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Childhood sexual abuse (CSA)

How does childhood sexual abuse affect HIV prevention?

What is childhood sexual abuse?

Childhood sexual abuse may be defined in many ways, but this fact sheet refers to unwanted sexual body contact prior to age 18, the age of consent to engage in sex. CSA is a painful experience on many levels that can have a profound and devastating effect on later physiological, psychosocial and emotional development. CSA experiences can vary with respect to duration (multiple experiences with the same perpetrator), degree of force/coercion or degree of physical intrusion (from fondling to digital penetration to attempted or completed oral, anal or vaginal sex). The identity of the perpetrator–ranging from a stranger to a trusted figure or family member–may also impact the long-term consequences for individuals. To distinguish CSA from exploratory sexual experimentation, the contact should be unwanted/coerced or there should be a clear power difference between the victim and perpetrator, often defined as the perpetrator being at least 5 years older than the victim. Many more children are sexually abused than are reported to authorities.1 Estimates of the prevalence of CSA in the US are about 33% for females under the age of 18 and 10% in males under 18 years of age.2 Men are significantly less likely than women to report CSA when it occurs.3 CSA is more likely to occur in families under duress. Children are at risk for CSA in families that experience stress, poverty, violence and substance abuse and whose parents and relatives have histories of CSA.

Does CSA affect HIV risk?

Yes. Because childhood and early adolescence are critical times in a person’s sexual, social and personal development, CSA can distort survivors’ physical, mental and sexual images of themselves. These distortions, combined with coping mechanisms adopted to offset the trauma of CSA, can lead CSA survivors into high-risk sexual and drug-using behaviors that increase the likelihood of HIV infection.4 Persons who experience CSA may feel powerless over their sexuality and sexual communication and decision-making as adults because they were not given the opportunity to make their own decisions about their sexuality as children or adolescents. As a result, they may engage in more high-risk sexual behavior, be unable to refuse sexually aggressive partners and have less sexual satisfaction in relationships. CSA survivors may have difficulties forming attachments and long term relationships and may dissociate from their feelings, resulting in having multiple sexual partners, “one night stands” and short-term sexual relationships. Adults who perceive positive aspects of their own CSA (such as gaining attention) may also use sex as a soothing or comforting strategy, which can lead to promiscuity and compulsive sexual patterns.5 The effects of CSA may be different for adult men and women. Female survivors of CSA may have lower condom self-efficacy with partners, use condoms less frequently, exhibit more sexual passivity and attract or be attracted to overly controlling partners.6 Male survivors of CSA may experience higher levels of eroticism, exhibit aggressive, hostile behavior and victimize others.7 Adults with CSA histories may use dissociation and other coping efforts to avoid negative thoughts, emotions and memories associated with the abuse. One of the most common dissociation methods is alcohol and drug abuse. A study of men and women with a history of substance abuse found that 34% had experienced CSA. CSA survivors with substance abuse problems were more likely than substance abusers who had not experienced CSA to exchange sex for money or drugs, have an HIV+ or high-risk partner and not use condoms.8 Sexual revictimization can also influence high-risk sexual behavior. One study of African American and white women found that CSA survivors who experience revictimization as adults had more unintended pregnancies, abortions, STDs and high-risk sexual behaviors than those who experienced only CSA.9

What’s being done?

There are many resources for CSA survivors, but few programs exist to reduce HIV-related sexual and drug-using risk behaviors and increase psychological well being. Most of these programs focus on women; there are even fewer programs for male CSA survivors. Good-Touch/Bad-Touch is a comprehensive child abuse prevention intervention designed for pre-school and kindergarten through sixth grade students. The program uses a variety of materials to teach children prevention skills including personal body safety rules, what abuse is and what action to take if threatened.10 The Children’s Medical Center in Dallas, TX, provides HIV/STD prevention for young female sexual abuse victims at a child abuse clinic. Adolescent females between 12 and 16 years old receive one-on-one evaluation and personalized education from an adolescent-focused HIV/STD counselor. Providing sensitive counseling close to the time of recognition of abuse can be a good method for prevention education.11 At Stanford University, CA, a trauma-focused group therapy intervention seeks to reduce HIV risk behavior and revictimization among adult women survivors of CSA. The groups focus on survivors’ memories of CSA to see if this helps increase safer behaviors and reduce stress. The women also receive case management.12 The Visiting Nurse Service of New York offers comprehensive in-home services to HIV-infected families. The children in these families are at high risk for repeating the histories and behaviors of their parents, including HIV infection, substance abuse, sexual abuse and mental illness. The program provides home-based interventions that include play therapy, health and safe sex education, family and individual counseling, relapse prevention for the parent and drug awareness and prevention for the children. Helping the child deal with anger and resentment towards the parent lessens the likelihood that their anger will be displaced on themselves, thus repeating the behavior of the parent. Supporting each family member is key to breaking the cycle of HIV and abuse in these families.13 At the University of California, Los Angeles, and King-Drew University, CA, a psychoeducational intervention aims to increase healthy behavior and decrease HIV risk behaviors in HIV+ women with histories of CSA. Women are taught communication and problem-solving tools and link CSA experiences to past and current areas of risk.14

What needs to be done?

Although dealing with CSA may seem like a daunting task for many HIV prevention programs, there are a variety of usable approaches to address CSA in adults. Programs can: include questions on abuse during routine client screening, reassess clients over time, provide basic education on the effects of CSA and offer referrals for substance abuse and mental health services. Program staff need basic training and support to help cope with the effects of CSA counseling and the relative high prevalence in certain populations.15 Persons who are likely to interact with CSA survivors such as medical and other health professionals, religious and peer counselors, including alcohol, substance abuse and rape counselors, and probation officers need to be educated on the effects of CSA on sexual and drug risk behaviors. They also need training on how to recognize symptoms of CSA and how to address these issues or provide appropriate referrals for treatment. Professionals should look beyond CSA symptoms and inquire about other childhood experiences that may have been problematic. CSA survivors often are forced to contend with other types of abuse and a dysfunctional family environment. A poor family environment may set the tone for abuse to occur and leave the survivor with little support to cope with the experience.

Says who?

