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How can HIV prevention be integrated into health care settings?

Prepared by Carol Dawson-Rose RN PhD, Janet Myers PhD MPH, and Karen McCready MA; CAPS Fact Sheet 68, July 2010

Why is HIV prevention important in health care settings?

HIV prevention is an important part of health care for all individuals. It is particularly key for those at risk of becoming infected, as well as for those who are already infected, who can then avoid transmitting HIV to others and stay healthy themselves. Many strategies can be used in health care settings to optimize HIV prevention, including: assessing HIV risk; enhancing access to HIV testing; providing HIV-infected patients with disclosure and partner services; screening and treating patients for problem drinking, drug use and sexually transmitted infections (STIs); and providing the best possible care to HIV-infected individuals including access to anti-retroviral therapy (ARVs) and adherence counseling.

Do health care settings have a role in finding new infections?

Health care settings are important sites for providing access to HIV testing and prevention messages, for finding new infections and for linking infected individuals into HIV care. In 2006, the CDC issued guidelines for primary health care providers suggesting expanded access to HIV testing for all patients 13 to 64 years old.¹ Providing HIV testing as a routine part of care has been most productive in emergency room and labor and delivery settings,^2,3 although community health centers have also provided important new access.⁴ Testing programs have also proven effective in helping pregnant women to not transmit HIV to their babies.³ One key strategy for expanding testing is rapid test technology.⁵ Rapid tests allow providers to perform a test and deliver the results in under an hour, although a confirmatory test is required for positive rapid test results. Appropriate follow-up care can be planned before the patient leaves the health care facility. Especially when HIV testing is newly introduced, providers in health care settings need to learn how to integrate HIV testing into regular care, and to refer patients for additional support services if needed. Providers should also be trained in documenting test results to ensure they are shared with other health care providers and to maintain the confidentiality of client information. Providers must ensure that HIV-infected persons get the care and support they need. Linkage to care is an important and often overlooked piece of integrating HIV testing into health care. Individuals who are just finding out they are infected often need a great deal of help and support to find an HIV provider, to make an appointment and to show up at that appointment. Intensive case management models show promise in enhancing linkages to care for newly-diagnosed individuals.⁶

What other HIV prevention strategies work in health care settings?

Risk assessment. Assessing HIV risk behaviors should be a standard part of new patient intake, regardless of HIV status. In-depth HIV prevention education is not necessary for every patient. However, health care providers should ask all patients about their sexual behavior, condom use, number of sexual partners, and alcohol and illicit drug use to assess a patient’s risk for acquiring or transmitting HIV. These quick questions may lead to longer discussions and counseling about safer sex or alcohol and drug use practices.⁷ Drug treatment. Helping patients get into alcohol or drug treatment can be an effective HIV prevention tool and can help HIV-infected persons stay healthy. Health care providers can have a profound effect on patients’ lives by showing an interest in drug-using patients and encouraging willing patients to enter drug or alcohol treatment programs. Because relapse is common in treating addictions, health care providers should use a non-judgmental approach. Screening and treating for STIs. Providers should encourage screening for STIs. They should also provide STI education, emphasize the link between HIV and STIs, and encourage screening for partners.⁹

How does positive prevention work in health care settings?

Prevention counseling. Brief prevention counseling delivered in health care settings at every visit has been shown to decrease the likelihood that HIV-infected individuals transmit HIV to others, particularly if interventions are tailored to sub-populations of HIV-infected patients.¹⁰ Important messages include: helping people understand the relative risks of their actions and the effectiveness of different prevention strategies such as using condoms; disclosing HIV status to sex and drug using partners; and understanding their responsibility with regard to prevention. Formal provider training is important to facilitate these approaches.^11,12 Viral suppression. A unique component that health care settings play in HIV prevention is helping HIV-infected persons find and adhere to an effective ARV regimen to help keep their viral load low. Some research has demonstrated that keeping the viral load below a threshold that is detectable with lab tests can help prevent up to 60% of new STIs.¹³ New research suggests that effective detection of HIV and treatment to reduce the viral load could reduce the overall community viral load and have a population-level impact on HIV transmission.¹⁴

How can HIV prevention capacity be increased in health care settings?

Risk assessment. Knowing how to assess risk among patients is key to HIV prevention of any kind. Having risk assessment tools and training providers to use them is critical. Written protocols. It is important to make sure that procedures are in place to guide testing efforts in health care settings.¹⁵ Having a “prevention plan” tailored to the clinic size, the service delivery model, the types of providers and the patient population is critical. Leadership. Successful clinic programs often have identified staff leaders who function as counselors or team leaders for positive prevention.¹⁶ Training. Underlying all of these important components is training. Training can facilitate buy-in from clinic providers and can address provider attitudes and beliefs about risk reduction and counseling.¹⁷ Training should outline staff responsibilities and anticipate changes to clinic flow.¹⁶

What are effective models for use in health care settings?

Positive STEPs¹⁷ is a training intervention to help HIV care providers deliver prevention counseling to their patients. The model was effective in improving provider attitudes, comfort, self-efficacy and frequency of delivering prevention counseling. Partnership for Health¹⁸ is an EBI (CDC’s Effective Behavioral Intervention) for providers in HIV clinics. Medical providers are trained to deliver brief risk-reduction counseling to their patients. All clinic staff are trained to integrate prevention messages into the clinic setting, and counseling is supplemented with written information for all patients. The intervention was effective in reducing unprotected intercourse by 38% among patients who had two or more sexual partners. Positive Choice¹⁹ is an interactive “Video Doctor.” Patients at HIV clinics completed an in-depth computerized risk assessment and received tailored risk-reduction counseling from a “Video Doctor” via laptop computer and a printed educational worksheet. Providers received a Cueing Sheet on reported risks for discussion during the clinical encounter. Provider-Delivered Counseling.^10,16 In a large federal demonstration project, brief counseling messages delivered by primary care providers in clinic settings were most effective in reducing risk among HIV-infected patients, although there were also benefits in programs delivered by prevention specialists and HIV-infected peers.

What needs to be done?

Health care providers need more and repeated training on how HIV prevention can be integrated into the care they deliver. There are still significant misperceptions among health care providers about who should be tested for HIV and when to implement rapid testing. Provider attitudes, beliefs and self-efficacy can affect whether or not they address prevention through HIV testing or by providing risk-reduction counseling. Methods that enhance provider uptake of HIV prevention in health care delivery settings need attention and further research. Leaders in health care settings can establish written protocols that guide HIV prevention practices, including HIV testing in their clinics. Establishing protocols, documentation and quality assurance practices can enhance testing and prevention practices in all types of health care settings.

