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¿Puede una vacuna contra el VIH lograr cambios significativos?

¿por qué necesitamos una vacuna?

Las vacunas son una de las herramientas más poderosas y costo-efectivas que tenemos para evitar las enfermedades. Una vacuna que impidiera la infección por VIH o que detuviera la progresión de la enfermedad ayudaría considerablemente en la lucha contra la pandemia del SIDA. Una pregunta crucial es si una vacuna basada en una determinada cepa del VIH sería eficaz para poblaciones en las cuales predomina otra cepa. También existen dudas sobre cómo una vacuna contra el VIH protegería a los individuos: aunque no evitara la transmisión de la infección, tal vez la vacuna pudiera evitar o retrasar el desarrollo de la enfermedad, o simplemente reducir la infecciosidad de las personas que contraigan el VIH. La educación y consejería de prevención del VIH son componentes importantes de los programas de vacunación. Incluso después de la comercialización de una vacuna, todavía continuará la necesidad de programas eficaces de prevención conductual. La vacuna contra el VIH no será una panacea universal, pero podría jugar un papel poderoso como parte de un conjunto de intervenciones preventivas.

¿ha habido avances?

Veinte años después del inicio de la epidemia, los investigadores continúan sus esfuerzos para superar los desafíos científicos planteados por los estudios de vacunas contra el VIH: 1) los métodos convencionales de diseño de vacunas (es decir, el empleo de virus inactivados o atenuados) se consideran muy peligrosos con el VIH; 2) el virus es sumamente variable y de mutación rápida; 3) la infección viral es permanente, no existe ningún caso documentado de curación del VIH y por lo tanto, no queda claro cómo el cuerpo podría montar una respuesta inmunológica eficaz y 4) falta un modelo animal perfecto que se pueda utilizar en los estudios de vacunas contra el SIDA.¹ Todavía no existe una vacuna contra el VIH cuya eficacia haya sido comprobada. Se han realizado más de 70 pequeños ensayos clínicos en humanos de más de 35 diferentes vacunas experimentales contra el VIH, pero sólo un producto, AIDSVAX, fabricado por VaxGen, se ha estudiado en un ensayo de escala grande (de fase III). Lamentablemente, dos ensayos diferentes de AIDSVAX realizados 1) en Norteamérica, Puerto Rico y los Países Bajos² y 2) en Tailandia, encontraron que la vacuna no evitó la infección por VIH en la población general del estudio y tampoco retrasó la progresión de la enfermedad entre aquellos participantes que contrajeron el VIH durante el ensayo.³ Una vacuna exitosa contra el VIH enseñaría al sistema inmunológico a reconocer al VIH antes de que éste causara un daño extenso. Los conceptos de vacunas que se desarrollan actualmente utilizan varios métodos para entrenar al sistema inmunológico a reconocer partes del VIH sin exponer a las personas al VIH mismo. Los primeros estudios de vacunas contra el SIDA se centraron en la creación de vacunas biotecnológicas que representan una porción de las proteínas que se encuentran en la superficie externa (envoltura) del VIH. Actualmente se están desarrollando diferentes estrategias; ninguna de éstas emplea el virus mismo del VIH y ninguna puede causar que un participante adquiera el VIH por la vacuna misma.

¿cuál es el efecto sobre la prevención?

Una vacuna eficaz contra el VIH no sustituye los esfuerzos de prevención del VIH, de la misma manera que la prevención no puede reemplazar una vacuna. La mejor manera de combatir la pandemia del VIH es utilizar diversas intervenciones a varios niveles y el poder protector de una vacuna puede ser un beneficio en la prevención del VIH. Desde la introducción del tratamiento antirretroviral (por sus siglas en español TAR o en inglés ART – término que está sustituyendo al de “tratamiento o terapia antirretroviral sumamente activa o altamente activa” conocido en español como TARSA o TARAA y en inglés como HAART), han aumentado las prácticas de riesgo de los hombres que tienen sexo con hombres (HSH).⁴ Existe la preocupación de que similarmente, quienes reciban una vacuna contra el VIH aumenten sus conductas de riesgo por sentirse invulnerables a la infección. En el ensayo de eficacia de VaxGen realizado en Norteamérica, los participantes más jóvenes y los HSH que creían haber recibido la vacuna y no un placebo fueron más propensos a afirmar que habían tenido sexo anal sin protección durante el ensayo. Las prácticas de riesgo declaradas por los participantes no aumentaron durante el transcurso del ensayo. En el ensayo⁵ de eficacia de VaxGen en Tailandia, los usuarios de drogas inyectables reportaron reducciones en su consumo de drogas y en su uso de agujas compartidas durante los primeros 12 meses.⁶ Esto puede deberse a la educación y consejería sobre la prevención y la reducción de riesgos que recibieron.

¿cuáles son las cuestiones éticas?

Sólo es posible probar la seguridad y eficacia de las vacunas contra el VIH si miles de individuos están dispuestos a participar en ensayos clínicos, dichos ensayos plantean inquietudes sobre los posibles perjuicios para los participantes. Aunque los voluntarios no estén infectados, ciertas vacunas contra el VIH pueden arrojar un resultado VIH+ en las pruebas convencionales para detectar los anticuerpos del VIH. Un resultado positivo de la prueba del VIH puede conducir a la estigmatización social o discriminación en el seguro médico, en el empleo y en asuntos de inmigración. Simplemente por haber participado en el ensayo de una vacuna contra el VIH, el individuo podría ser considerado “de alto riesgo”, homosexual o usuario de drogas; la discriminación en contra de estos y otros grupos es una realidad patente en muchos lugares. A los investigadores les incumbe asegurar que los participantes de los ensayos de vacunas reciban la asistencia necesaria para aliviar los riesgos de discriminación u otros perjuicios que su participación pudiera conllevar.⁷ Se debe involucrar a las comunidades para que participen de cerca en el diseño de los ensayos clínicos y en su implementación. Los investigadores también necesitan comprobar que los participantes den un consentimiento con pleno conocimiento de causa antes de inscribirse en un ensayo de vacuna. La comunidad y los posibles voluntarios necesitan recibir información detallada sobre el proceso del ensayo y deberán entender conceptos tales como “placebo,” “asignación aleatoria” y “estudio ciego” para poder evaluar las ventajas y desventajas de la participación. La asignación de educadores comunitarios y de pares que ayuden con la orientación comunitaria que acompaña a la investigación de vacunas contra el VIH también ampliará los conocimientos de los participantes sobre los ensayos de vacunas así como su aceptación de éstos.⁸

¿cuáles son los obstáculos?

