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Healthy Oakland Teens Description and Explanation of Study Instrument

What Are Heterosexual Men’s HIV Prevention Needs?

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

Heterosexual men are affected by HIV

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

Fighting stigma

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

Holistic approach

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

Quality healthcare

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

Resources and programs

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

Making a difference

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

Says who?

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

Special thanks to the following reviewers of this Fact Sheet: Tony Antoniou, Lisa Bowleg, Derek Canas, Hector Carrillo, Todd Genre, Barbara Green Ajufo, Davina Jones, Steve Kogan, Steven Lamm, Daryl Mangosing, Arik Marcell, Ashley Murray, Bob Siedle-Khan, Michelle Teti, Pamela Valera, Bill Woods Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. ©2018, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. This publication is a product of a Prevention Research Center and was supported by Cooperative Agreement Number 5U48DP004998 from the Centers for Disease Control and Prevention.

¿Qué debe hacerse para prevenir el VIH en los hombres negros?

Elaborado por Bob Haas y Barbara Green-Ajufo, DrPH, MPH

¿Quiénes son los hombres negros?

En los Estados Unidos, los hombres negros son descendientes de las diversas etnias de la diáspora africana. Son amigos y familiares: padres, abuelos, esposos, novios, hermanos, tíos, hijos, sobrinos y primos. Son colegas, profesionales y obreros. Tienen diferentes orientaciones sexuales, profesan diversas creencias religiosas y hablan diferentes idiomas, entre otras particularidades demográficas.

¿Es un riesgo el VIH para los hombres negros?

El VIH representa una crisis de salud para los hombres negros, sin importar su edad o su orientación sexual. En el 2015, el 33% de las infecciones por el VIH en los Estados Unidos fueron en hombres negros. El VIH se diagnostica en hombres negros ochos veces más que en hombres blancos y dos veces más que en hombres hispanos que no son negros. El riesgo de infección por el VIH en hombres negros es alto relativo a la población masculina en general. De cada 20 hombres negros, uno será diagnosticado con VIH. De no revertirse las tendencias actuales, esta prevalencia continuará. [2-4] Las estadísticas a continuación muestran la probabilidad en hombres negros de ser diagnosticados con VIH durante su vida.

• Hombres que tienen sexo con hombres (HSH): hombres negros (1/2); población masculina en general (1/6)
• Personas que se inyectan drogas: hombres negros (1/9); población masculina en general (1/36)
• Hombres heterosexuales: hombres negros (1/86); población masculina en general: 1/473

Entre los HSH, incluidos homosexuales y bisexuales, los hombres negros que tienen sexo con hombres (HNSH) tienen la mayor probabilidad de ser diagnosticados con el VIH (39% en 2015). [5] Los HNSH jóvenes corren un riesgo aún más alto. De todos los HNSH que fueron diagnosticados con el VIH en 2015, un 75% tenía menos de 34 años—con proporciones iguales para jóvenes de 13 a 24 años (37.7%) y jóvenes de 25 a 34 años (37.3%). [6]

Varias investigaciones han demostrado que los HNSH no suelen practicar más actos sexuales riesgosos (sexo anal sin condón o tener varias parejas) que los hombres de otros grupos raciales o étnicos. Sin embargo, tienen mayor probabilidad de ser diagnosticados con el VIH, sin importar la edad. [7-10] Según un estudio, el VIH es nueve veces más común entre los jóvenes negros que tienen sexo con hombres que entre los jóvenes blancos que tienen prácticas sexuales semejantes. [7]

La demanda y conciencia sobre la Profilaxis Pre-Exposición (PrEP)—un tratamiento biomédico eficaz—es menor entre HNSH que entre HSH blancos, por lo que se les receta menos. [11] De todas las recetas para PrEP en los Estados Unidos entre enero y septiembre de 2015, un 74% fue para blancos, un 12% para latinos y sólo un 10% para afro-americanos. [12]

¿Cuáles son los factores de riesgo del VIH para los hombres negros?

Muchos factores influyen en el riesgo para el VIH en los hombres negros.

