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What do we know about HIV superinfection?

revised 5/06

what is dual infection, co-infection, superinfection?

Dual infection is when a person is infected with two or more strains of HIV. That person may have acquired both strains simultaneously from a dually infected partner or from multiple partners. A different strain of the virus is one that can be genetically distinguished from the first in a “family” or phylogenetic tree. Acquisition of different HIV strains from multiple partners is often called co-infection if all the virus strains were acquired prior to seroconversion, that is, very early before any HIV infection is recognized. Acquisition of different HIV strains from multiple partners is called superinfection if the second virus is acquired after seroconversion when the first virus strain already has been established.¹ Superinfection and re-infection mean the same thing. Dual infections can be sequentially expressed, which can make co-infection look like superinfection. Sequentially Expressed Dual Infections (SEDI) may occur because immune responses against the predominant virus may allow other virus strains in the body to be expressed. Random shifts in evolving virus populations can also occur, which could look like superinfection even though dual infection was present from the beginning.

why does superinfection matter?

Superinfection is a concern because it may be a way for someone who is HIV+ to acquire drug resistance, and it may lead to more rapid disease progression.^2,3 Research on when superinfection may or may not occur could identify types of immune responses that may protect against infection. This could guide the development of HIV vaccines. People who are HIV+ and have HIV+ partners often ask about superinfection. Public health officials need information about superinfection in order to craft messages that help people understand the possible risks of unprotected sexual intercourse among HIV+ persons, without creating undue anxiety that could undermine rewarding relationships between HIV+ persons and disclosure of HIV status with prospective new partners.

does superinfection occur?

Many scientists believe that superinfection can occur. Research in monkeys has indicated that superinfection with viruses like HIV can occur.^4,5 Sixteen people with SEDI (apparent superinfection) have been reported in the scientific literature, including injection drug users in Asia, women in Africa, and men in Europe and the US. Laboratory analysis in some of these reports suggested that the second virus that appeared in these individuals was not present earlier in the course of infection, which suggests superinfection. The sensitivity of these laboratory assays is limited, and source partners have not been identified, so there is no way to know for sure when the second virus was acquired.

who is at highest risk?

Ninety-five percent of apparent superinfection cases have occurred during the first three years of infection.^6-9 Studies have found evidence of superinfection in 2 to 5% of persons in the first year of infection. Intermittent treatment in acute or recent HIV infection may prolong superinfection susceptibility.^10-11 In contrast, studies in persons with longer term infection have found no evidence of superinfection. One study found no cases after 1,072 person-years of observation.¹² Another found none after 215 person-years of observation among intravenous drug users.¹³ A third found none after 233 person-years and 20,859 exposures through unprotected sex.¹⁴ It is possible that people with very low viral load in their blood may be more susceptible to superinfection. Low viral load in the blood can occur during combination antiretroviral therapy or in “healthy non-progressors.” Antiviral immune responses and viral interference is lower in persons with low viral load, so superinfection may occur more frequently.¹⁵ More research is needed to know for sure.

is it bad to have more than one virus?

Dual infection can have a harmful effect on the health of HIV+ persons. Superinfected individuals may have higher viral loads and lower CD4 counts, which causes more rapid disease progression.^2,3 Disease progression can accelerate after a second virus appears.¹ Superinfection may also affect treatment of HIV, as it increases the likelihood of drug resistance.¹⁶ HIV+ persons with dual infection may not respond as well to available antiretroviral medication due to resistant strains.

what don’t we know?

There is a lot we still do not know about superinfection. First of all, we need to be more sure whether superinfection actually occurs between HIV+ persons. A definitive case of superinfection has not been documented, which would require that the timing of the second infection be traced to initiation of a relationship with a new sexual partner. Second, we need to understand how and when superinfection occurs. Among researchers some consensus is developing about the idea that HIV+ persons in early infection–and particularly the first year of infection–may be at higher risk for superinfection than HIV+ persons with chronic infection.¹⁷ We also should determine whether persons with suppressed viral load on treatment are susceptible to superinfection. Third, we need to know how to protect against superinfection. If superinfection is rare, or if it only happens in recent infection, it is important to determine what mechanisms make an HIV+ person immune to acquiring a second virus. It would be important to know if exposure to different viral strains may provide protective immunity against superinfection.¹⁸ Lastly, we must continue to provide up-to-date scientific data on superinfection, its causes and consequences to HIV+ persons and healthcare professionals who work with them.

what can we recommend right now?

Counseling about superinfection should be based on understanding the individual’s sexual relationships. Before providing advice about superinfection, the counselor should know whether the individual is in a continuing relationship with another HIV+ partner, whether the person routinely seeks out other HIV+ partners for unprotected sex, and whether there is disclosure of HIV status with prospective partners. This background should inform the discussion about the risks and benefits of sex among HIV+ partners. If the counselor does not have time to consider these personal issues, it would probably be best to simply say that “There is not enough information available about superinfection. If superinfection occurs at all, it probably occurs in the first few years after infection. After that, it may be rare.” Even less is known about superinfection as a result of sharing needles, although it is reasonable to expect that the same pattern of initial high risk followed by low risk during chronic infection may occur. However, because intravenous drug users are at high risk of hepatitis C infections from sharing needles, efforts to obtain clean needles through needle exchange should always be emphasized. Interested persons should be referred to on-going research studies so that important gaps in information can be filled.¹⁹ People with multiple sexual partners, or partners with multiple partners, should be counseled regarding the risks of other sexually transmitted infections. Vaccination for hepatitis B and periodic testing for syphilis is warranted.