Gran parte de los conocimientos especializados sobre el diseño y la fabricación de las vacunas contra el VIH se concentran en las compañías farmacéuticas y biotecnológicas del sector privado. Sin embargo, el compromiso de estas industrias por las vacunas contra el VIH no ha igualado la enorme necesidad de la salud pública.^9,10 Una vacuna contra el VIH sólo logrará controlar la pandemia si se hace disponible ampliamente en los países en vías de desarrollo, donde ocurren más del 95% de las nuevas infecciones. La gente de países con escasos recursos ha tenido que esperar una década o más para recibir vacunas cuyo uso ya está aprobado en las naciones industrializadas.^11,12 Además del costo, existen numerosos obstáculos al acceso a las vacunas contra el VIH. Las infraestructuras marginales de algunos países en vías de desarrollo pueden impedir la distribución de una vacuna. Incluso los países que pueden costear las vacunas tal vez no les den alta prioridad ni asignen suficientes recursos para investigarlas o comprarlas. Los programas de vacunación generalmente se enfocan en los niños. En el caso del VIH, son los adultos y los adolescentes sexualmente activos quienes tendrán la necesidad más inmediata de una vacuna. Se requieren nuevas formas de abordar la inmunización. Puede haber poca aceptación de las vacunas en comunidades en las cuales existe desconfianza al gobierno o estigma por asociación con el VIH/SIDA.

¿qué queda por hacer?

En años recientes, el sector público ha incrementado los fondos para la investigación y el acceso a las vacunas contra el VIH, pero se necesitan más recursos. Se deberá motivar la inversión del sector por medio de incentivos como el financiamiento indirecto, el apoyo público en la infraestructura de la investigación clínica y la fabricación de productos, y fomentando las colaboraciones públicas y privadas.⁹ Los gobiernos de los países desarrollados o con recursos financieros podrían hacer un compromiso para comprar vacunas contra SIDA para la gente de países en desarrollo. Se requiere de un liderazgo político constante para priorizar los recursos para las vacunas. Los ensayos de vacunas realizados hasta la fecha han incluido educación sobre la prevención del VIH y consejería para reducir los riesgos. Dichos ensayos pueden beneficiar aun más a los participantes si ofrecieran servicios de tratamiento de drogas y pruebas de detección y tratamiento de las ETS. La combinación de los esfuerzos médicos, conductuales y psicológicos como parte de una iniciativa de vacunas puede ser una herramienta poderosa contra el VIH. Las vacunas son un componente integral de una estrategia eficaz de prevención de enfermedades; su producción se hace imprescindible para detener la propagación del VIH. No obstante, una vacuna no eliminará por sí sola las condiciones sociales y estructurales que generaron y continúan alimentando la epidemia. Aun cuando las vacunas contra el VIH estén disponibles, las comunidades todavía necesitarán intervenciones conductuales de alta calidad para controlar la epidemia del VIH, así como normas que permitan que todos tengan acceso a las vacunas. Preparado por Chris Collins, MPP AIDS Vaccine Adv. Coal.; Traducción R. Schnaath

¿quien lo dice?

1. National Institute of Allergy and Infectious Diseases. Challenges in designing AIDS vaccines. May 2003. www.niaid.nih.gov/factsheets/challvacc.htm 2. AIDS Vaccine Advocacy Coalition. Understanding the results of the AIDSVAX trial. May 2003. https://www.avac.org/sites/default/files/resource-files/understanding_a…; 3. VaxGen Announces Results of its Phase III HIV Vaccine Trial in Thailand: Vaccine Fails to Meet Endpoints. Press release from VaxGen. www.vaxgen.com/pressroom/ 4. Valdiserri RO. Preventing new HIV infections in the US: what can we hope to achieve? Presented at the 10th Conference on Retroviruses and Opportunistic Infections, Boston, MA. February 10-14, 2003. 5. Bartholow B. Risk behavior and HIV seroincidence in the US trial of AIDSVAX B/B. Presented at the AIDS Vaccine 2003 Conference, New York, NY. September 2003. 6. Vanichseni S, van Griensven F, Phasithiphol B, et al. Decline in HIV risk behavior among injection drug users in the AIDSVAX B/E vaccine trial in Bangkok, Thailand. Presented at the XIV International AIDS Conference, Barcelona, Spain. July 2002. 7. UNAIDS. Guidance Document on Ethical Considerations in HIV Preventive Vaccine Research. June 2002. 8. van Loon KV, Lindegger GC, Slack CM. Informed consent: A review of the experiences of South African clinical trial researchers. Presented at the XIV International AIDS Conference, Barcelona, Spain. July 2002. Abst #TuOrG1170. 9. AIDS Vaccine Advocacy Coalition. https://www.avac.org/avac-report 10. Klausner RD, Fauci AS, Corey L, et al. The need for a global HIV vaccine enterprise. Science. 2003;300:2036-2039. 11. Public health considerations for the use of a first generation HIV vaccine: Report from a WHO-UNAIDS-CDC Consultation, Geneva, 20-21 November 2002. AIDS. 2003;17:W1-W10. 12. International AIDS Vaccine Initiative. AIDS Vaccines for the New World: Preparing Now to Assure Access. July 2000. www.iavi.org Resources AIDS Vaccine Advocacy Coalition (AVAC) 101 West 23rd St. #2227 New York, NY 10011 212/367-1021 www.avac.org HIV InSite: Vaccine Overview http://hivinsite.ucsf.edu/InSite?page=kb-08-01-11 HIV Vaccine Trials Network http://www.hvtn.org International AIDS Vaccine Initiative (IAVI) 110 William Street New York, NY 10038-3901 212/847-1111 www.iavi.org  National Institute of Allergy and Infectious Diseases (NIAID) Division of AIDS Vaccines www.niaid.nih.gov/aidsvaccine NIAID Vaccine Research Center https://www.niaid.nih.gov/about/vrc

Febrero 2004. Fact Sheet #38SR Special thanks to the following reviewers of this Fact Sheet: Barbara Adler, Emily Bass, Mark Boaz, Susan Buchbinder, Jose Esparza, Jorge Flores, Paula Frew, Ingelise Gordon, Ashraf Grimwood, Margaret McCluskey, Catherine Slack, Robert Smith, Steven Tierney, Steven Wakefield, Doug Wassenaar, Sandra Wearins, Dan Wohlfeiler.

¿Cuáles son las necesidades de prevención de la gente VIH+?

revisado 9/05

¿necesitan prevenir las personas VIH+?

Sí. Más de 1 millón de personas en los Estados Unidos tienen el VIH o el SIDA.¹ Los avances en el diagnóstico oportuno, el tratamiento y la atención para individuos VIH+ ya permiten que muchos gocen de mejor salud y más años de vida. Algunos han renovado su interés por la actividad sexual o por el consumo de drogas, lo cual aumenta su riesgo de adquirir otras ITS y de trasmitir el VIH a sus parejas no infectadas.² Por ello, muchas personas VIH+ requieren programas que les ayuden a mantenerse protegidas. La mayoría de las personas VIH+ se preocupan por no infectar a otros y toman medidas para evitarlo.³ Sin embargo, para un porcentaje importante la prevención es una lucha: entre el 20-50% reportan haber tenido contacto sexual sin protección con sus parejas VIH- o con las de condición de VIH desconocida.4 Para muchas personas seropositivas, los mismos desafíos estructurales, interpersonales y conductuales que las pusieron en riesgo de contraer el VIH persisten después de ser HIV+ y dichos desafíos afectan su capacidad de prevenir la transmisión del VIH.⁴ La prevención para personas VIH+ puede incluir intervenciones educativas y de fomento de habilidades, esfuerzos para realizar pruebas a más personas que ignoran ser VIH+, apoyo y pruebas para las parejas de individuos VIH+ y la incorporación de la prevención en la atención médica de rutina.⁵

¿en qué difieren los programas?