Estigma y discriminación: Es menos probable que los hombres negros que han experimentado estigma o discriminación usen PrEP como medida preventiva [13] o revelen que viven con el VIH. [14] Además, los hombres que han experimentado traumas relacionados con la discriminación por ser gay, negro o por vivir con el VIH, suelen tener más sexo anal sin protección. [15]. Se ha demostrado que las altas tasas de infección por el VIH, las actitudes racistas de parte de los homosexuales no negros, las redes sociales y los ambientes en los que se relacionan los homosexuales estigmatizan y aislan a los HNSH de los demás HSH. [16]

Disparidades en el continuo del cuidado para el VIH: Por la discriminación histórica hacia la población negra por parte de los sistemas de salud, los hombres negros suelen acudir menos a los servicios médicos. [17] Por consiguiente, es más probable que los HNSH, comparados con HSH blancos, no conozcan su estado serológico, sean diagnosticados tardíamente y descuiden su cuidado y tratamiento médico. [18-19]

Pobreza: Por la discriminación y el reducido acceso y retención en educación de calidad, prevalece más el desempleo o el subempleo en hombres negros que en hombres blancos. [20] Por ello, las posibilidades de vivir en la pobreza son mayores para los hombres negros, lo que también tiende a reducir el acceso a servicios médicos de calidad. [20] Las tasas de VIH aumentan de 3 a 5.5 veces de acuerdo con el incremento de la pobreza de un barrio (menos de 10% en barrios con nivel de pobreza bajo y más de 30% en barrios con nivel de pobreza alto). [21-22] Para las personas negras que viven con VIH, la pobreza está asociada a una menor vinculación en el cuidado médico para el VIH. [23]

Trauma sexual: Las tasas de asalto y abuso sexual son altas en HSH y están vinculadas a un mayor riesgo de infección por el VIH. Un 39% de los HSH en el estudio EXPLORE reportaron haber sufrido abuso sexual durante su niñez; y era más probable que los participantes negros en ese estudio hubieran tenido una historia de asalto sexual que no la hubieran tenido. [24-25]

Enfermedades transmitidas sexualmente (ETS): La presencia de ETS incrementa la probabilidad de transmitir o de contraer el VIH. ETS y tasas altas del VIH en la población negra incrementan la probabilidad de transmisión del VIH. [27-29]

Redes sociales y sexo con hombres de su raza: Las altas tasas del VIH en HNSH y la preferencia por tener relaciones con hombres de su propia raza incrementan la probabilidad de tener una pareja sexual que vive con el VIH. El análisis de varios estudios mostró que al menos un 29% de los HNSH en redes sexuales viven con el VIH; dentro de estas redes, el 47% de los hombres que viven con el VIH desconocen que son portadores del virus. [30]    

¿Qué se está haciendo?

Los resultados de las investigaciones realizadas con hombres negros de diversas edades, orientaciones sexuales y estados serológicos que se detallan a continuación han demostrado reducir las prácticas sexuales de riesgo y han incrementado la participación en el cuidado médico. [31]

Intervenciones comparativas aleatorizadas: Dos estudios "Muchos hombres, muchas voces"(Many Men Many Voices) y "Hermano a hermano" (Brother to Brother) demuestran que existe una relación positiva ya sea entre la reducción del número de instancias de sexo anal sin protección con parejas casuales, el número de cualquier acto sexual anal insertivo sin protección, número de parejas sexuales masculinas, y/o una mayor probabilidad de hacerse la prueba del VIH.

Intervenciones de encuestas pre-post o repetidas: Los HNSH que participaron en las intervenciones "D-up! Connect with Pride", "BRUTHAS", "Motivational Interviewing (MI)" y "Special Projects of National Significance (SPNS)" reportaron mejores resultados que los hombres cuya participación en estas intervenciones fue limitada o nula. Dichos estudios mostraron ya sea una reducción de sexo anal sin protección en diferentes momentos durante la intervención, una reducción de las instancias de sexo anal sin protección con la pareja principal, una reducción en el número de parejas sexuales, más uso del condón con la pareja principal, menos número de encuentros con prácticas sexuales riesgosas con parejas femeninas y/o una reducción de tener sexo bajo la influencia de drogas.

Diferentes estudios también registran un incremento en el apoyo social y la autoestima y disminución de la soledad, así como una mayor probabilidad de hacerse la prueba y consejería para el VIH, regresar a buscar los resultados de la prueba del VIH, y menos citas médicas perdidas. Un estudio demostró que entre más tiempo dedicaban los participantes a las reuniones de manejo de caso, más tiempo dedicaban también al cuidado médico para el VIH.