Says who?

1. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings.Morbidity and Mortality Weekly Report. 2006;55:1-17. 2. Haukoos JS, Hopkins E, Byyny RL, et al. Patient acceptance of rapid HIV testing practices in an urban emergency department: assessment of the 2006 CDC recommendations for HIV screening in health care settings. Annals of Emergency Medicine. 2008;51:303-309. 3. Tepper NK, Farr SL, Danner SP, et al. Rapid human immunodeficiency virus testing in obstetric outpatient settings: the MIRIAD study. American Journal of Obstetrics and Gynecology. 2009;201:31-36. 4. Myers JJ, Modica C, Bernstein C, Kang M, McNamara K. Routine rapid HIV screening in six Community Health Centers serving populations at risk. Journal of General Internal Medicine. 2009;24:1269–1274. 5. Branson BM. State of the art for diagnosis of HIV infection. Clinical Infectious Diseases. 2007;15:S221-225. 6. Christopoulos K, Koester K, Weiser S, et al. A comparative evaluation of the development and implementation of three emergency department HIV testing programs (forthcoming) 7. Schechtel J, Coates T, Mayer K, et al. HIV risk assessment: physician and patient communication. Journal of General Internal Med. 1997;12:722-723. 8. Bruce RD. Methadone as HIV prevention: High volume methadone sites to decrease HIV incidence rates in resource limited settings. International Journal of Drug Policy. 2010;21:122-124. 9. McClelland RS, Baeten JM. Reducing HIV-1 transmission through prevention strategies targeting HIV-1-seropositive individuals. Journal of Antimicrobial Chemotherapy. 2006;57:163-166. 10. Myers JJ, Shade S, Dawson Rose C, et al. Interventions delivered in clinical settings are effective in reducing risk of HIV transmission among people living with HIV. AIDS and Behavior. 2010;14:483-492. 11. Gilliam PP, Straub DM. Prevention with positives: A review of published research, 1998-2008. Journal of the Association of Nurses in AIDS Care. 2009;20:92-109. 12. Harder & Co. Community Research. Prevention with positives: Best practices Guide. Prevention with Positives Workgroup. 2009. 13. Porco TC, Martin JN, Page-Shafer KA, et al. Decline in HIV infectivity following the introduction of highly active antiretroviral therapy. AIDS. 2004;18:81-88. 14. 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. 15. Myers JJ, Steward, WT, Koester KA, et al. Written procedures enhance delivery of HIV “prevention with positives” counseling in primary health care settings. Journal of AIDS. 2004;37:S95-S100. 16. Koester KA, Maiorana A, Vernon K, et al. Implementation of HIV prevention interventions with people living with HIV/AIDS in clinical settings: Challenges and lessons learned. AIDS and Behavior. 2007;1:S17-S29. 17. Thrun M, Cook PF, Bradley-Springer LA, et al. Improved prevention counseling by HIV care providers in a multisite, clinic-based intervention: Positive STEPs. AIDS Education and Prevention. 2009;21:55-66. 18. Richardson J, Milam J, McCutchan A, et al. Effect of brief safer-sex counseling by medical providers to HIV-1 seropositive patients: A multi-clinic assessment. AIDS. 2004;18:1179-1186. 19. Gilbert P, Ciccarone D, Gansky SA, et al. Interactive “Video Doctor” counseling reduces drug and sexual risk behaviors among HIV+ patients in diverse outpatient settings. PLoS One. 2008;3.

Special thanks to the following reviewers of this Fact Sheet: Lucy Bradley-Springer, Kimberly Carbaugh, Mark Cichocki, Renata Dennis, Josh Ferrer, Mark Molnar, Quentin O’Brien, Jim Sacco. 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.” ©July 2010, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected].

What is the role of structural interventions in HIV prevention?

What are structural interventions?

Most HIV prevention interventions deal with individuals, one by one. Many of these interventions have been very successful. However, they often require a lot of staff time and reach a limited number of persons. Furthermore, those who do receive interventions may face pressures to continue high-risk behaviors from their peers who do not receive the intervention. Structural interventions change or influence social, political, or economic environments in ways that help many people all at onceperhaps without their even knowing it.¹ The term “structural interventions” means many things. Structural interventions include programs that change legal environments (often with community pressure or input) to make safer behavior easier, such as allowing syringes to be sold over the counter. They can also target the immediate social context of sexual or injection behaviors by changing the physical or normative environments within which they occur. Examples include Thai brothels that require condom use or European public health safer injection rooms. Structural interventions also include programs to reduce or abolish income inequality, racism, and other inequities and oppressions which create vulnerability to HIV/AIDS.

What structures create risk?

How can we know what social, political or economic structures or processes need changing? Generally, we learn this by studying naturally-occurring variation among areas or groups, or naturally-occurring experiments in which conditions change for reasons other than HIV-related interventions. Studies of naturally-occurring variation have shown that: 1) poor countries are more likely to have generalized HIV epidemics; 2) countries with more income inequality have higher HIV rates; 3) policies matter: localities where syringes can be bought legally have lower rates of HIV prevalence and incidence among injection drug users (IDUs).² Studies of natural experiments indicate that: 1) otherwise-positive social and political transitions like the end of apartheid in South Africa in the 1990s, the break-up of the Soviet Union in the 1990s, and the ending of the dictatorship in Indonesia in the late 1990s were followed by large HIV outbreaks; 2) wars cause the spread of HIV, STDs, prostitution, rape, sexual bondage and high-risk substance use and lead to increased numbers of sexual partners and rates of sexual partner change.³

Why structural interventions?