Says who?

1. Smith DM, Richman DD, Little SJ. HIV superinfection . Journal of Infectious Diseases. 2005;192:438-444. 2. Gottlieb GS, Nickle DC, Jensen MA, et al. Dual HIV-1 infection associated with rapid disease progression . The Lancet. 2004;363:610-622. 3. Grobler J, Gray CM, Rademeyer C, et al. Incidence of HIV-1 dual infection and its association with increased viral load set point in a cohort of HIV-1 subtype c-infected female sex workers . Journal of Infectious Diseases. 2004;190:1355-9. 4. Otten RA, Ellenberger DL, Adams DR, et al. Identification of a window period for susceptibility to dual infection with two distinct human immunodeficiency virus type 2 isolates in a Macaca nemestrina model . Journal of Infectious Diseases. 1999;180:673-84. 5. Fultz PN, Srinivasan A, Greene CR, et al. Superinfection of a chimpanzee with a second strain of human immunodeficiency virus . Journal of Virology. 1987;61:4026-4029. 6. Angel JB, Hu YW, Kravcik S, et al. Virological evaluation of the ‘Ottawa case’ indicates no evidence for HIV-1 superinfection . AIDS. 2004;18:331-334. 7. Smith DM, Wong JK, Hightower GK, et al. Incidence of HIV superinfection following primary infection . Journal of the American Medical Association. 2004;292:1177-1178. 8. Hu DJ, Subbarao S, Vanichseni S, et al. Frequency of HIV-1 dual subtype infections, including intersubtype superinfections, among injection drug users in Bangkok, Thailand . AIDS. 2005;19:303-308. 9. Grant R, McConnell J, Marcus J, et al. High frequency of apparent HIV-1 superinfection in a seroconverter cohort. 12th Conference on Retroviruses and Opportunistic Infections. 2005. Abst #287. 10. Altfeld M, Allen TM, Yu XG, et al. HIV-1 superinfection despite broad CD8+ T-cell responses containing replication of the primary virus . Nature. 2002;420:434-439. 11. Jost S, Bernard M, Kaiser L, et al. A patient with HIV-1 super-infection . New England Journal of Medicine. 2002;347:731-736. 12. Gonzales MJ, Delwart E, Rhee SY, et al. Lack of detectable human immunodeficiency virus type 1 superinfection during 1072 person-years of observation . Journal of Infectious Diseases. 2003;188:397-405. 13. Tsui R, Herring BL, Barbour JD, et al. Human immunodeficiency virus type 1 superinfection was not detected following 215 years of injection drug user exposure . Journal of Virology. 2004;78:94-103. 14. Grant R, McConnell J, Herring B, et al. No superinfection among seroconcordant couples after well-defined exposure. International Conference on AIDS, Bangkok, Thailand, 2004. Abst #ThPeA6949. 15. Marcus J, McConnell J, Liegler T, et al. Highly divergent viral lineages in blood DNA appear frequently during suppressive therapy in persons exposed to superinfection. 13th Conference on Retroviruses and Opportunistic Infections. 2006. Abst #297. 16. Smith DM, Wong JK, High-tower GK, et al. HIV drug resistance acquired through superinfection . AIDS. 2005;19:1251-1256.16. Gross KL, Porco TC, Grant RM. HIV-1 superinfection and viral diversity. AIDS. 2004;18:1513-1520. 17. Gross KL, Porco TC, Grant RM. HIV-1 superinfection and viral diversity . AIDS. 2004;18:1513-1520. 18. McConnell J, Liu Y, Kreis C, et al. Broad neutralization of HIV-1 variants in couples without evidence of systemic superinfection. 13th Conference on Retroviruses and Opportunistic Infections. 2006. Abst #92. 19. HIV+ persons who have HIV+ partners residing or visiting San Francisco can call the Positive Partners Study 1-415-734-4878.

Prepared by Robert M. Grant MD, J. Jeff McConnell MA Gladstone Institute of Virology and Immunology, UCSF May 2006 . Fact Sheet #56ER Special thanks to the following reviewers of this Fact Sheet: Jonathan Angel, Michael Carter, Mark Cichocki, Eric Delwart, Keith Folger, Geoffrey Gottlieb, Luc Perrin, Travis Porco, Peter Shalit, David Spach, Carolyn Williamson, Zenda Woodman. 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

Can HIV testing plus linking HIV+ people to care and treatment reduce HIV transmission?

Why is this an important question?

