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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

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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.

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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.

While you are setting up your equipment, getting the consent form, etc. take note of the surroundings for your field notes.

1. I’d like you to think back to the last time you got an HIV test. Take a minute to remember everything you can about it and then tell me the whole story. Starting from what led up to the test, why you went to get it, where it was done and then how you felt afterwards?

If they have never tested, skip to question # 6: Let interviewee describe the episode. Listen for answers to each of the following questions. Once interviewee's story is told, probe for any questions not answered. Content Areas for HIV Testing: Motivation: including why they decided to test, whether strictly voluntary, coerced or mandatory testing (prison, hospital), where they found out about testing/test site Location: Where was the test site? Procedures: Describe the actual test? (blood/Orasure) Who administered? How was the counseling? What was discussed in counseling? (Probe for discussion of risk behaviors, results, follow-up appointment) How did you feel after you left? Confidentiality: avoid using the words "confidential" or "anonymous" Were you concerned about privacy at all? (Probe for name or number given, familiar test site, familiar test counselor/administrator) Waiting Period: How was the waiting period? Tell me about any changes that occurred during this time period. Did you talk to anyone about HIV and/or the test during the waiting period? Results: When did you go back for results? IF didn’t get results ask why. If had another test where did get results, what was different this time? Where did you go for results? Who gave them? (probe for familiarity with results counselor) How was the result explained/presented to you? What were your results? Was this the result you were expecting? Why? How did you feel after receiving the results? What was discussed after you received the results? (probe for discussions around risk, 6 month window period, referrals given, IF NEGATIVE — ways to stay negative, any plans made to stay negative) Was talking to them useful/helpful? Did you just want to get out of there? Who did you share your results with? 2. How did this compare to other tests you’ve had, did you like it or not? Was it typical of other tests? 3. After this HIV test, did anything change in your life? (drug use, sex, views on risk) If yes, explain what changed. If NO ask: 4. Have you ever had an HIV test that caused you to change your beliefs or behaviors? If yes, please explain what changed. (Probe for what aspect of C&T caused the change; i.e. was it the risk assessment counseling, or receiving the test results) 5. Is there anything [else] that caused you to change your beliefs or behaviors? (i.e. drug use, sex, views on risk) If yes, please explain what it was, and what changed. 6. Have you ever thought about testing/or been approached about testing? What happened? How did you hear about it? Why did you decide not to test? What do you think would happen if you did test?

Now I’d like to ask you a few more general questions about HIV testing. If they have already discussed their testing pattern above skip 1,2 & 3. 1. How many times have you tested in your life? 2. How often do you test? 3. Do you test regularly? If so, why?

This next section is very general. We are just trying to get a sense of people’s everyday lives. 1. Describe yesterday. What did you do when you got up in the morning until you went to bed? Content Areas for Daily Life: Location(s) Who respondent interacted with during the day Drug Use Resources: eating, getting money Time frames (what time did they get up, what time to bed, etc.) 2. How, in any way, was this different from a typical day?

I have a couple general questions about drugs and then I’d like to ask you more specifically about the last time you used.1. What kinds of drugs do you use now? Probe for all drugs, including alcohol and those used sporadically 2. When do you use and how much? Ask for each drug mentioned above 3. Can you describe to me what happened the last time you used. Tell me the whole story from when it began until where you think it ended. I’d like to know who you were with, what you used, etc. Let interviewee describe the episode. Listen for answers to each of the following questions. Once interviewee's story is told, probe for any questions not answered. Content Areas for Drug Narrative: In this section we want to get at settings, people, and social and physical conditions which shape use; decisions and rules, spoken and tacit. Before Using: How were you feeling/What kind of mood were you in? What was going on at the time? Buying and preparing: Time and place. How were drugs procured? Who got them? Who paid? How did you get money for the drugs/buy in? If didn’t have money, how did you get your portion? Who was there? What are your relationships with these people? Who prepared drugs, how? How were drugs measured? Probe for using ONE syringe to divide up drugs into other syringes— was the loader’s syringe new or used; were receivers’ syringes new or used. Who or what determined how much each person got? Taking: How did you take the drugs (inject self, injected by another person, smoke, snort) Where did you get the (pipe, works)? Whose (rigs, pipe) did you use? Who went first (second, third, etc.) and why? Afterwards: How did you feel, what did you do afterwards? Did you need any other drugs to come down? 4. How, in any way, was this different from your usual experience using? 5. How does your drug use fit into your sex life? How does your drug use impact your sex life? Probe for drugs used before, during and after sex.