1. Green AH. Overview of child sexual abuse. In SJ Kaplan (ed.), Family violence: A clinical and legal guide. Washington, DC: American Psychiatric Press. 1996;73-104. 2. Finkelhor D. The international epidemiology of child sexual abuse. Child Abuse & Neglect. 1994;18:409-417. 3. Roesler TA, McKenzie N. Effects of childhood trauma on psychological functioning in adults sexually abused as children. Journal of Nervous and Mental Disease. 1994;182:145-150. 4. Prillo KM, Freeman RC, Collier C, et al. Association between early sexual abuse and adult HIV-risky behaviors among community-recruited women. Child Abuse & Neglect. 2001;25:335-346. 5. Paul, J. Understanding childhood sexual abuse as a predictor of sexual risk-taking among men who have sex with men: The Urban Men’s Health Study. Child Abuse & Neglect. 2001;125:557-584. 6. Watkins B, Bentovim A. The sexual abuse of male children and adolescents: a review of current research. Journal of Child Psychology & Psychiatry & Allied Disciplines. 1992;33:197–248. 7. Wyatt GE, Guthrie D, Notgrass CM. Differential effects of women’s child sexual abuse and subsequent revictimization. Journal of Consulting and Clinical Psychology. 1992;60:167-173. 8. Morrill AC, Kasten L, Urato M, et al. Abuse, addiction and depression as pathways to sexual risk in women and men with a history of substance use. Journal of Substance Abuse. 2001;13:169-184. 9. Wyatt GE, Myers HF, Williams JK, et al. Does a history of trauma contribute to HIV risk for women of color? Implications for prevention and policy. American Journal of Public Health. 2002;92:1-7. 10. Harvey P, Forehand R, Brown C, et al. The prevention of sexual abuse: Examination of the effectiveness of a program with kindergarten-age children. Behavior Therapy. 1988;19:429-435. 11. Squires J, Persaud DI, Graper JK. HIV and STD prevention counseling for adolescent girls seen in a child abuse clinic. Presented at the 14th International AIDS Conference, Barcelona, Spain. 2002. Abst # TuPeF5249. 12. Group Interventions to Prevent HIV in High Risk Women.www.med.stanford.edu/school/ Psychiatry/PSTreatLab/TraumaStudy.php 13. Mills R, Samuels KD, Bob-Semple N, et al. Breakin the cycle: multigenerational dysfunction in families affected with HIV/AIDS. Presented at the 14th International AIDS Conference, Barcelona, Spain. 2002. Abst #. ThPeE7828. 14. Wyatt GE, Myers H, Longshore D, et al. Examining the effects of trauma on HIV risk reduction: the women’s health intervention. Presented at the International Conference on AIDS, Barcelona, Spain. 2002. Abst# WePeF6853. 15. Paul JP. Coerced childhood sexual episodes and adult HIV prevention. FOCUS. 2003;18:1-4
Prepared by Gail Wyatt PhD, Tamra Loeb PhD, Inna Rivkin PhD, Jennifer Carmona PhD, Dorothy Chin PhD, John Williams MD, Hector Myers PhD, Douglas Longshore PhD and Charlotte Sykora PhD UCLA Women’s Health Project September 2003. Fact Sheet #52E Special thanks to the following reviewers of this Fact Sheet: Ruth Kelley, Jay Paul, Elizabeth Radhert.
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]. © September 2003, University of California
Resource

Abuso sexual infantil

¿Cuál es el efecto del abuso sexual infantil en la prevención del VIH?

¿qué es el abuso sexual infantil?

El abuso sexual infantil (ASI) tiene muchas definiciones, pero en esta hoja informativa nos referimos al contacto corporal no deseado antes de los 18 años, que es la edad en que se considera que una persona puede dar su consentimiento para tener contacto sexual. El ASI es una experiencia dolorosa a muchos niveles que puede tener, posteriormente, efectos profundos y devastadores en el desarrollo psicológico, psicosocial y emocional. Las experiencias de ASI pueden variar respecto a: duración (varios incidentes con el mismo agresor), grado de fuerza/coerción o grado de intrusión física (desde una caricia, a la penetración digital o al sexo oral, anal o vaginal intentado o consumado). La identidad del agresor/a (que podría ser un desconocido, una persona de confianza o un familiar) también puede influir en las consecuencias a largo plazo para las víctimas. Lo que distingue el ASI de la experimentación sexual exploratoria es el contacto indeseado o forzado o la clara desproporción de poder; comúnmente, se determina como agresor/a alguien que resulte por lo menos 5 años mayor que la víctima. El número de abusos sexuales infantiles excede el número de casos reportados a las autoridades.1 Se calcula que la prevalencia del ASI en EE.UU. es del 33% entre chicas menores de 18 años y del 10% entre chicos menores de 18 años.2 Los hombres son considerablemente menos propensos a reportar un incidente de ASI que las mujeres.3 La probabilidad de que el ASI ocurra aumenta en familias que sufren mucha tensión. Los niños están en riesgo de ser abusados sexualmente en familias que padecen estrés, pobreza, violencia y consumo de alcohol o drogas y cuyos padres y parientes tienen antecedentes de ASI.

¿afecta el riesgo de contraer el VIH?

Sí. Ya que la niñez y el comienzo de la adolescencia son etapas críticas del desarrollo sexual, social y personal, el ASI puede distorsionar la autoimagen física, mental y sexual de las víctimas. Estas distorsiones, junto con los mecanismos de defensa adoptados para compensar el trauma del ASI, pueden conducir a sus sobrevivientes a prácticas de alto riesgo en el sexo y al consumir drogas, las cuales aumentan sus probabilidades de contraer el VIH.4 Quienes han sufrido el ASI pueden sentirse sin poder respecto a su sexualidad, la comunicación sexual y la toma de decisiones en la edad adulta, pues no tuvieron la oportunidad de tomar decisiones propias sobre su sexualidad durante su niñez o adolescencia. Consecuentemente, es posible que estas personas participen en prácticas sexuales de alto riesgo, sean incapaces de rechazar a una pareja sexual agresiva y sientan menos satisfacción sexual en sus relaciones. Los sobrevivientes del ASI pueden disociarse de sus sentimientos y tener dificultades para formar lazos afectivos y relaciones a largo plazo, por lo cual llegan a tener varias parejas sexuales, “aventuras de una sola noche” y relaciones sexuales cortas. Los adultos que perciben algún aspecto positivo de su propio ASI (por ejemplo, la atención que recibieron) pueden usar el sexo como una manera de consolarse o reconfortarse, una conducta que puede llevar a la promiscuidad y a patrones sexuales compulsivos.5 El ASI puede tener efectos diferentes en hombres y en mujeres. Las mujeres sobrevivientes del ASI pueden usar condones con menos frecuencia, ser menos eficaces para establecer el uso de condones con sus parejas sexuales, demostrar más pasividad sexual y atraer o sentirse atraída a parejas exageradamente controladoras.6 Los hombres que sobreviven al ASI pueden sentir un mayor grado de erotismo, exhibir una conducta agresiva y hostil y agredir a otros.7 Los adultos con historial de ASI pueden valerse de la disociación y de otros mecanismos para evitar los pensamientos, emociones y recuerdos negativos asociados con el abuso. Uno de los métodos más comunes de disociación es el abuso del alcohol y drogas. Un estudio de hombres y mujeres con antecedentes de alcoholismo y drogadicción encontró que el 34% fueron víctimas del ASI. En comparación con otros consumidores de alcohol o drogas que no fueron víctimas, los sobrevivientes del ASI con problemas de alcohol o drogas tenían más probabilidades de tener sexo por dinero o drogas, de tener una pareja VIH + o de alto riesgo y de no usar condón durante el sexo.8 La revictimización sexual también puede influir en la conducta sexual de alto riesgo. Un estudio de mujeres afroamericanas y caucásicas encontró que las sobrevivientes del ASI revictimizadas ya siendo adultas tuvieron más embarazos indeseados, abortos terapéuticos, enfermedades de transmisión sexual (ETS) y prácticas sexuales de alto riesgo que quienes sólo fueron abusadas sexualmente en la niñez.9

