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Using science

How Is Science Used in HIV Prevention?

Is science needed?

Yes. While prevention science will not give “the answer,” science fills in critical pieces of the prevention puzzle. Science used in conjunction with an agency’s experience with clients can strengthen, inspire, target, and best use limited resources in HIV prevention programs. This fact sheet will cover some of the basic elements of prevention science, what they mean, and their implications for service. Using science in prevention is now mandated in many areas. In 1994, the Centers for Disease Control and Prevention (CDC) radically changed how it makes prevention program awards. The CDC’s guidance recommends that HIV Prevention Community Planning Groups (CPGs) use epidemiology, evaluation and behavioral science theories, findings, and methodologies in developing programs.1 Science that is applicable to HIV prevention can be broken down into five general categories:

  • epidemiology,
  • basic behavioral science,
  • behavior change theory,
  • intervention science, and
  • evaluation methodology.

How is epidemiology useful?

Epidemiology is the study of the occurrence of infections or disease in a population. It can tell you how many people are newly infected with HIV, what subpopulations have been infected, and who might be expected to be infected by HIV in the future. Behavioral epidemiology can tell you about the frequency of risk behaviors.2 Using local epidemiology can help program planners target specific audiences and behavior risks that are most in need of prevention in their community. It can also help planners be more thoughtful about how to best use limited resources. Health departments and the CDC can help by collecting local data for all populations.3

How is behavioral science useful?

Basic behavioral science explores the social, behavioral and cultural influences that help explain why people put themselves at risk, and why people continue to get infected with HIV. Research on human sexuality is key to understanding how people change risky sexual behaviors and can help in program design.4 It does not tell service providers what to do, but can suggest new ways of thinking about program elements. For example, recent research has shown that childhood sexual abuse is a predictor for risky sexual behavior in adulthood.5 Knowing this, program managers can incorporate questions on early abuse into needs assessments, add a segment on childhood abuse to multi-session education interventions, develop new programs for adults who were abused and/or give special training to direct service staff on sexual abuse issues.

How is behavior change theory useful?

Behavior change theory provides a framework to ideas on why and how people change behaviors that put them at risk for HIV infection. Using behavior change theories can help when crafting an intervention, to support each component in a model as the intervention is designed.6,7 For example, Paulo Freire’s theory of Popular Education states that teachers and students should learn from one another.8 Using this theory, a program can use discussion groups as opposed to lectures. This format can strengthen the intervention by empowering people to personally develop their own solutions to change their environment.

How is intervention science useful?

Intervention science explores which components of programs are more effective and which programs work well in certain populations. For example, in a recent study, the riskiest people did not attend small group educational sessions. A program for gay/ bisexual men in Portland, OR conducted outreach in bars and at community events, home meetings, and safer sex workshops. While most men attended outreach activities, few men were likely to attend safer sex workshops.9 Scientific study of the program showed that outreach was most likely to reach the riskiest men-younger men and men who reported unprotected anal intercourse. Interventions aimed at high risk-taking populations can rely on intensive individual outreach/counseling and/or innovative, minimally structured community-level social activities to help draw their intended audience.

How is evaluation methodology useful?

Evaluation encourages critical thinking about the process of designing interventions, and should not only occur at the end of an intervention. Good evaluation produces information about needs, service use patterns, impacts and outcomes. It also gives a voice to clients’ experiences, and allows service providers to learn about their programs so that they can make necessary changes to increase their effectiveness.10 An agency can hire a consultant or researcher for evaluation, or can conduct its own evaluation. For example, Tri-City Health Center in Fremont, CA surveyed suburban street youth to evaluate the effectiveness of their program of outreach and educational workshops. In response to youth feedback, Tri-City cancelled their scheduled workshops and added a drop-in center providing HIV education as well as support in areas such as dropping out of school, joblessness, substance abuse, abusive relationships and living with HIV.11

How do people access science?

No one should need an advanced degree to understand prevention science. Several organizations exist to help translate and summarize research into understandable and usable forms. CPGs are directed to incorporate prevention science in their comprehensive plans, which are available through local and state health departments.12 Local universities (especially schools of public health and social work, departments of sociology, psychiatry/psychology, or anthropology) are an excellent contact for research assistance.13 Mailing lists and newsletters from organizations that specialize in prevention science and technical assistance can also be invaluable resources.14

What still needs to be done?

To more closely link the efforts of researchers and service providers: 1) Researchers should share findings with local CBOs and with the CDC and DPHs, as well as become active members of CPGs. 2) CBOs should be more aggressive and proactive in using information outside of their agencies. 3) State DPHs and the CDC should recognize and act upon their role as translators of science. 4) National Institutes of Health, the CDC and private funders should provide adequate funding for integrating prevention science into prevention programs. 5) CBOs and researchers should forge long term partnerships to conduct collaborative projects.15 Using science in service provision is a specialized field. Most scientists are not trained in the real world application of research. Likewise, most service providers are not trained in research methods. A comprehensive HIV prevention strategy uses many elements to protect as many people at risk for HIV as possible. By closing the gap between HIV prevention science and prevention practice, we can ensure that our best efforts won’t be wasted, and we can make a difference in the fight against HIV.

Says who?