Let me ask you a few general questions about your relationships. 1. Do you currently have a steady partner(s) (girlfriend, boyfriend, husband, wife, etc.)? If so, tell me about her/him or them? Individual characteristics of their partner. (age, gender, and ethnicity). Relationship with this partner (duration and nature of relationship, where/when/how met partner; main, casual, paying or exchange) Probe around past sexual experiences with this partner. What attracted you to her/him? What did you like about her/him? (if appropriate)

Now I would like to ask some personal questions about your sexual behavior. We realize that this is a very personal subject, but your answers are very important to our research. Your answers will remain completely confidential and remember names will not be attached to any of this information. 1. I would like to talk about the last time you had sex with someone without a condom. When was that? NOTE: This includes when a condom broke and when there was dipping. 2. Could you think back now and try to remember as much as you can about that time, and tell me the story of how it happened? Try to remember when it happened, who you were with, what you were doing and how you felt. Let interviewee describe the episode. Listen for answers to each of the following questions. Once Interviewee's story is told, probe for any questions not answered. Content Areas for Sexual Interactions: Sexual partner: Individual characteristics of this sex partner. (age, gender, and ethnicity). Relationship with this partner (duration and nature of relationship, where/when/how met partner; main, casual, paying or exchange) Past sexual experiences with this partner What attracted you to him/her? (if appropriate) Before Sex: What was going on at that time? How did it happen? (When did it happen?, who initiated?, where were you?) How were you feeling? (Were you expecting to have sex? Did either one of you talk about it first? What were you hoping to get out of it?) Sexual Events: What happened? (types of sex: anal, oral, vaginal, mutual masturbation, digital, etc.) What determined the kinds of sex you had? (active vs. passive roles, verbal vs. nonverbal c communication, payment, consent, etc.)  How did you make a decision to NOT use a condom?/Why didn’t you use condoms? Birth control method of any kind used Using (Drugs): Drugs or alcohol used by you or this sex partner before, during or after having sex. (Injected drugs/non-injected drugs/alcohol; levels of intoxication) What did using have to do with this sexual encounter? (sex/drug exchanges, drugs enhancing sex, sex enhancing drug, etc.) HIV/AIDS: Issue of HIV ever discussed (Your status? Partner’s status? If so, how? Before or after sex?) If not discussed, then what did you believe (or assume)? Before or after sex? How did knowing or not knowing your partner’s HIV status affect having sex this time. After Sex: Thinking back over this particular experience, is there anything that you would have wanted to happen differently? Tell me about that. Generalizability - Typical or unusual compared to most of other sexual interactions Relationship potential - Someone you wanted to see again? To have sex with again? 3. How was this different from your usual experience having sex without a condom? 4. How was this different from the last time you had sex WITH a condom? 5. Thinking about when you have sex in general, what makes it easier to use condoms/protection with your partners? (Probes: nature of relationship; how long they knew their partner; serostatus) 6. Thinking about when you have sex in general, what are some of the reasons you haven’t used condoms/protection? 7. How are these situations (using a condom verses not using a condom) different. 8. How is having sex with your "steady partner" (whatever term interviewee uses) different from having sex with others, such as casual partners, one-night stands or tricks?

