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Sexual networks

How do sexual networks affect HIV/STD prevention?

What are sexual networks?

Focusing on risk behavior alone does not explain why some persons and communities continue to be infected with HIV and other sexually transmitted diseases (STDs) more than others. Networks help explain why persons can have the same risk behavior and yet one may have a much greater risk of contracting or transmitting HIV. Sexual networks are groups of persons who are connected to one another sexually. The number of persons in a network, how central high-risk persons are within it, the percentage in monogamous relationships and the number of “links” each has to others all determine how quickly HIV/STDs can spread through a network.1 Sexual networks are distinct from, but often overlap with social networks.

How do networks affect transmission?

The different ways persons select partners affect how quickly HIV/STDs can spread. Exclusively monogamous persons are, by definition, not part of a sexual network. If both are HIV-negative they remain so. Serial monogamists are persons who go from relationship to relationship one at a time. If they have unprotected sex, they have a higher risk of HIV/STDs than exclusively monogamous persons. Earlier partners’ risk may affect later partners. Concurrent relationships involve having more than one sexual partner in a given period and going back and forth between them. This increases the probability for transmission because earlier partners can be infected by later partners. Further, they can serve as “nodes”, connecting all persons in a dense cluster, creating highly connected networks that facilitate transmission. Concurrent partners can connect each of their respective clusters and networks as well. Concurrency alone can fuel an epidemic even if the average number of partners is relatively low. The two networks above show that what matters is not simply risk behavior, but risk configuration. Each has 8 persons (circles) connected into 9 relationships. Two persons each have 3 partners, and the other six each have 2 partners. Yet transmission will be less efficient in network A, and prevention will be more difficult in network B. In A, in just two steps from the index person, half the network can be infected and half spared; in B, two steps can result in everyone being infected except for the person on the extreme right. In A, sparing half the population from exposure requires cutting one bridge, while in B, it requires cutting three bridges. In a word, for epidemics, the network structure is destiny.3

What are key concepts of networks?

Number of partners. Programs can focus on persons with the largest number of ties to others in a network. With HIV/STDs, this suggests that in addition to promoting condom usage, programs seek to identify those with a high number of unprotected partners. Random spread broadens transmission. An infection spreads quickest when partnering is random.4 When partners select one another within groups such as age, ethnicity, class, religion or other characteristics, diseases may not spread to all subgroups. When partnering is anonymous or random, a disease can spread more quickly through all groups. Core groups. Core group members have high levels of risky behaviors. They contribute a disproportionate share of HIV/STDs, and can fuel sustained transmission. Centrality. How central an HIV+ person is to a network deeply influences transmission rates in a community. In Colorado Springs, CO, network analysts found that HIV+ persons had high levels of risk behavior but were located in peripheral areas of risk networks.5 This network configuration may have explained the relatively low HIV transmission levels. In contrast, HIV+ persons in New York City, NY occupied central positions within their needle-sharing and sexual risk networks, which helped explain the high observed levels of infection.6

Can sexual networks help explain racial differences in HIV/STD rates?

Yes. Sexual networks and partner selection help explain racial differences in HIV/STD infection rates. For example, African American gay and bisexual men may take no more risk than white men, but appear to get infected much faster.7 In the same way, Asian American gay and bisexual men report similar risk levels but get infected at lower rates.8 In one national study, it was shown that heterosexual African-Americans were getting infected with bacterial STDs at rates almost five times faster than whites after controlling for individual level risk factors. Sexually transmitted infections remain in African American populations because their partner choices are more segregated than other groups. In addition, non-core African-Americans (with few partners) are more likely to choose “core” sexual partners. 9

What interventions influence networks?

Partner notification. Many public health departments have developed highly confidential and sound techniques of partner notification and, through network analysis, have learned to trace “up” the chain of transmission to the transmitter rather than “down” the chain to those infected.10 This allows transmitters to be identified for treatment and HIV/STD prevention counseling. Message development. In addition to promoting condom use and counseling, media messages can be tailored to encourage network fragmentation by encouraging serial monogamy (“one partner at a time”) rather than overlapping partners. Community dialogue. Community-based organizations (CBOs) can play a key role in facilitating community dialogue about difficult questions about networks: How should communities balance sexual freedoms of all–including those at highest risk–with the health and future of their entire community? What community and cultural norms contribute to risky sexual networking? Additionally, CBOs should distinguish between traditionally-defined “risk groups” and those individuals with the very highest levels of risk to focus resources on them. Addressing venues which facilitate partner mixing. In many settings, identification of partners may be impossible. However, by focusing on venues which facilitate sexual mixing between members of both high- and low-risk networks, HIV/STD prevention workers may be able to reduce transmission. For example, many men with syphilis report meeting partners over the internet and in commercial sex venues.11,12 Working with bathhouse and sex club managers and internet service providers to negotiate respective roles in promoting safer behaviors should be a priority for HIV/STD intervention workers. In San Francisco, CA, AIDS educators and sex club owners developed a shared set of guidelines to reduce risky behavior in the clubs.13 In the Netherlands, the gay dating internet site www.dateguide.nl provides interactive safer sex education for every man as he logs on.14

What still needs to be done?

At the beginning of the epidemic, network analysis helped explain some of the most important features of AIDS and helped explain its causes.15 It can still be useful now for agencies, communities, and researchers to work together to encourage sexual networks that discourage HIV/STD transmission. It has long been known and understood that some individuals contribute much more to the spread of HIV/STDs than others. Ignoring that fact, and ignoring the role of sexual networks in fueling the epidemic, hampers our ability to slow HIV/STD transmission.

Says who?