¿qué se está haciendo al respecto?

Existen muchos recursos para quienes sobreviven el ASI, pero escasean los programas que aumenten el bienestar psicológico y reduzcan las prácticas riesgosas relacionadas con el VIH en el sexo y en el uso de drogas. La mayoría de estos programas se enfocan en la mujer; los programas destinados a los sobrevivientes masculinos son aun más escasos. Good-Touch/Bad-Touch es una intervención integral de prevención del abuso infantil diseñada para los niños de preescolar y kindergarten hasta los del sexto año de primaria. El programa utiliza una variedad de materiales para enseñar a los niños métodos de prevención que incluyen las reglas de la seguridad corporal, en qué consiste el abuso y qué hacer si se sienten amenazados.10 En una clínica para víctimas del ASI, el Children’s Medical Center en Dallas, TX, ofrece prevención del VIH/ETS para jovencitas víctimas del abuso sexual. Las adolescentes entre 12 y 16 años reciben una evaluación individual y educación personalizada de una consejera de VIH/ ETS especializada en las necesidades de las jóvenes. La provisión de consejería sensible y cercana al momento en que se reconoce el abuso, puede ser un buen método de educación preventiva.11 En la Universidad de Stanford, CA, una intervención de terapia grupal sobre el trauma busca reducir las conductas de riesgo del VIH y la revictimización entre mujeres adultas sobrevivientes al ASI. Los grupos se centran en los recuerdos que las sobrevivientes tienen del ASI para ver si éstos les ayudan a aumentar conductas más seguras y a reducir el estrés. Las mujeres también reciben servicios de manejo de casos.12 El Visiting Nurse Service de Nueva York ofrece servicios integrales a domicilio para familias infectadas con el VIH. Los niños de estas familias corren un alto riesgo de repetir las historias y conductas de sus padres, incluyendo la adquisición del virus, el abuso de drogas o alcohol, el abuso sexual y la enfermedad mental. El programa proporciona intervenciones realizadas en el hogar que incluyen terapia del juego, educación en salud y protección sexual, consejería familiar e individual, prevención de recaídas para los padres y concientización y prevención del uso de drogas para los hijos. Al ayudar al niño a afrontar el enojo y resentimiento que sienta hacia el padre, es menos probable que dirija ese enojo hacia sí mismo y que termine repitiendo la conducta de los padres. Para romper el ciclo del VIH y del abuso en estas familias, es fundamental apoyar a cada uno de los miembros de la familia.13 En la Universidad de California, Los Ángeles, y en la Universidad King-Drew, CA, una intervención psicoeducativa pretende incrementar las conductas sanas y disminuir las prácticas de riesgo del VIH en mujeres VIH+ con antecedentes de ASI. Las mujeres aprenden técnicas de comunicación y de resolución de problemas y vinculan sus experiencias de ASI con riesgos pasados y actuales.14

¿qué queda por hacer?

Aunque abordar el ASI parezca una tarea de enormes proporciones para muchos programas de prevención del VIH, existe una variedad de métodos utilizables para tratar el tema del ASI en adultos. Los programas pueden: incorporar preguntas sobre el abuso en la evaluación inicial de todos los clientes, hacer reevaluaciones periódicas, brindarles información básica sobre los efectos del ASI y remitirlos a programas de tratamiento de abuso de drogas y alcohol así como a servicios de salud mental. El personal de prevención del VIH necesita capacitación básica y apoyo para ayudar a sobrellevar los efectos de la consejería sobre el ASI y su prevalencia relativamente alta en ciertas poblaciones.15 El personal que probablemente tenga contacto con sobrevivientes del ASI como serían los profesionales médicos, consejeros religiosos, de pares, de abuso de drogas y de víctimas de violación, así como los policías para los delincuentes en libertad condicional, debe ser orientado de los efectos del ASI sobre las prácticas de riesgo en el sexo y en el uso de drogas. Estas personas también necesitan capacitación para reconocer los síntomas del ASI, afrontar la situación y remitir adecuadamente a los servicios de tratamiento existentes. Los profesionales deben mirar más allá de los síntomas del ASI e indagar sobre otras experiencias que tal vez fueron problemáticas durante la niñez. Muchas veces, los sobrevivientes del ASI son obligados a sufrir otras formas de abuso y un ambiente familiar disfuncional. Un ambiente familiar problemático puede crear condiciones favorables para el abuso y dejar al sobreviviente con poco apoyo para sobrellevar la experiencia. Preparado por Gail Wyatt PhD, Tamra Loeb PhD, Inna Rivkin PhD, Jennifer Carmona PhD, Dorothy Chin PhD, John Williams MD, Hector Myers PhD, Douglas Longshore PhD and Charlotte Sykora PhD. UCLA Women’s Health Project. Traducción: Rocky Schnaath. September 2003. Fact Sheet #52S

¿quien lo dice?