Adherence to Combination Therapy in AIDS Clinical Trials (1997)

Chesney, M., Ickovics J., for the Recruitment, Adherence and Retention Committee of the ACTG (1997). Presented at the Annual Meeting of the AIDS Clinical Trials Group, July 1997,Washington, D.C.

The Recruitment, Adherence and Retention Subcommittee of the AIDS Clinical Trials Group administered two questionnaires to 76 patients on combination therapy from 10 clinic AIDS Clinical Trials Units during May and June of 1997 (results were presented at the July, 1997 ACTG meeting by Drs. Margaret Chesney and Jeannette Ickovics). Eighty percent of the respondents were male, 30% were persons of color, the mean age was 40 years, 41 % were college graduates and the mean income was US$ 25,000. Of the 76 patients, 41% reported missing at least one dose "yesterday" (i.e., the day before completing the survey). Fourteen percent reported missing at least one dose the "day before yesterday." When these two days were examined together, a total of 18% of the patients missed at least one dose in the last two days. When asked about the last two weeks, 36% reported missing at least one dose. These data probably underestimate the problem because most of these patients were relatively new to their regimens. Adherence research indicates that adherence is better early on in the course of treatment and declines with time. The report of the ACTG survey also provided preliminary findings on some of the variables that are associated with or 'predict' nonadherence. These variables are important because they suggest ways that individuals who may have difficulties with adherence could be identified. The intent of studies finding such "predictors" is not to characterize persons who might not be prescribed medication but rather, to identify persons who may need additional assistance and to provide information that could be used to maximize the effectiveness of the assistance. The ACTG survey identified two predictors of nonadherence. The first of these was the frequency of alcohol intake, with a higher frequency associated with skipped doses. The average number of drinks per month among those who did not report skipping medication was 9, whereas the average number of drinks per month among those who reported skipping medication was 17. The second variable significantly associated with non adherence was "working outside the home for pay' " Specifically, 59% of the adherent survey respondents worked outside the home, the prevalence of working outside the home was significantly higher, at 85%, among those who are nonadherent. This latter variable is consistent with the data indicating that among the reasons for missing medications is being away from home and busy with other daily activities. A primary purpose of this survey was to test the feasibility of the two instruments: the baseline and the adherence follow-up questionnaires. The questionnaires took an average of 10 minutes each to complete and 89% and 93% thought the lengths of each (respectively) were fine. Ninety-six and 99% of the patients said that they thought others would be willing to complete the two instruments, respectively. Feb 01, 1998

Adherence and Effectiveness of Protease Inhibitors in Clinical Practice

Abstract of Presentation from the 5th Conference on Retroviruses and Opportunistic Infections February 1-5, 1998, Chicago, ILHECHT FM¹, COLFAX G², SWANSON M¹, CHESNEY MA^{1 1}University of California San Francisco, CA and ²Department of Public Health, SF CA Background: Adherence to protease inhibitor containing regimens for HIV infection is thought to be a important factor in determining the effectiveness of treatment, but there is limited data linking adherence to virologic outcomes. We measured adherence to protease inhibitor (PI) regimens in a public hospital clinic setting, and determined the association between adherence and undetectable HIV viremia. Methods: In 1-97 and 2-97 we surveyed patients at half of all clinic sessions at the San Francisco General Hospital AIDS clinic. Adherence was measured using a self-administered questionnaire that was reviewed by a trained interviewer for completeness. The questionnaire asked how many doses of protease inhibitors had been missed in each of the past 3 days. Patients were also asked if they took less pills than their doctor told them to take at each dose. A composite adherence measure was produced by calculating the proportion of recommended medication actually taken by patients in the prior 3 days, accounting for both missed and reduced doses. HIV-1 plasma RNA was measured by the bDNA test (Chiron, limit of detection 500 copies/ml), using measurements requested by physicians the day of the interview or the first measure performed after the interview. Results: Table 1: Patient Characteristics (n=135)

