón:

53. Le haría creer al compañero habitual que usted
 había tenido relaciones sexuales con otra persona?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(60)

54. Si le pidiera a un compañero habitual que usara
 preservativos/condones, Cree que se enojaría?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(61)

55. Se enojaría un compañero casual ?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(62)

56. Si le pidiera a un compañero habitual que usara
 preservativos/condones, Se pondría violento?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(63)

57. Se pondría violento un compañero casual?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(64)

58. Si le pidiera a un compañero habitual que usara
 preservativos/condones, cree que se rehusaría a tener
 relaciones sexuales con usted?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(65)

59. Se rehusaría a tener relaciones sexuales con usted un
 compañero casual ?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(66)

60. Imaginese que usted llevara preservativos/condones en un bolsillo o en
 una bolsa o una cartera.  Cree que sus amigas pensarían mal de usted?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No     9  RA	(67)

61. Si usted llevara preservativos/condones consigo, Cree que un
 compañero casual sentiría más respeto por usted que si no los llevara?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(68)

62. Si llevara preservativos/condones consigo, pensarían los
 hombres que está dispuesta a tener relaciones sexuales con un recién conocido?

	1   Sí	2   Probablemente Sí	3   Probablemente No	4   No	(69)

		Respondent ID __ __ __ __.
		(01-04)
		Card = 3	(05)

En las siguientes preguntas queremos saber que tanto le molestarían
 cosas que podrían sucederle a una persona que usara
 preservativos/condones.  Estas preguntas le pueden parecer un poco
 repetidas, pero son muy importantes y le agradecemos su paciencia.  Las
 respuestas pueden ser "Mucho"  "Algo" o "Muy poco."

63. Qué tanto le molestaría sentir menos placer
 sexual?  Diría que le molestaría mucho, algo, o muy poco?
		1   Mucho	2   Algo	3    Muy poco	(06)

64. Qué tanto le molestaría sentir ardor en los organos
 sexuales?

		1   Mucho	2   Algo	3    Muy poco	(07)

65. Qué tanto le molestaría  interrumpir el acto
 sexual?

		1   Mucho	2   Algo	3    Muy poco	(08)

66. Qué tanto le molestaría  sentirse culpable?

		1   Mucho	2   Algo	3    Muy poco	(09)

67. Qué tanto le molestaría que un
 preservativo/condón le fuera incómodo o le apretara mucho
 	  a su compañero?
		1   Mucho	2   Algo	3    Muy poco	(10)

68. Qué tanto le molestaría  que un
 preservativo/condón se quedara dentro de usted?

		1   Mucho	2   Algo	3    Muy poco	(11)

69. Qué tanto le molestaría  que un
 preservativo/condón se rompiera?

		1   Mucho	2   Algo	3    Muy poco	(12)

70. Qué tanto le molestaría sentir una barrera
 emocional con su compañero?

		1   Mucho	2   Algo	3    Muy poco	(13)

				BLANK	(14)

72. Qué tanto le molestaría  que su compañero
 tuviera dificultad para eyacular o acabar? 

		1   Mucho	2   Algo	3    Muy poco	(15)

73. Qué tanto le molestaría  que su compañero
 tuviera dificultad para mantener la erección?

		1   Mucho	2   Algo	3    Muy poco	(16)

74. Qué tanto le molestaría contraer una enfermedad
 venérea, como la gonorrea o el sífilis?

		1   Mucho	2   Algo	3    Muy poco	(17)

75. Qué tanto le molestaría  que su compañero
 habitual pensara que había tenido relaciones sexuales con otra persona?

		1   Mucho	2   Algo	3    Muy poco	(18)

76. Qué tanto le molestaría que un compañero
 habitual se sintiera enojada?

		1   Mucho	2   Algo	3    Muy poco	(19)

77. Qué tanto le molestaría que un compañero
 casual se sintiera enojada?

		1   Mucho	2   Algo	3    Muy poco	(20)

78. Qué tanto le molestaría  que un compañero
 habitual se rehusara a tener relaciones sexuales?

		1   Mucho	2   Algo	3    Muy poco	(21)

79. Qué tanto le molestaría  que un compañero
 casual se rehusara a tener relaciones sexuales?

		1   Mucho	2   Algo	3    Muy poco	(22)

80. Qué tanto le molestaría  que sus amigas pensaran
 mal de usted?

		1   Mucho	2   Algo	3    Muy poco	(23)

81. Ahora por favor dígame, qué tanto le gustaría que un
 compañero casual sintiera más respeto por usted?
  Diría que mucho, algo, o muy poco?