1. Potterat JJ, Muth SQ, Brody S. Evidence undermining the adequacy of the HIV reproduction number formula. Sexually Transmitted Diseases. 2000;27:644-645. 2. Morris M. Sexual networks and HIV. AIDS. 1997;11:S209-216. 3. Klovdahl AS, Potterat JJ, Woodhouse D, et al. HIV infection in a social network: A progress report. Bulletin de Methodologie Sociologique. 1992;36:24-33. 4. Laumann EO, Gagnon J, Michael R, Michaels S. The Social Organization of Sexuality. Chicago: The University of Chicago Press, 1994. 5. Rothenberg RB, Potterat JJ, Woodhouse DE, et al. Social network dynamics and HIV transmission. AIDS. 1998;12:1529-1536. 6. Friedman SR, Neaigus A, Jose B, et al. Sociometric risk networks and risk for HIV infection. American Journal of Public Health. 1997;87:1289-1296. 7. Centers for Disease Control and Prevention. HIV Incidence Among Young Men Who Have Sex With Men—-Seven U.S. Cities, 1994-2000. Morbidity and Mortality Weekly Report. 2001;50:440-444. 8. Choi KH, Operario D, Gregorich S, et al. Age and race mixing patterns of sexual partnerships among Asian men who have sex with men: implications for HIV transmission and prevention. AIDS Education and Prevention. 2003;15:S53-65. 9. Laumann EO, Youm Y. Racial/ethnic group differences in the prevalence of sexually transmitted diseases in the United States: a network explanation. Sexually Transmitted Diseases. 1999;26:250-61. 10. Ghani AC, Ison CA, Ward H, et al. Sexual partner networks in the transmission of sexually transmitted diseases. An analysis of gonorrhea cases in Sheffield, UK. Sexually Transmitted Diseases. 1996;23:498-503. 11. Klausner JD, Wolf W, Fischer-Ponce L, et al. Tracing a syphilis outbreak through cyberspace. Journal of the American Medical Association. 2000;284: 447-449. 12. Williams LA, Klausner JD, Whittington WL, et al. Elimination and reintroduction of primary and secondary syphilis. American Journal of Public Health. 1999;89:1093-1097. 13. Wohlfeiler D. Structural and environmental HIV prevention for gay and bisexual men. AIDS. 2000;14:S52-S56. 14. Harternik P, van Berkel M, van den Hoek K, et al. e-Dating: a developing field for HIV prevention. Published by the Dutch AIDS Fund. www.dateguide.nl 15. Auerbach DM, Darrow WW, Jaffe HW, et al. Cluster of cases of the acquired immune deficiency syndrome. Patients linked by sexual contact. American Journal of Medicine. 1984;76:487-92. Prepared by Prepared by Dan Wohlfeiler*, John Potterat *UCSF April 2003. Fact Sheet #50E Special thanks to the following reviewers of this Fact Sheet: Buzz Bense, Peggy Dolcini, Paul Etkind, Sam Friedman, Azra Ghani, Jed Herman, Ed Laumann, Virginia Loo, Robin Miller, Michael Samuel, Tom Valente, Russell Westacott.

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]. © April 2003, University of California

Resource

Redes sexuales

¿Cómo afectan las redes sexuales a la prevención del VIH/ETS?

¿qué son las redes sexuales?

El comportamiento de riesgo no es suficiente para explicar por qué algunas personas y comunidades (más que otras) siguen infectándose por el VIH y otras enfermedades de transmisión sexual (ETS). Las redes ayudan a explicar cómo dos personas pueden tener la misma conducta riesgosa y sin embargo una puede tener un riesgo mucho mayor de contraer o de transmitir el VIH. Las redes sexuales son grupos de personas interconectadas sexualmente. El número de personas en la red, la centralidad de las personas de alto riesgo, el porcentaje de relaciones monógamas y el número de “enlaces” que cada individuo tiene con los otros, son todos determinantes de la rapidez con la cual el VIH y las ETS pueden ser transmitidas por la red.1 Las redes sexuales son distintas a las redes sociales, aunque muchas veces se traslapan.

¿cómo afectan las redes en la transmisión?

Las diferentes maneras de elección de parejas afectan la rapidez de propagación del VIH y las ETS. Por definición, las personas exclusivamente monógamas no forman parte de ninguna red sexual. Si ambas personas son VIH-negativas, permanecerán así. Los monógamos seriales son personas que terminan una relación antes de pasar a la próxima. Si tienen sexo sin protección, corren más riesgo de contraer el VIH o una ETS que las personas exclusivamente monógamas. El riesgo de las parejas anteriores puede afectar a las parejas posteriores. En las relaciones concurrentes, se tiene más de una pareja sexual en el mismo periodo y se tienen relaciones sexuales con una y otra alternativamente; lo cual aumenta la probabilidad de transmisión, pues las parejas anteriores pueden ser infectadas por las parejas posteriores. Además, las relaciones concurrentes pueden servir como “puntos o nodos” que conectan a todas las personas de la red en una densa agrupación, creando redes ampliamente conectadas que facilitan la transmisión. Las parejas concurrentes también pueden conectar a cada una de sus agrupaciones y redes respectivas. La concurrencia por sí sola puede generar una epidemia aunque el número promedio de parejas sea relativamente reducido. Las dos redes representadas arriba demuestran que no solo importa la conducta de riesgo sino también de la configuración del riesgo. Cada red tiene 8 personas (círculos) interconectadas que forman 9 relaciones. Dos personas tienen 3 parejas cada una, y las otras seis tienen 2 parejas cada una, pero la transmisión será menos eficiente en la red A y la prevención será más difícil en la red B. En la red A, a tan sólo dos pasos de la persona índice, la mitad de los integrantes de la red se pueden infectar mientras que la mitad puede permanecer libre de infección; en la B, a dos pasos todos pueden resultar infectados menos la persona situada al extremo derecho. Para evitar la exposición de la mitad de la población de la red A, es necesario cortar un solo enlace, mientras que en la red B se deberán cortar tres enlaces. En otras palabras, cuando se trata de una epidemia, el destino de las personas depende de la estructura de su red sexual.3

¿cuáles son los conceptos clave?

Número de parejas: Los programas se pueden enfocar en las personas con el mayor número de enlaces en la red. Con respecto al VIH/ETS, esto sugiere que además de promover el uso de condones, los programas deben identificar a las redes con un alto número de parejas desprotegidas. La difusión aleatoria amplifica la transmisión: La infección se propaga con más rapidez cuando la formación de parejas se hace aleatoriamente.4 Cuando las parejas se eligen por compartir ciertas características (como edad, grupo étnico o clase socioeconómica), es posible que la enfermedad no llegue a transmitirse a todos los subgrupos. Cuando la elección se realiza en forma aleatoria o anónima, la enfermedad se puede transmitir más rápidamente entre todos los grupos. Grupos centrales: Los integrantes del grupo central tienen un comportamiento de riesgo alto, contribuyen desproporcionadamente a la transmisión del VIH/ETS y pueden alimentar una transmisión sostenida. Centralidad: El grado de centralidad de una persona VIH+ dentro de la red tiene una influencia profunda sobre las tasas de transmisión en la comunidad. En Colorado Springs, CO, un análisis de redes reveló que las personas VIH+ tenían niveles altos de conducta riesgosa pero se situaban en la periferia de las redes de riesgo.5 Esta configuración de red puede haber explicado los niveles relativamente reducidos del VIH. En contraste, las personas VIH+ en la ciudad de Nueva York, NY ocupaban posiciones centrales dentro de sus redes de uso de jeringas compartidas y de riesgo sexual, lo cual ayudó a explicar los elevados niveles de infección observados entre ellas.6

¿pueden las redes sexuales ayudar a explicar diferencias raciales en las tasas de VIH/ETS?