Characteristic	Number	Percent
Male	123	91.1 %
Race
White	90	67.2 %
African American	20	14.9 %
Latino	15	11.2 %
Median age (years)	39.8 years	Range 27.0-59.5 years
HIV Risk
MSM*	93	68.9 %
IDU*	12	8.9 %
MSM/IDU	11	8.1 %
41	7	14.1 %
Baseline CD4**
0-100	49	36.6 %
101-200	29	21.6 %
201-500	39	29.1 %
> 500	2	1.5 %
Unknown	16	11.9 %
Baseline median VL (n=61)	16060 copies/ul
Protease Inhibitor
Saquinavir	17	13.1 %
Indinavir	80	61.5 %
Ritonavir	24	18.5 %
Nelfinavir	2	1.5 %
Saquinavir/Ritonavir	7	5.4 %
Duration of PI Tx	205 days	Range 60-624 days
Adherence to PI Tx
100% adherent	98	72.6 %
80-99% adherent	10	7.4 %
< 80% adherent	27	20.0 %

* MSM=Men having sex with men and IDU=Injection drug use ** Before starting treatment with protease inhibitors. Patients: 388 patients agreed to fill out the survey (response rate 72%). Of these, 183 had taken protease inhibitors. Of the 183, 135 had taken protease inhibitors for more than 2 months at the time of the interview, and provided a medical record number to match laboratory data with the questionnaire. Overall, 41% of patients had detectable viremia. Figure 1: Proportion of Patients with Undetectable Viremia by Adherence Multivariate predictors of undetectable viremia: In a multiple logistic regression model controlling for CD4 count prior to beginning PI treatment, type of protease inhibitor, and whether new or changed reverse transcriptase inhibitors were started with the PI, adherence was associated with non-detectable viremia, OR=4.7, 95% CI 1.1 ñ 20.6. Conclusions (1) The proportion of patients with undetectable viremia was nearly twice as high in patients who reported taking 100% of their recommended protease inhibitor medication in a 3 day period, compared with patients taking less than 80% of medication. Adherence to protease inhibitor treatment is an important predictor of reaching undetectable viremia in clinical practice. (2) While self-reported adherence is likely underestimate missed doses, a simple self-report measure identifies clinically important non-adherence. (3) Nearly half our pts had detectable viremia. This is higher than reported in several clinical trials of protease inhibitor regimens, and suggest that the effectiveness of protease inhibitor regimens in clinical practice may be lower than the efficacy of these treatments established in clinical trial settings. Frederick M. Hecht, MD UCSF AIDS Program San Francisco General Hospital 995 Potrero Ave, Ward 84 San Francisco, CA, 94110 Phone:             (415) 476-4082       x.431 Fax: (415) 476-6953 [email protected]

Women with incarcerated partners are at particular risk for HIV infection. Their partners are over five times more likely than men in the general population to be HIV+. Incarcerated men also have a high incidence of injection drug use. Women with incarcerated partners are primarily low-income women of color for whom racism, poverty and sexism contribute to increased HIV risk and whose life stressors are exacerbated by their partners' imprisonment.

Program

The purpose of the HOME project is to design and test an intervention to reduce HIV risk among women whose male partner is being released from San Quentin State Prison. This study is funded by the National Institute of Nursing Research (NINR). The 12-month HOME intervention ran from February 2005 through January 2006. Weekly activities addressing HIV and STD prevention, women's health, and population-specific topics such as parole information were held at a center for visitors directly outside of the gates of San Quentin. Eleven women who visit incarcerated men were trained as peer educators and were closely involved with project staff in facilitating weekly activities. We collected data during the intervention period using the same quantitative surveys used in our formative research. We also are comparing participants in two cross-sectional surveys, one conducted immediately prior to the launch of the intervention and one conducted immediately after the intervention left the field. Finally, we conducted longitudinal qualitative interviews with the project peer educators.