  1. Valdiserri RO, Aultman TV, Curran JW. Community planning: a national strategy to improve HIV prevention programs. Journal of Community Health. 1995;20:87-100.
  2. Rothman KJ. Modern Epidemiology. Boston, MA: Little, Brown and Company; 1986.
  3. A database of epidemiological data for states and some cities is available on the Internet at: https://www.cdc.gov/hiv/basics/statistics.html
  4. Kelly JA, Kalichman SC. Increased attention to human sexuality can improve HIV-AIDS prevention efforts: key research issues and directions. Journal of Consulting and Clinical Psychology. 1995;63:907-918.
  5. Jinich S, Stall R, Acree M, et al. Childhood sexual abuse predicts HIV risk sexual behavior in adult gay and bisexual men. Presented at the 11th International Conference on AIDS, Vancouver, BC. 1996. Abstract Mo.D.1718.
  6. Valdiserri RO, West GR, Moore M, et al. Structuring HIV prevention service delivery systems on the basis of social science theory. Journal of Community Health. 1992;17:259-269.
  7. Herlocher T, Hoff C, DeCarlo P. Can theory help in HIV prevention? Fact sheet prepared by the Center for AIDS Prevention Studies, UCSF. August 1995.
  8. Wallerstein N. Powerlessness, empowerment, and health: implications for health promotion programs. American Journal of Health Promotion. 1992;6:197-205.
  9. Hoff CC, Kegeles S., Acree M, et al. Gay men at highest risk are best reached through outreach in bars and community events. Presented at the 11th International Conference on AIDS, Vancouver, BC. 1996. Abstract Tu.D.360.
  10. San Francisco HIV Prevention Plan. Report prepared by the San Francisco HIV Prevention Planning Council and the Department of Public Health AIDS Office. 1996.
  11. Carver LJ, Harper GW. Responding to the HIV prevention needs of suburban street youth. Presented at the 11th International Conference on AIDS, Vancouver, BC. 1996. Abstract Th.D.4921.
  12. For information on your local or state Community Planning group, please contact Lynne Greabell at NASTAD (202) 434-8090.
  13. A directory of universities is available here: https://www.usnews.com/best-colleges/rankings/national-universities
  14. CDC (800) 458-5231 (www.cdc.gov/nchstp/hiv_aids/dhap.htm)
    • American Psychological Association (202) 336-6042
    • National Minority AIDS Council (202) 483-6622
    • National Association of People With AIDS (202) 898-0414
    • Academy for Educational Development (202) 884-8700
    • National Alliance of State and Territorial AIDS Directors (202) 434-8090
    • Council of State & Territorial Epidemiologist (770) 458-3811
    • The US Conference of Mayors (202) 293-7330
    • GMHC Education Department (212) 807-7517 (www.gmhc.org)
    • The Center for AIDS Prevention Studies - https://prevention.ucsf.edu/ 
    • Rural Prevention Center (812) 855-1718 https://rcap.indiana.edu/ 
  15. Goldstein E, Wrubel J, Faigeles B, et al. Is research important for non-governmental organizations in the United States? Presented at the 11th International Conference on AIDS, Vancouver, BC. 1996. Abstract Th.C.4779.

Prepared by Ellen Goldstein and Pamela DeCarlo January 1997. Fact Sheet #25E

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

Resource

Prueba del VIH en casa

¿Que papel juega hacerse la prueba del VIH en casa?

¿será factible el examen casero para la detección del VIH?

Cuando por primera vez se planteó la posibilidad de poner al alcance del público un estuche casero para la detección del VIH, esa se encontró con oposición unánime.1 Hoy en día los Centros para el Control de Enfermedades (CDC, por sus siglas en Inglés), destacados miembros del sector salud, activistas “gay” y los defensores de la lucha contra el SIDA apoyan la idea del estuche casero para detectar el VIH.2 Los estudios que se han hecho sobre la factibilidad de las pruebas caseros han demostrado que no hay barreras técnicas en su uso.3 Se ha podido examinar en casa por mas de una década. Realmente, el nombre “examen casero” tiende a mal interpretarse puesto que la persona no obtiene resultados inmediatos, a como sucede con los estuches caseros para detectar el nivel de glucosa, colesterol, presión arterial y el embarazo. En realidad las pruebas son “estuches para ser recolectados” que se pueden comprar sin receta médica en cualquier farmacia o por medio del correo. El comprador del estuche se pincha el dedo, deposita una gota de sangre en un pedazo de papel absorbente, lo envía por correo y luego llama por teléfono (después de un tiempo específico) para obtener los resultados. En la primavera del 1996, la entidad encargada de administrar las medicinas y los alimentos de los EEUU (FDA), aprobó, Confide, el primer estuche casero para la detección del VIH. El estuche, que se vendió por una empresa filial de Johnson & Johnson, y después fue retirado del mercado. El FDA después aprobó Home Access HIV-1 Test System, que esta manufacturado por la empresa Home Access Health Corporation en Chicago. Actualmente, este es el único estuche para prueba casera que ha sido aprobado por el FDA, aunque varios otros estuches no-aprobados han sido anunciados por vente en periódicos y en el Internet. El FDA previene contra el uso de estuches no-aprobados, que no han sido completamente evaluados y que “no tienen una historia documentada de entregar resultados confiables.”4

¿en qué forma es diferente?

Tradicionalmente, hacerse la prueba del VIH ha implicado tener que ir al doctor o a la clínica, sacarse sangre, y después regresar por los resultados y recibir apoyo psicológico. Con el nuevo examen casero se ahorrarían dos viajes. Este método hará posible que las personas que viven en áreas rurales o recónditas de la ciudad en donde las clínicas son escasas, con muchos pacientes o que impliquen un largo viaje en bus se hagan la prueba del VIH. El examen casero también brinda privacidad. Algunas personas no van al doctor o a la clínica por temor a ser vistos por algún vecino, familiar o amigo. En un cantidad de estudios, los individuos que están a riesgo han expresado su preferencia por un sistema anónimo al hacerse la prueba.5 El examen casero ofrece el potencial de ser totalmente anónimo. Ofrecer otra opción para hacerse la prueba significa avanzar un paso hacia la resolución del problema nacional que enfrenta el sistema de hacerse el examen del VIH. Una proporción alarmantemente alta de aquellos que están a riesgo (más del 60%) todavía no se han hecho la prueba del VIH.6 Obtener resultados del VIH se vuelve cada vez más y más importante ya que el sistema inmunológico necesita fortalecerse y mantener bajo control a las infecciones oportunistas. A las mujeres embarazadas se les anima a hacerse la prueba voluntaria del VIH ya que los estudios demuestran que al suministrárseles Zidovudine (AZT), este puede reducir en dos tercios la tasa de transmisión del VIH de madre a feto.7

¿los resultados, son confiables?