Los programas de prevención del VIH para personas VIH+ difieren de los programas para personas VIH- en que deben responder a las necesidades clínicas, mentales y de apoyo social al tiempo que aumentan la capacidad del individuo para evitar la transmisión del VIH a sus parejas actuales y futuras. Estigma. El estigma hacia los hombres homosexuales, las mujeres, los consumidores de drogas, los trabajadores sexuales y las personas de minorías etnicas/raciales ha alimentado la epidemia del VIH en los Estados Unidos al crear condiciones sociales favorables para la transmisión del VIH.6 A esto se suma el estigma adicional de vivir con el VIH. Las víctimas del estigma (por haber revelado su orientación homosexual o consumo de drogas) pueden sufrir un trauma que les impide lidiar con la transmisión del VIH.⁷ Es importante tomar en cuenta estos factores estructurales con el fin de promover la fuerza y la capacidad de resistencia de las comunidades VIH+. Revelación. Una de las mayores preocupaciones de las personas VIH+ es cómo, cuándo y a quién revelar su condición de VIH.⁸ El mensaje tradicional ha sido que las personas VIH+ siempre deben revelar su condición de VIH a sus parejas. En la realidad, la revelación es un asunto difícil y complejo. Algunas personas VIH+ deciden no revelar su condición y no participar en conductas riesgosas. Muchas veces las personas VIH+ temen que la revelación provoque el rechazo de su pareja o de su familia, limite sus oportunidades sexuales o aumente el riesgo de violencia física y sexual. Una encuesta de personas VIH+ encontró que el 42% de los hombres homosexuales, el 19% de los heterosexuales y el 17% de las mujeres había tenido sexo sin revelar su condición de VIH⁹. Las personas VIH+ pueden revelar su condición de forma diferente a sus médicos, familiares, amigos, compañeros de trabajo, parejas sexuales y compañeros de inyección de drogas. Responsabilidad. Las personas con VIH viven con el hecho de haber sido infectadas (a veces por una persona de confianza a la que aman) y con la enorme responsabilidad de saber que pueden infectar a otros. Es una responsabilidad compleja, pero los programas de prevención deben ayudar a las personas VIH+ a explorarla y a comprender su significado a nivel personal.¹⁰

¿qué pueden hacer las personas VIH+?

Muchas personas VIH+ emplean estrategias que limitan la transmisión del VIH, por ejemplo, tener relaciones sólo con otras personas VIH+¹¹. Al saber que la pareja sexual también es VIH+ se evita el riesgo de transmisión y permite el contacto sexual sin uso de condón constante. Recientemente han surgido inquietudes sobre la súper infección entre parejas VIH+ (la posible transmisión de otra cepa del virus entre las personas VIH+), pero ésta parece suceder rara vez.¹² Otra estrategia es la de cambiar las actividades de alto riesgo por otras de menor riesgo. Por ejemplo, las personas VIH+ pueden evitar: ser la pareja insertiva durante el sexo anal y vaginal, el contacto sexual durante la menstruación, la lactancia materna y el uso compartido de jeringas. Algunas actividades menos riesgosas incluyen tener sexo oral y ser la pareja receptiva del pene.¹¹

¿qué puede hacer su organización o clínica?

Las personas VIH+ son un grupo diverso que requiere programas de prevención que se ajusten a sus necesidades específicas y tomen en cuenta a la persona en su totalidad sin limitarse a su conducta sexual o su consumo de drogas. Las relaciones personales, el empleo, la atención de salud, la vivienda, el estigma y la discriminación son temas que deben ser abarcados según la necesidad. Escuchar a las personas VIH+ e involucrarlas en el diseño, la provisión y la evaluación de programas asegurará que éstos sean relevantes y útiles.¹³ Los programas de prevención con las personas VIH+ pueden exigir cambios y ajustes institucionales en las organizaciones y clínicas que integren por primera vez los servicios de atención y de prevención. Las clínicas pueden capacitar a los profesionales de salud para proporcionar consejería sobre la prevención del VIH, enlazar con servicios sociales y preventivos así como remitir pacientes a otras organizaciones. Los programas de prevención pueden capacitar a su personal sobre tratamiento y cuidado del VIH, formar vínculos con clínicas y organizaciones para VIH+ de servicios, o remitir a sus pacientes a estos servicios. Es crítico que los profesionales médicos mantengan un tono sin juicios con respecto a las situaciones y conductas de los clientes VIH+.¹⁴ Es igualmente importante colaborar con las personas VIH+ para crear un plan de reducción de riesgos basado sus necesidades y capacidades.¹³ Los proveedores deben adoptar una actitud de apoyo y empatía enfocándose en el logro de metas, los puntos fuertes y las capacidades de resistencia del paciente. Los programas de prevención para gente positiva deben brindar los conocimientos, las capacidades y los recursos (como condones, jeringas esterilizadas y una estrategia para disminuir el consumo de alcohol y drogas) necesarios para poner en práctica un plan de reducción de riesgos.

¿qué se está haciendo al respecto?

En los EE.UU. existen varios programas preventivos para VIH+ que han probado eficacia.¹⁵ Healthy Relationships, intervención de reducción de riesgos de cinco sesiones grupales para hombres y mujeres. Fomenta el desarrollo de capacidades para la toma de decisiones y resolución de problemas. Los grupos permiten que las personas VIH+ interactúen, examinen los riesgos, desarrollen habilidades para limitar sus riesgos y reciban comentarios de otras personas. En un seguimiento realizado a los seis meses de haber iniciado el programa, los participantes reportaron una reducción importante en el coito sin protección y un mayor uso de condones.¹⁶ Choosing Life: Empowerment, Action, Results (CLEAR) ofrece a jóvenes VIH+ 18 sesiones individuales de 90 minutos con un consejero. CLEAR fomenta la motivación y aumenta la autoestima para aprender a preferir las actividades saludables sobre las autodestructivas. CLEAR tiene tres módulos: toma de decisiones sexuales, auto cuidado y consumo de alcohol y drogas. La participación también puede ser vía telefónica. Los jóvenes reportaron tener menos parejas sexuales, usar menos drogas y sentirse menos afligidos.¹⁷ A CLEAR se le conoce como Street Smart. Partnership for Health capacitó al personal de clínicas de VIH en ofrecer consejería breve sobre relaciones sexuales más protegidas, la cual fue complementada con materiales escritos y carteles en las clínicas. La consejería sobre las consecuencias negativas del sexo sin protección ayudó a reducir las conductas riesgosas de los pacientes con dos o más parejas.¹⁸

¿qué queda por hacer?

