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¿Cuáles son las necesidades de los indígenas norteamericanos y nativos de Alaska (IN/NA) para la prevención del VIH?

¿están en riesgo de contraer el VIH?

Sí. Los indígenas norteamericanos y nativos de Alaska (IN/NA) son una población única dentro de los EEUU, no sólo por la opresión que han sufrido durante el desarrollo de este país, sino también por su lucha continua por ser tomados en cuenta en el combate contra la epidemia del VIH/SIDA. Sin embargo, los IN/NA no son tan únicos que sean invulnerables a las mismas conductas que ponen a todas las personas en peligro de contraer el VIH. La larga historia de opresión de los IN/NA en los Estados Unidos ha tenido efectos devastadores sobre la salud y el bienestar de los pueblos indígenas. Esta historia, que incluye la colonización, la prohibición de los idiomas indígenas y de sus prácticas religiosas, y siglos de reubicación forzada, ha generado una desconfianza justificada de los programas e instituciones médicas del gobierno estadounidense.¹ Este legado sigue formando la experiencia de los IN/NA, que están excesivamente afectados por la pobreza, problemas de salud, violencia familiar y abuso de drogas y alcohol. Todos estos factores están asociados con el riesgo de VIH.² Al final del año 2000, los IN/NA representaban 2,337 casos de SIDA y 871 casos de VIH. Los IN/NA constituyen el 1% de la población total de EEUU y un poco menos del 1% de los casos reportados de SIDA y VIH³. Aunque estas cifras parecen reducidas en relación con otros grupos, el efecto es considerable. El bajo número de casos reportados y la falta de vigilancia detallada del VIH entre los IN/NA podría estar causando un conteo muy incompleto de las infecciones por VIH. Por otra parte, muchas veces los datos sobre la raza o grupo étnico de los IN/NA se anotan incorrectamente por las suposiciones que se hacen en base a su nombre, color de la piel y lugar de residencia, y hasta por el uso intencionado de datos engañosos por parte de la persona IN/NA.⁴ Un estudio de datos sobre las ETS en Oklahoma encontró que el 35% de los casos de clamidia y más del 60% de los casos de gonorrea entre los IN/NA se habían reportado incorrectamente como casos hispanos o angloamericanos.⁵

¿cuáles son los riesgos para los IN/NA?

La investigación sobre el VIH entre los IN/NA tiene una historia corta que empezó al principio de la década de los ’90 con unos cuantos estudios sobre comportamientos arriesgados. Según los CDC, las categorías más comunes de transmisión del VIH entre los hombres IN/NA son: hombres que tienen sexo con otros hombres (HSH) 51%, HSH usuarios de drogas inyectables (UDI) 13% y UDI heterosexuales 12%. Entre las mujeres, el mayor riesgo es el contacto heterosexual (41%), seguido del UDI (32%).³ Sin embargo, estos datos no incluyen información de California, que tiene la población indígena más grande de todos los 50 estados de EEUU.⁶ Los pueblos IN/NA están desmesuradamente afectados por factores sociales, conductuales y económicos que están asociados con el riesgo de VIH. Los IN/NA sufren más pobreza y desempleo: el 32% de ellos viven por debajo de la línea de pobreza, en comparación con el 13% de la población general de EEUU.⁷ Los indígenas norteamericanos también tienen tasas altas de uso de drogas y alcohol, ETS y violencia.⁸ Debido a su consumo de alcohol, los IN/NA tienen las tasas más altas de mortalidad relacionada con el alcohol entre todas las poblaciones de EEUU.⁹ Un estudio de usuarios de drogas NA encontró que el consumo de alcohol fue el factor que más aumentó su riesgo de contraer el VIH. Muchos individuos reportaron que habían perdido el conocimiento cuando tomaron alcohol y se enteraron más tarde que habían tenido sexo sin protección con personas completamente desconocidas o con quienes de otra manera no hubieran aceptado como pareja sexual.¹⁰ El mismo estudio demostró que las mujeres nativas de Alaska tienen un riesgo alto de infectarse por gonorrea y por VIH. Las mujeres NA estaban más propensas a inyectarse drogas que las mujeres de cualquier otro grupo étnico y sus parejas sexuales tendían ser UDI angloamericanos. Las parejas sexuales compuestas por una mujer NA y un hombre angloamericano usaron condones con menos frecuencia que otras parejas compuestas por una combinación de grupos étnicos.¹¹ En los estados con poblaciones de IN/NA superiores a 20,000, las tasas de gonorrea y sífilis son dos veces mayores que entre otros grupos étnicos.⁷ Las personas con ETS son más propensas tanto a transmitir el VIH como a infectarse si se exponen al virus. Un estudio entre adolescentes indígenas en más de 200 escuelas en reservaciones a lo largo de EEUU reveló que los jóvenes practicaban varias conductas arriesgadas: el uso de alcohol, tabaco y otras drogas; actividades sexuales sin protección suficiente; y comportamientos suicidas. En la mayoría de los casos, el uso de drogas se asociaba con otros comportamientos peligrosos.¹²

¿cuáles son los obstáculos?