Sí. Las redes sexuales y la selección de parejas ayudan a explicar las diferencias raciales en las tasas de VIH y ETS. Por ejemplo, aunque no se arriesguen más que los caucásicos los hombres afroamericanos gay y bisexuales, parecen infectarse mucho más rápidamente.7 De la misma manera, los hombres asiáticos gay y bisexuales reportan niveles parecidos de riesgo pero se infectan con menos frecuencia.8 Un estudio nacional demostró que los afroamericanos heterosexuales se infectaban con ETS casi cinco veces más rápidamente que los caucásicos después de controlar los factores de riesgo individuales. Las infecciones transmitidas sexualmente permanecen en las poblaciones afroamericanas porque la elección de parejas se hace en forma más segregada que en otros grupos. Además, los afroamericanos “no centrales” (con pocas parejas sexuales) son más propensos a elegir parejas sexuales “centrales”. En cambio, los caucásicos no centrales tienden a elegir parejas no centrales.9

¿qué intervenciones influyen en las redes?

Notificación de pareja: Muchos departamentos de salud pública han desarrollado técnicas sumamente confidenciales y confiables de notificación de parejas y, mediante el análisis de redes, han aprendido a rastrear “subiendo” por la cadena de transmisión hacia el transmisor en lugar de “bajar” por la cadena hacia las parejas infectadas.10 Esto les permite identificar a los transmisores y remitirlos a servicios de tratamiento y de asesoramiento sobre la prevención del VIH y las ETS. Formulación de mensajes: Además de la promoción del uso de condones y la consejería, se pueden difundir mensajes específicos en los medios de comunicación para fomentar la fragmentación de la red, lo cual se hace promoviendo la monogamia serial (“una pareja la vez”) en lugar de tener parejas concurrentes. Diálogo comunitario: Las organizaciones comunitarias (OC) pueden ser clave para facilitar el diálogo sobre las preguntas difíciles acerca de las redes en la comunidad: ¿Cómo deben las comunidades equilibrar las libertades sexuales de todos (incluyendo las personas de alto riesgo) con la salud y el futuro de la comunidad entera? ¿Qué normas comunitarias y culturales contribuyen a la formación de redes sexuales riesgosas? Las OC también deben distinguir entre los tradicionalmente definidos “grupos de riesgo” y aquellos individuos de más alto riesgo, con el fin de canalizar recursos hacia estos últimos. Lugares que facilitan el intercambio sexual de parejas: En muchos ambientes, la identificación de parejas puede ser imposible. Sin embargo, es posible que al focalizar lugares en donde las redes de alto riesgo se mezclan sexualmente con las de bajo riesgo, los promotores de la prevención del VIH y las ETS puedan reducir la transmisión. Por ejemplo, muchos hombres con sífilis informan haber conocido a parejas en internet y lugares de comercialización sexual.11,12 Los trabajadores de intervenciones contra el VIH y las ETS deben priorizar la colaboración con los gerentes de baños públicos y de clubes sexuales y con los proveedores de servicios de internet para negociar sus papeles respectivos en la promoción de conductas más seguras. En San Francisco, CA, los educadores de SIDA y los propietarios de clubes sexuales establecieron una serie de normas compartidas para reducir las prácticas riesgosas en los clubes.13 En los Países Bajos, el sitio en internetwww.dateguide.nl para hombres gay que buscan pareja proporciona a quien entre al sitio una educación interactiva sobre cómo protegerse en el sexo.14

¿qué queda por hacer?

Al principio de la epidemia, el análisis de redes ayudó a explicar algunos de los aspectos más importantes del SIDA así como sus causas, y puede ser útil todavía en las colaboraciones entre organizaciones, comunidades e investigadores para fomentar la formación de redes sexuales que impidan la transmisión del VIH y las ETS.15 Hace tiempo que se sabe y se entiende que algunos individuos contribuyen mucho más a la transmisión del VIH y las ETS que otros. No darle importancia a este hecho y al papel de las redes sexuales en alimentar la epidemia impide nuestra capacidad para desacelerar la transmisión del VIH y las ETS.

¿quién lo dice?

1. Potterat JJ, Muth SQ, Brody S. Evidence undermining the adequacy of the HIV reproduction number formula. Sexually Transmitted Diseases. 2000;27:644-645. 2. Morris M. Sexual networks and HIV. AIDS. 1997;11:S209-216. 3. Klovdahl AS, Potterat JJ, Woodhouse D, et al. HIV infection in a social network: A progress report. Bulletin de Methodologie Sociologique. 1992;36:24-33. 4. Laumann EO, Gagnon J, Michael R, Michaels S. The Social Organization of Sexuality. Chicago: The University of Chicago Press, 1994. 5. Rothenberg RB, Potterat JJ, Woodhouse DE, et al. Social network dynamics and HIV transmission. AIDS. 1998;12:1529-1536. 6. Friedman SR, Neaigus A, Jose B, et al. Sociometric risk networks and risk for HIV infection. American Journal of Public Health. 1997;87:1289-1296. 7. Centers for Disease Control and Prevention. HIV Incidence Among Young Men Who Have Sex With Men—-Seven U.S. Cities, 1994-2000. Morbidity and Mortality Weekly Report. 2001;50:440-444. 8. Choi KH, Operario D, Gregorich S, et al. Age and race mixing patterns of sexual partnerships among Asian men who have sex with men: implications for HIV transmission and prevention. AIDS Education and Prevention. 2003;15:S53-65. 9. Laumann EO, Youm Y. Racial/ethnic group differences in the prevalence of sexually transmitted diseases in the United States: a network explanation. Sexually Transmitted Diseases. 1999;26:250-61. 10. Ghani AC, Ison CA, Ward H, et al. Sexual partner networks in the transmission of sexually transmitted diseases. An analysis of gonorrhea cases in Sheffield, UK. Sexually Transmitted Diseases. 1996;23:498-503. 11. Klausner JD, Wolf W, Fischer-Ponce L, et al. Tracing a syphilis outbreak through cyberspace. Journal of the American Medical Association. 2000;284: 447-449. 12. Williams LA, Klausner JD, Whittington WL, et al. Elimination and reintroduction of primary and secondary syphilis. American Journal of Public Health. 1999;89:1093-1097. 13. Wohlfeiler D. Structural and environmental HIV prevention for gay and bisexual men. AIDS. 2000;14:S52-S56. 14. Harternik P, van Berkel M, van den Hoek K, et al. e-Dating: a developing field for HIV prevention. Published by the Dutch AIDS Fund. www.dateguide.nl 15. Auerbach DM, Darrow WW, Jaffe HW, et al. Cluster of cases of the acquired immune deficiency syndrome. Patients linked by sexual contact. American Journal of Medicine. 1984;76:487-92.