Structural interventions often address issues that seem to be unrelated to HIV. When people think about preventing HIV, they don’t normally consider eliminating income inequalities or stopping war. But these social, political and economic realities greatly influence high-risk behaviors. Issues that are not directly related to HIV often create conditions that encourage the spread of HIV, making structural interventions necessary. For example, the New York City government closed fire stations in poor minority sections of the city in the 1970s. As a result, uncontrolled fires destroyed many buildings. The social lives of building residents were severely traumatized. Great overcrowding took place in surrounding poor minority areas. Injection drug use (and later crack), alcoholism, sex trading, gangs and demoralization spread widelyfollowed later by outbreaks of STDs, HIV, tuberculosis and many other ills.⁴ The governments of wealthy countries, including the USA, as well as banks, corporations and other economic elites have aggressively pursued an organized global policy of social welfare cutbacks, privatization and competition. This has led many developing countries into massive debt, and increased income inequality and the growth of massive cities based around giant slums. Also, International Monetary Fund-imposed “structural adjustment programs” have forced large-scale cuts in health and education services in many African, Asian and Latin American countries. These policies and progams have greatly hampered these countries from providing effective prevention interventions and/or antiretroviral therapy or other medical care for their infected populations.^5,6

Examples of structural interventions

In many countries, sex workers have high rates of HIV and other STDs. Thailand and the Dominican Republic have instituted “100% condom” campaigns mandating that brothel owners enforce the use of condoms during all sex acts. These campaigns enlist the support of brothel owners and sex workers and, when possible, their customers. These programs have reduced HIV and STD transmission considerably by changing the immediate social context of sexual behaviors to reduce unprotected sex.^7,8 Most US states have laws that make it a crime to possess or distribute needles and many have laws that require a prescription to buy a needle and syringe. Consequently, IDUs often do not carry syringes for fear of police harassment or arrest. To address this on a legal level, the Connecticut legislature passed a partial repeal of needle prescription and drug paraphernalia laws. This resulted in dramatic reductions in needle sharing, and increases in pharmacy purchase of syringes by IDUs. Sharing dropped from 52% to 31% after the new laws, pharmacy purchase rose from 19% to 78%, and street purchase fell from 74% to 28%.⁹

How can we impact harmful policies?

It is not easy to avoid or end wars, urban development policies that hurt the poor and minorities and repressive sexual and drug policies that create underground environments. However, individuals and communities can make a difference. Grassroots or community-based movements are often a necessary step to larger structural interventions. The formation of such movements can sometimes be a structural intervention if this leads to changes in power relationships or group norms. “Chico Chats,” a program of the STOP AIDS Project in San Francisco, CA, offered workshops on community organizing and mobilization techniques. Participants formed an activist group called ¡Ya Basta! (Enough Already) and designed a video and workshop examining the issues of sexual silence and coming out in Latino families. The video is being shown throughout Latino communities in San Francisco.¹⁰ Community organizations and individuals began operating needle exchange programs (NEPs) in many states with high rates of HIV among IDUs. The NEPs were often illegal and unsupported. The people working at NEPs and other politically active groups worked with public officials to invoke “state of emergency” policies to allow NEPs to exist legally in many states.¹¹ Calcutta sex workers were aided by public health authorities to organize a community union that has enabled them to insist upon condom use. HIV prevalence among Calcutta sex workers has remained lower than in other Indian cities.¹²

What still needs to be done?

The relationship between structural factors such as economic, political and social marginalization and behaviors that place persons at risk for contracting or spreading HIV/AIDS and STDs cannot be ignored.^13,14 Nor can high-risk behaviors be seen as operating outside of social, political and economic contexts. A more focused discussion of these issues is sorely needed in HIV/AIDS circles. One way to reduce the likelihood of negative repurcussions when structural factors change, is to legally mandate that economic, urban development and foreign policy programs conduct scientific “HIV/AIDS impact statements.” A first step might be for HIV prevention agencies to produce and publicize such HIV/AIDS impact statements themselves.¹⁵ Funders need to take into account the broad range of activities that constitute HIV prevention. Many community-based organizations find themselves responding to all issues affecting HIV, including ones that may seem unrelated. Addressing these larger issues of war, poverty, restrictive laws and social inequalities such as racism and homophobia is a part of what many agencies do on a daily basis. Helping organize and support these efforts may lead to needed structural HIV prevention interventions.

Says who?

1. Friedman SR, O’Reilly K. Sociocultural interventions at the community level.AIDS. 1997; 11:S201-S208. 2. Friedman SR, Perlis T, Lynch J, et al. Economic inequality, poverty, and laws against syringe access as predictors of metropolitan area rates of drug injection and HIV infection. 2000 Global Research Network Meeting on HIV Prevention in Drug-Using Populations. Third Annual Meeting Report. Durban, South Africa, July 5 -7, 2000. 147-149. 3. Hankins CA, Friedman SR, Zafar T, et al. Transmission and prevention of HIV and STD in war settings: implications for current and future armed conflicts.AIDS. 2002:16(17):2245-52. 4. Wallace R. Urban desertification, public health and public order: ‘planned shrinkage’, violent death, substance abuse and AIDS in the Bronx. Social Science and Medicine. 1990;31:801-813. 5. Lurie P, Hintzen P, Lowe RA. Socioeconomic obstacles to HIV prevention and treatment in developing countries: the roles of the International Monetary Fund and the World Bank. AIDS. 1995;9:539-546. 6. Farmer P. Infections and Inequalities: the Modern Plagues. University ofCalifornia Press: Los Angeles. 1999. 7. Celentano DD, Nelson KE, Lyles CM, et al. Decreasing incidence of HIV and sexually transmitted diseases in young Thai men: evidence for success of the HIV/AIDS control and prevention program. AIDS. 1998;12:F29-F36. 8. Roca E, Ashburn K, Moreno L, et al. Assessing the impact of environmental-structural interventions. Presented at the International AIDS Conference,Barcelona, Spain. 2002. Abst #TuPeC4831. 9. Groseclose SL, Weinstein B, Jones TS, et al. Impact of increased legal access to needles and syringes on practices of injecting drug users and police officers–Connecticut, 1992-1993. Journal of Acquired Immune Deficiency Syndromes.1995;10:82-89. 10. The STOP AIDS Project. Q Action, ¡Ya Basta! San Francisco, CA. 415/865-0790 x303 11. Gostin LO. The legal environment impeding access to sterile syringes and needles: the conflict between law enforcement and public health. Journal of Acquired Immune Deficiency Syndromes. 1998;18:S60-70. 12. Piot P, Coll Seck AM. International response to the HIV/AIDS epidemic: planning for success. Bulletin of the World Health Organization. 2001;79:1106-1112. 13. Diaz RM, Ayala G, Marin BV. Latino gay men and HIV: risk behavior as a sign of oppression. Focus. 2000;15:1-5. 14. Friedman SR, Aral S. Social networks, risk potential networks, health and disease. Journal of Urban Health. 2001;78:411-418. 15. Friedman SR, Reid G. The need for dialectical models as shown in the response to the HIV/AIDS epidemic. International Journal of Sociology and Social Policy. (in press).

Prepared by Sam Friedman*, Kelly Knight** *National Development and Research Institutes, ** CAPS January 2003. Fact Sheet #46E Special thanks to the following reviewers of this Fact Sheet: Abu Abdul-Quader, Sevgi Aral, Judith Auerbach, Kim Blankenship, John Encandela, Mindy Fullilove, Carl Latkin, Peter Lurie.

Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © January 2003, University of California

¿Quienes son los hombres trans?

Transgenero (‘trans’) es un término sombrilla para aquellas personas las cuales la identidad de género y expresión no conforman las normas y expectaciones tradicionales asociadas al género asignado al nacer. Hombres transgenero, también conocidos como hombres trans, son personas a las que se les asigno ‘femenino’ a la hora de nacer y tienen una identidad de género y/o una expresión de genero masculina. Personas transgenero pueden auto identificarse y expresar su género en una variedad de formas y en muchas ocasiones prefieren ciertos términos y no otros. Algunos que transicionan de mujer a hombre no se identifican para nada como transgenero sino solamente como hombres, a un hombre trans se les debe de referir con pronombres masculinos. De cualquier manera, si uno no está seguro, lo mejor es de que con respeto se les debe preguntar en qué términos y que proverbios estar personas prefieren ser referidas. Información precisa sobre la diversidad de los cuerpos de los hombres trans no está al alcance ampliamente. Los hombres trans tienen diferentes tipos de cuerpos, dependiendo en el uso que hacen de testosteronas y cirugías usadas para la confirmación de su género (las cuales puede incluir la reconstrucción del pecho, histerectomía, metodioplastia, falloplastia,¹ etc.; visitar la página de internet en ingles: www.ftmguide.org para más información. Los hombres trans utilizan una amplia gama de términos y lenguajes para identificar su sexo y/o genero, describir sus partes corporales, y divulgar su estatus trans a otros. Por ejemplo, algunos hombres trans no se sienten cómodos con términos como “vagina” o “sexo vaginal” y suelen preferir llamarle “hoyo frontal” y “sexo frontal” o “sexo del hoyo frontal”, aunque esto no sea verdadero para todos los hombres trans. Esta diversidad crea necesidades únicas y barreras al negociar y adherirse a prácticas sexuales más seguras las cuales no son mencionadas en actuales programas de prevención del VIH.

¿Qué es lo que sabemos sobre el VIH y los hombres trans?

La comunidad transgenero es diversa y no se han llevado a cabo suficientes estudios con gente trans en general. En particular, tenemos información muy limitada sobre los hombres trans. Hasta la fecha, estudios relacionados con el VIH entra las personas trans han sido enfocadas casi exclusivamente en mujeres trans (personas las cuales se les asigno “masculino” al nacer y tiene una identidad de género femenina y/o una expresión de género femenina). De cualquier manera, existe evidencia que hay un subgrupo significante de hombres trans que llevan a cabo en sexo sin protección con otros hombres no-trans (trans MSM), incluyendo algunos hombres trans que están envueltos en el trabajo sexual. Varias ciudades han llevado a cabo estudios de necesidades que se enfocan en, o son inclusivas a los hombres trans y los riesgos de contrael el VIH, como Philadelphia, Washington D.C, San Francisco, y la provincia de Ontario. Los escasos estudios publicados que muestran casos entre los hombres trans reportadan un prevalencia del 0 – 3%.^2-4 Estas cifras son auto-reportadas, de cualquier forma, y están basadas en muestras pequeñas y no representativas, así que no tenemos información final sobre cifras actuales. Dado a que se asume número bajos de infección del VIH entre hombres trans este es relavito a otros grupos de alto riesgo, no han habido muchos estudios sobres actividades de riesgo entre los hombres trans. Nosotros si sabemos que los mensajes de prevención del VIH no están llegando a la mayoría de los hombres trans.⁵ También sabemos que trans MSM buscan servicios en organizaciones donde proveen servicios a hombres gay, donde hay poca o no hay educación para los hombres trans y sus parejas non-trans.⁴ Proveedores generalmente no están entrenados para identificar o dar servicios a los hombres trans gay o bisexuales en formas culturalmente sensitivas, ni entienden sus riesgos o necesidades de prevención especificas.

¿Qué es lo que no sabemos sobre el VIH y los hombres trans?

Nosotros no tenemos suficiente información sobre el VIH y los hombres trans. Métodos de colección de información en lugares donde se llevan a cabo estudios no identifican exactamente, no mantienen un control de los hombres trans ni capturan sus experiencias, lo cual contribuye a la falta de clarificación de las cifras de infección del HIV entre los hombres trans. Cifras del VIH y actividades sexuales de riesgo entre los hombres trans tampoco son muy entendidas puesto que continuamente se asume que las relaciones sexuales de los hombres trans son primariamente con mujeres non-trans. De cualquier manera, como cualquier otro hombre, los hombres trans pueden ser de cualquier orientación sexual y pueden tener sexo con diferentes tipos de parejas, incluyendo (pero no limitándose a) hombres non-trans, mujeres transgenero, y hombres transgenero.^6,7

¿Qué pone a riesgo a los hombres trans?

En un estudio, la mayoría de trans MSM reportaron consistentemente no usar condones durante el sexo anal receptivo y/o sexo frontal (vaginal) con otras parejas masculinas non-trans, y bajos el número de exámenes del VIH y baja percepción de riesgo.⁴ En áreas urbanas en donde la prevalencia de números del VIH entre non-trans MSM son estimadas de ser 17-40% y los números de Infecciones Transmitidas Sexualmente (ITS) están incrementando, trans MSM quienes practican sexo anal receptivo sin protección y/o copula (penetración) con non-tran MSM pueden ser especialmente vulnerable al VIH/ITS.^8,9 Los hombres trans pueden enfrontar complicados juegos de poderes y dinámicas de género en sus relaciones sexuales con otros hombres non-trans. Para un trans MSM, el tener sexo con una pareja hombre gay es una validación muy fuerte para identidad gay/queer, especialmente en los años iniciales de su transición, y puede esto ser más importante que el de insistir a usar un condón. Algunos hombres trans que usan testosteronas han reportado un incremento es su deseo sexual y un incremento en el interés sexual con hombres no trans después de comenzar el uso de hormonas, el cual puede contribuir al deseo de tomar riesgos seuxales.^4,10 Los hombres trans pueden enfrontar complicados juegos de poderes y dinámicas de género en sus relaciones sexuales con otros hombres non-trans.⁴ Para un trans MSM, el tener sexo con una pareja hombre gay es una validación muy fuerte para identidad gay/queer, especialmente en los años iniciales de su transición, y puede esto ser más importante que el de insistir a usar un condón. Algunos hombres trans que usan testosteronas han reportado un incremento es su deseo sexual y un incremento en el interés sexual con hombres no trans después de comenzar el uso de hormonas, el cual puede contribuir al deseo de tomar riesgos seuxales. ^4,10 Los hombres trans en testosterona y/o quienes hayan tenido una histerectomía pueden tener sequedad frontal (vaginal), lo cual incrementa sus riesgos de trauma frontal (vaginal) durante la penetración, y así incrementando sus riesgos de infección de las ITS, incluyendo el VIH¹⁰ Baja autoestima puede contribuir a practicar sexo de riesgo entre los hombres trans. Los números de depresión, uso de substancias, y atentos de suicidios son altos en esta población, pero existen múltiples barreras al tratar de obtener apoyo y tratamiento que sea culturalmente competente. ^3,11 El uso de drogas y alcohol es un gran factor de riesgo en cualquier comunidad, sin importar su identidad de género. Los hombres trans puede usar alcohol o drogas para realzar sus experiencias sexuales o para ayudar a aliviar o reducir ansiedades sobres sus cuerpos durante el sexo.⁴ Algunos hombres trans pueden sentir presión de usar drogas para poder pertenecer a algunas comunidades o subculturas de hombres gay. Aunque tenemos muy poca información sobre el compartir agujas para hormonas o uso de drogas entres los hombres trans, este también puede ser un factor de riesgo para algunos de ellos.