Millones de las pruebas realizadas para detectar la presencia de anticuerpos del VIH se han hecho por medio de una muestra de sangre seca.8  Este tipo de pruebas son bastante exactas, siempre y cuando se siga muy de cerca el protocolo de laboratorio en cuanto a la confirmación de la prueba y los mecanismos que lo garantizan. Algunos de los estuches enviados al laboratorio para ser examinados puede que no contengan la cantidad de sangre necesaria para conducir la prueba. En estos casos, los consejeros telefónicos van a tener que ser entrenados para aconsejar al cliente cuando los resultados no estén claros o por si necesitan confirmación.

¿quiénes se harán la prueba en casa?

La accesibilidad del examen casero puede brindar mayor seguridad a aquellas personas que aunque el riesgo de infección con el VIH sea bastante remota, andan buscando como reasegurarse. Si estas personas ya no pueden contar con las fuentes públicas para hacerse la prueba, puede ser que estos recursos sean utilizados para poner en práctica mas intervenciones dirigidas a los que se encuentran a mayor riesgo.9 Las ventas de los estuches para prueba casera no han sido tan numerosas como se esperaba de acuerdo a los resultados obtenidos de encuestas sobre las intenciones acerca de pruebas caseras. En el primer ano de vente, Home Access Health vendió 152,044 estuches; 148,039 personas llamaron para obtener sus resultados. El índice de resultados seropositivos fue 0,9%.10 Además de la negación y otras barreras psicológicas, muchos encuentran el costo por menor de $30-$40 por estuche a ser imposible. Las empresas que manufacturan los estuches de prueba casera están trabajando con varias agencias de salud publica y comunitarias, vendiéndoles los estuches al mayor para que puedan utilizarlos en sus campanas de prevención.

¿cuál es la preocupación?

Una de las preocupaciones es lo adecuado del apoyo psicológico. En una clínica u oficina del Doctor, los resultados usualmente se entregan en persona. Si el paciente se siente sumamente abrumado por la noticia, hay un experto presente que le puede ayudar. Las compañías que venden el estuche casero también pondrán consejeros a la disposición, pero estos estarán a millas de distancia en la línea telefónica. A como lo expuso uno de los que critican el examen casero “el número 1-800 no te puede abrazar cuando lloras.”11 Para algunos, lo remoto y lo anónimo de la orientación por teléfono les permite revelar con mayor facilidad sentimientos de dolor o información embarazosa. Además, ya existe una larga tradición en cuanto intervenir por medio del teléfono en crisis y en la prevención del suicidio. La propuesta de brindar apoyo psicológico por teléfono debería ser comparado con experiencias que actualmente ocurren al hacerse la prueba del VIH. Para muchos, la consejería ni es la adecuada, ni existe. De acuerdo a las datos arrojados por el National Health Interview Study (Estudio Nacional sobre la Salud), un tercio de aquellos que se hicieron la prueba del VIH obtuvieron los resultados por correo (16%) o por teléfono (17%). 12 En los sitios públicos, se hacen cerca de 2,5 millones de pruebas anuales. En 1995, 25% de las personas que tuvieron resultados positivos y 33% de las personas que tuvieron resultados negativos, faltaron de regresar por sus resultados.13 Por contraste, 97,4% de las personas que compraron estuches de prueba casera llamaron para obtener sus resultados.10 Otra de las preocupaciones es el potencial de abuso al que el estuche casero pudiera prestarse. Algunos temen que los patrones, familiares o proveedores al cuidado de salud puedan enviar muestras de sangre sin el consentimiento de la persona. Aunque ya existen leyes que protegen en caso de que se hagan sin el permiso de la persona ya sea por discriminación o por ser VIH positivos. Estos estatutos necesitan ser enforzados; nuevas leyes de protección deberán ser creadas a medida que se adquiere experiencia con el examen casero.

¿cuáles son las limitaciones?

Un resultado positivo a la prueba no garantiza el acceso a los cuidados de salud necesarios. A como lo escribió la Comisión Nacional del SIDA “Es muy cruel que muchos de los pobres crean que van a obtener acceso al sistema de salud y servicios sociales por medio de un diagnóstico VIH positivo.”14 No obstante, esto no debería impedir que la gente busque como hacerse la prueba. “La falta de buenos servicios de salud y de servicios sociales para las personas infectadas con el VIH es argumento para incrementarlos, no para reducirlos.”15 Hacerse la prueba del VIH no necesariamente significa el final. El reto mas importante se el de lograr un acceso seguro a servicios de cuidados de salud y de apoyo psicológico continuo para todas aquellas personas que se hacen la prueba. Si estos resultan ser VIH positivos, deberían recibir los cuidados médicos necesarios para mantenerse saludables, y si el resultado es negativo deberán recibir el apoyo necesario para mantenerse negativos.

¿quién lo dice?