		6   Mucho	5   Algo	4    Muy poco	(24)

82. Qué tanto le gustaría no tener que preocuparse de
 darle a su compañero habitual una enfermedad como sífilis,
 gonorrea o SIDA?
		6   Mucho	5   Algo	4    Muy poco	(25)

83. Qué tanto le gustaría que las relaciones sexuales
 fueran mas limpias a causa del
preservativo/condón?

		6   Mucho	5   Algo	4    Muy poco	(26)

Para las siguientes preguntas, primero dígame si le gustaría o
 le molestaría y luego dígame cuanto le gustaría o le
 molestaría:

84. Le gustaría o le molestaría quedar embarazada
 ahora?  Qué tanto:  Mucho, algo o muy poco?

	le gustaría:	6   Mucho	5   Algo	4    Muy poco	(27)

	le molestaría:	1   Mucho	2   Algo	3    Muy poco	

85. Le gustaría o le molestaría que las relaciones
 sexuales duraran más?  Qué tanto?
	le gustaría:	6   Mucho	5   Algo	4    Muy poco	(28)
	le molestaría:	1   Mucho	2   Algo	3    Muy poco	

86. Le gustaría o le molestaría que los hombres pensaran que
 está dispuesta a tener relaciones sexuales con un recién
 conocido? Qué tanto?
	le gustaría:	6   Mucho	5   Algo	4    Muy poco	(29)
	le molestaría:	1   Mucho	2   Algo	3    Muy poco	

87. Le gustaría o le molestaría usar un
 preservativo/condón con un compañero habitual?  Qué tanto?
	le gustaría:	6   Mucho	5   Algo	4    Muy poco	(30)
	le molestaría:	1   Mucho	2   Algo	3    Muy poco	

88. Le gustaría o le molestaría usar un
 preservativo/condón con un compañero casual?
Qué tanto?
	le gustaría:	6   Mucho	5   Algo	4    Muy poco	(31)
	le molestaría:	1   Mucho	2   Algo	3    Muy poco	

89. Le gustaría o le molestaría llevar un
 preservativo/condón consigo?
Qué tanto?
	le gustaría:	6   Mucho	5   Algo	4    Muy poco	(32)
	le molestaría:	1   Mucho	2   Algo	3    Muy poco	

90. De sus amigas más cercanas, Cuántas cree que
 llevan preservativos/condones consigo?  Diría que casi todas,
 mas de la mitad, la mitad, menos de la mitad, o casi ninguna?

[SI NO SABE, DIGA:  "Aunque no sepa con seguridad, conteste lo que se
 imagine"]

	1   Casi 	2   Más de	3   La Mitad	4   Menos de	5   Casi	(33)
	Todas	la Mitad		la mitad	Ninguna

				 7   NO TIENE NINGUNA AMIGA [PASE A LA P.93]

91. De sus amigas más cercanas, Cuántas cree que usan
 preservativos/condones cuando tienen relaciones sexuales con un
 compañero habitual?

	1   Casi 	2   Más de	3   La Mitad	4   Menos de	5   Casi	(34)
	Todas	la Mitad		la mitad	Ninguna

92. De sus amigas más cercanas, Cuántas cree que usan
 preservativos/condones cuando tienen relaciones sexuales con un
 compañero casual?  

	1   Casi 	2   Más de	3   La Mitad	4   Menos de	5   Casi	(35)
	Todas	la Mitad		la mitad	Ninguna
				 7   NINGUNA AMIGA TIENE C. CASUAL 				 

93.  Trate de imaginarse que tan cómoda se sentiría en las
 siguientes situaciones.

Qué tan cómoda se sentiría al comprar un
 preservativo/condón?  Diría que muy cómoda,
 algo cómoda, algo incómoda, o muy incómoda?