Despite major progress against HIV, 21% of HIV+ people in the US are unaware that they are positive¹ and an estimated 33% of those who know they are HIV+ are not engaged in care and treatment for their infection.² Another 38% of newly diagnosed HIV+ individuals test so late that they receive an AIDS diagnosis at the same time as, or within one year of, learning they are positive.³ There were an estimated 56,300 new HIV infections per year between 1996 and 2006.⁴ Clearly, the US can and must do better in responding to the HIV/AIDS epidemic. One way to increase the percentage of HIV+ people engaged in care and treatment for their infection and improve their health outcomes is to focus on coordinating or co-locating HIV testing, care and treatment, social services and prevention programs. Increasing the percentage of HIV+ people who know their serostatus and are receiving care and antiretroviral treatment could also have benefits for HIV prevention.⁵ The National HIV/AIDS Strategy places testing and linkage to care, treatment and support services at the heart of the effort to improve the health outcomes of HIV+ individuals and prevent new infections.⁶ What is the scientific basis for this approach, how might it actually be implemented, and will it have the desired results in the real world?

Can HIV testing and linking HIV+ persons to care plus treatment reduce HIV incidence?

Although it is not proven conclusively, there are strong data showing that HIV treatment reduces an individual’s viral load and thus the potential for them to transmit HIV.^7,8 A Swiss study concluded that HIV+ individuals whose virus was suppressed at or below 50 copies for more than six months and who had no STIs were very unlikely to transmit the virus to HIV- partners through sexual contact.⁸ A study of over 3,000 serodiscordant heterosexual couples in Africa found a much lower transmission rate when the HIV+ partner was receiving treatment (only 1 seroconversion for a rate of 0.37 per 100 person years), compared to couples where the HIV partner was not receiving treatment (102 seroconversions, for a rate of 2.24 per 100 person years).⁹ Mathematical models predict some level of reduction in new HIV cases from high levels of participation in testing and treatment.¹⁰ A study in San Francisco found that expansion of HIV treatment was linked to a reduction in “community viral load,” the estimated average viral load of all HIV+ persons in a community. This reduction was thought to be at least partly responsible for declines in new HIV cases in San Francisco in recent years.¹¹Additionally, studies in British Columbia, Canada have suggested that reductions in the number of new HIV infections among injection drug users may also be linked to expanded HIV treatment.¹²

How can this be accomplished?

One possible approach is called Testing and Linkage to Care Plus, or TLC+, a framework for integrating HIV testing, care and treatment, social services and prevention-with-positives activities into a comprehensive initiative that can be implemented by individual providers or jurisdictions.¹³ This approach is not new; many providers and jurisdictions have been implementing TLC+ in whole or part for some time. TLC+ proponents have argued that this approach should be replicated nationwide. A study is being conducted in Washington, DC and the Bronx, NY on the feasibility of the TLC+ approach in highly impacted urban settings.¹⁴ TLC+ is a reframing of the “Test & Treat” concept, which generally seeks to achieve near universal knowledge of serostatus and treatment of all individuals found to be HIV+ in order to improve health outcomes and reduce incidence.¹³ The TLC+ approach emphasizes informed patient choice in HIV care decisions and the importance of securing social services in order to successfully engage and retain HIV+ people in care and treatment.¹⁵ TLC+ acknowledges that supporting HIV+ persons’ participation in primary medical care and needed social services is more likely to engage them in addressing HIV than immediately encouraging them to start HIV treatment. Elements of TLC+ include:

• Expanding and promoting HIV testing both as a routine part of medical care population-wide and through programs targeting individuals who are members of high-risk groups or engaging in high-risk behaviors
• Linking newly diagnosed HIV+ individuals ASAP to a primary care provider, and innovative programs to re-engage previously diagnosed individuals who have fallen out of care or treatment
• Assessing and meeting the social services needs of HIV+ people in order to support their initial engagement in care
• Measuring CD4s and viral load and thoroughly counseling patients about the role of HIV treatment in assuring individual health and preventing transmission of HIV, as well as options for when to start treatment
• Testing for STIs, TB and hepatitis B and C
• Supporting retention in care and treatment adherence by ensuring ongoing linkage to needed social services and support
• Prevention-for-positives counseling and linkage to services that support engagement in safe behaviors

Should HIV+ people be on treatment to prevent HIV transmission?

The potential benefits of HIV treatment, both for the individual and community, have much to do with when an individual decides to initiate HIV treatment and how much support they have to remain adherent to treatment. Earlier treatment might benefit both individual and community health. Federal treatment guidelines recommend starting treatment at 500 CD4s or below, and support consideration of treatment at 500 or above.¹⁶ Some providers, notably the San Francisco Department of Public Health, are now offering HIV treatment to all diagnosed HIV+ people, and even encouraging consideration of treatment at 500 CD4s and above. Providers should fully inform their HIV+ patients about the risks and benefits of either treatment strategy. A current study called START seeks to determine the risks and benefits of initiating HIV treatment at different CD4 thresholds. It is essential that HIV+ people make treatment decisions primarily to benefit their own health, with secondary consideration of the possible benefits for prevention. In keeping with values of patient empowerment and informed choice, providers can explain to an HIV+ person that engaging in treatment might help them in their goal of preventing transmission, but the choice of whether, when and why they decide to take medications must be left in the patient’s hands.

What are concerns about TLC+?