¿Qué puede ayudar?

Noviasgo en el Internet. Varios hombres trans conocen a sus parejas sexuales no-trans en el internet. Conocer parejas por medio de anuncios personales puede permitir los hombres trans describir sus cuerpos y genero inicialmente (si ellos deciden hacerlo) y así discutir sexo más seguro con posible parejas antes de encontrarse en persona.⁴ Materiales educacionales para parejas no-trans. Parejas hombres no-trans de los hombres trans frecuentemente no tienen experiencia con los hombres trans ni acceso a educación sexual con ellos, lo cual los lleva a tener una idea equivocada sobre sexo más seguro. Para hombres gay no-trans, sexo más seguro frecuentemente solo significa usar condón para el sexo anal y pueden no estar consientes del riesgo asociado con el sexo frontal (vaginal). Vea la próxima sección que contiene informacion en materiales disponibles. Gran visibilidad en la comunidad gay. Hombres gay y bisexuales necesitan ser educados sobre la presencia de los hombres trans en sus comunidades. Visibilidad incrementada y conocimiento sobre los hombres trans puede ayudar a crear un medioambiente de bienvenida, ayuda a incrementar inclusividad, y ayuda los hombres trans a sentirse con más poder es sus relaciones con otros hombres no-trans.⁷

¿Qué es lo que se está haciendo?

tm4m (tm4m.org) es un projecto basado en San Francisco para los hombres trans que juega con otros hombres (o que quiere jugar con ellos). Este provee información, educación, y apoyo a los hombres trans que tienen sexo con otros hombres por medio de talleres educacionales mensuales y grupos de discusión, materiales informativos y continuamente trabajan en adoptar aceptación y crear comunidad. tm4m es un esfuerzo colaborativo co-patrocinado por Eros, Trannywood Pictures y TRANS:THRIVE (un programa del Centro de Salud para Asiaticos y personas de las islas del pacifico). El Grupo de Trabajo de Hombres Trans Gay/Bi/Queer ha conducido un estudio de necesidades con trans MSM, creado recursos de salud sexual,¹² y la página electrónica www.queertransmen.org También proveen entrenamiento y consulta sobre la inclusión de trabajadores de prevención a través de la provincia. Los resultados serán usados para crear una intervención en el internet para prevenir la extensión del VIH y promover la salud sexual de personas transgeneros y sus parejas. El proyecto STOP AIDS de San Francisco, California se esfuerza en incluir los hombres trans en su programación y educación comunitaria. Estos incluyen transgenero hombres en la declaración de la misión de su agencia y han cambiado los métodos de colectar información que mejor reflejen cuerpos en transición e identidades de géneros en comunidades de hombres gay.

¿Qué queda por hacer?

Necesitamos implementar métodos de colección de información mas inclusiva para mejor captar subgrupos de personas transgenero. Proveedores de salud no deben asumir que todos los hombres que ellos ven han sido asignados ‘hombre’ al nacer. ¹³ Uno no puede decir que alguien es trans al solo mirarlo. El mejor método para colección de información es una pregunta de dos partes: 1) pregunta sobre identidad de género actual y 2) pregunta que sexo fue asignado al nacer. Si uno no está seguro, debería de preguntar los hombres trans por su nombre y pronombres preferidos y usar estos términos. Si los números del VIH entre los hombres trans están de hecho bajos, tenemos nosotros la oportunidad de envolvernos en un trabajo verdadero de prevención para mantener esos números bajos. Adquirir un mayor entendimiento de los comportamientos de riesgo de los hombres trans y las diferente formas en las cuales ellos mismos se protegen, ayudara a proveer educacion apropiada y efectiva de prevención del VIH para los hombres trans y sus parejas sexuales.

¿Quién lo dice?

1. Es importante notar que pocos hombres trans tienen penes completamente funcionales, debido primariamente a las bajas tasas del éxito de la cirujía, altos números de complicaciones y el alto costo de la cirujía. 2. Herbst J, Jacobs E, Finlayson T, et al. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: A systematic review. AIDS and Behavior. 2007. 3. Clements-Nolle K, Marx R, Guzman R, et al. HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: Implications for public health intervention. American Journal of Public Health. 2001;91:915-921. 4. Sevelius J. ‘‘There’s no pamphlet for the kind of sex I have’’: HIV-related risk factors and protective behaviors among transgender men who have sex with non-transgender men. Journal of the Association of Nurses in AIDS Care. 2009;20:398-410. 5. Hein D, Kirk M. Education and soul-searching: The Enterprise HIV prevention group. In: Bockting W, & Kirk, S., editor. Transgender and HIV: Risks, prevention, and care.Binghamton, NY: The Haworth Press; 2001. p. 101-117. 6. Schleifer D. Make me feel mighty real: Gay female-to-male transgenderists negotiating sex, gender, and sexuality. Sexualities 2006;9(1):57-75. 7. Bockting W, Benner A, Coleman E. Sexual identity development among gay and bisexual female-to-male transsexuals: Emergence of a transgender sexuality. Archives of Sexual Behavior. 2009;38(5). 8. Colfax G, Coates T, Husnik M, Huang Y, Buchbinder S, Koblin B, et al. Longitudinal patterns of methamphetamine, popper (amyl nitrite), and cocaine use and high-risk sexual behavior among a cohort of San Francisco men who have sex with men. Journal of Urban Health. 2005;82:i62-i70. 9. CA Department of Health Services. California HIV counseling and testing annual report: January - December 2003. Sacramento, CA: Office of AIDS; 2006. 10. Gorton N, Buth J, Spade D. Medical therapy and health maintenance for transgender men: A guide for health care providers: Lyon-Martin Women’s Health Services; 2005. 11. Newfield E, Hart S, Dibble S, Kohler L. Female-to-male transgender quality of life. Quality of Life Research 2006;15(9):1447-57. 12. Gay/Bi/Queer Transmen’s Working Group of the Ontario Gay Men’s HIV Prevention Strategy. Primed: The Back Pocket Guide for Transmen & The Men Who Dig Them. Toronto, Ontario; 2007. 13. Center of Excellence for Transgender HIV Prevention. Recommendations for inclusive data collection of trans people in HIV prevention, care, and services. University of California, San Francisco. 2009. www.transhealth.ucsf.edu