Los programas de prevención con personas VIH+ necesitan poner atención a los obstáculos estructurales que se interponen a la protección durante las relaciones sexuales y el consumo de drogas. Dichos obstáculos pueden incluir vivienda inestable, falta de acceso a la atención médica y encarcelamiento repetido. Es necesario examinar más a fondo cómo los traumas sufridos durante la infancia y la adultez, el abuso sexual, revelarse como homosexual, el racismo y la homofobia afectan la capacidad de una persona VIH+ para mantener conductas más seguras. Puesto que la conducta sexual de riesgo entre personas VIH+ frecuentemente es una decisión y un riesgo compartido con la pareja,¹⁹ se requiere más énfasis en el trabajo con parejas (homo o heterosexuales) tanto en programas de prevención como en la investigación. Los programas de prevención con personas VIH+ presentan la oportunidad y el reto de establecer relaciones e integrar servicios en áreas con las que tradicionalmente no se ha colaborado. Es clave involucrar a las personas VIH+ en el diseño de los programas. Los programas de tratamiento, de prevención y de servicios sociales deben trabajar conjuntamente para realmente ayudar a los pacientes a afrontar múltiples problemas. Preparado por Kelly Knight MEd and Carol Dawson-Rose RN PhD, CAPS

¿quién lo dice

1. Glynn M, Rhodes P. Estimated HIV prevalence in the United States at the end of 2003. Presented at the National HIV Prevention Conference, Atlanta, GA. 2005. Abst #595. 2. Janssen RS, Valdiserri RO. HIV prevention in the Unites States: increasing emphasis on working with those living with HIV. Journal of AIDS. 2004;37:S119-S121. 3. Marks G, Crepaz N, Senterfitt JW, et al. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States. Journal of AIDS. 2005;39:446-453. 4. Crepaz N, Marks G. Towards an understanding of sexual risk behavior in people living with HIV: a review of social, psychological and medical findings. AIDS. 2002;16:135-149. 5. Centers for Disease Control and Prevention. Advancing HIV prevention: new strategies for a changing epidemic – United States, 2003. Morbidity and Mortality Weekly Report. 2003;52:329-332. 6. Herek GM, Capitanio JP, Widaman KF. Stigma, social risk, and health policy: public attitudes toward HIV surveillance policies and the social construction of illness. Health Psychology. 2003;22:533-540. 7. Knight KR. With a little help from my friends: community affiliation and perceived social support. In HIV+ Sex. PN Halkitis, CA Gómez, RJ Wolitsky, eds. American Psychological Association; Washington DC. 2005. 8. Parsons JT, Missildine W, Van Ora J, et al. HIV serostatus disclosure to sexual partners among HIV-positive injection drug users. AIDS Patient Care and STDs. 2004;18:457-469. 9. Ciccarone DH, Kanouse DE, Collins RL, et al. Sex without disclosure of positive HIV serostatus in a US probability sample of persons receiving medical care for HIV infection. American Journal of Public Health. 2003;93:949-954. 10. Wolitski RJ, Bailey CJ, O’Leary A, et al. Self-perceived responsibility of HIV-seropositive men who have sex with men for preventing HIV transmission. AIDS and Behavior. 2003;7:363-372. 11. Parsons JT, Schrimshaw EW, Wolitski RJ, et al. Sexual harm reduction practices of HIV-seropositive gay and bisexual men: serosorting, strategic positioning, and withdrawal before ejaculation. AIDS. 2005;19:S13-S25. 12. Grant RM, McConnell JJ, Herring B, et al. No superinfection among seroconcordant couples after well-defined exposure. Presented at the International Conference on AIDS. 2004. Abst #ThPeA6949. 13. National Association of People with AIDS. Principles of HIV prevention with positives. www.napwa.org/pdf/PWPPrinciples.pdf (Accessed 4/20/06) 14. Dawson-Rose C, Shade SB, Lum P, et al. The healthcare experience of HIV positive injection drug users. Journal of Multicultural Nursing and Health. 2005;11:23-30. 15. https://www.cdc.gov/hiv/effective-interventions/index.html (Accessed 4/20/06) 16. Kalichman SC, Rompa D, Cage M, et al. Effectiveness of an intervention to reduce HIV transmission risks in HIV-positive people. American Journal of Preventive Medicine. 2001;21:84-92. 17. Rotheram-Borus MJ, Swendeman D, Comulada WS, et al. Prevention for substance-using HIV-Positive young people: telephone and in-person delivery. Journal of AIDS. 2004;37:S68-S77. 18. Richardson JL, 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. Remien RH, Wagner G, Dolezal C, et al. Factors associated with HIV sexual risk behavior in male couples of mixed HIV status. Journal of Psychology and Human Sexuality. 2001;13:31-48.

Septiembre 2005 . Hoja #37SR

Can Barrier Methods Help in HIV Prevention?

Why barrier methods?

Barrier methods are a relatively low-cost, accessible and important part of the pregnancy and sexually transmitted disease (STD) prevention landscape. Barrier methods can be physical or chemical substances which prevent pregnancy and/or block the spread of STDs including HIV. They do not include hormonal contraceptive methods. People have successfully used contraceptive physical barriers for centuries.¹ Since the beginning of the HIV epidemic, the latex male condom has been the exclusive prevention tool. After two decades, there is a call to create a greater selection of barrier methods to combat HIV. Because HIV rates continue to increase among women and among men who have sex with men (MSM)^2,3, it is time to strengthen both current condom use programs and develop other barrier methods that optimize usage and choice in prevention.

What methods are available?

Currently, the male and female condoms are used for the prevention of HIV, STDs and unintended pregnancy.^4,5 The female condom, made of polyurethane plastic, is also used for receptive anal sex, but it was not designed for that purpose.⁶ The diaphragm, cervical cap and sponge are often used with a spermicide and block the cervix to prevent conception. Although studies have shown that these cervical blocking methods may also prevent certain STDs⁷, research has not been conducted to show that they prevent HIV. Dental dams are latex sheets used to provide a barrier in oral/anal and oral/vaginal sex. Spermicides (gels, creams, foams, or films that can be inserted into the vagina) are available for preventing pregnancy. One of the most widely used spermicides, Nonoxynol 9 (N-9), was recently tested for its ability to prevent HIV. The study of female sex workers in Thailand, South Africa, Cote d’Ivoire and Benin, randomly assigned women to use either a gel containing 52.5 mg of N-9 or a placebo, a vaginal moisturizer known as Replens. Preliminary results showed that there were more new HIV infections among the N-9 group than in the Replens group.⁸ In August, 2000, the CDC recommended against N-9 as a sole barrier method for HIV prevention.⁹ This study documented the harmful effects of a relatively large dose of N-9 on HIV infection. N-9 is commonly used in much smaller amounts as part of a condom lubricant. The impact of small doses of N-9 is not clear.

Why do we need alternatives to male condoms?