Formative research

Prior to developing HOME, we conducted several studies with women with incarcerated partners. Based on information gathered in focus groups and pilot studies, we developed an HIV prevention intervention that addresses the specific needs of women with incarcerated partners and facilitates their utilization of community services. This intervention was a peer-led HIV education workshop that provided HIV information, facilitated supportive relationships between visitors and provided referrals as needed. This program and its evaluation are described in a published article (Comfort M, Grinstead OA, Faigeles B, Zack B. Reducing HIV risk among women visiting their incarcerated male partners.Criminal Justice and Behavior, 2000, Vol 21, p. 57-71). We also conducted a series of cross-sectional surveys of women leaving the prison after visiting. These descriptive surveys showed that women visitors are most often low income women of color and that the majority of visitors are raising children. Survey results also indicated that women are spending a large portion of their income on visiting, phone calls and other costs of maintaining their relationship with an incarcerated man. (Grinstead O, Faigeles B, Bancroft C, Zack B. The financial cost of maintaining relationships with incarcerated men: results from a survey of women prison visitors. Journal of African American Men. 2001.)

Video

In response to our findings that many women are unaware of or minimize the risk of having an incarcerated partner, we created "Inside/Out: Real Stories of Men and Women and Life After Incarceration." This 17-minute video presents real stories of four women whose partners have been incarcerated and five men who have served time. The video explores the challenges faced by women after their partners are released from prison. Inside/Out focuses on the health risks in prison and highlights the need for honest communication around health issues when planning for the future. The accompanying discussion guide is designed to draw women with incarcerated partners and other at-risk women into a discussion about the risks of partner incarceration and other partner risk issues. 

Research findings

In an effort to deepen our understanding of how circumstances of forced separation and the interdiction of physical contact affect women's sexual behavior, we investigated the development and maintenance of heterosexual couples' intimacy when the male partner is incarcerated. We recognize that correctional control extends to these women's bodies, both when they are within the facility's walls visiting their mates and when they are at home striving to remain connected to absent men. Using our formative qualitative interviews with 20 women who visit their incarcerated partners and 13 correctional officers who interact with prison visitors, we examined how institutional constraints such as the regulation of women's apparel, the prohibition of physical contact, and the lack of forums for privacy result in couples forging alternative "spaces" in which their relationships occur. Romantic scripts, the build-up of sexual tension during the incarceration period and conditions of parole promote unprotected sexual intercourse and other HIV/STD risk behavior following release from prison. (Comfort M, Grinstead O, McCartney K, Bourgois P, Knight K. You cannot do nothing in this damn place": sex and intimacy among couples with an incarcerated male partner. J Sex Res. 2005 Feb;42(1):3-12.)

• Please see the Science-to-Community Report on HOME.
• "You can't do nothing in this damn place":  Sex and intimacy among couples with an incarcerated male partner.  The Journal of Sex Research (2005).
• Bringing it HOME: Design and implementation of an HIV/STD intervention for women visiting incarcerated men. AIDS Education and Prevention (2008).
• Effectiveness of an HIV prevention program for women visiting their incarcerated partners:  the HOME project.  AIDS Behavior (2011).

¿Cómo afectan los medicamentos opioides a las personas con VIH?

Elaborado por Kathleen Clanon, MD and Pamela DeCarlo | July 2017

¿Son los opioides una preocupación?

Sí. Los medicamentos que se recetan para aliviar el dolor como oxicodona, hidrocodona y metadona ayudan a millones de personas a manejar efectivamente el dolor crónico. Pero para algunas personas, estos opioides también se han convertido en una compleja trama de mal uso y  abuso que ha llevado a incrementos dramáticos en la incidencia de la adicción, sobredosis, infecciones por hepatitis B y C y posiblemente por el VIH. [1]

Las recetas de opioides en los Estados Unidos se duplicaron entre 2001 y 2015 sin que se haya registrado una disminución en la cantidad de dolor reportada. Solamente el uso de oxicodona e hidrocodona se triplicó entre 2000 y 2015. Los profesionales de la salud recetaron 259 millones de recetas de opioides para calmar el dolor en 2012—suficiente para cada uno de los adultos en los Estados Unidos. [2]

El Centro de Control y Prevención de Enfermedades recomienda no recetar opioides como terapia de primera línea o de rutina para el dolor crónico. [3]

¿Por qué preocupa el uso de opioides?