Una publicación del Centro de Estudios para la Prevención del SIDA (CAPS) y el Instituto de Investigaciones sobre SIDA (ARI), Universidad de California en San Francisco (UCSF). Se autoriza la reproducción (citando a UCSF) más no la venta de copias este documento. También disponibles en inglés - https://prevention.ucsf.edu/resources/factsheets-english-and-spanish. Para recibir las Hojas de Datos por correo electrónico escriba a [email protected] con el mensaje “subscribe CAPSFS nombre apellido” ©UCSF 2010    

What is the role of the Black church for Black gay men and HIV prevention?

Why the Black church?

Many Black men in the US grow up in families that are significantly involved with the Black church. As a long-standing institution developed for and by Black people, the Black church provides religious education and spiritual formation, and buffers against societal oppressions. The church has been a vital and trusted institution in the Black community, providing support, defining values, and building community.¹ Using the biblical themes of social justice and inherent dignity of all people, the Black church helped restore and promote the self esteem and self-worth of Black people who were victims of racial and other kinds of oppression. However, some Black gay men feel alienated from Black religious congregations. These men experience various homophobic and AIDS-phobic messages that increase their feelings of shame, diminish their religious identity, and are separated from important resources of the Black church.¹ The Black church is a part of many Black gay men’s lives, and, unfortunately, so is HIV. The HIV/AIDS epidemic has had a devastating effect on Black gay men in the US. Black gay and bisexual men are the most heavily impacted population in the Black community. Among all men who have sex with men (MSM), black MSM accounted for 10,600 (36%) estimated new HIV infections in 2010. From 2008 to 2010, new HIV infections increased 22% among young (aged 13-24) MSM and 12% among MSM overall—an increase largely due to a 20% increase among young black MSM.² At the end of 2010, of the estimated 872, 990 persons living with an HIV diagnosis, 440,408 (50%) were among MSM with 31% of those living with the disease being African American.² Black men who have sex with other men may self-identify as gay, same gender-loving, bisexual, straight, or may refuse to be categorized at all. For this Fact Sheet, we use the term “Black gay men” to refer to all Black men who have sex with men.

How has the church positively affected Black gay men?

Churches have traditionally occupied a special place in the African American experience.³ For many Black gay men, church is a part of their identity. Often, generations of families are involved in the church: their great grandparents helped build the church, their grandparents provided leadership, their parents work and volunteer at the church. For many, going to church was a requirement as children and they may have gone to Sunday school, sang in the choir or participated in other church activities. As adults, Black gay men are often involved in church leadership positions. Spirituality is a resource for HIV- and HIV+ Black gay men.⁴ Spirituality has been used to cope with life-threatening events, physical illness and emotional and psychological stresses. Belief in God is an important strength for many Black Americans. Religious participation also provides positive health benefits, increased life satisfaction, and is especially supportive in crisis moments.

How has the church negatively affected Black gay men?

Many religious traditions view homosexuality as a sin and have strictly defined visions of masculinity and femininity. Black gay men experience homophobia and AIDS phobia that is sanctioned by the Black church. These oppressions and messages experienced in church increase Black gay men’s internalized homophobia, which can increase risk taking and decrease access to support.⁵ Many Black gay men attend church knowing that homosexuality is considered a sin, and pastors may know or believe that they have gay men in their congregations. The common yet contradictory scene of gay men singing in the choir while homosexuality is denounced in the pulpit, creates an “open closet” at the center of church life.⁶ This contradiction in the church has a damaging effect on gay men’s personal and sexual lives.⁷ The Black church’s views on homosexuality also negatively affect the Black community at-large. These views and attitudes influence the entire congregation, increasing stigma against homosexuality in the community,⁶ and presenting potential problems for friends and family of gay men who are torn between their personal love for the men and their religious beliefs. These tensions play a role in reducing the amount of social support gay men receive from the community.

How can the church help in HIV prevention?

Within the context of the Black church, religion is an extraordinary opportunity to expose oppression and marginalization (homophobia and heterosexism) and create a framework for all people to be validated by virtue of their humanity, regardless of their sexual orientation. The Black church can also be a practical setting for health promotion interventions and can serve key roles in developing and/or delivering interventions.⁸Using the justice and liberation themes of religion, HIV prevention messages can be framed in validating and life-affirming ways to everyone, including Black gay men. Thus, religion can encourage Black gay men and couples to engage in sexual behaviors that promote their emotional, psychological, and sexual well being, maximizing HIV prevention efforts.

What can gay men do?

Most Black gay men do not regularly engage in HIV risk behaviors such as having unsafe sex, but may cycle in and out of risk at different times in their lives.⁹ Similar to many people, risk for Black gay men often occurs during periods of stress and life changes—death of a family member or friend, loss of employment, relationship breakdowns, or depression.¹⁰ In times of profound crisis, spirituality and support from the church can protect Black gay men from falling into risky behaviors. Despite negative views on homosexuality, Black gay men have forged many ways to deal with the condemnation of the Black church and move in and out of these different paths.¹ Some Black gay men reject their homosexual identity and pray to God to help change them. Some Black gay men co-exist with church doctrine. They may participate actively in the church and socialize with other gay members of the congregation, yet remain “in the closet,” never publicly identifying as gay within the church.¹¹ Some Black gay men reject their religious identity, unable to accept a religion that labels them as sinners. However, to walk away from the church is to walk away from family, and the absence of religious affiliations can be a void in their lives. Many may reject religious traditions but remain deeply spiritual. Some Black gay men are able to integrate their own identity with the teachings of the bible, developing a personal relationship with a higher power that may or may not include traditional religious institutions, but incorporate religious communion in more affirming and welcoming environments.¹² These gay men remain deeply spiritual, but seek to express their spirituality, including prayer, music and fellowship via other outlets, believing that God created them as worthy and capable of living healthy loving lives that include sexually fulfilling relationships.¹²

What can the Black church do?