	1   Muy 	2   Algo	3   Algo	4   Muy	(36)
	cómoda	cómoda	incómoda	incómoda	

94. Qué tan cómoda se sentiría al pedirle a un
 compañero habitual que use un
	 preservativo/condón?

	1   Muy 	2   Algo	3   Algo	4   Muy	(37)
	cómoda	cómoda	incómoda	incómoda	

95. Qué tan cómoda se sentiría  al pedirle a un
 compañero casual que use un preservativo/condón?

	1   Muy 	2   Algo	3   Algo	4   Muy	(38)
	cómoda	cómoda	incómoda	incómoda	

96. Qué tan cómoda se sentiría  al ver a su
 compañero ponerse un preservativo/condón?

	1   Muy 	2   Algo	3   Algo	4   Muy	(39)
	cómoda	cómoda	incómoda	incómoda	

97. Qué tan cómoda se sentiría  al ponerle un
 preservativo/condón a su compañero?

	1   Muy 	2   Algo	3   Algo	4   Muy	(40)
	cómoda	cómoda	incómoda	incómoda	

98. Qué tan cómoda se sentiría si un
 compañero habitual usara un preservativo/condón?

	1   Muy 	2   Algo	3   Algo	4   Muy	(41)
	cómoda	cómoda	incómoda	incómoda	

99. Qué tan cómoda se sentiría  si un
 compañero casual usara un preservativo/condón?

	1   Muy 	2   Algo	3   Algo	4   Muy	(42)
	cómoda	cómoda	incómoda	incómoda	

100. Qué tan cómoda se sentiría al estar
 desnuda frente a un compañero sexual?

	1   Muy 	2   Algo	3   Algo	4   Muy	(43)
	cómoda	cómoda	incómoda	incómoda	

101. Qué tan cómoda se sentiría  al tener
 relaciones sexuales con la luz prendida?

	1   Muy 	2   Algo	3   Algo	4   Muy	(44)
	cómoda	cómoda	incómoda	incómoda	

102. Qué tan cómoda se sentiría al tener
 relaciones sexuales con un compañero nuevo?

	1   Muy 	2   Algo	3   Algo	4   Muy	(45)
	cómoda	cómoda	incómoda	incómoda	

Ahora, quisiera preguntarle...
103. Tiene hijos?
	(46-47)
		  (00) NO  	 SI       Cuántos?____ ____
				                     BLANK	(48)

SI ES NECESARIO:  Tiene esposo o un compañero habitual?

SI>>>[PASE A LA P. 105] 		NO>>>[PASE A LA P. 111]

105. Está embarazada? 

	1	SI 	[PASE A LA P. 111]	(49)
	0	NO
	7	EL/ELLA NO PUEDE TENER HIJOS [PASE A LA P. 111]
	8	NO SABE
	9	RA

106. Está intentando quedar embarazada?

	1	SI 	[PASE A LA P. 111]	(50)
	0	NO
	7	EL/ELLA NO PUEDE TENER HIJOS [PASE A LA P. 111]
	8	NO SABE
	9	RA

IF Q103 ABOVE IS 00, GO TO Q108

107. Ha dado a luz durante los últimos tres meses?

	1	SI 	[PASE A LA P. 111]	(51)
	0	NO
	7	EL/ELLA NO PUEDE TENER HIJOS [PASE A LA P. 111]
	8	NO SABE
	9	RA

108. Aparte de preservativos/condones, Ha usado usted o su
 compañero habitual algún método para evitar tener
 hijos en los últimos 12 meses?

	SI   >>>>>>>>[SI LA RESPUESTA ES SI]  Qué clase?	(52)
			[ANOTE TODAS LAS QUE SE APLIQUEN]
	1  PASTILLA/LA PILDORA
	0   NO	2  DIU
	3  DIAFRAGMA
		4  ESPONJA/JALEA/ESPUMA
	5  LAVADO
	9   RA	6  RETIRARSE
			7  ABORTO
			8  OTRO ____________________

SI LA RESPUESTA ES SI, PASE A LA P. 111

109.  Hay alguna razón por la cual su compañero
 habitual no pueda tener hijos, ya sea por operación o cualquier otra
 causa?

	1	SI 	[PASE A LA P. 111]	(53)
	0	NO
	8	NO SABE
	9	RA

110. Hay alguna razón por la cual no pueda tener hijos, ya sea
 por operación o cualquier otra causa?

	1	SI 		(54)
	0	NO
	8	NO SABE
	9	RA

111. Ahora le voy a hacer algunas preguntas acerca de cómo se ha
 sentido en los últimos siete días.  Desde el [DIA DE LA
SEMANA DE HOY] de la semana pasada.

Le molestaron cosas que por lo general no le molestan?

	0   NO	[SI LA RESPUESTA ES SI, DIGA]:	(55)
		Cuántos días durante la semana pasada?

			1     1-2 DIAS	2     3-4 DIAS	3     5-7 DIAS

112. Se sintió sin ganas de comer o tuvo mal apetito?

	O   NO	[SI LA RESPUESTA ES SI, DIGA]:	(56)
		Cuántos días durante la semana pasada?