  1. Anon. Banned at home: an FDA ruling on AIDS test. Time. 1989; April 18:26.
  2. Leary WE. Government panel hears call for expanded AIDS testing. New York Times. 1994;June 23:A18.
  3. Frank AP, Wandell MG, Headings MD, Conant MA, Woody G, Michel C. Anonymous HIV testing using home collection and telemedicine: a multicenter evaluation. Archives of Internal Medicine. 1997;157:309-314.
  4. Center for Biologics Evaluation and Research, Food and Drug Administration (FDA). Testing yourself for HIV-1, the virus that causes AIDS–Home test system is available. 1997;July 25.
  5. Hirano D, Gellert GA, Fleming K, et al. Anonymous HIV testing: the impact of availability on demand in Arizona. American Journal of Public Health. 1994;84:2008-2010.
  6. Sweeney PA, Fleming PL, Karon JM, Ward JW. A minimum estimate of the number of living HIV infected persons confidentially tested in the United States. Presented at the Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) 1997;Sept.-Oct., Toronto, Canada.
  7. Conner EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. New England Journal of Medicine. 1994;331:1173-1180.
  8. Gwinn M, Redus MA, Granade TC. HIV-1 serologic test results for one million newborn dried-blood specimens: assay performance and implication for screening. Journal of Acquired Immune Deficiency Syndrome. 1992;5:505-12.
  9. Valdiserri RO, Weber JT, Frey R, Trends in HIV seropositivity in publicly finded HIV counseling and testing programs: implications for prevention policy. American Journal of Preventive Medicine. 1998;14:31-42.
  10. Home Access Health. http://www.homeaccess.com.
  11. Ocamb K. Home HIV testing is near. POZ. 1994;June-July:48-52. (quoting Dennis Ouellet, LA Free Clinic).
  12. Schoenborn CA, Marsh Sl, Hardy AM. AIDS knowledge and attitudes for 1992. Data from the National Health Interview Survey. Advance Data. 1994;243:1-15.
  13. Centers for Disease Control. Update: HIV counseling and testing using rapid tests–United States. Morbidity and Mortality Weekly Report. 1998;47: 211-5.
  14. National Commission on AIDS. Report of the Working Group on Social and Human Issues. Washington, DC: National Commission on AIDS, 1991.
  15. Bayer R, Stryker J, Smith MD. Testing for HIV infection at home. New England Journal of Medicine. 1995;332: 1296-1299.

Preparado por Jeff Stryker, Traducción Sandra Galvez CAPS Revisado Deciembre 1998. Hoja Informativa 11Sr. Alentamos la reproducción de este documento; aunque, no se admite la venta de copias y UCSF deberá ser mencionada como fuente de esta información. Para obtener copias, llame por favor al National Prevention Information Network al 800/458-5231 o al Internet https://prevention.ucsf.edu/. Estas hojas informativas están disponibles en ingles. Cualquier comentario o pregunta acerca de esta hoja informativa puede ser electrónicamente dirigido al [email protected]. ©Deciembre 1998, University of California.

Resource

Adolescentes

¿Qué necesitan los adolescentes en la prevención del VIH?

¿pueden contraer los adolescentes el VIH?

Desafortunadamente, sí. Los casos de infección del VIH se incrementan más aceleradamente en los jóvenes. La mitad de todos los casos de VIH se presentan en personas menores de 25 años. De todos los casos de VIH de 1994-1997 en jóvenes de 13-24 años, 44% eran mujeres y 63% Afro-Americanos. Mientras la cifra de nuevos casos de SIDA se reduce en los diferentes grupos de edad, no se ha observado una reducción comparable en la cantidad de nuevas infecciones en los jóvenes.1 Las relaciones sexuales implican riesgo para un joven, no solo del VIH, sino además para otras Enfermedades de Transmisión Sexual (ETS) y los embarazos no planeados. Actualmente, los adolescentes experimentan tasas alarmantes de ETS. Cada año, tres millones de jovenes entre los 13 y 18 años-es decir, un cuarto de todos con experiencia sexual-contraerán alguna ETS. La clamidia y la gonorrea ocurren con mayor frecuencia entre la juventud que en personas mayores.2 En especial, algunas jóvenes Afro-Americanas y Latinas sexualmente activas corren mayor riesgo de infectarse con VIH, especialmente aquellas que provienen de barrios pobres. En un estudio de desertores escolares jóvenes en el “U.S. Job Corps” se descubrió que las jóvenes Afro-Americanas tenían mayores tasas de infección con VIH y que los índices de infección entre las mujeres entre los 16 y 18 años era mayor a las de los hombres jóvenes en un 50%.3 Otro estudio de mujeres adolescentes Afro-Americanas y Latinas reveló que las jóvenes con novios mayores que ellas (3 años mayor o más) corren mayor riesgo de infectarse con el VIH.4

¿cómo se exponen al riesgo?

La adolescencia es un período de desarrollo marcado por la curiosidad y la experimentación acompañada de una miríada de cambios emocionales. La conducta sexual y/o el uso de drogas suelen formar parte de esta exploración. Durante esta etapa de crecimiento y cambios, los jóvenes reciben mensajes contradictorios. Por un lado a la juventud se le exhorta a abstenerse sexualmente mientras se les satura de imágenes glamorosas de personajes de cine y televisión teniendo sexo, fumando y tomando. Este doble estándar existe para las chicas-de las que se espera se conserven vírgenes-y los chicos-con la presión de demostrar su hombría por medio de la agresividad y la actividad sexual. En nombre de la cultura, la religión y la moralidad, a la juventud suele negársele el derecho a estar informados sobre el funcionamiento de su cuerpo y los riesgos para la salud para poder protetegerse mejor.5 Un reciente sondeo a nivel nacional con jóvenes reveló que de 1991 a 1997, la prevalencia de la actividad sexual disminuyó en un 15% para los estudiantes masculinos, 13% en estudiantes blancos y 11% en estudiantes Afro-Americanos. Sin embargo no se presentó reducción alguna respecto a la experiencia sexual en estudiantes femeninas o en Latinos. Hubo un incremento del uso del condón del 23% en estudiantes sexualmente activos. Sin embargo, solo cerca de la mitad de los estudiantes sexualmente activos usaron condones durante su última relación sexual.6 No todos los adolescentes corren el mismo riesgo de infectarse con VIH. La juventud no es un grupo homogéneo, por lo tanto, dentro de esa categoría existen subgrupos que participan en mayor cantidad de actividades sexuales sin protección y abusan de las drogas, lo cual les vuelve más vulnerables al VIH y otras ETS. Esto incluye a jóvenes homosexuales o que experimentan relaciones con personas del mismo sexo, usuarios de drogas, delincuentes juveniles, desertores escolares, vagabundos, desamparados o jóvenes inmigrantes. Alcanzar a este grupo de jóvenes con actividades de prevención se dificulta debido a que no asisten a la escuela regularmente y tienen acceso limitado al sistema de salud u otros servicios similares.7

¿puede ayudar la educación?