Estudio mixto de pre-post y grupo de control: Los hombres jóvenes de color que participaron en la intervención denominada STYLE (Strength through youth livin' empowered) reportaron un 83% de retención en el cuidado médico; asimismo, su probabilidad de asistir a sus visitas médicas era mayor que para los que no participaron (2.58, 95% CI 1.34-4.98).

¿Qué falta por hacer?

La prevención del VIH en hombres negros no debe enfocarse solamente en las prácticas sexuales de alto riesgo sino también en los factores sociales y estructurales. Hacen falta políticas sanitarias que prevengan nuevas infecciones, que ayuden a entender las disparidades de transmisión del VIH que existen entre la población blanca y negra y que esclarezcan el papel de las intervenciones estructurales.[32-33] Necesitamos combinar intervenciones biomédicas con intervenciones de comportamiento; entender que las particularidades de los diferentes grupos requieren abordajes distintos; reducir la transmisión de ETS; tener en cuenta circunstancias traumáticas; reducir las barreras estructurales y de acceso; y considerar la intersección de las condiciones de salud y condiciones sociales.

Es también urgente tener en cuenta el estigma y las huellas invisibles que deja. Exposiciones de datos deben integrar el contexto, la perspectiva de la comunidad y explicaciones comprehensivas. Deben desarrollarse estrategias que ayuden a las parejas y a los familiares a escuchar cuando su ser querido revela que es homosexual o que vive con el VIH. También es necesario aplicar ampliamente intervenciones exitosas en aquellas áreas donde las tasas del VIH en los hombres negros son más altas.

¿Quién lo dice?

1. CDC. HIV among Afr. Americans. Feb 2017.

2. Gavett G. Timeline: 30 Yrs. of AIDS in Blk. Americans. KQED Frontline. Jul 10, 2012.

3. Hess K, et al. Est. lifetime risk of dx of HIV infect in the U.S. CROI 2016. Boston, abstract 52.

4. CDC. Lifetime risk of HIV dx. Feb 2016.

5. CDC. HIV in the U.S.: At A Glance. Dec 2, 2016.

6. CDC. HIV among Afr. Am. gay and bisexual men. Jul 2016.

7. Millett GA, et al. Greater Risk for HIV Infect of Blk MSM: Lit Rev. AJPH. Jun 2006;96(6):1007-19.

8. Millet GA, et al. Disparities in HIV Infect among Blk and Wht MSM: Meta-Analysis. AIDS. Oct 1 2007;21(15):2083-91.

9. Magnus M, et al. Elevated HIV Prev. Despite Lower Rates of Sexual Risk Behav among Blk MSM in DC. AIDS Patient Care STDS. Oct 2010;24(10): 615–22.

10. Maulsby C, et al. HIV among Blk MSM in the U.S.: Lit. Rev. AIDS and Behav Jan 2014;18(1):10-25.

11. Cohen SE, et al. Response to race and PH impact potential of PrEP in the U.S. J Acquir Immune Defic Syndr. Sep 1 2015;70(1):e33-e35.

12. Highleyman L. PrEP use rising in U.S. but large racial disparities remain. nam aidsmap. Jun 24, 2016.

13. Chaill S, et al. Stigma, med mistrust, and racism affect PrEP awareness and uptake in Blk compared to Wht MSM in Jackson, MS and Boston, MA. AIDS Care, 2017.

14. Overstreet NM, et al. Internalized stigma and HIV status disclosure among HIV-pos MSM. AIDS Care 2013;25 4, 466-471.

15. Fields EL, et al. Assoc. of Discrimination-Related Trauma with Sexual Risk among HIV-Pos Afr. Am. MSM. AJPH. May 2013;103(5):875-80.

16. Raymond HF, et al. Racial Mixing and HIV Risk among MSM. AIDS Behav Aug 2009;13(4):630-37.

17. Lisa Eaton, et al. Role of Stigma and Med Mistrust in Routine Hlth Care Engagement of MSM. AJPH. Feb 2015;105(2): e75–e82.

18. Levy ME, et al. Understand Structural Barriers to Accessing HIV Test & Prev Servs among Blk MSM in the U.S. AIDS Behav. 2014 May; 18(5): 972–996.

19. Christopoulos KA, et al. Link and Retention in HIV Care among MSM in the U.S. Clin Infect Dis. 2011 Jan 15; 52(Suppl 2): S214–S222.