1. Green AH. Overview of child sexual abuse. In SJ Kaplan (ed.), Family violence: A clinical and legal guide. Washington, DC: American Psychiatric Press. 1996;73-104. 2. Finkelhor D. The international epidemiology of child sexual abuse. Child Abuse & Neglect. 1994;18:409-417. 3. Roesler TA, McKenzie N. Effects of childhood trauma on psychological functioning in adults sexually abused as children. Journal of Nervous and Mental Disease. 1994;182:145-150. 4. Prillo KM, Freeman RC, Collier C, et al. Association between early sexual abuse and adult HIV-risky behaviors among community-recruited women. Child Abuse & Neglect. 2001;25:335-346. 5. Paul, J. Understanding childhood sexual abuse as a predictor of sexual risk-taking among men who have sex with men: The Urban Men’s Health Study. Child Abuse & Neglect. 200;125:557-584. 6. Watkins B, Bentovim A. The sexual abuse of male children and adolescents: a review of current research. Journal of Child Psychology & Psychiatry & Allied Disciplines. 1992;33:197–248. 7. Wyatt GE, Guthrie D, Notgrass CM. Differential effects of women’s child sexual abuse and subsequent revictimization. Journal of Consulting and Clinical Psychology. 1992;60:167-173. 8. Morrill AC, Kasten L, Urato M et al. Abuse, addiction and depression as pathways to sexual risk in women and men with a history of substance use. Journal of Substance Abuse. 2001;13:169-184. 9. Wyatt GE, Myers HF, Williams JK, et al. Does a history of trauma contribute to HIV risk for women of color? Implications for prevention and policy. American Journal of Public Health. 2002;92:1-7. 10. Harvey P, Forehand R, Brown C, et al. The prevention of sexual abuse: Examination of the effectiveness of a program with kindergarten-age children. Behavior Therapy. 1988;19:429-435. 11. Squires J, Persaud DI, Graper JK. HIV and STD prevention counseling for adolescent girls seen in a child abuse clinic. Presented at the 14th International AIDS Conference, Barcelona, Spain. 2002. Abst # TuPeF5249. 12. Group Interventions to Prevent HIV in High Risk Women.www.med.stanford.edu/school/ Psychiatry/PSTreatLab/TraumaStudy.html 13. Mills R, Samuels KD, Bob-Semple N, et al. Breakin the cycle: multigenerational dysfunction in families affected with HIV/AIDS. Presented at the 14th International AIDS Conference, Barcelona, Spain. 2002. Abst #. ThPeE7828. 14. Wyatt GE, Myers H, Longshore D, et al. Examining the effects of trauma on HIV risk reduction: the women’s health intervention. Presented at the International Conference on AIDS, Barcelona, Spain. 2002. Abst# WePeF6853. 15. Paul JP. Coerced childhood sexual episodes and adult HIV prevention. FOCUS. 2003;18:1-4.
Special thanks to the following reviewers of this Fact Sheet: Ruth Kelley, Jay Paul, Elizabeth Radhert.
Resource

HIV/STD/unintended pregnancy

How Do HIV, STD and Unintended Pregnancy Prevention Work Together?

Why is it important?

HIV is a sexually transmitted disease (STD). HIV, other STDs (such as gonorrhea, syphilis, herpes, chlamydia and trichomoniasis), and unintended pregnancy are all adverse consequences of sexual behavior. If someone is at risk for unintended pregnancy or common STDs, that means they are engaging in an activity that could also put them at risk for HIV. In addition, these STDs may increase the likelihood of HIV acquisition. STDs are the most frequently reported diseases in the US. Every year in the US, about 12 million new cases of STDs occur, 3 million of them among teenagers.1 In 1996, for the first time in the US, the number of AIDS deaths decreased. However, new cases continue to occur, and the largest proportionate increase in AIDS incidence in 1996 occurred among men and women who acquired AIDS through heterosexual contact (28% increase for men, 23% for women).2 Over half of the 6.4 million pregnancies in the US in 1988 were unintended (56%). As many of those pregnancies ended in abortion (44%) as in birth (43%).3 In 1996, over half a million young women under age 20 gave birth, and two-thirds of those were unintended.4 Unintended pregnancy has great personal and social consequences.

Do STDs affect HIV?

Absolutely. First, an HIV- person who has an STD is 2- to 5-times more susceptible to HIV acquisition because the lesions and immune response associated with STDs make it easier for HIV to enter the body. Second, an HIV+ person who has an STD can be more infectious and more easily transmit HIV to an uninfected partner. Third, an HIV+ person may be more likely to acquire other STDs. This “epidemiological synergy” may be responsible for the explosive growth of HIV in some populations.5 Many research studies have shown the connection between HIV and STDs. A study in Malawi found that HIV+ men with gonorrhea had concentrations of HIV in their semen eight times higher than HIV+ men who did not have another STD. After treatment for the STD, HIV concentration in semen decreased to levels not significantly different from pre-STD levels. This suggests that STDs increase the infectiousness of HIV, and that detecting and treating STDs in HIV+ persons may help prevent HIV transmission.6 Clients at urban STD clinics in Miami, FL who had at least two HIV tests were found to have high rates of HIV and syphilis. Among clients tested twice, 10% acquired syphilis and 4% HIV in the interval. African-Americans accounted for 77% of HIV seroconversions and the rate was highest in women, especially 15-19 year olds. The majority of HIV infections were acquired heterosexually. A total of 18% of all seroconversions were associated with syphilis acquired between two HIV tests.7

Are STD and HIV prevention connected?

Yes and no. While the epidemics of STD and HIV have grown in parallel, prevention efforts to combat the adverse consequences of sexual behavior have not always worked in tandem. In the US HIV epidemic, heterosexual transmission is an increasing cause of infection, and people of color and younger people are increasingly infected. This is also true of STDs in the Southeast and selected large cities across the US, where syphilis, gonorrhea and HIV epidemics clearly overlap, especially among young African-American women.8 HIV prevention efforts may be more effective among certain populations if condom use and HIV are addressed together with STD or pregnancy prevention. Young people are much more likely to know someone who has had an STD or an unintended pregnancy than they are to know someone with HIV. HIV prevention programs, as well as family planning and STD clinics, might create a more effective and realistic message by putting all three together-HIV, STDs and unintended pregnancy-and saying condoms can protect against all three.9,10

What’s working?