Si. Las escuelas son un sitio ideal para que los jóvenes aprendan a conocer los riesgos para la salud, incluyendo el VIH, las ETS y los embarazos no planeados. A nivel nacional y global se ha comprobado, por medio de estudios, que la educación sexual a niños y jóvenes no estimula el incremento en la actividad sexual y sí ayuda a la juventud a abstenerse por más tiempo. Los programas educativos exitosos utilizan un curriculó y mensajes claros sobre los riesgos del sexo sin protección y las formas de evitar el riesgo, enseñan y practican la comunicación, tratan el tema de la influencia de la sociedad y de los medios de comunicación, y promueven que se hable del tema de la sexualidad abiertamente.8 Adicionalmente, los programas de prevención para adolescentes dirigidos cuidadosamente pueden ser muy efectivos a nivel de costo.9

¿sólo en la escuela se encuentra la solución?

No. La juventud necesita recibir mensajes de prevención de formas diversas y en sitios diferentes. Las escuelas por si solas no pueden realizar esta tarea. En los EEUU, a muchas escuelas se les prohibe el uso de fondos federales si utilizan un currículo abierto en cuanto a la sexualidad. El gobierno federal asignó $50 millones anuales a aquellas escuelas cuyos programas están basados en la abstinencia-sin tocar el tema de los anticonceptivos o el sexo seguro.10 Aunque es cierto que los programas de abstinencia logran retrasar el inicio de la actividad sexual, en general, no reducen la cantidad de actividades sexuales de riesgo de la forma en que lo logran las intervenciones basadas en el sexo seguro.11 Los jóvenes que no asisten a la escuela con mayor frecuencia presentan conductas que les pone a riesgo de contraer VIH/ETS, y tienen menor acceso a programas de prevención. Un sondeo nacional con jóvenes entre los 12 y 19 años de edad reveló que el 9% no asistían a la escuela. Los desertores escolares estuvieron significativamente más propensos a haber tenido relaciones sexuales que los que sí asistían, tenían 4 o más parejas sexuales y habían experimentado con el alcohol, marihuana y cocaína.12 Deberían crearse programas de prevención más intensivos para los desertores escolares y los que están en riesgo de desertar. Es necesario que los programas dirigidos a los adolescentes que no tienen una vida estable se lleven a cabo en los sitios que ellos frecuentan tales como en centros de detención juvenil y escuelas alternativas. La instrucción impartida por miembros de este mismo grupo puede utilizar el método del empoderamiento, enseñar sobre prevención de VIH, ETS, además de movilizar y anexar recursos para los jóvenes por medio de organizaciones comunitarias y sociales.13 El apoyo familiar para que los jóvenes eviten caer en conductas de riesgo es de incalculable valor. Las conversaciones francas sobre condones entre padres e hijos adolescentes puede conducir a los jóvenes a adoptar conductas que les prevendrán de contraer el VIH y otras ETS. Cuando las madres hablan y contestan preguntas sobre el uso del condón previo al iniciamiento sexual, los adolescentes han reportado el uso del condón la primera y última vez que tuvieron sexo, así como un mayor uso del condón durante el transcurso de sus vidas.14 En Los Angeles, CA, el “WEHO Lounge” es una cafetería y centro de detección e información de VIH localizado entre dos discotecas “gay.” Ofrece pruebas orales de detección del VIH confidenciales, foros comunitarios semanales, consejería impartida por miembros de este grupo, distribución gratuita de condones y una biblioteca juvenil con recursos relacionados al VIH. Este “Lounge” tambien vende cafés. Al colocar este recurso en la comunidad y adaptarlo a la necesidad y hábitos de los hombres jóvenes “gay”, el programa ha tenido un exito fenomenal.15 El Proyecto VIDA de Chicago, IL, una organización que provee servicios a la comunidad, conduce prevención del VIH a mujeres Latinas entre los 12 y 24 años en riesgo de infección. VIDA recluta y conduce intervenciones dirigidas por miembros de este mismo grupo en las que se incorporan temas como el empoderamiento y la autoestima. Ellos actúan en la creencia de que es imposible separar los riesgos de contraer VIH de las presiones culturales, ambientales, interpersonales e intrasíquicas que enfrentan las jóvenes Latinas; y que es posible vencer estos obstáculos aprendido a manejar situaciones difíciles.16

¿qué queda por hacer?

Los programas de prevención para adolescentes deben tomar en cuenta las necesidades y habilidades que presenta la edad de este grupo. Los programas deben tener un enfoque en los factores contextuales que contribuyen a que los jóvenes participen en mayor cantidad de actividades sexuales y bajos índices en el uso del condón, tales como la baja auto-estima, la depresión, el uso de drogas, actividades de pandillas, la presión de vivir en ambientes urbanos turbulentos o aburridos ocasionados por la falta de empleo. Cualquier programa para adolescentes debe ser interesante, divertido e interactivo, debe incluir la opinión de los jóvenes en cuanto al diseño e implementación. Esto se aplica especialmente a jóvenes de otras culturas que no forman parte de la gran mayoría. Los programas para jóvenes inestables que corren el riesgo de contraer VIH deben implementarse en otros locales aparte de la escuela, tales como casas de refugio para jóvenes sin hogar o que se han escapado de ellos, centros comerciales, centros de detención, y centros comunitarios. No basta con que los jóvenes reciban la información adecuada ni con practicar las habilidades de auto-protección, es también necesario facilitar el acceso a los condones para poder mantenerles libres de riesgo.