			1     1-2 DIAS	2     3-4 DIAS	3     5-7 DIAS

113. Sintió que no podía quitarse de encima la
tristeza ni aún con el apoyo de su familia y amigos?

	O   NO	[SI LA RESPUESTA ES SI, DIGA]:	(57)
		Cuántos días durante la semana pasada?

			1     1-2 DIAS	2     3-4 DIAS	3     5-7 DIAS

114. Se sentió deprimida?

	O   NO	[SI LA RESPUESTA ES SI, DIGA]:	(58)
		Cuántos días durante la semana pasada?

			1     1-2 DIAS	2     3-4 DIAS	3     5-7 DIAS

115. Sintió que su vida había sido un fracaso?

	O   NO	[SI LA RESPUESTA ES SI, DIGA]:	(59)
		Cuántos días durante la semana pasada?

			1     1-2 DIAS	2     3-4 DIAS	3     5-7 DIAS

116. Se sintió con miedo?

	O   NO	[SI LA RESPUESTA ES SI, DIGA]:	(60)
		Cuántos días durante la semana pasada?

			1     1-2 DIAS	2     3-4 DIAS	3     5-7 DIAS

117. Tuvo sueño inquieto?

	O   NO	[SI LA RESPUESTA ES SI, DIGA]:	(61)
		Cuántos días durante la semana pasada?

			1     1-2 DIAS	2     3-4 DIAS	3     5-7 DIAS

118. Se ha sentido sola?

	O   NO	[SI LA RESPUESTA ES SI, DIGA]:	(62)
		Cuántos días durante la semana pasada?

			1     1-2 DIAS	2     3-4 DIAS	3     5-7 DIAS

119. Se sintió triste?

	O   NO	[SI LA RESPUESTA ES SI, DIGA]:	(63)
		Cuántos días durante la semana pasada?

			1     1-2 DIAS	2     3-4 DIAS	3     5-7 DIAS

120. Pasó ratos llorando?

	O   NO	[SI LA RESPUESTA ES SI, DIGA]:	(64)
		Cuántos días durante la semana pasada?

			1     1-2 DIAS	2     3-4 DIAS	3     5-7 DIAS

121. Ahora, me podría decir, Dónde nació?

	1	ESTADOS UNIDOS  	[PASE A LA SIGUIENTE PREGUNTA]	(65)
	2	PUERTO RICO  	[PASE A LA P.123]
	3	MEXICO   		[PASE A LA P.123]
	4 	REPUBLICA DOMINICANA	[PASE A LA P.123]
	5	COLOMBIA	[PASE A LA P.123]
	6	CENTRO AMERICA	[PASE A LA P.123]
	7	SUR AMERICA,(NO COLOMBIA)	[PASE A LA P.123]
	8	CUBA/ESPAÑA	[PASE A LA P.123]
	9	OTRO ______________	[PASE A LA SIGUIENTE PREGUNTA]

PARA LOS QUE NACIERON EN LOS ESTADOS UNIDOS
O CUALQUIER OTRO PAIS APUNTADO ARRIBA COMO #9

122.  Las familias de la mayoría de las personas que viven en los
 Estados Unidos provienen de otros países.
 De dónde viene su familia?

			[NO LEA LAS ALTERNATIVAS] 

[SI RESPONDE DICIENDO MAS DE UN PAIS, PREGUNTE:  "De cuál
 país proviene la mayoría de su familia o por cuál
 país siente mas cariño o apego?"]
[MARQUE SOLAMENTE UNO]

	2	PUERTO RICO	(66)
	3	MEXICO
	4	REPUBLICA DOMINICANA
	5	COLOMBIA
	6	CENTRO AMERICA
	7	SUR AMERICA, (NO COLOMBIA)
	8	CUBA

123. Cuánto tiempo ha vivido en los Estados Unidos?

	___ ___    AÑOS [MENOS DE UN AÑO = UN AÑO {01}]	(67-68)

		Respondent ID __ __ __ __.
		(01-04)
		Card = 4	(05)

124. Por lo general, Qué idioma lee y habla usted?
  Diría que sólo español, más
 español que inglés, ambos por igual, más inglés
 que español o sólo inglés?
	(06)
	1   Sólo 	2   Español más 	3   Ambos	4   Inglés más	5   Sólo
	español	que inglés	por igual	que español
	inglés

125.  Por lo general, Qué idioma habla en su casa?
	(07)
	1   Sólo 	2   Español más 	3   Ambos	4   Inglés más	5   Sólo
	español	que inglés	por igual	que español	inglés

126. Por lo general, En qué idioma piensa?
	(08)
	1   Sólo 	2   Español más 	3   Ambos	4   Inglés más	5   Sólo
	español	que inglés	por igual	que español	inglés