In rural Tanzania, a community-level program focused on improving diagnosis and treatment of STDs as means to prevent HIV infection. The program included training existing health center staff in STD management, ensuring availability of effective antibiotics for STDs, and providing periodic outreach to educate on STDs and increase health care use. Individuals in the intervention communities had lower HIV incidence (by about 40%) compared to persons in non-intervention communities.11 Project RESPECT was a randomized HIV counseling and testing program conducted at STD clinics in five cities in the US with high HIV seroprevalence. The program evaluated whether interactive counseling is more effective than informational messages in reducing risk behaviors and preventing HIV and other STD transmission. The program found relatively little difference between 4-session and 2-session interactive counseling interventions, but found lower rates of new STDs, including HIV, among those groups compared to groups that only received information. Reported condom use increased across all groups. Project RESPECT demonstrated that brief risk-reduction counseling strategies can be effectively conducted in busy public clinic settings, and that counseling interventions can change STD rates in high-risk populations.12 An HIV prevention program was implemented at an STD clinic in the South Bronx, NY, due to the clinic’s access to large numbers of high-risk men and women. The program was designed to have minimal disruption on clinical services while providing culturally-appropriate counseling. Patients had access to either a video on condom use in English or Spanish, or both the video and an interactive group session. Patients were given coupons for free condoms at a pharmacy several blocks from the clinic. Clients who saw the video were more likely to redeem coupons than those who did not, and clients who saw the video and participated in group sessions were even more likely to redeem coupons.13 People of Color Against AIDS Network (POCAAN) in Seattle, WA found that because of the stigma of HIV, prevention educators were not always successful at reaching at-risk populations, especially young African-American and Latino males ages 13-35. In 1990 POCAAN decided to educate about STDs and sexual health since these messages were more acceptable to the target population. The program uses street outreach and presentations in various settings such as juvenile facilities, middle and high schools, ESL classes and drug treatment centers. They offer referral vouchers that ensures clients will be seen at an STD clinic and that it will be free. In addition, POCAAN continually updates and educates its staff about STDs and works hard to integrate STD prevention messages into all its HIV-related activities.14

What still needs to be done?

It is time to further integrate STD, HIV and unintended pregnancy efforts, both on a programmatic and a research level. Wherever and whenever feasible, HIV prevention behavior change programs, STD clinics, family planning clinics and primary care facilities need to incorporate all three-HIV, STDs and unintended pregnancy-in their education, testing, counseling and treatment services.10 Research on HIV, both clinical and behavioral, needs to include the effects of STD and pregnancy. Although funding for HIV, STDs and family planning have traditionally been separate, government agencies and foundations need to provide funds for improved coordination or integration. Workers in STD, HIV and family planning should be cross-trained. Community Planning Groups should consider STD and unintended pregnancy prevention plans as well in areas where the epidemiology warrants. A comprehensive HIV prevention strategy uses many elements to protect as many people at risk for HIV as possible. As funding for social services grow more scarce, it is important to not pit STDs and unintended pregnancy against HIV in the fight for money, but to adopt new approaches to fight these overlapping epidemics.

Says who?

1. Eng TR, Butler WT, eds. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC : National Academy Press; 1997. 2. Centers for Disease Control and Prevention. Update: trends in AIDS incidence-United States, 1996 . Morbidity and Mortality Weekly Report. 1997;46:861-867. 3. Forrest JD . Epidemiology of unintended pregnancy and contraceptive use . American Journal of Obstetrics and Gynecology. 1994;170:1485-1489. 4. Centers for Disease Control and Prevention. State-specific birth rates for teenagers-United States, 1990-1996 . Morbidity and Mortality Weekly Report. 1997;46:837-842. 5. Wasserheit JN. Epidemiological synergy. Interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases . Sexually Transmitted Diseases. 1992;19:61-77. 6. Cohen MS, Hoffman IF, Royce RA, et al. Reduction of concentration of HIV-1 in semen after treatment of urethritis: implications for prevention of sexual transmission of HIV-1 . The Lancet. 1997;349:1868-1873. 7. Otten MW, Zaidi AA, Peterman TA, et al. High rate of seroconversion among patients attending urban sexually transmitted disease clinics . AIDS. 1994;8:549-553. 8. St. Louis ME, Wasserheit JN, Gayle HD. Editorial: Janus considers the HIV pandemic-harnessing recent advances to enhance AIDS prevention . American Journal of Public Health. 1997;87:10-12. 9. Cates W. Sexually transmitted diseases and family planning. Strange or natural bedfellows, revisited . Sexually Transmitted Diseases. 1993;20:174-178. 10. Stein Z. Family planning, sexually transmitted diseases, and the prevention of AIDS-divided we fail? American Journal of Public Health. 1996;86:783-784. 11. Grosskurth H, Mosha F, Todd J, et al . Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomized controlled trial . The Lancet. 1995;346:530-536. 12. Kamb ML, Bolan G, Zenilman J, et al. Does HIV/STD prevention counseling work? Results from a multi-center randomized trial. Presented at 12th Meeting of the International Society of Sexually Transmitted Diseases Research, Seville, Spain. 1997.

  • Contact: Mary Kamb (404) 639-2080.

13. O’Donnell LN, San Doval A, Duran R, et al. Video-based sexually transmitted disease patient education: its impact on condom acquisition . American Journal of Public Health. 1995;85:817-822

  • Contact: Lydia O’Donnell, Education Development Center, (617) 969-7100 X2368.

14. US Conference of Mayors. Sexual Health and STDs: an avenue to HIV prevention services. AIDS Information Exchange. 1995:12:6-8.

Contact: Kevin Harris (206) 322-7061 x233.

Prepared by Pamela DeCarlo* and Nancy Padian PhD** *CAPS, **UCSF Department of Obstetrics, Gynecology and Reproductive Sciences

December 1997. Fact Sheet #31E

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 Francisco 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]. © December 1997, University of California

Resource

VIH/ETS/embarazos no planeados

¿Como trabajan: la prevención de las ETS, del VIH y de los embarazos no planeados?