Concerns have been raised that expanded HIV testing and treatment of HIV+ people as a prevention intervention is intended to replace behavioral prevention programs. However, behavioral counseling and other forms of support for safe behaviors are an important component of the TLC+ model. Additionally, successful HIV prevention must take many forms and should include educational, behavioral, structural and biomedical interventions. Concerns have also been raised that describing the possible benefits of treatment for prevention may cause HIV+ people who are taking medications to abandon safe sex and syringe use behaviors. However, a range of studies have shown that HIV+ people on treatment do not exhibit increased sexual risk behavior, even when they achieved an undetectable viral load.¹⁷ Most HIV+ people are concerned about not infecting others and make efforts to prevent transmission.¹⁸ Nevertheless, it is essential to counsel HIV+ patients to practice safe sex, including condom use, whether on treatment or not and whether they achieve undetectable viral loads or not.

What steps needs to be take place to implement TLC+ nationally?

The concepts behind TLC+ are contained in the National HIV/AIDS Strategy, and it is critical that the federal government achieve unprecedented coordination in the planning and funding of this approach across all agencies, as well as with state and local governments and AIDS service organizations. TLC+ may take several years to be fully implemented because it depends upon the thoughtful coordination of surveillance, testing, care and treatment, social services and prevention programs and their funding streams to support it. TLC+ also demands improved reimbursement and targeting of HIV testing activities, and increased coverage of the cost of care and treatment, which could be achieved largely through effective implementation of national health care reform. The Ryan White Program will need to be reconfigured to support the high level of staffing necessary to link HIV+ people to care, treatment and social services when it is reauthorized by Congress in 2013.

Says who?

1. Centers for Disease Control and Prevention. HIV in the United States. Fact Sheet. July 2010. 2. HRSA. HIV/AIDS Bureau. Outreach: Engaging people in HIV care. August 2006. 3. Valdiserri RO. Late HIV diagnosis: Bad medicine and worse public health. PLoS Medicine. 2007; 4:e200. 4. Hall HI, Song R, Rhodes P, et al. Estimation of HIV Incidence in the United States. JAMA. 2008;300:520-529. 5. Cohen J. Treatment as Prevention. Science. 2010;327:1196-1197. 6. Office of the White House. National HIV/AIDS Strategy for the United States.July 2010. 7. CDC. Effect of antiretroviral therapy on risk of sexual transmission of HIV infection and superinfection. Fact sheet. August 2009. 8. Engsig F, Omland L, Larsen M, et al. Risk of high-level viraemia in HIV-infected patients on successful antiretroviral treatment for more than 6 months. HIV Medicine. 2010. 9. Donnell D, Baeten JM, Kiarie J, et al. Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis. Lancet. 2010;375:2092-2098. 10. Granich RM, Gilks CF, Dye C, et al. Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model. Lancet. 2009;373:48-57. 11. Das M, Chu PL, Santos G-M, et al. Decreases in community viral load are accompanied by reductions in new HIV infections in San Francisco. PLoS ONE. 2010;5:e11068. 12. Montaner J, Wood E, Kerr T, et al. Association of expanded HAART coverage with a decrease in new HIV diagnoses, particularly among injection drug users in British Columbia, Canada. Presented at the CROI. 2010. 13. Project Inform. TLC+: Testing, Linkage to Care and Treatment. 14. El-Sadr W. TLC-Plus: Feasibility of an enhanced test, link-to-care plus treat approach for HIV prevention in the US. 15. Statement on ART as prevention: Scaling down HIV requires scaling up human rights, testing and treatment. Sign-on letter from the International Council of AIDS Service Organizations. 2009. 16. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents.Department of Health and Human Services. 2009;1-161. 17. Crepaz N, Hart TA, Marks G. Highly active antiretroviral therapy and sexual risk behavior: A meta-analytic review. JAMA. 2004;292:224-236. 18. Marks G, Crepaz N, Senterfitt JW, et al. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States. Journal of AIDS. 2005;39:446-453.

Special thanks to the following reviewers of this Fact Sheet: Julia Dombrowski, Reuben Granich, Peter Kilmarx, Kim Koester, Monica Ruiz, George Rutherford, Allison Zerbe. Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. To receive Fact Sheets via e-mail, send an e-mail to [email protected] with the message “subscribe CAPSFS first name last name.” ©October 2010, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected].

¿Qué necesitan los hombres jóvenes que tienen sexo con hombres para la prevención del VIH?

revisado 4/01

¿están en riesgo de contraer VIH?

Sí. En los EEUU más de la mitad de los casos nuevos de VIH/SIDA en hombres de 13 a 24 años, ocurren por contacto sexual entre hombres.¹ Varios estudios encontraron que del 26% -50% de los hombres jóvenes que tienen sexo con hombres reportó haber tenido relaciones sexuales recientes sin protección, muchas de las cuales se dieron con parejas de estatus de VIH desconocido o diferente al del entrevistado.^2-4 El índice de conductas de riesgos que toman los jóvenes HSH también se ha incrementado.⁵ El término de hombres jóvenes que tienen sexo con hombres (jóvenes HSH) se refiere a todo aquel menor de 30 años que se identifique como gay/bisexual, así como a quien no se identifique como tal pero que practique el sexo con otro hombre Un gran número de jóvenes HSH urbanos está infectado con VIH. Un estudio con participantes entre los 15 y 22 años en siete ciudades (Baltimore, Dallas, Los Angeles, Miami, Nueva York, El Area de la Bahía de San Francisco y Seattle) reveló una alta prevalencia (número total de infecciones existentes) general del 7%, que varía entre 2% y 12% entre subgrupos. El 82% de los jóvenes VIH+ no sabían que estaban infectados antes participar en éste estudio.⁶ Los jóvenes HSH de raza no blanca (no caucásicos), especialmente los afroamericanos, están siendo mayormente afectados por el VIH. En el estudio mencionado arriba, el 14% de los afroamericanos resultaron VIH+ comparado con un 3% de asiáticos, 3% de caucásicos, 7% de hispanos y un 13% de hombres de razas mezcladas (o “mixtas” como se les denomina en EEUU).⁶

¿por qué corren riesgos los jóvenes HSH?