Con frecuencia el VIH se vuelve invisible dentro de las comunidades IN/NA que afrontan muchos otros problemas graves y más visibles, tales como el alcoholismo, la diabetes y el desempleo. Por lo tanto, muchas veces se niega tajantemente que el VIH sea un problema. Al igual que en muchas otras comunidades muy unidas, puede ser difícil mantener la confidencialidad en las comunidades IN/NA, especialmente en zonas rurales. Esto puede dificultar algunas actividades importantes de prevención, como el llegar a hacerse la prueba del VIH, hablar con profesionales médicos sobre prácticas sexuales, obtener tratamiento para dejar las drogas, o comprar condones en tiendas locales. Los HSH IN/NA tienen una amplia gama de identidades, desde “gay” hasta “doble espíritu” y pueden no responder a servicios diseñados para hombres homosexuales urbanos.¹³ Los HSH IN/NA pueden sentirse aislados y evitar buscar los servicios que necesitan a causa del estigma y la negación que existen en torno a la homosexualidad en algunas comunidades IN/NA. Los IN/NA consideran que ellos pertenecen a naciones indígenas soberanas, cada una con su propio gobierno. Las relaciones entre estos gobiernos tribales y los gobiernos estatales y federal son muy complejas. Muchos gobiernos estatales y locales se equivocan al suponer que el Servicio de Salud Indígena (IHS, siglas en inglés) es la única institución responsable de las necesidades médicas de los IN/NA. Menos del 1% del presupuesto del IHS se dedica a comunidades urbanas, pero más de la mitad de todos los IN/NA en EEUU viven en zonas urbanas. Como consecuencia, muchas veces se les niega a las tribus y organizaciones IN/NA las mismas oportunidades para recibir fondos que otros ciudadanos tienen.

¿qué es lo que se está haciendo?

Para responder al aumento de casos de ETS y VIH entre los adolescentes de una tribu rural de Arizona, educadores en salud tribales colaboraron con representantes de las escuelas y del departamento de salud pública para establecer varios programas. Entre ellos se incluyen clínicas, pláticas presentadas por indígenas norteamericanos VIH positivos, dramas sobre el VIH producidos por y para jóvenes, reuniones comunitarias, y anuncios de radio y en la prensa. Los casos de ETS y VIH en esta tribu alcanzaron el máximo en 1990 y en los seis años siguientes se redujeron gradualmente hasta conseguir una reducción total del 69%.¹⁴ El Grupo de Trabajo de Pueblos Indígenas (Indigenous People’s Task Force o IPTF) de Minneapolis, MN, promueve la salud y la educación para personas indígenas. Su programa de educación de pares y teatro llamado Gikinooamaagad (Guerreros/Maestros) brinda a los jóvenes instrucción integral sobre la prevención del VIH/SIDA, el teatro y enseñanzas tradicionales. Los programas del IPTF han sido reconocidos por el Cirujano General de EEUU.¹⁵ El Centro de Recursos de Salud para Indígenas Norteamericanos de Tulsa, OK, ofrece un grupo social para hombres indígenas “doble-espíritu.” El grupo les ayuda a formar un sentimiento de comunidad, aumentar su autoconfianza y reducir sus conductas arriesgadas. El programa también presenta un taller para mejorar las relaciones de pareja que ayuda a los participantes a determinar lo que quieren de sus relaciones, a reconocer y manejar las situaciones que promueven comportamientos riesgosos, y a aumentar sus habilidades de negociación.¹⁶

¿qué queda por hacer?

Si bien las comunidades IN/NA son diferentes entre sí, éstas comparten un sentido de orgullo, autodeterminación, espiritualidad y adaptabilidad que les ha ayudado a luchar contra la infección por VIH. Dichos empeños deben empujarse para asegurar que se mantenga la prevención del VIH. Esto no puede suceder sin la cooperación y colaboración de las diversas agencias que trabajan con los IN/NA, tales como los sistemas tribales de servicios de salud, los departamentos de salud gubernamentales y las organizaciones no lucrativas. Por ejemplo, para permitir que las comunidades IN/NA tengan más acceso a los recursos de prevención, es preciso simplificar el complicado sistema de canalización de fondos. El VIH debe hacerse visible en las comunidades IN/NA para evitar su propagación. La visibilidad se puede aumentar obteniendo datos confiables sobre el VIH, incluyendo a los IN/NA en el diseño y realización de programas de prevención del VIH, respondiendo al estigma con respecto a la homosexualidad y al uso de drogas, y formando conexiones con programas de prevención de ETS, violencia, embarazos no deseados, y abuso de alcohol y drogas.