¿por qué es importante? El VIH es una enfermedad de transmisión sexual (ETS). El VIH, otras ETS (como la gonorrea, la sífilis, el herpes, la clamidia y la tricomoniasis), y los embarazos no planeados son consecuencias adversas del comportamiento sexual. Si alguien está a riesgo de un embarazo no planeado, o de alguna ETS común, significa que está participando en una actividad que adicionalmente le pone a riesgo de contraer el VIH. Estas ETS, a su vez, pueden aumentar las posibilidades de adquirir el VIH. En los EEUU, las enfermedades que se reportan con mayor frecuencia son las ETS. Cada año ocurren cerca de 12 millones de nuevos casos de ETS, 3 millones de estos entre los jóvenes.1 En 1996, por primera vez en los EEUU se experimentó un descenso en la cantidad de muertes a causa del SIDA. Sin embargo, continúan apareciendo nuevos casos, en 1996 se observó el mayor incremento proporcional de casos de SIDA entre hombres y mujeres que adquirieron el SIDA por contacto heterosexual (28% para hombres, 23%, en mujeres).2 En los EEUU, un poco más de los 64 millones de embarazos en 1998 no fueron planeados (56%). Una cantidad casi igual de embarazos terminaron en abortos (44%) así como en nacimientos (43%).3 En 1996, un poco más de medio millón de mujeres menores de 20 años dieron a luz, y dos tercios de estos no fueron planeados. Los embarazos no planeados4 tienen graves consecuencias personales y sociales. ¿las ETS afectan al VIH? Indudablemente. Primero, una persona VIH- con una ETS tiene de 2 a 5 veces más posibilidades de contraer el VIH debido a las lesiones y a la respuesta del sistema inmune ante la presencia de una ETS; lo cual facilita la entrada del VIH. Segundo, una persona VIH+ con una ETS es más infecciosa, por lo tanto transmite más facilmente el VIH a su pareja VIH-. Tercero, una persona VIH+ puede tener más posibilidades de contraer otras ETS. Esta “sinergia epidemiológica” puede ser la responsable del aumento de VIH en algunas poblaciones.5 Muchos estudios han demostrado la conección entre el VIH y las ETS. Un estudio en Malawi descubrió que los hombres infectados con VIH y gonorrea tenían una concentración de VIH en el sémen 8 veces mayor a la de hombres VIH positivos que no estaban infectados con ninguna otra ETS. Después del tratamiento para las ETS, la concentración de VIH en el sémen declinó a niveles no muy diferentes a los que tenían previos a la ETS. Esto indica que las ETS incrementan los niveles infecciosos del VIH y que la detección y tratamiento de las ETS en personas VIH positivas puede contribuir a prevenir la transmisión del VIH.6 ¿existe alguna conneción entre la prevención de las ETS y las del VIH? Si y no. A pesar de que tanto la epidemia de las ETS como la del VIH han crecido paralelamente, la labor de prevención al combatir las consecuencias adversas del comportamiento sexual no siempre ha funcionado en tándem. En los EEUU, la transmisión del VIH por vía heterosexual sigue creciendo al igual que en personas de color y los jóvenes. Lo mismo ocurre con las ETS en el Sureste y en ciertas urbes a lo largo de los EEUU, en donde la gonorrea y el VIH convergen claramente, especialmente entre la mujer joven Afro-Americana.7 La labor de prevención del VIH podría ser más eficaz en ciertas poblaciones si el uso del condón y el VIH formara parte de las campañas de prevención de embarazos y de ETS. Los jóvenes tienen mayores posibilidades de conocer a alguien con una ETS o que haya tenido un embarazo no planeado que conocer a alguien con VIH. Los programas de prevención del VIH, al igual que las clínicas de ETS y planificación familiar pueden desarrollar o crear un mensaje más eficaz y realista si se combinaran los tres elementos-VIH, ETS, embarazos no planeados -usando el mensaje que los condones les protegen en contra de los tres.8,9 ¿qué está funcionando? En una área rural de Tanzania, un programa a nivel comunitario se esforzó por mejorar el diagnóstico y tratamiento de las ETS como una forma de prevenir la infección del VIH. El programa capacitó al personal de salud existente en cuanto al manejo de casos de ETS y asegurando la disponibilidad de antibióticos eficaces para combatir las ETS; además educó a la comunidad en cuanto a las ETS y promovió el cuidado de la salud. Se reportaron menores índices de SIDA entre las personas que participaron en la intervención comunitaria (como en un 40%) en comparación con las personas que no participaron en dicha intervención.10 El “Proyecto RESPECT” (RESPETO), un programa aleatorio, ofreció consejería y pruebas de detección de VIH en clínicas de ETS de 5 ciudades estadounidenses con altos índices de seroprevalencia del VIH. El programa evaluó si la consejería interactiva era más eficaz que los mensajes informativos en cuanto a reducir conductas de alto riesgo y prevenir el VIH u otras ETS. El programa registró un impacto relativamente mínimo-entre las intervenciones de consejería interactiva de 2 y 4 sesiones. Sin embargo se presentaron menos casos de ETS, incluyendo el VIH, entre esos grupos al compararse con los grupos que solo recibieron los mensajes informativos. Se reportó un aumento en el uso del condón en todos los grupos. El”Proyecto RESPECT” demostró que la estrategia de una breve consejería puede ser muy útil en clínicas públicas y que las intervenciones con consejería pueden tener un impacto en las tasas de ETS en poblaciones de alto riesgo (de contagio).11 Un programa de prevención del VIH fue implementado en una clínica de ETS al Sur del Bronx, New York, debido a la alta concentración de hombres y mujeres a riesgo de contagio. El programa fue diseñado para interrumpir en lo más mínimo con los servicios clínicos, mientras se impartía consejería apropiada al medio cultural del paciente. Estos tenían acceso a un video, en Español o Inglés, sobre el uso del condón, o a una combinación de video y sesión de grupo interactivo. Los pacientes recibieron cupones para condones gratis válidos en una farmacia cercana a la clínica. Los clientes que vieron el video usaron más los cupones (que los que no lo vieron), y los que vieron el video y participaron en la sesión de grupo aún más.12 En Seattle, Washington la organización de “People of Color Against AIDS Network” o POCAAN, descubrió que debido al estigma que rodea al VIH, los educadores de prevención no siempren tuvieron éxito atrayendo a las poblaciones a mayor riesgo especialmente a los hombres Afro-Americanos y Latinos entre los 13 y 35 años de edad. En 1990, POCAAN decidió enviar el mensaje enseñando sobre ETS y salud sexual ya que esta población era más receptiva a este tipo de intervención. El programa hace uso del reclutamiento y concientización en las calles y al hacer presentaciones en diferentes sitios tales como centros de detención juvenil, en escuelas secundarias, en clases de Inglés como segunda lengua (ESL) y en centros para el tratamiento de droga-adicción. Este programa aseguró servicios gratis en una clínica de ETS para los participantes. Adicionalmente, POCAAN continuamente educa y pone al día a su personal en lo que a ETS se refiere y se esfuerzan mucho por integrar el tema de las ETS en mensajes de prevención y en toda actividad relacionada con el VIH.13 ¿qué queda por hacer? Es hora de integrar aún más las ETS, el VIH y los embarazos no planeados en esfuerzos programáticos y científicos. Siempre y cuando sea factible, los programas de prevención del VIH, las clínicas para las ETS, las de planificación familiar, y las que ofrecen cuidado primario, necesitan incorporar estos tres elementos-VIH, ETS y embarazos no planeados-en sus servicios de educación, de la prueba de detección, de consejería, y de tratamiento.9 Los estudios sobre VIH, tanto clínicos como conductuales, deben incluir los efectos de las ETS y de los embarazos. Aunque los recursos para combatir el VIH, los embarazos no planeados, y las ETS se hacen tradicionalmente por separado, las agencias del gobierno y las fundaciones deben designar fondos para mejorar la coordinación o integración de estos. Los trabajadores de ETS, VIH y planificación familiar deben recibir el mismo entrenamiento. Los grupos de planificación comunitaria (de programas de VIH locales) deben tomar en cuenta aquellos grupos que muestran altos indices de ETS y de embarazos no planeados ademas del VIH en su programación. A medida que los fondos para servicios escasean, es importante que los servicios para combatir las ETS, los embarazos no planeados, y el VIH no tengan que competir por fondos; más bien sería adoptar nuevas formas de lucha para combatir estas epidemias convergentes.