Desgraciadamente, no existe una respuesta sencilla. Las razones por las que ocurre el sexo desprotejido son complejas y múltiples.^3,7 La adolescencia y el inicio de la edad adulta comúnmente se caracterizan por la experimentación sexual y el consumo de drogas. Aunque la mayoría de los jóvenes HSH llegará a practicar ciertas conductas de riesgo, sólo un pequeño porcentaje tomará riesgos constantemente. Muchos jóvenes luchan con tensiones personales, interpersonales y sociales que pueden limitar su capacidad de protegerse. Para algunos jóvenes HSH [en los EEUU] existen factores individuales capaces de impulsarles a tener sexo desprotegido, por ejemplo: sentimientos de invulnerabilidad ante el VIH, altos niveles de optimismo por los medicamentos antivirales, percepción de que el sexo desprotegido es más placentero que el sexo protegido, depresión o tristeza, conflicto con la identidad sexual o racial [que frecuentemente se ven como separadas y parte de dos comunidades diferentes] y consumo de alcohol o drogas (como cristal/speed, poppers).⁸ Proteger su salud no es necesariamente la preocupación principal del joven HSH como lo son las motivaciones interpersonales de querer sentirse parte de algo, querer compañía y tener intimidad. Además, existen otros factores interpersonales que pueden contribuir al sexo desprotegido como no saber comunicar o negociar relaciones sexuales más seguras con una pareja sexual. Los jóvenes HSH con pareja son más propensos que los solteros al sexo desprotejido.⁴ Los factores sociales también pueden influir en los riesgos que toman los jóvenes HSH. Muchos jóvenes se sienten aislados o rechazados por las fuentes de tradicionales de apoyo como la familia, la escuela o la comunidad religiosa.⁹ La homofobia, el racismo y la pobreza también ponen en riesgo a estos jóvenes. Algunos jóvenes HSH (especialmente los indigentes) luchan con preocupaciones diarias como evitar la violencia, buscar un lugar dónde vivir o conseguir comida. Estas preocupaciones inmediatas pueden opacar la necesidad de protegerse al inyectarse drogas y al tener sexo. Los jóvenes HSH tienen pocos lugares públicos dónde reunirse. Los bares gay y las areas públicas de encuentro o “de ligue” son sitios visibles y accesibles que ofrecen anonimato para el joven que intenta explorar su identidad sexual. Estos sitios están asociados con niveles altos para la toma de riesgos pues tienen una alta tensión sexual. Además, la escena del bar al enfatizar el consumo de alcohol, crea un escenario ideal para los encuentros sexuales bajo la influencia del mismo. Se ha encontrado que todo esto contribuye consistentemente al sexo desprotegido.¹⁰ Poco se sabe del papel de la Internet en la vida de éstos jóvenes y cómo la utilizan para obtener apoyo social, conocer nuevas amistades, tener encuentros sexuales, y conseguir pareja.

¿qué se ha hecho?

El proyecto Mpowerment es una intervención de múltiples niveles por y para jóvenes gay. Ellos mismos se encargan del programa. Debido a que el VIH puede ser un tema poco atractivo para muchos jóvenes HSH, el proyecto se concentra en sus intereses y preocupaciones sociales. Ellos coordinan y planean actividades que les permiten crear una comunidad más fuerte y más saludable en la que el sexo protegido sea la norma aceptada mutuamente. Al participar, los jóvenes del proyecto reducen sus tasas de sexo anal desprotegido con parejas casuales y con novios.³ Mpowerment ha comprobado su eficacia como intervención para la prevención del VIH. Ofrece adiestramientos a agencias comunitarias y un manual sobre cómo replicar éste modelo.¹¹ La organización COLOURS en Filadelfia ofrece grupos de apoyo, adiestramiento de pares y manejo de casos individuales para jóvenes de raza no blanca. Tienen promotores que asisten a los bares y clubes de sexo frecuentados por adultos HSH de raza no blanca y ofrecen condones y consejería a jóvenes que se relacionan con una pareja mayor. También promueven programas para el tratamiento del alcohol y drogas dirigidos a jóvenes HSH.¹² La Asociación Americana de Psicología (APA sus siglas en inglés) ha implementado el proyecto Healthy Schools for Gay and Lesbian Students (escuelas sanas para estudiantes gay y lesbianas) que imparte adiestramiento a psicólogos, consejeros, enfermeras y trabajadoras sociales de las escuelas para que puedan trabajar exitosamente con estudiantes gay, lesbianas y bisexuales. La meta es crear un ambiente escolar más hospitalario y que la educación sobre prevención de VIH toque temas importantes para ellos/as.¹³ “Chico Chats”, un programa del proyecto STOP AIDS en San Francisco, imparte una serie de talleres intensivos durante un mes. Los participantes llegan a conocerse mientras que entablan conversaciones conducidas por un moderador sobre temas como identidad, imagen corporal, relaciones de pareja y cómo todo ésto se vincula con el VIH. Un componente clave de los talleres es aprender las técnicas sobre organización y movilización comunitaria. Los participantes formaron un grupo activista llamado ¡Ya Basta! Diseñaron un video y un taller que examina los temas del silencio sexual y la forma de “salir del closet” en el contexto de las familias latinas. El video está siendo presentado a la comunidad latina de San Francisco.¹⁴