HIV/AIDS has posed a significant challenge to Black churches and their congregations. Each church is different—some may be able to create change and address AIDS and homophobia and some may not be able or willing to.¹³ HIV prevention programs need to respect the philosophical differences between the church and public health and be open to negotiation. A number of programs and organizations exist to address HIV/AIDS within the Black Church. For example, the Balm in Gilead Inc. provides support for faith-based institutions to address HIV and other health challenges.¹⁴ The Ark of Refuge is a faith-based HIV prevention program that provides HIV/AIDS education and prevention services for African Americans.¹⁵ Project Bridge is a faith-based substance abuse and HIV/AIDS prevention program for African American adolescents.¹⁶ YOUR Blessed Health (YBH) is a program designed to increase the capacity of faith-based organizations and faith leaders to prevent HIV/AIDS among African American youth in their organizations.¹⁷ In response to the homophobia of many traditional Black churches, several inclusive churches have arisen across the country. For example, the Unity Fellowship Church was founded in 1982 for openly gay and lesbian African Americans.¹⁸ The Fellowship, a coalition of Christian churches and ministries, supports mostly Black churches and faith organizations to move towards radical inclusivity of all marginalized populations.¹⁸ The Metropolitan Community Church was founded in 1968 as a Christian church for LGBT persons of all races.¹⁹ A survey of Black churches in California that excluded the most conservative churches found a range of institutions with four patterns of acceptance for homosexuality and HIV prevention: non-condemning, accepting, open and affirming, and radically inclusive. Churches classified as gay friendly and radically inclusive tended to be racially diverse.¹²

What needs to be done?

The growing disparities in HIV/AIDS and other health problems, particularly among African American and other poor racial/ethnic groups, coupled with dwindling financial resources requires even greater attention to and help from religious and faith-based organizations.²⁰ While some Black churches may continue to struggle with interpreting scripture related to same sex behavior, others have found success utilizing community based participatory research (CBPR) approaches to fully involve church leaders in the development, implementation, and evaluation of HIV intervention strategies.²¹ Community-level interventions have strong effects on normative and structural influences on HIV-risk behavior and can work across broad segments of the MSM population. ²² Mobilizing Black churches against HIV/AIDS require active involvement of community members, putting them in control of the questions and issues investigated.²³ Due to the institution’s elevated social standing in the lives of many Black gay men, the Black church represents a logical, yet largely untapped venue for HIV intervention programming. HIV continues to ravage Black gay men—an already disenfranchised and highly stigmatized population. Given its mandate for love, justice and mercy, the Black church has a history of confronting injustice and oppression. Black church leadership and Black gay men must develop a strategy that values the lives of Black gay men. HIV+ and HIV- Black gay men are a vulnerable population who are entitled to compassionate and courageous support. HIV related anti-stigma efforts by church leaders, as well as the mobilization of community utilizing themes of compassion for prevention and outreach, may be effective ways for the church to use their teachings to engage with this population.

Says Who?

1. Miller RL Jr.  Legacy denied: African American gay men, AIDS, and the black church. Social Work. 2007;52:51-61. 2. HIV Among Gay and Bisexual Men Fact Sheet, Centers for Disease Control, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. March 2013 3. Francis SA, Liverpool J. A review of faith-based HIV prevention programs. J Relig Health. 2009;48(1):6–15. doi: 10.1007/s10943-008-9171-4. 4. Miller RL Jr. An appointment with God: AIDS, place, and spirituality. Journal of Sexuality Research. 2005;42:35-45. 5. Peterson JL, Jones KT. HIV prevention for Black men who have sex with men in the US. American Journal of Public health. 2009;99:976-980. 6. Fullilove MT, Fullilove RE. Stigma as an obstacle to AIDS action: The case of the African American community. American Behavioral Scientist. 1999;42:1117-1129. 7. Yakushko O. Influence of social support, existential well-being, and stress over sexual orientation on self-esteem of gay, lesbian and bisexual individuals. International Journal for the Advancement of Counseling. 2005;27:131-1143. 8. Kim, K., Linnan, L., Campbell, M., Brooks, C.,Koenig, H., & Wiesen, C. (2008). The WORD (Wholeness, Oneness, Righteousness, Deliverance): A faith-based weight-loss program utilizing a community-based participatory research approach. Health Education & Behavior, 35, 634-650. 9. Elam G, Macdonals N Hickson FCI, et al. Risky sexual behaviour in context: qualitative results from an investigation into risk factors for seroconversion among gay men who test for HIV. Sexually Transmitted Infections. 2008;84:473-477. 10. Grinstead O. Seroconversion narratives and insights for HIV prevention. FOCUS. 2006;21:1-4. 11. Pitt RN.”Still looking for my Jonathan”: gay Black men’s management of religious and sexual identity conflicts. Journal of Homosexuality. 2010;57:39-53. 12. Foster ML, Arnold E, Rebchook G, Kegeles SM. ‘It’s my inner strength’: spirituality, religion and HIV in the lives of young African American men who have sex with men. Cult Health Sex. 2011 Oct;13(9):1103-17. Epub 2011 Aug 9. 13. Francis SA, Liverpool J. A review of faith-based HIV prevention programs. Journal of Religious Health. 2009;48:6-15. 14. Balm in Gilead (http://www.balmingilead.org) 15. The Ark of Refuge (http://www.arkofrefuge.org) 16. Marcus MT, et al. Community-based participatory research to prevent substance abuse and HIV/AIDS in African-American adolescents. Journal of Interprofessional Care. 2004;18:347-59. 17. YOUR Blessed Health (YBH)  18. Unity Fellowship Church, The Fellowship, Metoropolitan Community Church 19. Metropolitan Community Churches (http://mccchurch.org) 20. Agatha N. Eke, Aisha L. Wilkes & Juarlyn Gaiter. Organized religion and the fight against HIV/AIDS in the Black community: the role of the Black church. African Americans and HIV/AIDS, 2010, pp 53-68. 21. Berkley-Patton J, Bowe-Thompson C, Bradley-Ewing A, Hawes S, Moore E, Williams E, Martinez D, Goggin, K. Taking it to the pews: A CBPR-guided HIV awareness and screening project with black churches. AIDS Education and Prevention. 2010;22(3):218–237. 22. Peterson JL, Jones KT. HIV prevention for Black men who have sex with men in the United States. Am J Public Health 2009;99(6):976–980. 23. Hill WA, McNeely C. HIV/AIDS disparity between African-American and Caucasian men who have sex with men: Intervention strategies for the Black church. Journal of Religion and Health 2011   Special thanks to the following reviewers of this Fact Sheet: Michael Foster, Shelley Francis, Susan Kegeles, Eddie Kornegay, Joan Liverpool, Maureen Miller, Richard Pitt Jr., Sylvia Rhue, Leo Wilton 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. ©2009, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected].