Male condoms are an extremely effective means of HIV, STD and pregnancy prevention. What most often limits condoms’ effectiveness is user failure rather than product failure. For example, users may fail to either put on a condom before genital contact or completely unroll the condom. In addition, some people fail to use a condom with every act of sexual intercourse. Some don’t use condoms because they reduce sexual sensation. For others, using condoms is seen as a barrier to intimacy. Male condom use requires male participation or negotiation. Female-controlled and receptive-partner-controlled options (such as female condoms or future microbicides) may be used without the participation or consent of the insertive partner. These methods are still detectable by sexual partners and partners can still refuse to use them. Female- and receptive-partner-controlled options can be used in situations where it is difficult to negotiate condom use such as in an abusive relationship, where there is economic disincentive to use a condom¹⁰ or where the insertive partner refuses to use a condom.⁵ Female-controlled HIV/STD prevention methods can be empowering¹¹ and are vital in an HIV epidemic that is increasingly infecting women, especially in developing countries. Finally, there is no barrier method that allows women to protect themselves from HIV and still get pregnant. Hopefully, a barrier method can be developed that separates the control of fertility from the prevention of STDs. This is an important consideration for many women.²

What are the drawbacks?

Barrier methods can provide protection against HIV and STDs, yet they are not an option for everyone. Although some methods are low-cost, others, such as the female condom, may have limited accessibility because of their cost. Most barrier methods require application before each act of sexual intercourse, making consistent use more difficult. Barrier methods may not protect against STDs that are transmitted via skin-to-skin contact such as herpes and human papilloma virus (HPV). Products may be messy or may require adequate cleaning and storage, which may not be available to some people. Some barrier methods are inserted into the vagina which requires comfort and familiarity with one’s body. Diaphragms and cervical caps require a health care worker to fit the devices. Further, individuals may have sensitivities to products’ chemicals or materials, such as latex allergies.¹ Barrier methods under development are addressing some of these limitations.

What about microbicides?

Microbicides are topically-applied chemical barriers that prevent HIV and/or STD transmission. They are not currently available, but are under development and being tested for efficacy as an alternative to current methods. Microbicides may come in the form of gels, creams, foams or films that can be inserted into the vagina or rectum. Development is currently focused on creating products which destroy or immobilize germs or viruses through a variety of mechanisms: breaking down the outer cell membranes of pathogens, enhancing normal vaginal defenses, providing a physical coating to the vagina or the rectum, inhibiting HIV from entering cells or preventing HIV replication if HIV does enter a cell.¹² Studies show that there is large potential demand for microbicides from women in the US and internationally.¹³ People are also willing to participate in efficacy trials, as studies in women and MSM have shown.^14,15

What’s being done?

Male condoms are currently the best comprehensive prevention method. Education and prevention campaigns must be continued to optimize condom usage while also searching for alternatives. HIV prevention efforts may be more effective among certain populations if condom use and HIV are addressed together with STD and unintended pregnancy prevention. Some STD and family planning clinics are encouraging condom use for both STDs and HIV prevention with great success.¹⁶ New physical barrier methods currently being researched include the disposable diaphragm, alternative types of cervical shields, caps and sponges and alternative types of condoms, both male and female. New materials are also under development, including various plastics and silicone rubber.² It is also important to examine the potential for adapting current products and testing existing products for HIV prevention. As these products are already FDA approved, the testing process is not as lengthy.

What are the next steps?

The development of alternative barrier methods must be a priority among private and public researchers alike. With over 50 microbicides in the research pipeline, one should be on the market by the year 2005. Advocacy groups have played a large role in increasing awareness and attention to microbicides and should continue advocating for accessible barrier methods.¹⁶ Although US government funding for microbicides has increased, in the 1998 fiscal year, microbicide-related research received only 1% of the National Institutes of Health AIDS research budget.¹⁷ There is no single solution to HIV and STD prevention. Prevention requires continued work on many levels, including increasing access to products, advocating for social change to eliminate unsafe situations that many people are in, and developing stronger prevention and treatment alternatives. Barrier methods are an integral part of these prevention alternatives and must be developed to their fullest potential to enhance health and prevent disease. Says who? 1. Feldblum P, Joanis C. Modern barrier methods: effective contraception and disease prevention. Family Health International. 1994. 2. The Population Council and International Family Health. The case for microbicides: a global priority . 2000. 3. Microbicides: a new weapon against HIV. American Foundation for AIDS Research (AmFAR) Report. www.amfar.org . 4. Pinkerton SD, Abramson PR. Effectiveness of condoms in preventing HIV transmission . Social Science and Medicine. 1997;44:1303-1312. 5. Elias CJ, Coggins C. Female-controlled methods to prevent sexual transmission of HIV . AIDS. 1996;3:S43-51. 6. Gibson S, McFarland W, Wohlfeiler D, et al. Experiences of 100 men who have sex with men using the REALITY condom for anal sex . AIDS Education and Prevention. 1999;11:65-71. 7. Rosenberg MJ, Davidson AJ, Chen JH, et al. Barrier contraceptives and sexually transmitted diseases in women: a comparison of female-dependent methods and condoms . American Journal of Public Health. 1992; 82:669-674. 8. UNAIDS. Nonoxynol-9 not effective microbicide, trial shows https://pubmed.ncbi.nlm.nih.gov/12296062/  9. Gayle H. Dear Colleague. Centers for Disease Control and Prevention. August 4, 2000. 10. Abdool Karim Q, Abdool Karim SS, Soldan K, et al. Reducing the risk of HIV infection among South African sex workers: socioeconomic and gender barriers . American Journal of Public Health. 1995;85:1521-1525. 11. Gollub EL. The female condom: tool for women’s empowerment . American Journal of Public Health. 2000;90:1377-1381. 12. Heise L. Topical microbicides: new hope for STI/HIV prevention. Center for Health and Gender Equity (CHANGE). Takoma Park, MD. 13. Darroch JE, Frost JJ. Women’s interest in vaginal microbicides . Family Planning Perspectives. 1999;31:16-23 14. Hammet TR, Mason TH, Joanis CL, et al. Acceptability of formulations and application methods for vaginal microbicides among drug-involved women: results of product trials in three cities . Sexually Transmitted Diseases. 2000;27:119-126. 15. Gross M, Buchbinder SP, Celum C, et al. Rectal microbicides for U.S. gay men: are clinical trials needed? Are they feasible? Sexually Transmitted Diseases. 1998;39:55-61. 16. 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. 17. Harrison PF. A new model for collaboration: the alliance for microbicide development . International Journal of Gynecology and Obstetrics. 1999;67:S39-S53. PREPARED BY Beth Freedman MPH, Nancy Padian PhD, CAPS, ARI December 2000. Fact Sheet #39E 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]. © December 2000, University of California

What is the role of male condoms in HIV prevention?

revised 01/05

do condoms work?