Preparado por Dan Wohlfeiler*, John Potterat. *UCSF Traducción Rocky Schnaath Septiembre 2003. Hoja Informativa 50S

Resource

Stigma (fact sheet)

How does stigma affect HIV prevention and treatment?

Prepared by Pamela DeCarlo and Maria Ekstrand, PhD Community Engagement (CE) Core | October 2016

What is HIV/AIDS stigma?

HIV-related stigma is a significant problem globally.  HIV stigma inflicts hardship and suffering on people living with HIV and interferes with research, prevention, treatment, care and support efforts. HIV-related stigma refers to negative beliefs, feelings and attitudes towards people living with HIV, their families and people who work with them. HIV stigma often reinforces existing social inequalities based on gender, race, ethnicity, class, sexuality and culture. Stigma against many vulnerable populations who are disproportionately affected by HIV (such as the stigma of homosexuality, drug use, poverty, migration, transgender status, mental illness, sex work and racial, ethnic and tribal minority status) predates the epidemic and intersects with HIV stigma, which compounds the stigma and discrimination experienced by people living with HIV (PLWH) who belong to such groups.1 HIV-related discrimination, also known as enacted HIV stigma, refers to the unfair and unjust treatment of someone based on their real or perceived HIV status. Discrimination also affects family members and friends, caregivers, healthcare and lab staff who care for PLWH. The drivers of HIV-related discrimination usually include misconceptions regarding casual transmission of HIV and pre-existing prejudices against certain populations, behaviors, sex, drug use, illness and death. Discrimination can be institutionalized through laws, policies and practices that unjustly affect PLWH and marginalized groups.1

How is HIV stigma harmful?

Stigma and discrimination add barriers which weaken the ability of people and communities to protect themselves from HIV and to stay healthy if they are living with HIV. To persons living with HIV. Fear of stigma, discrimination and potential violence, may keep people from disclosing their status to family, friends and sexual partners. This can increase isolation and undermine their ability to access and adhere to treatment, and undermine prevention efforts such as using condoms and not sharing drug equipment. Enacted stigma can result in losing housing and jobs, being ostracized by family, and being treated badly in healthcare facilities, among other effects. To vulnerable populations. The way people experience stigma varies across countries and communities. Stigma discourages people from seeking information and programs, for fear it will make others think they have HIV, are promiscuous or unfaithful, or are members of populations associated with HIV, like people who inject drugs, sex workers and gay men. It can make people less likely to get tested for HIV, use condoms, ask their partners about their status, use clean needles and injection equipment, or access biomedical prevention options such as male circumcision and pre-exposure prophylaxis (PrEP).

How do people cope with stigma?

Several factors help individuals cope with HIV-related stigma, and respond to feelings of worthlessness, depression, and anger associated with their diagnosis. Many people learn to manage or cope with stigma quite well and have very positive relationships not impacted greatly by stigma, especially if they have supportive family and friends. Social support. For many PLWH, social support can help buffer the impact of any stigma. A study of African American PLWH found many had experienced stigma and discrimination, but the impact was softened by having non-PLWH in their social networks express interest and take the initiative to offer help. Connection with other PLWH gave them an opportunity to share their feelings and to fight for their rights.2 A study of young African American men who have sex with men (MSM) found that stigma of racism and homophobia was associated with delayed HIV testing, but that men with peer support tested earlier.3 Adapting and coping. Although it can be difficult for persons in already stigmatized communities to identify as HIV-positive, many PLWH do accept their HIV status and successfully form an identity of being pro-active and choosing to live. Adequate treatment for depression and anxiety, along with acceptance of one’s diagnosis, provide a protective buffer against stigma and promote acceptance of lifelong HIV treatment.4

How is HIV stigma addressed?

Stigma exists, and should be targeted at multiple levels: individual, interpersonal (family, friends, social networks), organizational, community and public policy.5 Involving PLWH in the design, creation, implementation and evaluation of stigma reduction programs is critical to success. Individual level Increasing individual knowledge about HIV transmission, prevention and care, as well as access to services and legal rights is important. One study in South Africa found that while some PLWH experienced stigma through insults and arguments with family members during conflict, they knew that disclosing someone’s status without their consent was a crime. In these instances, threatening to go to the police, or sometimes actually calling the police, allowed PLWH to fight back and maintain their self-esteem.6 Interpersonal level The We Are Family campaign from Greater Than AIDS and the Georgia Department of Public Health, reinforces the importance of social support for PLWH. The video campaign features a grandmother and her grown son, a college student and his parents, a pastor and his congregation, a recovering addict and his mother, a transgender woman and her sister, and childhood best friends, all supporting one another following an HIV diagnosis.7 Organizational level Healthcare providers are often named by PLWH as important sources of stigma.8 Programs for training healthcare workers9 should address culturally-specific stigma drivers, including personal fears of infection, prejudice towards vulnerable groups, and misconceptions or lack of knowledge about HIV transmission, prevention, treatment and universal precautions.10 Programs also should address how the effect of stigma, discrimination, breaches of confidentiality and negative attitudes can negatively impact patients’ lives, health, and ability to follow treatment regimens. Biomedical and behavioral approaches to HIV prevention, such as PrEP, routine HIV testing, starting treatment soon after diagnosis (test and treat), and treatment for PLWH to viral suppression, have been successful in the US and several countries in reducing new HIV infections and improving the life and health of PLWH. However, HIV stigma and discrimination can greatly impact the success of these interventions. Stigma surrounding PrEP use, including assumptions about promiscuity, can negatively affect PrEP access and uptake.11 Prejudice among healthcare workers may result in drug users, young adults, women12 and other marginalized populations not being offered either PrEP or HIV testing. Community level The Let’s Stop HIV Together campaign, launched by the Centers for Disease Control and Prevention (CDC), raises awareness about HIV and its impact on the lives of all Americans, and fights stigma by showing that persons with HIV are real people—mothers, fathers, friends, brothers, sisters, sons, daughters, partners, wives, husbands, and co-workers. The campaign offers facts about HIV, links to testing sites across the US, guidance for taking action against stigma, and online stories about PLWH, and the people who care for them.13 Policy level In Ghana, the Commission on Human Rights and Administrative Justice, the Ghana AIDS Commission and the Health Policy Project developed a web-based mechanism for PLWH to report discrimination in employment, health care, education and other areas. Reports can be anonymous, and all reports result in mediation, investigation and legal resolution by human rights and legal organizations.14