¿quién lo dice? 1. Eng TR, Butler WT, eds. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC : National Academy Press; 1997. 2. Centers for Disease Control and Prevention. Update: trends in AIDS incidence-United States, 1996 . Morbidity and Mortality Weekly Report. 1997;46:861-867. 3. Forrest JD . Epidemiology of unintended pregnancy and contraceptive use . American Journal of Obstetrics and Gynecology. 1994;170:1485-1489. 4. Centers for Disease Control and Prevention. State-specific birth rates for teenagers-United States, 1990-1996 . Morbidity and Mortality Weekly Report. 1997;46:837-842. 5. Wasserheit JN. Epidemiological synergy. Interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases . Sexually Transmitted Diseases. 1992;19:61-77. 6. Cohen MS, Hoffman IF, Royce RA, et al. Reduction of concentration of HIV-1 in semen after treatment of urethritis: implications for prevention of sexual transmission of HIV-1 . The Lancet. 1997;349:1868-1873. 7. Otten MW, Zaidi AA, Peterman TA, et al. High rate of seroconversion among patients attending urban sexually transmitted disease clinics . AIDS. 1994;8:549-553. 8. St. Louis ME, Wasserheit JN, Gayle HD. Editorial: Janus considers the HIV pandemic-harnessing recent advances to enhance AIDS prevention . American Journal of Public Health. 1997;87:10-12. 9. Cates W. Sexually transmitted diseases and family planning. Strange or natural bedfellows, revisited . Sexually Transmitted Diseases. 1993;20:174-178. 10. Stein Z. Family planning, sexually transmitted diseases, and the prevention of AIDS-divided we fail? American Journal of Public Health. 1996;86:783-784. 11. Grosskurth H, Mosha F, Todd J, et al . Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomized controlled trial . The Lancet. 1995;346:530-536. 12. Kamb ML, Bolan G, Zenilman J, et al. Does HIV/STD prevention counseling work? Results from a multi-center randomized trial. Presented at 12th Meeting of the International Society of Sexually Transmitted Diseases Research, Seville, Spain. 1997.

  • Contact: Mary Kamb (404) 639-2080.

13. O’Donnell LN, San Doval A, Duran R, et al. Video-based sexually transmitted disease patient education: its impact on condom acquisition . American Journal of Public Health. 1995;85:817-822

  • Contact: Lydia O’Donnell, Education Development Center, (617) 969-7100 X2368.

14. US Conference of Mayors. Sexual Health and STDs: an avenue to HIV prevention services. AIDS Information Exchange. 1995:12:6-8. Contact: Kevin Harris (206) 322-7061 x233.

Preparado por Pamela DeCarlo*, Nancy Padian PhD**; Traducción Romy Benard-Rodriguez* *CAPS, **UCSF Department of Obstetricts, Gynecology and Reproductive Services Agosto 1998. Hoja Informativa 31S.

Resource

Mental health

How Does Mental Health Affect HIV Prevention?

What does mental health have to do with HIV prevention?

A s much as the HIV epidemic has changed over the past 20 years, most reasons for continued high risk behavior have remained very much the same. Some factors that contribute to these behaviors are: loneliness, depression, low self-esteem, sexual compulsivity, sexual abuse, marginalization, lack of power and oppression. These issues do not have quick fixes. Addressing these basic issues requires time and effort and may extend beyond the capabilities of most HIV prevention programs. One thing we have learned from HIV prevention research is that “one size does not fit all.” Programs need different components to address the different needs of clients. Increasing knowledge, skills building and increasing access to condoms and syringes are good methods, but don’t work for everyone or on their own. For many, the barriers to behavior change are mental health problems. This fact sheet focuses on non-acute mental health issues and does not address the effect of severe mental illness or brain disorders on HIV prevention. What people do and what they experience affects their mental health. Substance use and abuse, discrimination, marginalization and poverty are all factors that impact mental health and, in turn, can place people at risk for HIV infection.

Do mental health issues affect HIV risk?

Yes. The decision to engage in risky sexual or drug using practices may not always be a consciously made “decision.” Rather, it is based on an attempt to satisfy some other need, for example: LOW SELF-ESTEEM. For many men who have sex with men (MSM), low self-esteem and internalized homophobia can impact HIV risk-taking. Internalized homophobia is a sense of unhappiness, lack of self-acceptance or self-condemnation of being gay. In one study, men who experienced internalized homophobia were more likely to be HIV+, had less relationship satisfaction and spent less social time with gay people.1 Male-to-female transgender persons (MTFs) identify low self-esteem, depression, feelings of isolation, rejection and powerlessness as barriers to HIV risk reduction. For example, many MTFs state that they engage in unprotected sex because it validates their female gender identity and boosts their self-esteem.2 ANXIETY AND DEPRESSION. Young adults who suffer from anxiety and depression are much more likely to engage in high risk activities such as prostitution, both injection and non-injection drug use and choosing high risk partners. One study that followed inner-city youths for several years found that change in risk behavior was not associated with knowledge, access to information, counseling or knowing someone with AIDS. Reducing symptoms of depression and other mental health issues were, however, associated with reductions in HIV-related risk behaviors.3 SEXUAL ABUSE. Persons who experience incidents of sexual abuse during childhood and adolescence are at a significantly higher risk of mental health problems and HIV risk behavior. A study of adult gay and bisexual men found that those who had been abused were much more likely to engage in unprotected anal intercourse and injecting drug use.4 For many women, sexual abuse is combined with physical and/or emotional abuse in childhood or adolescence. HIV risk is only one of the consequences of this abuse for women. Women may turn to drug use as a way of coping with abuse experience(s). They may also have difficulty adjusting sexually, causing difficulty negotiating condom use with partners and increasing the likelihood of sexual risk taking.5 Women who have been abused have higher rates of sexually transmitted diseases (STDs) including HIV.6 POST-TRAUMATIC STRESS DISORDER (PTSD). PTSD may account for high sexual risk-taking activities. In one study among female crack users in the South Bronx, NY, 59% of women interviewed were diagnosed with PTSD due to violent traumas such as assault, rape or witness to murder, and non-violent traumas such as homelessness, loss of children or serious accident.7  A national study of veterans found that substance abusers who suffered from PTSD were almost 12 times more likely to be HIV-infected than veterans who were not substance abusers nor suffering from PTSD.8

What factors impact mental health?