¿quién lo dice?

1. Centers for Disease Control and Prevention. Young people at risk-epidemic shifts further toward young women and minorities. Fact sheet prepared by the CDC. July 1998. 2. Eng TR, Butler WT, eds. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: National Academy Press; 1996. 3. Valleroy LA, MacKellar DA, Karon JM, et al. HIV infection in disadvantaged out-of-school youth: prevalence for US Job Corps entrants, 1990 through 1996 . Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 1998;19:67-73. 4. Miller KS, Clark LF, Moore JS. Sexual initiation with older male partners and subsequent HIV risk behavior among female adolescents . Family Planning Perspectives. 1997;29:212-214. 5. UNAIDS. Force for Change: World AIDS Campaign with Young People . Report prepared by UNAIDS, The Joint United Nations Programme on HIV/AIDS for World AIDS Day 1998. 6. Centers for Disease Control and Prevention. Trends in sexual risk behaviors among high school students-United States, 1991-1997 . Morbidity and Mortality Weekly Report. 1998;47:749-752. 7. Rotheram-Borus MJ, Mahler KA, Rosario M. AIDS prevention with adolescents . AIDS Education and Prevention. 1995;7:320-336. 8. UNAIDS. Impact of HIV and sexual health education on the sexual behavior of young people: a review update . Report prepared by UNAIDS, The Joint United Nations Programme on HIV/AIDS for World AIDS Day 1997. 9. Pinkerton SD, Cecil H, Holtgrave D.R. HIV/STD prevention interventions for adolescents: cost-effectiveness considerations . Journal of HIV/AIDS Prevention and Education for Adolescents and Children. 1998;2:5-31. 10. Associated Press. Sex education that teaches abstinence wins support. New York Times. July 23,1997:A19. 11. Jemmott JB, Jemmott LS, Fong GT. Abstinence and safer sex HIV risk-reduction interventions for African-American adolescents: a randomized controlled trial . Journal of the American Medical Association. 1998;279:1529-1536. 12. Centers for Disease Control and Prevention. Health risk behaviors among adolescents who do and do not attend school-United States, 1992 . Morbidity and Mortality Weekly Report. 1994;43:129-132. 13. Zibalese-Crawford M. A creative approach to HIV/AIDS programs for adolescents . Social Work in Health Care. 1997;25:73-88. 14. Miller KS, Levin ML, Whitaker DJ, et al. Patterns of condom use among adolescents: the impact of mother-adolescent communication . American Journal of Public Health. 1998;88:1542-1544. 15. Weinstein M, Farthing C, Portillo T, et al. Taking it to the streets: HIV testing, treatment information and outreach in a Los Angeles neighborhood coffee house. Presented at the 12th World AIDS Conference, Geneva, Switzerland; 1998. Abstract #43125. 16. Harper GW, Contreras R, Vess L, et al. Improving community-based HIV prevention for young Latina women. Presented at the Biennial Meeting of the Society for Community Research and Action, New Haven, CT; June,1999.

Preparado por Gary Harper, PhD MPH* y Pamela DeCarlo**, Traducción Romy Benard Rodríguez** *Departamento de Psicología, Universidad DePaul, **CAPS

Septiembre 1999. Hoja Informativa 9SR.

