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Despite major progress against HIV, 21% of HIV+ people in the US are unaware that they are positive and an estimated 33% of those who know they are HIV+ are not engaged in care and treatment for their infection.Another 38% of newly diagnosed HIV+ individuals test so late that they receive an AIDS diagnosis at the same time as, or within one year of, learning they are positive. There were an estimated 56,300 new HIV infections per year between 1996 and 2006. Clearly, the US can and must do better in responding to the HIV/AIDS epidemic. One way to increase the percentage of HIV+ people engaged in care and treatment for their infection and improve their health outcomes is to focus on coordinating or co-locating HIV testing, care and treatment, social services and prevention programs. Increasing the percentage of HIV+ people who know their serostatus and are receiving care and antiretroviral treatment could also have benefits for HIV prevention. The National HIV/AIDS Strategy places testing and linkage to care, treatment and support services at the heart of the effort to improve the health outcomes of HIV+ individuals and prevent new infections. What is the scientific basis for this approach, how might it actually be implemented, and will it have the desired results in the real world?

Los programas educativos sobre la sexualidad y el VIH tienen varias metas: disminuir los embarazos no planeados, reducir las enfermedades de transmisión sexual (ETS) incluyendo la del VIH y mejorar la salud sexual de los jóvenes. En 2005 en los EE.UU., el 63% de todos los alumnos del último año de preparatoria (high school) habían tenido relaciones sexuales, pero sólo el 21 % de las alumnas usaron pastillas anticonceptivas antes del último coito y sólo el 70 % de los varones usaron condón en el último coito. En el 2000, el 8.4 % de las chicas entre 15 y 19 años se embarazaron, produciendo una de las tasas más altas de embarazo adolescente en el mundo occidental industrializado. Casi la mitad de los nuevos casos de ETS en EE.UU. del año 2000 (9.1 millones) se presentaron en jóvenes entre los 15 y los 24 años de edad. Algunos de los numerosos factores que influyen en la conducta sexual y el uso de protección entre los adolescentes tienen poco que ver con las relaciones sexuales, por ejemplo: la crianza en una comunidad desfavorecida, la falta de apego a los padres o el fracaso escolar. Otros factores de naturaleza sexual como las creencias, los valores, las percepciones de normas de los pares, las actitudes y habilidades relacionadas con la conducta sexual y con el uso del condón o de anticonceptivos, son factores en los que los programas de enseñanza potencialmente pueden incidir para generar cambios de conducta. Estos programas no pueden por sí solos eliminar las conductas sexuales riesgosas, pero sí pueden ser una pieza eficaz dentro de una iniciativa integral.

Sex and HIV education programs have multiple goals: to decrease unintended pregnancy, to decrease STDs including HIV and to improve sexual health among youth. In 2005, almost two-thirds (63%) of all high school seniors in the US had engaged in sex, yet only 21% of all female students used birth control pills before their last sex and only 70% of males used a condom during their last sexual intercourse. In 2000, 8.4% of 15-19 year old girls became pregnant, producing one of the highest teen pregnancy rates in the western industrial world. Persons aged 15-24 had 9.1 million new cases of STDs in 2000 and made up almost half of all new STD cases in the US. There are numerous factors affecting adolescent sexual behavior and use of protection. Some of these factors have little to do with sex, such as growing up in disadvantaged communities, having little attachment to parents or failing at school. Other factors are sexual in nature, such as beliefs, values, perceptions of peer norms, attitudes and skills involving sexual behavior and using condoms or contraception. It is these sexual factors that sex/HIV education programs can potentially affect, thereby impacting behavior. Sex/HIV education programs alone cannot totally reduce sexual risk-taking, but they can be an effective part of a more comprehensive initiative.

In China, sexual transmission has become the major driving force behind the HIV epidemic, accounting for more than half (52%) of the estimated 700,000 people currently living with HIV. Men who have sex with men (MSM) may contribute to the rapid acceleration of the epidemic throughout China. Studies with Chinese MSM have documented an increasing HIV prevalence, a high HIV incidence, and high rates of unprotected intercourse and sexually transmitted infections (e.g., syphilis) known to facilitate sexual transmission of HIV. Moreover, our work found that HIV-transmission risk behavior is highly prevalent among HIV-positive MSM in China. Nonetheless, no HIV prevention interventions have targeted HIV-positive Chinese MSM. Several interventions have demonstrated efficacy in reducing sexual risk behaviors among HIV-positive MSM in the U.S. Adapting such interventions for HIV-positive MSM in China would help accelerate the process of developing an efficacious intervention for this risk group. The proposed three-year study (R34) will adapt and pilot-test currently available evidence-based behavioral interventions to reduce HIV-transmission risk behavior among HIV-positive MSM in Chongqing, China. This study will be implemented in five phases, guided by Wainberg et al.’s intervention adaptation model. In Step 1, we will identify core components of efficacious interventions (e.g., key theoretical constructs, intervention messages, delivery modes) through the review of the literature. In Step 2, we will explore cultural, psychosocial, and contextual factors associated with sexual risk behaviors and generate ideas for intervention strategies for HIV-positive MSM by conducting 15 key informant interviews with individuals knowledgeable about HIV-positive MSM and 30 in-depth interviews with HIV positive MSM. In Step 3, we will adapt efficacious interventions through reviewing the core elements of efficacious interventions identified in Step 1 and collating those elements with qualitative data collected in Step 2 with an intervention adaptation working group of 10 health professionals and MSM lay workers who serve HIV-positive MSM. In Step 4, we will pilot-test the adapted intervention with 16 HIV-positive MSM and refine the intervention if necessary. In Step 5, we will test the feasibility of implementing and assessing the intervention refined in Step 4 by conducting the intervention with 50 HIV-positive MSM and having these 50 men complete baseline and 3-month surveys.