¿qué más se necesita?

Para ser eficientes, los programas para jóvenes HSH deberán considerar el contexto de sus vidas y los factores individuales, interpersonales y sociales que los pone en riesgo. Una educación integral sobre salud y sexualidad debe dirigirse tanto a los que se identifican como gay o bisexual como a los que no lo hacen. Desgraciadamente, muchos programas escolares tienen un enfoque en la reproducción o la abstinencia hasta el momento del matrimonio, marginando aún más a los jóvenes HSH. Hay una necesidad urgente de crear programas de prevención y bienestar para jóvenes HSH de raza no blanca. Los programas existentes para hombres mayores HSH de raza no blanca también deben estar disponibles para los jóvenes. Estos programas deben incluir los temas de la sexualidad, identidad gay, cultura, etnicidad, racismo, homofobia, pobreza y violencia. Los programas deben considerar las necesidades de prevención de VIH para jóvenes que son VIH+ y VIH-. Es necesario prestar especial atención a la forma de llegar a los jóvenes HSH marginados como los indigentes, los trabajadores sexuales o los que están bajo el sistema de justicia criminal. Es posible que ellos no se identifiquen a sí mismos como gay o bisexuales y que sus necesidades inmediatas sean la comida y un techo. Se necesitan programas que promuevan el apoyo para jóvenes HSH y los incluyan directamente en la planificación e implementación de los mismos; por ejemplo crear lugares seguros donde los jóvenes puedan socializar y tengan acceso a servicios, implementar programas escolares que instruyan sobre la sexualidad y necesidades de gay y bisexuales; promover mayor aceptación del joven HSH en las escuelas, familias, comunidades religiosas, la comunidad gay en general y en las comunidades de razas no blancas.¹⁵ La homofobia social puede impedir la implementación de programas de prevención para jóvenes HSH y puede desalentarles para que utilicen los servicios de prevención.¹⁶ La política no debe interferir con los servicios de prevención para jóvenes HSH. Dirigir mensajes de prevención y ofrecer servicios a estos jóvenes son respuestas adecuadas ante la grave amenaza que enfrenta la salud pública. Si no se toma acción inmediata muchos más hombres perderán sus vidas a causa del VIH.

¿quién lo dice?

1. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report . 2000;12.
2. Molitor F, Facer M, Ruiz JD. Safer sex communication and unsafe sexual behavior among young men who have sex with men in California. Archives of Sexual Behavior. 1999;28:335-343.
3. Kegeles SM, Hays RB, Pollack LM, et al. Mobilizing young gay and bisexual men for HIV prevention: a two-community study . AIDS. 1999;12:1753-1762.
4. Hays RB, Kegeles SM, Coates TJ. Unprotected sex and HIV risk-taking among young gay men within boyfriend relationships . AIDS Education and Prevention. 1997;9:314-329.
5. Ekstrand ML, Stall RD, Paul JP et al. Gay men report high rates of unprotected anal sex with partners of unknown or discordant HIV status . AIDS. 1999;13:1525-1533.
6. Valleroy LA, MacKellar DA, Karon JM et al. HIV prevalence and associated risks in young men who have sex with men . Young Men’s Survey Study Group. Journal of the American Medical Association. 2000;284:198-204.
7. Strathdee SA, Hogg RS, Martindale SL et al. Determinants of sexual risk-taking among young HIV-negative gay and bisexual men . Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 1998;19:61-66.
8. Choi KH, Kumekawa E, Dang Q et al. Risk and protective factors affecting sexual behavior among young Asian and Pacific Islander men who have sex with men: Implications for HIV prevention . Journal of Sex Education & Therapy. 1999;24:47-55.
9. Beeker C, Kraft JM, Peterson JL, et al. Influences on sexual risk behavior in young African-American men who have sex with men. Journal of the Gay and Lesbian Medical Association. 1998;2:59-67.
10. Greenwood GL, White EW, Page-Shafer K, et al . Correlates of heavy substance use among young gay and bisexual men: The San Francisco Young Men’s Health Study . Drug and Alcohol Dependence. 2001:61:105-112.
11. CDC. Compendium of HIV prevention interventions with evidence of effectiveness . 1999.
12. The COLOURS Organization, Inc . Philadelphia, PA. 215/496-0330.
13. Clay RA. Healthy Schools project hoped to ease discrimination . APA Monitor. 1999;30.
14. The STOP AIDS Project . Q Action, ¡Ya Basta! San Francisco, CA. 415/865-0790 x303.
15. Seal DW, Kelly JA, Bloom FR, et al. HIV prevention with young men who have sex with men: what young men themselves say is needed . AIDS Care. 200;12:5-26.
16. Stokes JP, Peterson JL. Homophobia, self-esteem, and risk for HIV among African American men who have sex with men . AIDS Education and Prevention. 1998;10:278-292.