Resource

Healthy Oakland Teens

Healthy Oakland Teens Description and Explanation of Study Instrument

A questionnaire based on findings from earlier surveys was developed and pilot tested on junior high school students. The content and wording of the survey was modified based on pilot study results and participant feedback and used in the present study to assess demographic characteristics, HIV/AIDS/STD-related knowledge, attitudes, and beliefs, sexual behaviors and drug and alcohol use. The final instrument included 102 items at pretest and 97 items at follow-up, and required approximately 40 minutes to complete. The instrument contained the following sections that were used to develop scales. Sexual behaviors were assessed including dating, kissing, deep kissing, breast touching, and genital touching. These individual-item measures were dichotomous assessments for lifetime behaviors and for practices during the past two months. Those students who had experienced sexual intercourse were asked about their lifetime and prior two months practice of vaginal, anal, and oral sex. Demographics, including gender, age, ethnicity, and the primary language spoken at home were measured. Socioeconomic status was assessed by examining the proportion of students who participated in the school district's free lunch program. An AIDS -related knowledge score was created by adding the number of correct answers to 11 true-false questions regarding AIDS transmission, general medical aspects of AIDS, and knowledge of preventive behaviors. Examples of items included, "Only people who look sick can spread the AIDS virus," "A person can get the AIDS virus even if he or she has sexual intercourse just one time without a condom," and "Birth control pills prevent a woman from getting the AIDS virus." (scale range 0 to 11, seventh grade baseline mean=7.9, Cronbach's alpha=.64). The perceived costs and benefits of preventive behaviors scale combines statements about the negative and positive aspects of condom use. Examples of items include "It would really bother me to stop having sexual intercourse to put on a condom," "Condoms would be too much trouble to use," and "Condoms slip off easily." Responses are in the Likert format ranging from "definitely" to "definitely not" (range 0 to 21, seventh-grade baseline mean=11.1, Cronbach's alpha=.43; for negative aspect items only, six items, Cronbach's alpha=.47). We decided to retain this scale even though it has a relatively low reliability, since perceived barriers have previously been shown to be related to sexual behaviors and were specifically targeted in our intervention. The perceived peer norms scale used the CDC's national survey of adolescent AIDS-related attitudes (CDC, 1988). This scale measures the perceived prevalence of risk behaviors among the friends of adolescents, using Likert response options. Examples of items include, "How many of your friends do you think have had sexual intercourse?" and "How many of your friends think condoms are too much trouble to use?" A high score indicates that friends are believed to have the lowest risk behaviors and attitudes regarding condom use (five items, range 0 to 20, seventh grade baseline mean=15.1, Cronbach's alpha =.62) The attitudes regarding sexually active students scale consists of three statements referring to sexually active boys and girls (for a total of six statements), "Having sexual intercourse makes a boy (a girl) popular," "Having sexual intercourse at my age is a `cool' thing for a boy (a girl) to do," and "Having sexual intercourse with someone besides his (her) steady partner makes a boy (a girl) 'cool' or popular." Students responded on a 4 point Likert format scale ranging from "strongly agree" to "strongly disagree." (Six item scale, range 0 to 18, seventh-grade baseline mean=13.5, Cronbach's alpha=.88) The partner norms scale combines three items regarding attitudes toward a sexual partner who suggested using a condom, (i.e. "If the person I was about to have sex with suggested using a condom, I would feel like that person cared about me,"), (3 items, range 0 to 9, seventh grade baseline mean=7.3, standardized Cronbach's alpha=.69) The self-efficacy scale measures confidence in one's ability to refuse unsafe situations or use of a condom in appropriate situations. Examples of items include "I would refuse to have sexual intercourse without a condom," and "I would use a condom even if I were drunk or high." A high score reflects the strongest refusal and condom use self-efficacy (range 0-15, seventh grade baseline mean=11.2, Cronbach's alpha=.62) Alcohol consumption. Students were asked at what age they had consumed their first drink (open-ended), their frequency of drinking and their frequency of getting "really drunk" (7 response categories ranging from "never" to "almost every day"). Questions about marijuana smoking included the age at first use, frequency of use, and frequency of getting "really high." These questions used the same format as for alcohol consumption.
Resource

Heterosexual Men - 2018

What Are Heterosexual Men’s HIV Prevention Needs?

Prepared by Joshua Middleton and Reverend William Francis Community Engagement (CE) Core | March 2018

Heterosexual men are affected by HIV

HIV is a concern for heterosexual men, as almost 14% of new male HIV cases in 2016 occurred among heterosexuals, through sex with a woman (9.5%) and injecting drug use (3.9%). Most of those cases were among Black (63%) and Latino (22%) men, and men living in the Southeast (62%) and Northeast (19%) of the US.[1] These statistics, however, may not give us an accurate picture of HIV among heterosexual men. Because sexuality is complex, some heterosexually-identified men may have sex with men, but still identify as straight.[2] The CDC tracks HIV infections through means of infection, not by a person’s identity. Therefore, a heterosexual man who tells his healthcare provider he ever had a sexual encounter with a man is categorized under “men who have sex with men,” and if he says he has ever injected a drug, is categorized under “people who inject drugs (PWID).” Because of this, heterosexual men are seldom mentioned or addressed in the world of HIV prevention, care and research—where men are classified based on federal guidance and misconceptions, and not on men’s own identity.[3] This may be helpful for tracking the HIV epidemic, but it hampers service organizations who want to serve straight men who are at risk for or living with HIV, because funding for programs is linked to mode of transmission.

Fighting stigma

Misunderstanding, discrimination and HIV stigma. Heterosexual men may be reluctant to access testing and education programs at HIV-related organizations because they are concerned they might be labeled as gay or in the closet. Heterosexual men living with HIV can feel excluded from HIV clinics that brand their sites as safe and inclusive spaces for gay and bisexual men, which may be less about homophobia, and more about wanting a safe space for connection with and support from their community.[4] HIV criminalization. Straight men often are blamed for the HIV epidemic among heterosexual women, and may carry guilt, shame and fear of criminal charges. Between 2008 and 2016 in the US, there were 279 cases of HIV criminalization. This occurs when a person is prosecuted for not disclosing their HIV status to a partner. The majority of prosecutions are of heterosexual men.[5] Religion. Religion is an important part of many heterosexual men’s lives, yet sometimes the church may be the place where they are exposed to the beliefs that HIV is a punishment from God, and homosexuality and sex outside of marriage are sins.[6] These religious views may deter open dialogue around HIV, such as HIV testing and prevention, or disclosing HIV status.

Holistic approach

Addressing issues that impact heterosexual men as a whole person—body, mind and spirit—can be more effective than addressing HIV transmission mode. Health inequalities and structural barriers, not necessarily sexual risk taking behaviors, make men more likely to contract HIV and less likely to seek and have access to HIV programs.[3] Family, relationships and intimacy. It is important for heterosexual men to explore their identity as a father, a romantic partner and a member of a family unit.[7] Men view intimacy in many different ways, including being able to communicate with their partner, being transparent and comfortable expressing their feelings, spending quality time with their partners, and having healthy and satisfying sexual lives.[8] Men and boys may need support developing communication skills with their partners. Social injustice and resilience. The largest proportion of heterosexual HIV cases occur among Black men in the Southeast. This is also true for other race/ethnic groups except American Indian/Alaska Native where the largest number is in the West. The second largest number of cases among Black, Latino, and White men occur in the Northeast US. Latino men, the second largest race/ethnic group with HIV also are most affected in the South and Northeast US. Black and Latino men also face disproportionate rates of unemployment, racism, incarceration and lack of education, which can be more pressing issues to contend with than HIV and healthcare. Despite these challenges, many Black men have supportive communities, are highly resilient and persevere. HIV prevention and care services can support Black men by partnering with educational and vocational services to bolster men’s efforts to survive and thrive amid their adversities.[8] Incarceration and post-incarceration services. Programs for heterosexual men should address the impact of incarceration on men, their partners, family and community. Sex with men, sexual assault and injection drug use are risks while incarcerated. People living with HIV (PLWH) may face treatment interruption both in prison and jail, and upon release—which can increase their viral loads and infectivity. Programs can provide education and risk reduction for men affected by incarceration,[9] as well as support finding employment, healthcare and housing upon release.[3]