Falta de información sobre los riesgos de los opioides. Los opioides hacen que las personas se sientan bien y alivian el dolor sin producir efectos secundarios muy notorios. Además, los pacientes tienden a creer que los médicos no recetarían algo peligroso. A veces los pacientes no entienden que los opioides pueden crear dependencia física y algunos médicos tampoco entienden los riesgos o no los explican adecuadamente. Las personas a las que se les receta medicamentos opioides deben preguntar a sus proveedores de la salud si realmente son la manera más segura de manejar el dolor.

Sobredosis. De 2000 a 2014, hubo casi medio millón de muertes a causa de sobredosis de drogas, y más del 60 % de las muertes por sobredosis por drogas incluyeron un opioide. Todos los días, 46 personas mueren en los Estados Unidos por una sobredosis de opioides. [2]

Los opioides son altamente adictivos. Hasta un 25% de las personas que toman opioides a largo plazo terminan luchando con la dependencia. [4] Dicha dependencia se desarrolla extremadamente rápido. A los tres días de tomar opioides, ya existe la posibilidad de que su consumo se vuelva crónico y el riesgo aumenta rápidamente con cada día de uso. [5]

¿Cómo afectan los opioides a las personas viviendo con VIH?

Posibles efectos negativos para las personas viviendo con VIH. Para las personas que viven con el VIH (PVV), el uso de opioides a largo plazo puede provocar depresión, contribuir recaídas en el uso de substancias y hasta incrementar el dolor crónico. [6]

Incremento de conductas riesgosas. Igual que el alcohol y otras drogas, los opioides por receta pueden interferir con el juicio y la capacidad de tomar decisiones, y pueden resultar en que una persona haga cosas que en otras circunstancias no haría. Al disminuir las inhibiciones, los opioides pueden fomentar conductas riesgosas (como tener sexo sin protección o compartir jeringas) que incrementan el riesgo de transmitir o contraer el VIH o la hepatitis C o B [7].

Transición a inyectarse y a la heroína. La epidemia del mal uso de opioides por receta ha llevado a muchas personas a inyectarse por primera vez. Casi un 80% de los nuevos consumidores de heroína reporta haber usado opioides por receta primero. [8]

¿Cuáles son los riesgos para las personas viviendo con VIH?

Uso a largo plazo de opioides. Hasta un 85% de PVV sufren dolores crónicos. A muchas se les receta opioides para aliviar el dolor. Los efectos secundarios del consumo de opioides a largo plazo incluyen: una disminución en la libido, menos testosterona, depresión, arritmia y problemas neurológicos. El uso continuo de opioides para calmar el dolor puede en cambio incrementar el dolor crónico en PVV en vez de aliviarlo.

Abuso de opioides. El uso problemático de opioides por receta puede ser común en PVV, especialmente si tienen una historia de abuso de drogas, problemas de salud mental y poca adherencia al tratamiento antirretroviral. Una investigación demostró que un 62% de PVV que consumen opioides por receta los toman de manera problemática. [9]

Recaídas y sobredosis. Para PVV con una historia de abuso de alcohol y de drogas, los opioides pueden ocasionar recaídas en el uso de sustancias. Las sobredosis accidentales son comunes, sobre todo cuando los opioides se mezclan con alcohol o benzodiazepinas (como Valium o Xanax), antidepresivos o medicamentos anticonvulsivos. [3]

Atención para el VIH. Los factores específicos del cuidado médico del VIH pueden determinar si los profesionales de la salud observan o no las normas federales para recetar opioides. Por ejemplo, el personal médico puede valorar la retención de pacientes con VIH o un sentido de alianza con sus pacientes como más importante que lineamientos federales conservadores acerca de recetar opioides. Capacitaciones especializadas sobre el recetar opioides podrían ser necesarias para los profesionales de la salud que atienden a las personas con VIH.