Yes. The condom is one of the only widely available and highly effective HIV prevention tools in the US.¹ When used consistently and correctly, latex male condoms can reduce the risk of pregnancy and many sexually transmitted infections (STIs), including HIV by about 80-90%^1-6. Condoms, including female condoms, are the only contraceptive method that is effective at reducing the risk of both STIs and pregnancy. When placed on the penis before any sexual contact, the male condom prevents direct contact with semen, sores on the head and shaft of the penis and discharges from the penis and vagina. Condoms thus should effectively reduce the transmission of STIs that are transmitted primarily through genital secretions such as gonorrhea, trichomoniasis, chlamydia, hepatitis B and HIV.^1-6 Because condoms only cover the penis, they provide less protection from STIs primarily transmitted through skin-to-skin contact such as genital herpes, syphilis, chancroid and genital warts. Abstinence, mutual monogamy between uninfected partners, reducing the number of sexual partners and correctly and consistently using condoms during intercourse are all essential to slowing the spread of HIV/STIs.⁷ Condom effectiveness depends heavily on the skill level and experience of the user. Appropriate education, counseling and training on partner negotiation skills can greatly increase the ability of a person to use a condom correctly and consistently.²

what are the advantages?

Accessibility. Using condoms does not require medical examination, prescription or fitting. Condoms can be bought at drug stores, grocery stores, vending machines, gas stations, bars and the internet, and are distributed free at many STI and HIV clinics. Sexual enhancement. Using condoms can help delay premature ejaculation. Lubricated condoms can make intercourse easier and more pleasurable for women. And condoms do away with the “wet spot” left by semen leakage after sex. Using condoms helps reduce anxiety and fears of pregnancy and STIs so that men and women can enjoy sex more. Protect fertility. Some STIs can affect a woman’s ability to get pregnant; condoms can protect against some STIs and therefore help reduce the risk of infertility.⁸

what are the disadvantages?

Lack of cooperation. Women cannot directly control whether a condom is used and have to rely upon male cooperation. When men refuse, condom use may be impossible. Physical problems. Many men and their partners complain that condoms reduce sensitivity. Proper condom use requires an erect penis. Some men cannot consistently maintain an erection so condom use becomes difficult. Trying different kinds of condoms (such as thinner condoms) and using water-based lubricant can help increase sensation. Embarrassment. Some men and women may be embarrassed to buy condoms at a store, or take free condoms from a clinic. Others may be embarrassed to suggest or initiate using condoms because they perceive condom use implies a lack of trust or intimacy.⁹

how are they used?

The most important key messages for condom use are quite simple: 1) Use a new condom every time, with every act of intercourse, if there is a risk of pregnancy or STIs. 2) Before penetration, carefully unroll the condom onto the erect penis, all the way to the base. Put it on before the penis comes in contact with the partner’s vagina or anus. 3) After ejaculation (while the penis is still erect), hold the rim of the condom against the base of the penis during withdrawal.^2,10 Even with adequate training and access to condoms, people won’t always use condoms perfectly. In the real world, people may fall in love, or make mistakes, or get drunk or simply decide not to use condoms. Having sex under the influence of alcohol and/or drugs greatly increases the chances of condom non-use, misuse and failure.¹¹

what are concerns?

Condom education/distribution in schools. Although schools can be an important source of information on HIV/STIs, only 2% of public schools have school-based health centers, and only 28% of those make condoms available to students.¹³ In 2000, persons aged 15-24 had 9.1 million new cases of STIs and made up almost half of all new STI cases in the US. 47% of US high school students have had sexual intercourse.¹⁵ Condom breakage and slippage (condom failure). Condom quality has been improving¹⁶ and for most users condom failure is relatively rare. About 4% of condoms break or slip off.² However some persons report much higher rates. In one study, gay men who were unemployed and reported amphetamine and/or heavy alcohol use were more likely to report condom failure. Men who were frequent users of condoms and used lubricant reported less failure¹¹. Counseling and education on condom use can greatly reduce condom failure.² Effectiveness of N-9. Condoms lubricated with the spermicide nonoxynol-9 (N-9) often cost more, have no proven protective advantage over condoms without N-9, have a shorter shelf life and might be harmful if used excessively. Many manufacturers have discontinued N-9 condoms.^2,16

what works?

The following programs have been documented as effective by the Centers for Disease Control and Prevention, and are currently being replicated nationwide.¹⁷ Training on condom use and negotiation. The SISTA Project is a social skills training intervention for African American women designed to increase their comfort with and use of condoms. In small group sessions, women learn sexual assertion skills and proper condom use and discuss cultural and gender triggers that affect condom negotiation. Homework activities involve their male partners. Participants reported more condom use.¹⁸ Changing community norms. The Mpowerment Project is a community-level program developed by and for young gay men that increases peer support and acceptance for safer sex. Peer-led M-groups use a gay-positive and sex-positive approach to teach men negotiation and condom use and train and motivate them to conduct informal outreach with their friends. Participants reported decreased rates of unprotected anal intercourse.¹⁹ Combining HIV prevention with STI and unintended pregnancy prevention.The VOICES/VOCES program was implemented in an STI clinic and uses culturally-specific videos and skills building to increase condom use and negotiation among African American and Latino/a heterosexuals. The program is bilingual and includes education about different types of condoms and condom distribution. Participants reported more condom use and fewer repeat STIs.²⁰

what needs to be done?

Better marketing and increased accessibility to condoms is needed in the US. Although condom use has increased in the past decade, there are still unacceptably high rates of STIs among sexually active adolescents and young adults and among gay men, two populations that are also at increased risk for HIV. New approaches to condom promotion are needed, ideally before the onset of sexual activity. For adolescents to use them, condoms must be easily and anonymously accessible, widely available and low cost. Distributing free condoms can also help increase condom use.²¹ To effectively address HIV prevention, all persons should have accurate and complete information about different prevention options. But the emphasis needs to be different for different groups. For example, while young people who have not started sexual activity need information and access to condoms, the first priority should be to encourage abstinence and delay of sexual intercourse. When targeting those at highest risk for HIV, the first priority should be to encourage correct and consistent condom use along with avoiding high-risk behaviors and partners.⁷ Are condoms foolproof? No. Neither are seat belts, helmets, abstinence pledges or vaccines. But in the real world we drive to work, vaccinate our children, and hope to get through the day unscathed. No public health strategy can guarantee perfect protection. The real question is not are condoms 100% effective, but how can we more effectively use condoms and other approaches to help reduce the risk of disease.

Says who?