Preparado por Pilgrim Spikes MPH, Phd, Bob Hays PhD, Greg Rebchook PhD, Susan Kegeles PhD; Traducción Romy Benard y Maricarmen Arjona CAPS Septiembre 2001. Hoja Informativa 8SR

What Are U.S. Latinos’ HIV Prevention Needs?

revised 4/02

Are Latinos at risk for HIV?

HIV continues to be a major health threat for Latinos in the US, many of whom are disadvantaged due to racism, economic disparities and language barriers. Latinos in the US (including residents of Puerto Rico) are disproportionately affected by HIV, accounting for 18% of total AIDS cases while comprising 14% of the US population.¹ The majority of AIDS cases among the Latino population in 2000 were concentrated among those born in the continental US (35%) and Puerto Rico (25%), followed by those born in Mexico (13%), Central or South America (8%) and Cuba (2%). An additional 18% were reported from Latinos with unknown place of birth (15%) or born elsewhere (3%).²

What puts Latinos at risk?

Latinos in the US include a diverse mixture of racial and ethnic groups and cultures. Latinos share common factors with other ethnic groups that increase vulnerability to HIV, such as discrimination,³ poverty, lack of information, substance use and negative attitudes toward condoms. AIDS case rates and risk behaviors among Latinos in the US vary by region. In the Northeast and along the eastern seaboard, where many Latinos from Puerto Rico live, Latino rates are up to three times higher than the national average.⁴ In this region, the main risk for transmission is injection drug use, believed to be fueled by the concentration of heroin availability. By comparison, in the West and Southwest, the majority of AIDS cases occurs among men who have sex with men (MSM), although cases are also high among injection drug users (IDUs) in certain areas. In 2000, 47% of AIDS cases among Latino men were attributed to sex with men, 33% to injection drug use, and 14% to sex with women. In the same year, 65% of AIDS cases among Latina women were attributed to sex with men, and 32% to injection drug use.¹ Thus, among both male and female Latinos, as with most other groups, unprotected sex with an HIV+ man is the most common route for becoming infected with HIV, followed by the sharing of an unclean syringe/needle with an HIV+ person. HIV risk dynamics among immigrant and migrant Latinos can be more complex than among US born Latinos, as they are dealing with conflicting cultural norms while trying to adjust to life in a new country. For some, this results in higher risk; for others, lower risk. Levels of acculturation, poverty, employment, migrant labor conditions and connection to traditional Latino values can influence HIV risk.⁶

What are barriers to prevention?

The social and political climate in the US today poses serious problems for effective HIV prevention in Latino communities. Racial and ethnic discrimination, anti- immigrant attitudes, policies on mandatory testing for immigrants, and fear of deportation for undocumented immigrants can prevent many Latinos from receiving and accessing adequate resources and services for HIV prevention, including HIV counseling and testing. Traditionally in Latino cultures, sex and sexuality are not discussed. For some Latina women, this sexual silence dictates that they should not know about or talk to men about sex because it suggests promiscuity. Therefore, their ability, comfort and success in insisting on condom use with male partners may be limited. Sexual silence can prevent MSM from discussing their sexual preference, instilling low self-esteem and personal shame. In addition, the lack of parental discussions and education regarding sex and condoms seems to contribute to the disproportionate number of unintended pregnancies, sexually transmitted diseases and HIV cases among Latino youth.⁹ Injection drug use is one of the main risk factors for HIV transmission, yet many IDUs do not have access to clean needles and drug treatment. Access is even more difficult for monolingual, immigrant Latino IDUs who may not use needle exchange sites or other public services due to lack of knowledge and fear of being recognized or deported.

How does culture affect prevention?

Familismo is a traditional Latino commitment to family and a central support to family members. Familismo can be a powerful incentive in helping heterosexual Latino men reduce unprotected sex with casual partners outside of primary partnerships. However, for many Latino MSM, familismo and homophobia can create conflict because families may perceive homosexuality as wrong. MSM are forced to separate their sexual identity from their family life, leading to low self-esteem and personal shame.⁸ Machismo may lead men to view sex as a way to prove masculinity. This can mean that frequency and type of sex are most often determined by men, leaving women in fear of violence or abandonment if they resist male sexual advances.7Machismo may also be used as an excuse for unprotected sex.

What’s being done?