¿Cuáles son los riesgos para personas que están en riesgo de adquirir el VIH?

Falta de conocimiento y de programas relacionados con el uso más seguro de drogas inyectables. La epidemia de opioides ha ocasionado un aumento en el consumo de drogas inyectables. Los nuevos consumidores de estas drogas suelen ser personas de raza blanca que viven en zonas rurales o suburbanas, tienen poco conocimiento sobre prácticas de inyección más seguras y sobre los riesgos de contraer hepatitis o VIH y tienen poco (o nulo) acceso a programas educativos y a servicios para consumidores de drogas inyectables como la distribución de jeringas esterilizadas. [11] Estos factores fomentan las condiciones para la propagación rápida del VIH en comunidades específicas.

Hepatitis C. Actualmente, la transmisión de hepatitis C es un riesgo significativo para personas que se inyectan, sobre todo entre los jóvenes y los habitantes de pueblos pequeños y zonas rurales en los Estados Unidos que se inyectan opioides. En 2013, hubo 30,000 nuevos casos de hepatitis C y un incremento de infecciones de hepatitis C en 28 Estados, lo que equivale a un incremento de más de un 150% desde 2010 [11].

Transmisión potencial rápida del VIH. En 2015, el primer brote de VIH vinculado a la inyección de opioides por receta ocurrió en una zona rural del Estado de Indiana. El VIH se propagó rápidamente dentro de esta pequeña comunidad, con 135 pesonas seropositivas, el 80% de las cuales reportaron haber disuelto e inyectado pastillas de oximorfona.

¿Qué debe hacerse?

Ante el dramático aumento de recetas, uso, adicción y sobredosis de opioides en los años recientes, varias agencias federales, estatales y locales han desarrollado normas, reglamentos y programas para promover la seguridad. En 2016, el Centro de Control y Prevención de Enfermedades elaboró una serie de normas con la finalidad de mejorar la comunicación entre profesionales de la salud y pacientes sobre los riesgos y los beneficios de los opioides para el dolor crónico y para mejorar la seguridad y eficacia del tratamiento para el dolor, así como para reducir los riesgos asociados a terapias a largo plazo con opioides, incluyendo la adicción, sobredosis y mortalidad.

Profesionales de la salud

Cuidado o manejo del dolor sin opioides. Los profesionales que atienden a PVV deben tomar en cuenta la edad, género, condición socio-económica, salud mental y consumo de drogas de la persona, ya que el manejar el dolor sin tener en cuenta esas variables puede tener un éxito limitado. El Centro de Control y Prevención de Enfermedades recomienda no recetar opioides como terapia de primera línea para el dolor crónico, por lo que los profesionales deben considerar otros medios para manejar el dolor. La terapia cognitiva conductual, fisioterapia, hipnosis o marihuana para uso medicinal también pueden aliviar el dolor en las personas con VIH. [13]

Prevención de sobredosis. Si profesionales y pacientes deciden usar opioides, los proveedores deberían discutir y proveer a los pacientes material escrito sobre los riesgos de la dependencia y la sobredosis, así como considerar prescribir también naloxona para revertir los efectos potencialmente fatales de una sobredosis.

Personas que viven con el VIH

PVV a las que se les receta opioides deben discutir cualquier inquietud con su médico y preguntar sobre métodos para manejo del dolor que no incorporan opioides. En caso de recetárseles opioides, deberán usarlos por la menor cantidad de tiempo posible y ser conscientes de que se puede crear dependencia casi inmediatamente, dentro de tres días de su consumo. [5] PVV que han venido tomando opioides durante mucho tiempo deberían hablar con su médico sobre cómo pueden irlos dejando o reducir su consumo.