1. Scientific evidence on condom effectiveness for STD prevention. Report from the NIAID. July 2001. 2. Warner L, Hatcher RA, Steiner MJ. Male Condoms. In: Hatcher RA, Trussel J, Stewart F, et al, editors. Contraceptive Technology. New York: Ardent Media Inc. 2004:331-353. 3. Holmes KK, Levine R, Weaver M. Effectiveness of condoms in preventing sexually transmitted infections. Bulletin of the World Health Organization. 2004;82:454-461. 4. Weller S, Davis K. Condom effectiveness in reducing heterosexual HIV transmission. Cochrane Database Systematic Review. 2002;(1):CD003255. 5. Hearst N, Chen S. Condom promotion for AIDS prevention in the developing world: is it working? Studies in Family Planning. 2004;35:39-47. 6. CDC. Male latex condoms and STDs. 7. Halperin DT, Steiner MJ, Cassell MM, et al. The time has come for common ground on preventing sexual transmission of HIV. Lancet. 2004;364:1913-1915. 8. Ness RB, Randall H, Richter HE, et al. Condom use and the risk of recurrent pelvic inflammatory disease, chronic pelvic pain, or infertility following an episode of pelvic inflammatory disease. American Journal of Public Health. 2004;94:1327-1329. 9. Miller LC, Murphy ST, Clark LF, et al. Hierarchical messages for introducing multiple HIV prevention options: promise and pitfalls. AIDS Education and Prevention. 2004;16:509-25. 10. ASHA. The right way to use a male condom. 1/30/05. 11. Stone E, Heagerty P, Vittinghoff E, et al. Correlates of condom failure in a sexually active cohort of men who have sex with men. Journal of AIDS. 1999;20:495-501. 12. McElderry DH, Omar HA. Sex education in the schools: what role does it play? International Journal of Adolescent Medical Health. 2003;15:3-9. 13. Santelli JS, Nystrom RJ, Brindis C, et al. Reproductive health in school-based health centers: findings from the 1998-99 census of school-based health centers. Journal of Adolescent Health. 2003;32:443-451. 14. Weinstock H, Berman S, Cates W. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspectives in Sexual and Reproductive Health. 2004;36:6-10. 15. Youth risk behavior surveillance–US, 2003. Morbidity and Mortality Weekly Report. 2004;53:1-98. 16. Condoms: extra protection. Consumer Reports. Feb 2005. 17. https://www.cdc.gov/hiv/effective-interventions/index.html 18. DiClemente RJ, Wingood GM. A randomized controlled trial of an HIV sexual risk reduction intervention for young African-American women. Journal of the American Medical Association. 1995;274:271-276. 19. Kegeles SM, Hays RB, Pollack LM, et al. Mobilizing young gay and bisexual men for HIV prevention: a two-community study. AIDS. 1999;13: 1753–1762. 20. O’Donnell CR, O’Donnell L, San Doval A, et al. Reductions in STD infections subsequent to an STD clinic visit: using video-based patient education to supplement provider interactions. Sexually Transmitted Diseases. 1998;25:161–168. 21. Cohen DA, Farley TA. Social marketing of condoms is great, but we need more free condoms. Lancet. 2004;364:13. Prepared by Markus Steiner PhD* and Pamela DeCarlo** *Family Health International, **CAPS January 2005. Fact Sheet #2ER Special thanks to the following reviewers of this Fact Sheet: Barb Adler, Daniel Bao, Willard Cates, Bill Cayley Jr, Rick Crosby, Scott Dougherty, Ralph DiClemente, Paul Feldblum, Steve Gibson, Daniel Halperin, Norman Hearst, Mary Hoban, John James, Doug Kirby, Andrzej Kulczycki, Kay Stone, Koray Tanfer, Lee Warner, Dan Wohlfeiler.

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 2005, University of California

How does disclosure affect HIV prevention?

why is disclosure important in HIV?

Disclosure of HIV+ status is a complex, difficult and very personal matter. Disclosing one’s HIV+ status entails communication about a potentially life threatening, stigmatized and transmissible illness. Choices people make about this are not only personal but vary across different age groups, in different situations and contexts, and with different partners, and may change with time, depending on one’s experiences. Disclosure may have lifelong implications since more people are living longer, and often asymptomatically, with HIV. Public health messages have traditionally urged disclosure to all sexual and drug using partners. In reality, some HIV+ persons may choose not to disclose due to fears of rejection or harm, feelings of shame, desires to maintain secrecy, feelings that with safer sex there is no need for disclosure, fatalism, perceived community norms against disclosure, and beliefs that individuals are responsible for protecting themselves.¹ This Fact Sheet primarily focuses on disclosure in the context of sex. Discussing and disclosing HIV status is a two-way street. Be it right or wrong, most people feel that when a person knows that he/she is HIV+ then he/she has an obligation to tell the other person, and counselors are encouraged to help people with this process. Also, laws in some areas require disclosure of HIV+ status prior to sex.² However, both partners should be responsible for knowing their own status, disclosing their own status when it seems important, and asking their partner about their status if they want to know. Most HIV+ persons disclose their status to some, but not all, of their partners, friends and family. Disclosure generally becomes easier the longer someone has been living with HIV, as he/she becomes more comfortable with an HIV+ status. Disclosure to sex partners is more likely in longer-term, romantic relationships than in casual relationships (one-night stands, anonymous partners, group scenes, etc.).³ Disclosure also varies depending on perceived HIV status of partners, level of HIV risk of sex activities, sense of responsibility to protect partners (personal vs. shared responsibility) and alcohol or drug use.

does disclosure affect sexual relationships?

The relationship between disclosure, sexual risk behaviors and potential transmission of HIV varies. Research findings have presented a mixed picture.⁴ Some studies have found that increased disclosure is associated with reduced sexual risk behavior.⁵ Other studies show that disclosure doesn’t always alter risk taking behaviors.⁶ Even with disclosure, unsafe sex sometimes occurs. Some people engage in safer sex behaviors without any discussion of HIV status.⁷ Disclosure can provide psychological benefits. In one study, HIV+ injection drug users who disclosed their status experienced increased intimacy with partners and reaffirmation of their sense of self.⁸ Many HIV+ persons who disclose their status find that it reduces anxiety about transmission, so sex can be much more comfortable and relaxed. A challenging issue for many people is the timing of disclosure. If it’s not done relatively early, it can become more difficult as time goes on, and can cause significant disruption to an ongoing relationship if the disclosed-to partner feels betrayed due to the lack of an earlier disclosure. HIV+ persons who have thought through a disclosure plan and have a consistent strategy for managing disclosure are less likely to engage in risky sexual behaviors than those who do not disclose or have inconsistent disclosure strategies.⁵

does disclosure affect social relationships?

Yes. Disclosure to significant others can help increase support for HIV+ persons. A study of Latino gay men found that disclosure was related to greater quality of social support, greater self-esteem, and lower levels of depression.⁹ Disclosure also can lead to support that facilitates initiation of, and adherence to, HIV treatment and medications.^10,11 Disclosing HIV+ status can and sometimes does result in rejection, discrimination or violence. Disclosing to certain persons also can be more of a burden than a benefit. One study found that friends were disclosed to most often and perceived as more supportive than family members, and mothers and sisters were disclosed to more often than fathers and brothers and perceived as more supportive than other family members.¹²

what are the controversies?