Prevention Point Philadelphia, in collaboration with other AIDS organizations, operated a full service needle exchange site from a van that traveled to an area with many shooting galleries. The van offered needle exchange, oral HIV testing, bilingual social service and drug treatment referrals and medical care. The van reached many homeless, Spanish-speaking Puerto Rican IDUs who were regular shooting gallery users. Many of them had never accessed preventive medical care or social services. In San Antonio, TX, a three-session small group intervention was offered to English-speaking Mexican-American women who had a sexually transmitted disease (STD). The intervention sought to help women recognize their risk for HIV and other STDs, make a plan to change and then build skills to help reduce those risks. The intervention significantly reduced rates of subsequent STDs.¹¹ Hermanos de Luna y Sol, is an ongoing intervention for Latino gay/bisexual men at Mission Neighborhood Health Center in San Francisco, CA, based on empowerment education and social support. The program provides outreach, six structured discussion sessions and ongoing support to maintain behavior change. Sessions deal with the common history of oppression among Latino gay men, social support and community and emotional issues around sex and sexuality. The impact of AIDS and HIV transmission are discussed in the final two sessions. The program has been successful in recruiting men and increasing condom use among participants.¹² Mujeres Unidas y Activas is a community education, organizing and advocacy project created by and for Latina immigrant and refugee women in San Francisco, CA. The project includes components such as information meetings, friendship circles, workshops and advocacy. Although the project was not developed to specifically target HIV risk behaviors, women who attended up to nine types of activities showed increases in sexual communication comfort, were less likely to maintain traditional sexual gender norms and reported changes in decision-making power.¹³

What still needs to be done?

Latinos are concerned about the HIV epidemic and are motivated to learn and to teach their children about prevention.¹⁴ Providers and social service agencies should capitalize on this by providing Spanish-language or bilingual education and services such as anonymous and confidential HIV testing. Incorporating HIV prevention messages into general health services, Spanish media and religious settings would decrease stigma and increase access to HIV prevention programs. As Latinos, we must attempt to break the silence around sexuality in our communities and overcome homophobia. Latinos can encourage healthy sexuality by discussing gender role expectations, teaching children about sexuality and accepting diversity in our own community. Programs can build upon the protective aspects of Latino culture and emphasize resiliency. Larger societal factors such as poverty, racism and homophobia must also be addressed in order to reduce their impact on risk behavior.

Says who?

1.Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, Midyear Edition. 2001;13. https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html  2. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, Year End Edition. 2000;12. https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html  3. Díaz RM, Ayala G. Social discrimination and health: the case of Latino gay men and HIV risk. National Gay and Lesbian Task Force. 4. Kaiser Family Foundation. Key Facts: Latinos and HIV/AIDS. November 2001. 5. Klevens RM, Díaz T, Fleming PL, et al. Trends in AIDS among Hispanics in the United States, 1991-1996. American Journal of Public Health. 1999;89:1104-1106. 6. Organista K, Carrillo H, Ayala G. HIV prevention with Mexican migrants: review, critique and recommendations. Journal of Acquired Immune Deficiency Syndrome. 2004;37:S227-39 7. Gómez CA, Marín BV. Gender, culture and power: barriers to HIV prevention strategies for women. The Journal of Sex Research. 1996;33:355-362. 8. Díaz RM. Latino Gay Men and HIV: Culture, Sexuality and Risk Behavior. New York: Routledge Press, 1998. 9. The National Campaign to Prevent Teen Pregnancy. Whatever Happened to Childhood? The Problem of Teen Pregnancy in the United States. 1997. 10. Porter J, Perez G. Taking it to the street: shooting gallery needle exchange site for drug injectors at highest risk for HIV. Presented at the International Conference on AIDS, Geneva, Switzerland; 1998. Abst #33402. 11. Shain RN, Piper JM, Newton ER, et al. A randomized, controlled trial of a behavioral intervention to prevent sexually transmitted disease among minority women. New England Journal of Medicine. 1999;340:93-100. 12. Hermanos de Luna y Sol. Contact: 415/552-1013 x296 13. Gómez CA , Hernandez M, Faigeles B. Sex in the New World: An Empowerment Model for HIV Prevention among Latina Immigrant Women. Health Education & Behavior. 1999;26:200-212. 14. Kaiser Family Foundation. Latinos’ View of the HIV/AIDS Epidemic at 20 Years: Findings from a National Survey. 2001. 15. Ortiz-Torres B, Serrano-Garcia I, Torres-Burgos N. Subverting culture: promoting HIV/AIDS prevention among Puerto Rican and Dominican women. American Journal of Community Psychology. 2000;28:859-881. 16. Raj A, Amaro H, Reed E. Culturally tailoring HIV/AIDS prevention programs: Why, when and how. In: Kazarian & Evans (Eds) Handbook of Cultural Health Psychology. San Diego: Academic Press, 2001; 195-239.

Prepared by Cynthia Gómez, PhD, CAPS April 2002. Fact Sheet #17ER Special thanks to the following reviewers of this Fact Sheet: Hortensia Amaro, George Ayala, Jaime Calderón-Soto, Alejandra Cano, Dennis De Leon, José Ramón Fernandez-Peña, Francisco Gonzales, Barbara Marín, Kurt Organista, Prisci Quijada, Carlos Soles, Carlos Velazquez, Luis Villanueva.

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. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © September 2001, University of California

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

¿qué son las redes sexuales?

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

¿cómo afectan las redes en la transmisión?

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

¿cuáles son los conceptos clave?

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

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

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

¿qué intervenciones influyen en las redes?

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

¿qué queda por hacer?

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

¿quién lo dice?

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

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