Quality healthcare

Talking about health. Many men don’t feel comfortable talking about their sexual health and behaviors with their doctors, and doctors typically don’t ask these questions. Cultural male stereotypes and seeing the bulk of health services and promotions focused on women, hamper men’s willingness to seek out health care services, including HIV testing.[10] Healthcare providers need to take a proactive role engaging men, and provide a non-judgmental, safe environment where men can feel free and safe to talk about their sexual health. HIV testing. Providers and clinics need greater awareness that heterosexual men can be at risk for HIV, and should offer all men HIV testing, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP). Half of heterosexual men living with HIV were diagnosed 5 years or more after they were infected, later than any other population. Providers should talk to men of every age about HIV and HIV risk reduction, and let them know that HIV testing is a part of routine healthcare.[11] HIV treatment and PrEP. PLWH who are on antiretroviral treatment and have undetectable viral loads do not transmit the virus to their partners.[5] PrEP, a medication for people who do not have HIV, can be used by men and women to protect themselves from HIV safely. These medical breakthroughs can help heterosexual men avoid HIV transmission, safely have children, reduce stress and worry, and increase trust and sexual pleasure in relationships.

Resources and programs

There has been resistance in the HIV community to track, fund, research and provide HIV services for heterosexual men, perhaps due to the focus on the mode of transmission and reluctance to acknowledge men’s own heterosexual identity.[3] For example, for the past five years there have been more new HIV cases from heterosexual transmission than from injecting drug use transmission among men,[1] yet programs and services for PWID far outnumber those for straight men. Programs for heterosexual men should collaborate with mainstream organizations, as straight men are less likely to use HIV-specific services. Programs should reach out to places where straight men go, such as the grocery store, gym, barbershops, sporting events, clubs, churches, colleges, vocational services. Heterosexual men prefer to hear messages from other straight men in community locations.[12] Programs, providers and researchers can do a better job of supporting Black men’s strengths and stop highlighting weaknesses. Increasing HIV testing, education, care and treatment, including PrEP for heterosexual men, can help address HIV. Increasing quality education, job and housing opportunities, as well as providing safe spaces for Black men that foster social support can also address HIV.[7]

Making a difference

It is time to recognize and fully address HIV among heterosexual men. Organizations, health departments and clinics should consider the needs of heterosexual men when planning their budgets, and include men in program planning, service delivery, research and policymaking. Straight men can help fight stigma and invisibility by speaking up, disclosing their status, working in HIV organizations and taking their place at the table to advocate for funding and programs. "Until we all come together, HIV is not going to end." -Rev. Francis

Says who?

1. Centers for Disease Control and Prevention. HIV Surveillance Report, 2016. November 2017; vol. 28. 2. Carrillo H, Hoffman A. From MSM to heteroflexibilities: Non-exclusive straight male identities and their implications for HIV prevention and health promotion. Global Public Health. 2016;11:923-36. 3. Bowleg L, Raj A. Shared communities, structural contexts, and HIV risk: prioritizing the HIV risk and prevention needs of Black heterosexual men. American Journal of Public Health. 2012;102:S173-S177. 4. Kou N, Djiometio JN, Agha A, et al. Examining the health and health service utilization of heterosexual men with HIV: a community-informed scoping review. AIDS Care. 2017;29:552-558. 5. Halkitis PM, Pomeranz JL. It’s time to repeal HIV criminalization laws. Huffington Post. August 1, 2017. 6. Wilson PA,  Wittlin NM, Muñoz-Laboy M, et al. Ideologies of Black churches in New York City and the public health crisis of HIV among Black men who have sex with men. Global Public Health. 2011;6: S227–S242. 7. Abrahams C, Jones D, Viera A, et al. The forgotten population in HIV prevention: Heterosexual Black/African American men: Key findings and strategies. Harm Reduction Coalition position paper. December 2009. 8. Teti M, Martin AE, Ranade R, et al. “I’m a keep rising. I’m a keep going forward, regardless”: Exploring Black men’s resilience amid sociostructural challenges and stressors. Qualitative Health Research. 2012; 22:524–533. 9. Valera P, Chang Y, Lian Z. HIV risk inside US prisons: A systematic review of risk reduction interventions conducted in US prisons. AIDS Care, 2017;29:943-952. 10. Marcell AV, Morgan AR, Sanders R. The socioecology of sexual and reproductive health care use among young urban minority males. Journal of Adolescent Health. 2017;60:402-410. 11. CDC. HIV testing. CDC National HIV Surveillance System, 2015. 12. Murray A, Toledo L, Brown EE, et al. “We as Black men have to encourage each other:» Facilitators and barriers associated with HIV testing among Black/African American men in rural Florida. Journal of Health Care for the Poor and Underserved. 2017;28:487-498.

Special thanks to the following reviewers of this Fact Sheet: Tony Antoniou, Lisa Bowleg, Derek Canas, Hector Carrillo, Todd Genre, Barbara Green Ajufo, Davina Jones, Steve Kogan, Steven Lamm, Daryl Mangosing, Arik Marcell, Ashley Murray, Bob Siedle-Khan, Michelle Teti, Pamela Valera, Bill Woods 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. ©2018, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. This publication is a product of a Prevention Research Center and was supported by Cooperative Agreement Number 5U48DP004998 from the Centers for Disease Control and Prevention.