What needs to be done?

Both the US White House and UNAIDS reports recommend focusing on key populations that have high and disproportionate rates of HIV, and are at higher risk for transmitting and acquiring HIV.1,15 Reducing stigma for other conditions common among persons at risk for or living with HIV—such as substance use, mental health problems, sex work and homelessness—and addressing homophobia are important efforts to improve health outcomes. However, promotion of disclosure of HIV status must be accompanied by protections for PLWH. This calls for a continued commitment to civil rights enforcement.

Says who?

1. UNAIDS. Reduction of HIV-related stigma and discrimination. Guidance Note. 2014. www.unaids.org/en/resources/documents/2014/ReductionofHIV-relatedstigma… 2. Mosack KE, Stevens PE, Brouwer AM, et al. Shared illness and social support within two HIV-affected African American communities. Qualitative Health Research. 2015 Oct 28. 3. Scott HM, Pollack L, Rebchook GM, et al. Peer social support is associated with recent HIV testing among young black men who have sex with men. AIDS and Behavior. 2014;1:913-920. 4. Katz IT, Ryu AE, Onuegbu AG, et al. Impact of HIV-related stigma on treatment adherence: systematic review and meta-synthesis. Journal of the International AIDS Society. 2013, 16(Suppl 2):18640. 5. Stangl AL, Lloyd JK, Brady LM, et al. A systematic review of interventions to reduce HIV-related stigma and discrimination from 2002 to 2013: how far have we come? Journal of the International AIDS Society. 2013;16(Suppl 2):18734.) 6. Abrahams N, Jewkes R. Managing and resisting stigma: a qualitative study among people living with HIV in South Africa. Journal of the International AIDS Society. 2012;15:17330. 7. We Are Family. www.greaterthan.org/we-are-family-love-saves-lives/ 8. UNAIDS. Key programmes to reduce stigma and discrimination and increase access to justice in national HIV responses. Guidance Note. 2012. https://www.unaids.org/en/resources/documents/2012/Key_Human_Rights_Programmes  9. Kidd R and Clay S. Understanding and challenging HIV stigma: Toolkit for action. International Center for Research on Women. 2003. www.icrw.org/publications/understanding-and-challenging-hiv-stigma-tool… 10. Ekstrand ML, Ramakrishna J, Bharat S, et al. Prevalence and drivers of HIV stigma among health providers in urban India: implications for interventions. Journal of International AIDS Society. 2013;16:18717. 11. Calabrese SK, Underhill K. How Stigma Surrounding the Use of HIV Preexposure prophylaxis undermines prevention and pleasure: A call to destigmatize “Truvada whores.” American Journal of Public Health. 2015;105:1960–1964. 12. Auerbach JD, Kinsky S, Brown G, et al. Knowledge, attitudes, and likelihood of pre-exposure prophylaxis (PrEP) use among US women at risk of acquiring HIV. AIDS Patient Care and STDs. 2015. 29:102-110. 13. CDC. Let’s Stop HIV Together. www.cdc.gov/actagainstaids/campaigns/lsht/ 14. UNAIDS. On the Fast-Track to end AIDS by 2030: Focus on location and population. 2015. www.unaids.org/en/resources/documents/2015/FocusLocationPopulation 15. The White House. The National HIV/AIDS Strategy: Updated to 2020. https://www.hiv.gov/federal-response/national-hiv-aids-strategy/nhas-update

Prepared by Pamela DeCarlo and Maria Ekstrand PhD, CAPS *CAPS October 2016 . Special thanks to the following reviewers of this Fact Sheet: Sarah Calabrese, Barbara Green-Ajufo, Cynthia Grossman, William Holzemer, Sebastian Kevany, Daryl Mangosing, Cynthia Tucker. 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. ©2016, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected].

Resource

Adapting programs

Can HIV Prevention Programs Be Adapted?

Why adapt?

We know that many HIV prevention interventions have made a difference, and that prevention efforts have helped to lower rates of HIV infection in many different populations.1 But as the HIV epidemic changes, so too do the number and groups of people at risk for HIV. Adapting interventions allows us to use principles we know are effective to address the needs of those newly at risk, who may not have been studied yet. Developing new interventions is expensive and time consuming, and it makes good sense to adapt programs that have been demonstrated to be effective.2 Using existing tools and theories of successful programs can save time and money. In an age when money for prevention is limited, adapting interventions can be cost-effective.

Aren’t all populations different?

Yes and no. While each community or population is unique, there are many similarities between populations and their social, political and emotional environments. While injecting drug users in Chicago, IL may have very different needs than young gay men in Eugene, OR, both may benefit from similar aspects of programs. For example, using peer educators to help spread the message and change community norms can be effective for both groups.3,4 HIV prevention is more than simply teaching safer sex and safe drug use nuts and bolts. Prevention programs need to take into account the life context in which a person applies safer sex, and the relationship to the HIV epidemic of the person. Prevention programs need to be tailored to these different situations, not reinvented entirely.

What helps with adaptation?