¿quién lo dice?

1. National Institutes of Health. Women of color health data book: adolescents to seniors. 1999. NIH publication #99-4247.www4.od.nih.gov/orwh/WOCEnglish.pdf (accessed January 2002). 2. Vernon I. Killing Us Quietly: Native Americans and HIV/AIDS. University of Nebraska Press, 2001. 3. Centers for Disease Control and Prevention. U.S. HIV and AIDS cases reported through December 2001, Year-end edition. HIV/AIDS Surveillance Report. 2001;13 (2). (accessed April 2006). 4. Rowell RM, Bouey PD. Update on HIV/AIDS among American Indians and Alaska Natives. The IHS Primary Care Provider. 1997;22:49-53. (accessed April 2006). 5. Thoroughman DA, Frederickson D, Cameron HD, et al. Racial Misclassification of American Indians in Oklahoma state surveillance data for sexually transmitted diseases. American Journal of Epidemiology. 2002;155(12): 1137-41. 6. Smith AS, Ahmed B, Sink L. US Census Bureau. An Analysis of State and County Population Changes by Characteristics: 1990-1999. Working Paper Series No. 45. (accessed April 2006). 7. Centers for Disease Control and Prevention. HIV/AIDS among American Indians and Alaskan Natives – United States, 1981-1997. Morbidity and Mortality Weekly Report. 1998;47:154-160. (accessed April 2006). 8. Morrison-Beedy D, Carey MP, Lewis BP, et al. HIV risk behavior and psychological correlates among Native American women: an exploratory investigation. Journal of Women’s Health and Gender-Based Medicine. 2001:10;487-494. 9. Indian Health Service. Trends in Indian Health–1997. U.S. Department of Health and Human Services, Public Health Service, Indian Health Service, Office of Planning, Education, and Legislation, Division of Program Statistics. 1998. 10. Baldwin JA, Maxwell CJ, Fenaughty AM, et al. Alcohol as a risk factor for HIV transmission among American Indian and Alaska Native drug users. American Indian and Alaska Native Mental Health Research. 2000;9:1-16. 11. Fisher DG, Fenaughty AM, Paschane DM, et al. Alaska Native drug users and sexually transmitted disease: results of a five-year study. American Indian Alaska Native Mental Health Research. 2000;9:47-57. 12. Potthoff SJ, Bearinger LH, Skay CL, et al. Dimensions of risk behaviors among American Indian youth. Archives of Pediatric and Adolescent Medicine. 1998;152:157-163. 13. National Native American AIDS Prevention Center. HIV Prevention for gay/bisexual/two-spirit Native American men. 1996. https://www.nnaapc.net/ (accessed April 2006). 14. Yost D, Hamstra S, Roosevelt L. HIV/AIDS and STD prevention in a rural Arizona Indian tribe. Presented at the International Conference on AIDS, Geneva, Switzerland. 1998. Abst #43162. 15. Indigenous People’s Task Force, 1433 East Franklin Ave. Suite 18A, Minneapolis, MN 55404. Contact Sharon Day 612/870-1723.www.indigenouspeoplestf.org (accessed January 2002). 16. Indian Healthcare Resource Center of Tulsa, 550 South Peoria, Tulsa, OK 74120. Contact Tommy Chesbro 918/382-1275 https://www.ihcrc.org/(accessed January 2002).

Preparado por Ron Rowell MPH*, Paul Bouey PhD MPH** *San Francisco Foundation, **Pangaea Global AIDS Foundation Tradución Rocky Schnaath Abril 2002. Hoja Informativa 43S

How does childhood sexual abuse affect HIV prevention?

What is childhood sexual abuse?

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

Does CSA affect HIV risk?

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

What’s being done?

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

What needs to be done?

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

Says who?

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

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

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

How does HIV prevention work on different levels?

what are levels?