Políticas sanitarias

Sabemos cómo prevenir el VIH y contamos con múltiples intervenciones eficaces para prevenirlo. El brote del VIH en personas que se inyectan drogas en zonas rurales de Indiana demuestra lo que puede pasar cuando el gobierno estatal y las comunidades no invierten en la prevención. Tenemos que comprometernos a promover la educación y los servicios de reducción de riesgos como programas de acceso a jeringas, prevención de sobredosis, incluyendo acceso a naloxona y programas de rehabilitación. [14]

Aunque el conocimiento científico acumulado durante años demuestra la necesidad, la eficacia y los beneficios económicos de programas para personas que se inyectan drogas, aún existen barreras políticas y legislativas para su implementación. Tenemos que apoyar, proteger y ampliar la legislación actual y los programas que promueven la salud y el bienestar de las personas que consumen y usan mal los opioides por receta, incluidas las personas que se inyectan drogas y sus parejas.

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¿Quién lo dice?

1. RTI International. Opioids In America: A complex crisis. A comprehensive response. 
2. CDC. Opioid painkiller prescribing: Where you live makes a difference. CDC Vital Signs. July 2014. www.cdc.gov/vitalsigns/opioid-prescribing
3. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR. 2016;65:1-49.
4. CDC. Injury prevention and control: Opioid overdose. Drug overdose deaths in the United States continue to increase in 2015. www.cdc.gov/drugoverdose/epidemic/
5. Shah A, Hayes CJ, Martin BC. Characteristics of initial prescription episodes and likelihood of long-term opioid use — United States, 2006–2015. MMWR. 2017;66:265–269. http://dx.doi.org/10.15585/mmwr.mm6610a1
6. Liu B, Liu X, Tang SJ. Interactions of opioids and HIV infection in the pathogenesis of chronic pain. Front Microbiol. 2016;7:103.
7. Zule WA, Oramasionwu C, Evon D, et al. Event-level analyses of sex-risk and injection-risk behaviors among nonmedical prescription opioid users. Am J Drug Alcohol Abuse. 2016;42:689-697.
8. Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA Psychiatry. 2014;71(7):821-826.
9. Turner AN, Maierhofer C, Funderburg NT, et al. High levels of self-reported prescription opioid use by HIV-positive individuals. AIDS Care. 2016;28:1559-1565.
10. Starrels JL, Peyser D, Haughton L, et al. When human immunodeficiency virus (HIV) treatment goals conflict with guideline-based opioid prescribing: A qualitative study of HIV treatment providers. Subst Abus. 2016;37:148-153.
11. National Institute on Drug Abuse. Prescription opioids and heroin. NIDA Research Report Series. 2015. www.drugabuse.gov/publications/research-reports/prescription-opioids-heroin
12. Conrad C,  Bradley HM,  Broz D, et al. Community outbreak of HIV infection linked to injection drug use of oxymorphone — Indiana, 2015. MMWR. 2015;64:443-444. www.cdc.gov/mmWr/preview/mmwrhtml/mm6416a4.htm
13. Merlin JS. Chronic pain in patients with HIV infection: What clinicians need to know. Topics in Antiviral Medicine. 2015;23:120-124.
14. Raymond D. Injecting opana: Indiana’s HIV outbreak and America’s opioid epidemic. Harm Reduction Coalition. March 2015. https://harmreduction.org/ 

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Gracias a Rachel Anderson, Emily Behar, Neisha Becton, Holvis Delgadillo, Linda Gowing, Barbara Green-Ajufo, Renata Henry, Daryl Mangosing y Savannah O’Neill por revisar esta hoja informativa. Kathleen Clanon está afiliada con Alameda County Health Care Services Agency. 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).