Program planners can choose from a variety of elements of prevention programs that can address their own local population, setting or intervention needs. Staff training and technical assistance to understand and effectively implement programs is key for successful adaptation. Understanding the community is integral to adapting programs.5 Service organizations often know their populations best, whether through outreach or needs assessment. Before adapting an intervention, it is essential to understand the characteristics of the original program and its audience, and how they are different or similar to the new environment. Theory gives a background for behavior change, and may also be useful in assessing whether an intervention is appropriate for a different target group. For example, the Social Cognitive theory of behavior calls for learning through interactions with other people and using physical and social environments to produce change.6 Role playing, community building, interactive videos and job training can all be components of a program using this theory. Peer education has been an important element of prevention programs and serves as a powerful motivator especially for disenfranchised people. Such programs recruit peer educators who are at high risk, and teach them how to educate and help save the lives of their friends and colleagues.7 This recognizes that people in their own communities have tremendous power of persuasion and can be effective agents of change. Another successful prevention element involves addressing notions of family, community and ethnic pride.8 For example, offering parenting and communicating classes often attracts more participation from parents than offering classes specifically about HIV. Appealing to protecting and supporting the community or family-children, spouses, relatives-can be more encouraging than simply protecting oneself.

What are some examples?

The STOP AIDS project in San Francisco, CA, has served as a model for HIV prevention across the country.9 The model, based on community mobilization and outreach and small group meetings, has been adapted and used for gay men across the country.9 The STOP AIDS model has been used in Los Angeles, CA, West Palm Beach, FL, Phoenix, AZ and Chicago, IL, among other cities. In San Francisco, clients have been recruited on the streets and at bars, while in Chicago, the program has gone into schools. They have found that HIV prevention programs work better when high levels of local commitment are established in a city. Healthy Oakland Teens (HOT), a peer-based sex education program at a junior high school in Oakland, CA, trained ninth graders to lead classes on sexuality and HIV/AIDS to seventh graders. After one year, students in the program were less likely to initiate activities such as deep kissing, genital touching, and sexual intercourse.10 HOT was then adapted to address Balinese youth who were perceived at risk for HIV due to increasing HIV seroprevalence and an extensive tourist and sex industry in Bali. In Bali, researchers found that among members of traditional Balinese youth groups, only 14% of those who were sexually active had used condoms. Although most still lived at home, only 33% reported feeling comfortable discussing sexuality with their parents, while 75% felt comfortable discussing it with their peers. The HOT model of peer education was therefore seen to be appropriate, and the setting was changed from public schools to traditional Balinese youth groups which reach all Balinese youth regardless of socioeconomic status or educational level.11 One successful prevention program for gay men in small cities recruited popular opinion leaders from bars, and trained them to deliver and model prevention messages to their peers.12 This program was then adapted to address minority women in inner city housing developments. However, the program didn’t work there. The reason? Women didn’t know their neighbors, and because of high crime rates in the housing developments, were reluctant to open their doors to someone they didn’t know. This program was then reworked, starting by helping women in the housing developments establish a sense of community through potluck dinners and music festivals. As a result, not only did the women increase condom use and communication, but the community began to tackle other issues besides HIV such as drugs and violence in the housing development.13

What needs to be done?

Service organizations need to commit time and resources to training staff in effective use of prevention programs, including using theory, conducting needs assessments and reaching out to researchers and other organizations to find out what interventions have been shown to be effective. Community planning groups (CPGs) need to facilitate better communication and stable relationships between researchers, community based organizations and Health Departments. CPG Program Coordinators can help link CPGs with local researchers to help community-based prevention planners determine the best adaptations to make. Researchers need to move from small scale efficacy studies to wide scale field trials. Many interventions are effective in what can be a very controlled research environment (clients often receive payment, staff is well paid and often have advanced degrees). These interventions then need to be tested in the “real world” to see how they may need to be adapted or modified to ensure effectiveness under different conditions and with different populations. Funders need to commit funds to adaptation and pilot testing new programs at the community level. A comprehensive HIV prevention strategy uses many elements to protect as many people at risk for HIV as possible. Adapting existing interventions can be a money-saving and effective prevention strategy.

Says who?

  1. Office of Technology Assessment. The Effectiveness of AIDS Prevention Efforts. 1995.
  2. Holtgrave DR, Qualls NL, Curran JW, et al. An overview of the effectiveness and efficiency of HIV prevention programs . Public Health Reports. 1995;110:134-146.
  3. Weibel W, Jimenez A, Johnson W, et al. Positive effect on HIV seroconversion of street outreach intervention with IDUs in Chicago. Presented at the 9th International Conference on AIDS. Berlin, Germany, 1993. Abstract WSC152.
  4. Hays RB, Rebchook, GM, Kegeles SM. The Mpowerment project: a community-level HIV prevention intervention for young gay and bisexual men . American Journal of Public Health. 1996;86:1-8.
    • Contact: Susan Kegeles 415/597-9159.
  5. Herek GM, Greene B, eds. AIDS, identity, and community : the HIV epidemic and lesbians and gay men . Thousand Oaks, CA: Sage Publications; 1995.
  6. Bandura A. Social cognitive theory and exercise of control over HIV infection. In DiClemente RJ, ed. Preventing AIDS: Theories and Methods of Behavioral interventions . New York, NY: Plenum Press; 1994.
  7. Grinstead OA, Zack B, Faigeles B. Effectiveness of peer HIV education for prisoners. Presented at the Biopsychosocial Conference on AIDS; Brighton, England. 1994.
    • Contact: Barry Zack, Marin AIDS Project 415/457-2487.
  8. Díaz RM. HIV risk in Latino gay/bisexual men: a review of behavioral research. Report prepared for the National Latino/a Lesbian and Gay Organization. 1995.
    • Contact: Jose Ramón Fernández-Peña, Mission Neighborhood Health Center, 415/552-1013 X386.
  9. Wohlfeiler D. Community Organizing and Community Building Among Gay and Bisexual Men. In Minkler M, ed. Community Organizing and Community Building for Health . Rutgers University Press. (in press).
    • Contact: Dan Wohlfeiler 415/575-1545.
  10. Ekstrand ML, Siegel D, Nido V, et al. Peer-led AIDS prevention delays initiation of sexual behaviors among US junior high school students. Presented at 11th International Conference on AIDS, Vancouver, BC. 1996.
    • Contact: Maria Ekstrand 415/597-9160.
  11. Merati T, Wardhana M, Ekstrand M, et al. HIV risk taking among youth participating in peer-led AIDS education programs in traditional Balinese youth groups. Presented at the 11th International Conference on AIDS; Vancouver BC. 1996. Th.C.4411.
  12. Kelly JA, St. Lawrence JS, Stevenson LY, et al. Community AIDS/HIV risk reduction: the effects of endorsements by popular people in three cities . American Journal of Public Health. 1992;82.1483-1489.
    • Contact: Jeff Kelly 414/287-4680.
  13. Sikkema KJ, Kelly J, Heckman T, et al. Effects of community-level behavior change intervention for women in low-income housing developments. Presented at the 11th International Conference on AIDS; Vancouver BC. 1996. Tu.C.453.
Contact: Kathy Sikkema 414/287-6100.