20. Ethnic and Racial Minorities and SES. Factsheet. APA.

21. Alameda Co. CA eHARS data (2008-2012). Verbal communication with Nina Murgai, Dir, HIV/AIDS Surv Unit.

22. Wiewel EW, et al. Assoc bwt Neighborhood Poverty and HIV Dx among Males and Females in NYC, 2010-2011. PH Rep. Mar-Apr 2016;131(2):290-302.

23. Lechtenberg RJ, et al. Poverty, Race, Engagement: Diff Assoc with Retention in Care among PLWH in Alameda Co. UCSF CFAR HIV Hlth Disparities Symposium, Mar 24, 2017.

24. Mimiaga MM, et al. Child Sexual Abuse Assoc with HIV Risk–Taking Behav and Infect among MSM in the EXPLORE Study. J Acquir Immune Defic Syndr. 2009 Jul 1:51(3):340-348.

25. Millett GA, et al. Rev of HIV epidemics in Blk MSM across African diaspora. Lancet. Jul 28 – Aug 3;380(9839):411-23.

26. CDC. STDs and HIV – CDC Factsheet. Nov 17, 2015.

27. CDC. 2015 STDs Surveillance – STDs in Racial and Ethnic Minorities. Jan 23, 2017.

28. Scott HM, et al. Racial/ethnic and sexual behav disparities in rates of STIs, SF (1999-2008). BMC Pub Hlth. Jun 6, 2010;10:315.

29. Pathela P, et al. MSM have higher risk for newly dx HIV and syphilis compared with heterosexual men in NYC. J Acquir Immune Defic Syndr. Dec 1, 2011;58(4):408-16.

30. Hurt CB, et al. Invest Sexual Network of Blk MSM: Implications for Transmission and Prev of HIV Infect in U.S. J Acquir Immune Defic Syndr. Dec 1, 2012;61(4):515-21.

31. Maulsby C, et al. Rev of HIV Interv for Blk MSM. BMC Pub Hlth. 2013;13:625.

32. Peterson, JL, et al. Soc. discrimination and resiliency not assoc with differ in HIV infect in blk and wht MSM. JAIDS 2014:66;538-543.

33. Sullivan PS, et al. Understand racial HIV/STI disparities in blk and wht MSM. PLoS One 2014;9: e90514.

Gracias a Emily Arnold, Jesse Brooks, Lorenzo Hinojosa, Loren Jones, Micah Lubensky, Daryl Mangosing, Janet Myers, Nasheedah Bynes-Muhammad, Rob Newells, John Peterson, Greg Rebchook, Andrew Reynolds y Wilson Vincent por revisar esta hoja informativa. Agradecemos la reproducción y la difusión de esta hoja, siempre que sea de manera gratuita y que se cite a la University of California San Francisco.

©2017, University of CA. Preguntas y comentarios pueden enviarse a [email protected].

Esta publicación es un producto del Centro de Investigación sobre la Prevención con el apoyo de los Centros de Control y Prevención de Enfermedades (Cooperative Agreement Number 5U48DP004998).

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. 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. Men are significantly less likely than women to report CSA when it occurs. 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.

CAPS and Centerforce, a community-based organization that has been providing services to prisoners and their families for thirty years, have been collaborating since 1993 to design and evaluate HIV prevention interventions for incarcerated men and their female partners. Our previous work with male prisoners includes the evaluation of a peer-led HIV education orientation for arriving prisoners; development and evaluation of a prerelease intervention for men leaving prison; development and evaluation of a health promotion intervention for HIV+ prisoners preparing for release;3 and a multi-site study to conduct formative research and develop and test an HIV, STD and hepatitis intervention for young men preparing for release from prison. Early in the course of these studies, men expressed a need for HIV prevention interventions specifically tailored for the needs of the women with whom they were in romantic and sexual relationships. In response, we conducted formative research with women visiting men imprisoned in a California state prison and we piloted a single session intervention designed for this population that was taught by a peer educator. Our formative work with women visiting incarcerated men indicated that it was feasible to engage women in intervention and research evaluation activities. However, a single-session intervention did not have a measurable effect on the HIV risk behavior of study participants. We decided to develop a multi-component intervention targeting the specific needs of women with incarcerated male partners. We designed and evaluated Health Options Mean Empowerment (HOME), an intervention to reduce HIV risk among women whose male partner was being released from state prison.