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

individual level

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

couple/family level

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

community level

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

medical level

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

policy/legal level

HIV infection is closely linked to and often fueled by structural factors such as poverty, discrimination and lack of power for women. The Center for Young Women’s Development is a peer-run organization in San Francisco, CA that promotes self-sufficiency, community safety and youth advocacy among young women aged 14-18 who are involved in the juvenile justice, foster care systems and/or have lived on the streets. The Center provides employment, leadership and training for young women to educate others in their community. Equipped with the knowledge and opportunity to train others, young women are more likely to incorporate these skills into their own lives.¹² Political and legislative factors can also hamper HIV prevention. For example, there is currently a ban on federal funding for needle exchange programs in the US. Connecticut addressed the problem of access to clean needles through a program that cost the state nothing and was highly effective. A partial repeal of needle prescription and drug paraphernalia laws resulted in dramatic reductions in needle sharing, and increases in pharmacy purchase of syringes by IDUs. Needle sharing dropped from 52% before the new laws to 31% after implementation, street purchase fell from 74% to 28%, and pharmacy purchase rose from 19% to 78%.¹³

what have we learned?

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

Says who?

1. Kelly JA, Kalichman SC. Behavioral research in HIV/AIDS primary and secondary prevention: recent advances and future directions. Journal of Consulting and Clinical Psychology. 2002;70:629-639. 2. Vlahov D, Des Jarlais DC, Goosby E, et al. Needle exchange programs for the prevention of human immunodeficiency virus infection: epidemiology and policy. American Journal of Epidemiology. 2001;154:S70-77. 3. Valdiserri RO, Ogden LL, McCray E. Accomplishments in HIV prevention science: implications for stemming the epidemic. Nature Medicine. 2003;9:881-886. 4. Chesney MA, Koblin BA, Barresi PJ, et al. An individually tailored intervention for HIV prevention: Baseline data from EXPLORE study. American Journal of Public Health. 2003;93:933-938. 5. Kamb ML, Fishbein M, Douglas JM Jr, et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. Project RESPECT Study Group. Journal of the American Medical Association. 1998;280:1161-1167. 6. Mills R, Samuels KD, Bob-Semple N, et al. Breakin’ the cycle: multigenerational dysfunction in families affected with HIV/AIDS. Presented at the 14th International AIDS Conference, Barcelona, Spain. 2002. Abst #ThPeE7828. 7. El-Bassel N, Witte SS. Gilbert L, et al. The efficacy of a relationship-based HIV/STD prevention program for heterosexual couples. American Journal of Public Health. 2003;93:963-969. 8. Hays RB, Rebchook GM, Kegeles SM. The Mpowerment Project: community-building with young gay and bisexual men to prevent HIV1. American Journal of Community Psychology. 2003;31:301-312. 9. Sikkema KJ, Hoffmann RG, Brondino MJ, et al. Outcomes of a community-level intervention among adolescents in inner-city housing developments. Presented at the International Conference on AIDS, Barcelona, Spain. July 2002. Abst# WeOrD1276. 10. Fuchs J, Colfax G. A shot or a pill: exploring biomedical approaches to HIV prevention. Focus. 2004;19:1-4. 11. Schneir A, Kipke MD, Melchior LA, et al. Children’s Hospital Los Angeles: a model of integrated care for HIV-positive and very high risk youth. Journal of Adolescent Health. 1998;23(2Suppl):59-70. Computerized referral system:www.caars.net 12. Center for Young Women’s Development. www.cywd.org 13. Groseclose SL, Weinstein B, Jones TS, et al. Impact of increased legal access to needles and syringes on practices of injecting-drug users and police officers-Connecticut, 1992-1993. Journal of Acquired Immune Deficiency Syndromes. 1995;10:82-89.

Prepared by The Center for AIDS Prevention Studies, University of California, San Francisco July 2004. Fact Sheet #1ER Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © July 2004, University of California

What are rural HIV prevention needs?

are rural populations at risk?

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

what are rural challenges?

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

what puts rural populations at risk?

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

what’s being done?

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

what needs to be done?

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

Says who?

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

Prepared by Anne Bowen PhD*, Alan Gambrell MPubAff**, Pamela DeCarlo*** *University of Wyoming, **WordPortfolio, Inc., ***CAPS May 2006 . Fact Sheet #26ER Special thanks to the following reviewers of this Fact Sheet: James Anderson, Janet Arno, Keith Bletzer, Lucy Bradley-Springer, Angeline Bushy, Irene Hall, Rachel Kachur, Bronwen Lichtenstein, Deborah Preston, David Seal, Dale Stratford, Craig Thompson, Mohammad Torabi, Eric Wright. Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © May 2006, University of California

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

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

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

Is female-to-female transmission possible?

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

What are barriers to prevention?

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

What’s being done?

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

What still needs to be done?

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

Says who?

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

Prepared by Pamela DeCarlo and Cynthia Gómez, PhD January 1997. Fact Sheet #24E Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National AIDS Clearinghouse at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © January 1997, University of California