Prepared by Pamela DeCarlo and Jeff Kelly

Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National AIDS Clearinghouse at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. ©1996, University of California

Resource

Adaptación de programas

Se pueden adaptar los programas de prevención del VIH?

¿para qué adaptarlos? Sabemos que muchas intervenciones de prevención del VIH han logrado hacer la diferencia y que los esfuerzos de prevención han ayudado a reducir las tasas de infección con VIH en diferentes poblaciones.1 Así como la epidemia del VIH cambia, igual ocurre con las cantidades y los grupos poblacionales afectados por el este virus. Adaptar intervenciones nos permite usar los principios que han comprobado ser eficaces y luego ser aplicadarlos a aquellos grupos que recién entran a formar parte del riesgo y que por lo tanto no han sido analizados. Crear intervenciones consume tiempo y dinero, por esta razón adaptar programas que han demostrado su eficacia es lo más sensato.2 Usando las herramientas y teorías de otros programas exitosos puede ahorrarnos tiempo y dinero. En una época en la que los fondos de prevención escasean, adaptar intervenciones puede ser lo más apropiado para el bolsillo. ¿acaso son iguales los diferentes grupos poblacionales? Sí y no. A pesar de que cada comunidad o población es única, existen muchas semejanzas entre ellas, incluyendo el entorno social, político y emocional. Si bien es cierto que los usuarios de drogas intravenosas de Chicago, IL y los jóvenes gay de Eugene, OR tienen diferentes necesidades, ambos pueden beneficiarse de ciertos aspectos que ofrecen los programas de intervención. Por ejemplo, ambas poblaciones pueden usar personas del mismo grupo para transmitir mensajes y cambiar normas de grupo.3,4 La prevención del VIH va más allá de la enseñanza del sexo seguro y del uso responsable de las drogas. Los programas de prevención necesitan tomar en cuenta el contexto de la vida de la persona que practica el sexo seguro y la relación de esta persona con respecto a la epidemia. Los programas de prevención pueden ser adaptados de acuerdo a las circunstancias que se presentan, no necesariamente reinventarlo totalmente. ¿cómo se logra esta adaptación? Para adaptar un programa, es esencial conocer bien a la comunidad a intervenir.5 Las organizaciones que ofrecen servicios a nivel comunal son quienes mejor conocen a su población, a través del reclutamiento o del estudio de sus necesidades. Antes de adaptar un programa de intervención es necesario entender muy bien las características del programa original, a su audiencia habrá también que identificar las diferencias y semejanzas con relación al ambiente al que será adaptado. La teoría nos brinda las bases para ejercer el cambio conductual, esta a su vez puede ser muy útil para darse cuenta si la intervención es apropiada para el grupo que será intervenido. Por ejemplo, la teoría Social Cognitiva nos conduce al aprendizaje por medio de la interacción con otras personas, utilizando el entorno social y físico para producir el cambio.6 Las dramatizaciones, la creación de la conciencia a nivel comunitario, los juegos interactivos, la enseñanza de un oficio, todos estos elementos pueden formar parte de un programa basado en esta teoría. La educación impartida por personas del mismo grupo al que se va a tratar puede ser un elemento exitoso y sirve de gran motivación, especialmente entre las personas en desventaja. Estos programas reclutan a aquellas personas que están a riesgo y se les entrena para que puedan educar y salvar las vidas de aquellos que corren el mismo riesgo.7 Esto pone en evidencia que hay miembros dentro de la comunidad que pueden actuar como agentes que tienen la capacidad de lograr el cambio. Otro elemento exitoso consiste en utilizar principios de familia, el orgullo por la raza y despertar el sentido de comunidad.8 Por ejemplo, se obtiene mayor participación de los padres de familia al ofrecer clases de comunicación entre padres e hijos que si se ofrecieran clases específicas sobre el VIH. Hacer un llamado a la comunidad para que proteja a la familia, a los hijos, esposos y esposas y a que se apoyen entre sí, puede ser más estimulante que hacer un llamado para protegerse a sí mismo. ¿algunos ejemplos? El proyecto “STOP AIDS” de San Francisco, CA ha servido de modelo en la prevención del VIH en toda la nación.9 El modelo, basado en la movilización de la comunidad, el reclutamiento y las pequeñas reuniones de grupo, ha sido adaptado y usado por hombres gay a lo largo del país. El modelo de “STOP AIDS” se ha usado en los Angeles, CA, West Palm Beach, FL, Phoenix, AZ y en Chicago, IL, entre otras. En San Francisco, los clientes han sido reclutados en la calle y en los bares, mientras que en Chicago el programa se ha hecho en las escuelas. Se ha descubierto que los programas de prevención funcionan mejor si ya existe un sentido de responsabilidad comunitario en la ciudad que se piensa intervenir. El “Healthy Oakland Teens” (HOT), un programa de educación sexual impartido por los estudiantes de una escuela en la ciudad de Oakland, CA, entrenó a jóvenes del noveno grado para impartir clases de sexualidad y de VIH/SIDA a los estudiantes del séptimo grado. Un año más tarde, los participantes del programa estuvieron menos propensos a iniciar actividades tales como los besos apasionados, tocarse los genitales o iniciar relaciones sexuales.10 HOT fue adaptado para jóvenes Balineses ya que ha habido un incremento en la seroprevalencia debido al incremento del turismo y a la industria del sexo en Balí, Indonesia. En Balí, los investigadores descubrieron que entre los grupos de jóvenes tradicionales, sólo el 14% de los activos sexualmente habían usado condones. A pesar de que la mayoría aún vivía con sus padres, solo el 33% reportó sentir confianza al hablar sobre la sexualidad con sus padres, mientras que el 75% sentía más confianza hablando de sexo con sus amigos. El modelo inicialmente usado por HOT pareció ser el más apropiado para lograr la adaptación, solo que esta vez las bases no iban a ser en las escuelas, sino que se adiestró a grupos tradicionales, que llevaran el mensaje a todo jóven Balinés sin importar el nivel educacional o socio-económico.11 Otro de los programas que resultó exitoso, reclutó a líderes del gusto popular que asistía a los bares, a estos se les adiestró para diseminar mensajes de prevención a este grupo.12 Este programa se adaptó a un grupo de mujeres de minoría racial residentes en viviendas gubernamentales. Sin embargo, el programa no funcionó en este ambiente. ¿El motivo? Las mujeres no se conocían entre sí, y por a las altas tasas de crimen registradas en este tipo de viviendas, no existía la confianza de para abrir las puertas a desconocidos. Este programa volvió a intentarse, esta vez comenzando ayudando a las mujeres a crear conciencia comunitaria, organizando festivales, música y cenas a la que cada una traía un platillo. El resultado fue el incremento del uso del condón y una mayor comunicación. Entre otras cosas se logró tratar temas que afectaban a la comunidad en estos complejos de vivienda tales como las drogas y la violencia.12 ¿qué se puede hacer? Las organizaciones que ofrecen servicios deben invertir tiempo y dinero en la capacitación del personal sobre cómo aprovechar los programas de prevención al máximo, esto incluye: el uso de la teoría, el estudio de las necesidades de la población a la que se piensa intervenir tanto como cultivar la relación entre ivestigadores y organizaciones para estar enterados sobre el tipo de programas que han demostrado su eficacia. Los grupos de planificación comunitaria (CPGs) pudieran crear y mantener una relación estable entre los investigadores, las organizaciones a nivel comunitario y el Departamento de Salud. Los coordinadores de programas de los CPGs, además, deberían poner en contacto a los CPGs con los investigadores locales, ambos a su vez pueden ayudar a los planificadores de prevención a nivel comunitario a determinar cuáles son las adaptaciones más apropiadas. Los investigadores necesitan pasar de los estudios con eficacia en menor escala a los de mayor escala. Muchas intervenciones son eficaces en un área de mucho control (los clientes son remunerados, el personal bien pagado y con un nivel alto de educación). Estas intervenciones deben ser puestas a prueba en el “mundo real”, solo así se sabrá cuáles son las modificaciones que habrán de hacerse para poder asegurar la efectividad bajo circunstancias diferentes. Los administradores de estos fondos deberán comprometerse a designar dinero para la adaptación de programas y para llevar a cabo programas piloto a nivel comunitario. Un programa de prevención completo, utiliza muchos elementos para proteger del VIH a la mayor cantidad de gente posible. Adaptar los programas de intervención existentes puede ahorrar dinero además de ser una estrategia eficaz en la prevención.