There is debate around whether partners have a right to know if their partner is HIV+, in order to be able to make a fully informed decision about what sexual behavior to engage in. Some HIV+ persons believe that if they only have protected sex, there is no need for disclosure, especially with casual partners, and that encouraging disclosure only serves to further stigmatize HIV+ persons. These issues can be complicated by complex gender role norms and local laws—23 states have laws that make it a crime for a person to engage in certain risk behaviors without disclosing their HIV status.² People may use disclosure as a way to limit their partners to only persons of the same status, be it HIV+ or HIV- (sometimes known as serosorting). The success of serosorting as a prevention strategy depends upon honest and accurate disclosure on the part of any two sexual partners.¹³ Even when persons do choose to disclose, their awareness of their own HIV status may not be accurate.¹⁴ For example, some people who think that they are HIV- may be, in fact, in the acute stage of HIV infection. If an individual is in the acute stage of HIV infection, which are the initial weeks to months after acquiring HIV when the body has not yet produced a detectable antibody response, then he or she will have a negative result on a standard HIV test. This is especially concerning because when people are in this stage of infection, they more readily transmit the virus during unprotected sex than at other times.¹⁵

what’s being done?

Because many experts believe that HIV+ status disclosure helps prevent HIV transmission and increases social support for HIV+ individuals, there are efforts to develop programs to encourage disclosure and make it a constructive experience. Most programs to support HIV status disclosure have been part of overall prevention and well-being programs for HIV+ persons. Programs may include discussions of the benefits of disclosure, when to disclose and to whom. Programs should include practicing skills to discuss HIV status in the context of sexual negotiation and dating. The Healthy Living Project is a 15-session, individually delivered, cognitive behavioral intervention to help HIV+ persons cope with the challenges of living with HIV. The project addressed issues of stress, coping and adjustment, safer behavior, including disclosure to partners, and health-related behaviors. Participants reported fewer unprotected sexual risk acts with persons of HIV- or unknown status.¹⁶ Healthy Relationships is a 5-session, small-group skills-building program for HIV+ persons, and is one of the CDC’s Diffusion of Effective Interventions (DEBI). It is designed to reduce participants’ stress related to safer sexual behaviors and disclosure of their HIV status to family, friends and sex partners. Participants reported significantly less unprotected intercourse and greater condom use at follow-up.¹⁷ Other disclosure approaches have aimed at encouraging both HIV+ and HIV- persons to not make assumptions about their partner’s HIV status, to get tested, to disclose their own status and practice safer sex with all partners. The Department of Public Health in San Francisco, CA, created the Disclosure Initiative social marketing campaign which aims to normalize the disclosure of HIV status for both HIV+ and HIV- men.¹⁸

what needs to be done?

We need to normalize and facilitate comfortable discussions about HIV, so that disclosure of HIV+ status isn’t such a difficult thing to do. The more HIV is talked about, and the more people come out about being HIV+, the less stigma there will be. Disclosure is a two-way street. That means it is up to both people who are having sex with each other to address the issue. People living with HIV often are much happier in their relationships (long and short-term) when their HIV status is known by their partner. There’s no simple answer or policy for disclosure of HIV. Clinicians, counselors and programs need to be sensitive to the complexity of disclosure, and understand that disclosure is not for all people in all contexts. However, disclosing one’s HIV status can facilitate support for HIV+ persons and may lead to better communication, including discussion of risk reduction practices between sexual partners.

Says who?

1. Wolitski RJ, Parsons JT, Gómez CA, et al. Prevention with HIV-seropositive men who have sex with men: lessons from the Seropositive Urban Men’s Study and the Seropositive Urban Men’s Intervention Trial. Journal of AIDS. 2004;37:S101-109. 2. Galletly CL, Pinkerton SD. Conflicting messages: how criminal HIV disclosure laws undermine public health efforts to control the spread of HIV. AIDS and Behavior. 2006;10:451-461. 3. Duru OK, Collins RL, Ciccarone DH, et al. Correlates of sex without serostatus disclosure among a national probability sample of HIV patients. AIDS and Behavior. 2006;10:495-507. 4. Simoni JM, Pantalone D. Secrets and safety in the age of AIDS: does HIV disclosure lead to safer sex? Topics in HIV Medicine. 2004;12:109-118. 5. Parsons JT, Schrimshaw EW, Bimbi DS, et al. Consistent, inconsistent, and non-disclosure to casual sex partners among HIV-seropositive gay and bisexual men. AIDS. 2005;19:S87-S97. 6. Crepaz N, Marks G. Serostatus disclosure, sexual communication and safer sex in HIV-positive men. AIDS Care. 2003;15:379-387. 7. Klitzman R, Exner T, Correale J, et al. It’s not just what you say: Relationships of HIV dislosure and risk reduction among MSM in the post-HAART era. AIDS Care. 2007;19:749-756. 8. Parsons JT, VanOra J, Missildine W, et al. Positive and negative consequences of HIV disclosure among seropositive injection drug users. AIDS Education and Prevention. 2004;16:459-475. 9. Zea MC, Reisen CA, Poppen PJ, et al. Disclosure of HIV status and psychological well-being among Latino gay and bisexual men. AIDS and Behavior. 2005;9:15-26. 10. Stirratt MJ, Remien RH, Smith A, et al. The role of HIV serostatus disclosure in antiretroviral medication adherence. AIDS and Behavior. 2006;10:483-493. 11. Klitzman RL, Kirshenbaum SB, Dodge B, et al. Intricacies and inter-relationships between HIV disclosure and HAART: a qualitative study. AIDS Care. 2004;16:628-640. 12. Kalichman SC, DiMarco M, Austin J, et al. Stress, social support, and HIV-status disclosure to family and friends among HIV-positive men and women. Journal of Behavioral Medicine. 2003;26:315-332. 13. Cairns G. New directions in HIV prevention: serosorting and universal testing. IAPAC Monthly. February 2006:42-45. 14. MacKellar DA, Valleroy LA, Behel S, et al. Unintentional HIV exposures from young men who have sex with men who disclose being HIV-negative. AIDS. 2006;20:1637-1644. 15. Pilcher CD, Eron JJ, Galvin S, et al. Acute HIV revisited: new opportunities for treatment and prevention. Journal of Clinical Investigation. 2004;113:937-945. 16. The Healthy Living Project Team. Effects of a behavioral intervention to reduce risk of transmission among people living with HIV: the Healthy Living Project randomized controlled study. Journal of AIDS. 2006; 44:213-221. 17. Kalichman SC, Rompa D, Cage M, et al. Effectiveness of an intervention to reduce HIV transmission risks in HIV-positive people. American Journal of Preventive Medicine. 2001;21: 84-92. Program information 18. hivdisclosure.com All websites accessed July 2007.

Prepared by Robert H. Remien and Mark Bradley HIV Center for Clinical & Behavioral Studies, NY State Psychiatric Institute and Columbia University July 2007. Fact Sheet #64E Special thanks to the following reviewers of this fact sheet: Mark Cichocki, Joe Imbriani, Phebe Lam, Jennifer Lewis, Bradford McIntyre, Bob Munk, Michael Paquette, Tom Patterson, Steve Pinkerton, Jane Simoni, Jef St De Lore, David Vance, John K. Williams. 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 2007, University of CA.