Many persons who suffer from mental health problems turn to substance use as a means of coping. Substance use has been shown to decrease inhibitions and impair judgement, which can contribute to HIV risk-taking. Injection drug users (IDUs) who suffer from depression are at higher risk for needle sharing.9 Environmental factors such as poverty, racism and marginalization can lead to mental health problems such as low self-esteem which can in turn, lead to substance use and other HIV risk behaviors. Inner-city young adults with high rates of HIV risk behaviors also experience higher rates of suicidality, substance misuse, antisocial behavior, stressful events and neighborhood murders.10

What’s being done?

Addressing mental health issues does not only mean getting clients to see an individual counselor or therapist. Community-level and structural programs can also address mental health needs. For example, a program can hire a trained facilitator and offer support groups for survivors of sexual abuse. Open houses or drop-in centers where individuals can meet each other can serve to combat loneliness and depression. Offering mobile vans that deliver syringe exchange as well as clothing or food can reach isolated groups that are at high risk for mental health problems and HIV. The Bodyworkers Program in New York, NY, provides MSM sex workers with free HIV prevention and mental health counseling, peer counseling and access to medical services. Male body workers, escorts, street hustlers, porn stars, go-go dancers and others cited several mental health issues that are barriers to accessing prevention and medical services. They are: mistrust, shame, isolation, fear of personal relationships, sexual compulsivity, depression, low self-esteem, substance abuse and a history of physical/sexual abuse.11 The HAPPENS (HIV Adolescent Provider and Peer Education Network for Services) Program in Boston, MA, provides a network of youth-specific care to HIV+, homeless and at-risk youth. The program conducts street outreach, offers individual HIV risk reduction counseling and links youth to appropriate social, medical and mental health services. All health care visits include a mental health intake and mental health services are offered both on a regular basis and at times of crisis.12 A program in New Haven, CT, used a street-based interactive case management model to reach drug-using women with or at risk for HIV. Case managers traveled in mobile health units to provide intensive one-on-one counseling on-site. Counseling often included discussions among members of the client’s family and peers. Case managers also provided transportation, crisis intervention, court accompaniment, family assistance and donated food and clothing.13

What are the implications for prevention programs?

Persons working in HIV prevention need to be aware of the close association between mental health, social and environmental factors and an individual’s ability to make and maintain behavior changes. Prevention program staff should be trained to look for and identify mental health problems in clients. If mental health staff are not available on-site, programs can provide referrals to counselors as needed. Some service agencies have integrated mental health services into their overall services and can provide counseling as part of their prevention interventions. Mental health issues are often overlooked because of stigma on an institutional and individual level. These issues may vary across communities and by geographic region. Addressing mental health problems is an integral part of health promotion and should be a part of HIV prevention. It is not about labeling or putting people down, but aboutproviding accurate diagnoses and treatments for mental and physical health.

Says who?

1. Ross MW, Rosser BR. Measurement and correlates of internalized homophobia: a factor analytic study. Journal of Clinical Psychology. 1996;52:15-21. 2. Clements-Nolle K, Wilkinson W, Kitano K. HIV Prevention and Health Service Needs of the Transgender Community in San Francisco. in W. Bockting & S Kirk editors: Transgender and HIV: Risks, prevention and care. Binghampton, NY: The Haworth Press, Inc. 2001; in press. 3. Stiffman AR, Dore P, Cunningham RM, et al. Person and environment in HIV risk behavior change between adolescence and young adulthood. Health Education Quarterly. 1995;22:211-226. 4. Bartholow BN, Doll LS, Joy D, et al. Emotional, behavioral and HIV risks associated with sexual abuse among adult homosexual and bisexual men. Child Abuse and Neglect. 1994;9:747-761. 5. Miller M. A model to explain the relationship between sexual abuse and HIV risk among women. AIDS Care. 1999;1:3-20. 6. Petrak J, Byrne A, Baker M. The association between abuse in childhood and STD/HIV risk behaviors in female genitourinary (GU) clinic attendees. Sexually Transmitted Infections. 2000;6:457-461. 7. Fullilove MT, Fullilove RE, Smith M, et al. Violence, trauma and post-traumatic stress disorder among women drug users. Journal of Traumatic Stress. 1993;6:533-543. 8. Hoff RA, Beam-Goulet J, Rosenheck RA. Mental disorder as a risk factor for HIV infection in a sample of veterans. Journal of Nervous and Mental Disease. 1997;185:556-560. 9. Mandel W, Kim J, Latkin C, et al. Depressive symptoms, drug network, and their synergistic effect on needle-sharing behavior among street injection drug users. American Journal of Drug and Alcohol Abuse. 1999;25:117-127. 10. Stiffman AR,Doré P, Earls F, et al. The influence of mental health problems on AIDS-related risk behaviors in young adults. Journal of Nervous and Mental Disease. 1992;180:314-320. 11. Baney M, Dalit B, Koegel H, et al. Wellness program for MSM sex workers. Presented at the International Conference on AIDS, Durban, South Africa. 2000. Abstract #MoOrD255. 12. Woods ER, Samples CL, Melchiono MW, et al. Boston HAPPENS Program: a model of health care for HIV-positive, homeless and at-risk youth. Journal of Adolescent Health. 1998;23:37-48. 13. Thompson AS, Blankenship KM, Selwyn PA, et al. Evaluation of an innovative program to address the health and social service needs of drug-using women with or at risk for HIV infection. Journal of Community Health. 1998;23:419-421.

PREPARED BY JIM DILLEY, MD*, PAMELA DECARLO** *AIDS HEALTH PROJECT, **CAPS September 2001. Fact Sheet #42E

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]. © September 2001, University of California