¿quién lo dice?

  1. Office of Technology Assessment. The Effectiveness of AIDS Prevention Efforts. 1995.
  2. Holtgrave DR, Qualls NL, Curran JW, et al. An overview of the effectiveness and efficiency of HIV prevention programs . Public Health Reports. 1995;110:134-146.
  3. Weibel W, Jimenez A, Johnson W, et al. Positive effect on HIV seroconversion of street outreach intervention with IDUs in Chicago. Presented at the 9th International Conference on AIDS. Berlin, Germany, 1993. Abstract WSC152.
  4. Hays RB, Rebchook, GM, Kegeles SM. The Mpowerment project: a community-level HIV prevention intervention for young gay and bisexual men . American Journal of Public Health. 1996;86:1-8.
  • Contact: Susan Kegeles 415/597-9159.
  1. Herek GM, Greene B, eds. AIDS, identity, and community : the HIV epidemic and lesbians and gay men . Thousand Oaks, CA: Sage Publications; 1995.
  2. Bandura A. Social cognitive theory and exercise of control over HIV infection. In DiClemente RJ, ed. Preventing AIDS: Theories and Methods of Behavioral interventions . New York, NY: Plenum Press; 1994.
  3. Grinstead OA, Zack B, Faigeles B. Effectiveness of peer HIV education for prisoners. Presented at the Biopsychosocial Conference on AIDS; Brighton, England. 1994.
  • Contact: Barry Zack, Marin AIDS Project 415/457-2487.
  1. Díaz RM. HIV risk in Latino gay/bisexual men: a review of behavioral research. Report prepared for the National Latino/a Lesbian and Gay Organization. 1995.
  • Contact: Jose Ramón Fernández-Peña, Mission Neighborhood Health Center, 415/552-1013 X386.
  1. Wohlfeiler D. Community Organizing and Community Building Among Gay and Bisexual Men. In Minkler M, ed. Community Organizing and Community Building for Health . Rutgers University Press. (in press).
  • Contact: Dan Wohlfeiler 415/575-1545.

10.  Ekstrand ML, Siegel D, Nido V, et al. Peer-led AIDS prevention delays initiation of sexual behaviors among US junior high school students. Presented at 11th International Conference on AIDS, Vancouver, BC. 1996.

  • Contact: Maria Ekstrand 415/597-9160.

11.  Merati T, Wardhana M, Ekstrand M, et al. HIV risk taking among youth participating in peer-led AIDS education programs in traditional Balinese youth groups. Presented at the 11th International Conference on AIDS; Vancouver BC. 1996. Th.C.4411. 12.  Kelly JA, St. Lawrence JS, Stevenson LY, et al. Community AIDS/HIV risk reduction: the effects of endorsements by popular people in three cities . American Journal of Public Health. 1992;82.1483-1489.

  • Contact: Jeff Kelly 414/287-4680.

13.  Sikkema KJ, Kelly J, Heckman T, et al. Effects of community-level behavior change intervention for women in low-income housing developments. Presented at the 11th International Conference on AIDS; Vancouver BC. 1996. Tu.C.453. Contact: Kathy Sikkema 414/287-6100.

Preparado por Pamela DeCarlo y Jeff Kelly, Traducción Romy Benard-Rodríquez Mayo 1997. Hoja Informativa 23S.