How do sexual networks affect HIV/STD prevention?

What are sexual networks?

Focusing on risk behavior alone does not explain why some persons and communities continue to be infected with HIV and other sexually transmitted diseases (STDs) more than others. Networks help explain why persons can have the same risk behavior and yet one may have a much greater risk of contracting or transmitting HIV. Sexual networks are groups of persons who are connected to one another sexually. The number of persons in a network, how central high-risk persons are within it, the percentage in monogamous relationships and the number of “links” each has to others all determine how quickly HIV/STDs can spread through a network.¹ Sexual networks are distinct from, but often overlap with social networks.

How do networks affect transmission?

The different ways persons select partners affect how quickly HIV/STDs can spread. Exclusively monogamous persons are, by definition, not part of a sexual network. If both are HIV-negative they remain so. Serial monogamists are persons who go from relationship to relationship one at a time. If they have unprotected sex, they have a higher risk of HIV/STDs than exclusively monogamous persons. Earlier partners’ risk may affect later partners. Concurrent relationships involve having more than one sexual partner in a given period and going back and forth between them. This increases the probability for transmission because earlier partners can be infected by later partners. Further, they can serve as “nodes”, connecting all persons in a dense cluster, creating highly connected networks that facilitate transmission. Concurrent partners can connect each of their respective clusters and networks as well. Concurrency alone can fuel an epidemic even if the average number of partners is relatively low. The two networks above show that what matters is not simply risk behavior, but risk configuration. Each has 8 persons (circles) connected into 9 relationships. Two persons each have 3 partners, and the other six each have 2 partners. Yet transmission will be less efficient in network A, and prevention will be more difficult in network B. In A, in just two steps from the index person, half the network can be infected and half spared; in B, two steps can result in everyone being infected except for the person on the extreme right. In A, sparing half the population from exposure requires cutting one bridge, while in B, it requires cutting three bridges. In a word, for epidemics, the network structure is destiny.³

What are key concepts of networks?

Number of partners. Programs can focus on persons with the largest number of ties to others in a network. With HIV/STDs, this suggests that in addition to promoting condom usage, programs seek to identify those with a high number of unprotected partners. Random spread broadens transmission. An infection spreads quickest when partnering is random.⁴ When partners select one another within groups such as age, ethnicity, class, religion or other characteristics, diseases may not spread to all subgroups. When partnering is anonymous or random, a disease can spread more quickly through all groups. Core groups. Core group members have high levels of risky behaviors. They contribute a disproportionate share of HIV/STDs, and can fuel sustained transmission. Centrality. How central an HIV+ person is to a network deeply influences transmission rates in a community. In Colorado Springs, CO, network analysts found that HIV+ persons had high levels of risk behavior but were located in peripheral areas of risk networks.⁵ This network configuration may have explained the relatively low HIV transmission levels. In contrast, HIV+ persons in New York City, NY occupied central positions within their needle-sharing and sexual risk networks, which helped explain the high observed levels of infection.⁶

Can sexual networks help explain racial differences in HIV/STD rates?

Yes. Sexual networks and partner selection help explain racial differences in HIV/STD infection rates. For example, African American gay and bisexual men may take no more risk than white men, but appear to get infected much faster.⁷ In the same way, Asian American gay and bisexual men report similar risk levels but get infected at lower rates.⁸ In one national study, it was shown that heterosexual African-Americans were getting infected with bacterial STDs at rates almost five times faster than whites after controlling for individual level risk factors. Sexually transmitted infections remain in African American populations because their partner choices are more segregated than other groups. In addition, non-core African-Americans (with few partners) are more likely to choose “core” sexual partners. ⁹

What interventions influence networks?

Partner notification. Many public health departments have developed highly confidential and sound techniques of partner notification and, through network analysis, have learned to trace “up” the chain of transmission to the transmitter rather than “down” the chain to those infected.¹⁰ This allows transmitters to be identified for treatment and HIV/STD prevention counseling. Message development. In addition to promoting condom use and counseling, media messages can be tailored to encourage network fragmentation by encouraging serial monogamy (“one partner at a time”) rather than overlapping partners. Community dialogue. Community-based organizations (CBOs) can play a key role in facilitating community dialogue about difficult questions about networks: How should communities balance sexual freedoms of all–including those at highest risk–with the health and future of their entire community? What community and cultural norms contribute to risky sexual networking? Additionally, CBOs should distinguish between traditionally-defined “risk groups” and those individuals with the very highest levels of risk to focus resources on them. Addressing venues which facilitate partner mixing. In many settings, identification of partners may be impossible. However, by focusing on venues which facilitate sexual mixing between members of both high- and low-risk networks, HIV/STD prevention workers may be able to reduce transmission. For example, many men with syphilis report meeting partners over the internet and in commercial sex venues.^11,12 Working with bathhouse and sex club managers and internet service providers to negotiate respective roles in promoting safer behaviors should be a priority for HIV/STD intervention workers. In San Francisco, CA, AIDS educators and sex club owners developed a shared set of guidelines to reduce risky behavior in the clubs.¹³ In the Netherlands, the gay dating internet site www.dateguide.nl provides interactive safer sex education for every man as he logs on.¹⁴

What still needs to be done?

At the beginning of the epidemic, network analysis helped explain some of the most important features of AIDS and helped explain its causes.15 It can still be useful now for agencies, communities, and researchers to work together to encourage sexual networks that discourage HIV/STD transmission. It has long been known and understood that some individuals contribute much more to the spread of HIV/STDs than others. Ignoring that fact, and ignoring the role of sexual networks in fueling the epidemic, hampers our ability to slow HIV/STD transmission.

Says who?

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. Prepared by Prepared by Dan Wohlfeiler*, John Potterat *UCSF April 2003. Fact Sheet #50E Special thanks to the following reviewers of this Fact Sheet: Buzz Bense, Peggy Dolcini, Paul Etkind, Sam Friedman, Azra Ghani, Jed Herman, Ed Laumann, Virginia Loo, Robin Miller, Michael Samuel, Tom Valente, Russell Westacott.

Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © April 2003, University of California