127. Por lo general, Qué idioma habla con sus amigos?
	(09)
	1   Sólo 	2   Español más 	3   Ambos	4   Inglés más	5   Sólo
	español	que inglés	por igual	que español	inglés

128. Cuántos años de educación formal ha completado?
			____  ____  AÑOS	(10-11)

129. Está usted:
	1	casada  o viviendo con su compañero,	(12)
	2	soltera,
	3	separada o divorciada, o
	4	viuda?

130. Cuál es su religión?________________________

	1	CATOLICA	(13)
	2	CRISTIANA [NO CATOLICA]
	3	OTRA: (ESPECIFIQUE.. _________)
	4	NINGUNA

131. Qué tan importante es la religión en su vida?
  Diría que es:	

	1	sumamente importante	(14)
	2	muy importante
	3	importante
	4 	algo importante
	5	nada importante

132. Cúantos años tiene de estar empleada, de tiempo
 completo o de tiempo parcial, sin incluir trabajo en su casa?

	_____  AÑOS  	(15-16)

133. Diría que vive en un pueblo, una ciudad, en los
 alrededores de una ciudad o en un área rural?

	1	PUEBLO	(17)
	2	CIUDAD
	3	ALREDEDORES
	4	RURAL

134. Podría decirme cual es su código postal o zip code?

		___ ___ ___ ___ ___	(18-22)

		99998	DK          99999	RA	

135. Por favor dígame dentro de qué categoría caen los
 ingresos de su familia  para el año 1990: [SI VIVE SOLO, "sus ingresos
 personales"]

	1	menos de $10,000	(23)
	2	entre $10,001 y $20,000
	3	entre $20,001 y $40,000
	4	más de $40,000
	8	NO SABE
	9	RA

136. Como ya le expliqué su número de teléfono se
 escogió al azar o a la suerte.  Para no volver a llamar a esta casa,
 Me podría decir si hay otro número de teléfono
 que pertenece a su casa?  

	[SI LA RESPUESTA ES SI]   Cuál es?__________________

	Hay otro más?	NUMEROS TELEFONICOS

		______________________________
		______________________________
		______________________________

	CUANTOS TELEFONOS SON?    ______	(24)
	[INCLUYENDO EL QUE SE ESTA LLAMANDO]

137.  En el futuro, es posible que hagamos un estudio de las actitudes y
 conductas sexuales de los adolescentes Hispanos o Latinos.  Será un
 estudio bastante diferente a éste y adecuado a los intereses y
 sensibilidad de los adolescentes.  Para incluir a un adolescente en ese
 estudio no sólo se necesitaría el consentimiento de ese o esa
 adolescente sino también el permiso de uno de los padres o
 guardián

Hay algún adolescente en esta casa que tenga 15, 16, o 17 años de edad?

	SI (Cuantos son?) ______	NO	  0   [PASE AL FINAL]	(25)

	Podría darme el nombre del padre, la madre o el
 guardián que podría dar el permiso para entrevistar al/a los
  adolescente(s), si le volviéramos a llamar?

	_________________________________

138.  Podría darme el/los nombre(s) del/de los adolescente(s)?

	_____________________________________________________

					_____ MUJERES 	(26)

Hemos terminado.  Tal vez reciba una llamada de mi supervisor para verificar
 mi trabajo.  Muchísimas gracias por su ayuda.  Si desea recibir
 más información sobre el SIDA o su prevención puede
 llamar, gratis y sin dar su nombre al              1-800-344-7432      .

Quiere que le repita el número?. . . .  De nuevo, ¡muchísimas gracias!

__________________________________________________________

139. TIME AT THE END OF INTERVIEW:  ________________________

	CUANTO TIEMPO TARDO LA ENTREVISTA  [EN MINUTOS]   ___ ___	(27-28)

140. LANGUAGE OF INTERVIEW:	1     SPANISH	(29)

141. LANGUAGE CHOICE: 

		1      RESPONDENT 	         0       RANDOMLY BY INTERVIEWER	(30)

142. INTERVIEWER'S NAME:_________________________ [ ___ ___ ___ ]	(31-33)

DATE OF INTERVIEW:_____________________________

INTERVIEW TERMINATED BEFORE COMPLETION:

	1    SI	0    NO	(34)

		[SI LA RESPUESTA ES SI]: __ __ __  ITEM NUMBER 	(35-37)

IS RESPONDENT A MEMBER OF HOUSEHOLD?          	(38)

		1  YES	0  NO