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International

What works best in HIV prevention globally?

what does HIV look like internationally?

With 39 million people living with HIV worldwide, the HIV/AIDS epidemic threatens every aspect of global economic development.^1,2 In 2005, over 4 million people were newly infected with HIV, and almost 3 million died of an AIDS-related illness. HIV/AIDS is among the top 10 causes of death in developing countries, and the leading cause of death in Sub-Saharan Africa. Although Sub-Saharan Africa is the hardest-hit region, HIV is spreading into parts of Asia and Eastern Europe with alarming speed. HIV is transmitted primarily through three mechanisms: sexual intercourse (about 80% of infections worldwide);³ exposure to infected blood or blood products,including injecting drug use; and transmission by HIV+ mothers to their newborns. The international community recognizes the urgency of stopping the AIDS epidemic, yet funding, political will, accountability and human resources have fallen short of needs. Although known interventions could prevent nearly two-thirds of new infections projected to occur between 2002 and 2010, fewer than one in five people at high risk of infection have access to the most basic prevention services.⁴

how is prevention tailored?

Prevention studies and national experiences over the past 20 years strongly suggest that strategies are likely to be most effective when they are carefully tailored to the nature and stage of the epidemic in a specific country or community. Despite a limited amount of rigorous evaluation on prevention programs, evidence demonstrates that tailoring prevention strategies to a region’s epidemic profile is most effective and cost-effective.⁵

Low-level epidemics occur in regions where the HIV prevalence in the general population is low (less than 1%) and the highest prevalence in a key population is also low (less than 5%). Key populations include sex workers, men who have sex with men (MSM) and injecting drug users (IDUs).
Concentrated epidemics occur in regions where the HIV prevalence in the general population is less than 1% and the highest prevalence in a key population is more than 5%.
Generalized low-level epidemics occur in regions where the HIV prevalence in the general population is 1%-10% and the highest prevalence in a key population is 5% or over.
Generalized high-level epidemics occur in regions where the HIV prevalence in the general population is 10% or over and the highest prevalence in a key population is 5% or over.

The following activities are relevant across all epidemic profiles:

surveillance of risk behaviors, sexually transmitted infections (STIs) and HIV
school-based sex education
peer-based programs
information, education, and communication (IEC)
STI screening and treatment
voluntary counseling and testing (VCT)
harm reduction for IDUs
condom promotion, distribution and social marketing
blood safety practices
prevention of mother-to-child transmission (MTCT) and universal precautions

low-level epidemic

Providing widespread VCT, screening for STIs and postexposure prophylaxis may not be cost-effective in a low-level epidemic. In this setting, such as in the Middle East and North Africa, HIV/AIDS control strategies should emphasize:

individual-level interventions that target key populations
limited education through the mass media
prevention programs for HIV+ persons
VCT that is available to key populations with the highest levels of risk behavior and infection rates
MTCT prevention to known HIV+ mothers
addressing market inefficiencies in condom procurement and distribution—including strategies such as bulk purchases and incentives
responding to community attitudes toward sexual activity, as they may dictate people’s response to sex education materials.

concentrated epidemic

In a concentrated epidemic, as in East Asia and the Pacific, Europe and Central Asia, Latin America and the Caribbean, and South Asia, prevention priorities should include:

promotion of VCT among key populations
HIV screening of pregnant women, guided by individuals’ risk profiles
peer-based programs for key populations to educate individuals at risk, promote safer behaviors and distribute condoms
needle exchange and drug substitution programs for IDUs
STI screening and treatment for key risk groups
targeted distribution and promotion of condoms to key populations, linked to VCT and STI care.

Contextual factors—such as government acceptance of needle exchange programs, incarceration of drug users and harassment of sex workers—will likely have a major impact on the effectiveness of prevention efforts. HIV/AIDS is typically concentrated in socially or economically marginalized populations in concentrated epidemics, so attention to socioeconomic factors and to stigmatization of key populations will be vital.

generalized low-level epidemic

Here, as in some countries in Sub-Saharan Africa (Tanzania), targeted interventions must be maintained or strengthened. Interventions for broader populations must be aggressively implemented. Prevention priorities should include:

maintaining surveillance in the entire population, with a focus on young people
extending mass media IEC beyond basic education
providing routine VCT and STI screening and treatment beyond key populations
strengthened condom distribution to ensure universal access
offering HIV screening to all pregnant women
broadening peer approaches and targeted IEC to include all populations with higher rates of STIs and risk behavior.

Contextual factors remain critical, but population level factors now have greater priority. The most important is likely to be the status of women, especially with regard to their ability to control their sexual interactions, to negotiate VCT, to be protected from abuse and to have property rights following the death of a spouse.

generalized high-level epidemic

In a generalized high-level epidemic, such as in some countries in Sub-Saharan Africa (Botswana and Zimbabwe), an attack on all fronts is required. Prevention efforts should focus on broadly based, population-level interventions that can mobilize an entire society. Prevention should include:

offering routine, universal VCT and STI screening and universal treatment
distributing condoms free in all possible venues
providing VCT for couples seeking to have children
counseling pregnant women and new mothers to make informed choices for breastfeeding
implementing individual-level approaches to innovative mass strategies with accompanying evaluations of effectiveness
using the mass media as a tool for mobilizing society and changing social norms
using venues to reach large numbers of people for a range of interventions—workplaces, transit venues, political rallies, schools, universities and military camps

In a generalized high-level epidemic, contextual factors—such as poverty and the fragility of the health care infrastructure—will dramatically affect service provision at every level. The status of women becomes an overriding concern in this setting, requiring priority action to radically alter gender norms and reduce the economic, social, legal and physical vulnerability of girls and women.

what needs to be done?

The magnitude and seriousness of the global pandemic calls for action. The appropriate mix and distribution of prevention and treatment interventions depends on the stage of the epidemic in a given country and the context in which it occurs. In the absence of firm data to guide program objectives, national strategies may not accurately reflect the priorities dictated by the particular epidemic profile, resulting in highly inefficient investments in HIV/AIDS prevention and care. This waste undoubtedly exacerbates funding shortfalls and results in unnecessary HIV infections and premature deaths.

Says who?

1. The information in this fact sheet is taken directly from the following chapter: Bertozzi S, Padian NS, Wegbreit J, et al. HIV/AIDS Prevention and Treatment. In: Disease Control Priorities in Developing Countries. April 2006. 2. UNAIDS (Joint United Nations Programme on HIV/AIDS). 2006 Report on the global AIDS epidemic. 3. Askew I, Berer M. The contribution of sexual and reproductive health services to the fight against HIV/AIDS: A review. Reproductive Health Matters. 2003;11:51–73. 4. Stover J, Bertozzi S, Gutierrez JP, et al. The global impact of scaling-up HIV/AIDS prevention programs in low- and middle-income countries. Science. 2006;311:1474-1476. 5. Wegbreit J, Bertozzi S, Demaria LM, et al. Effectiveness of HIV prevention strategies in resource-poor countries: tailoring the intervention to the context. AIDS. 2006;20:1217-1235.

Prepared by Nancy Padian PhD, Womens Global Health Imperative, UCSF; Stefano Bertozzi, PhD; Instituto Nacional de Salud Publica, Mexico January 2007. Fact Sheet #62E Special thanks to the following reviewers of this fact sheet: James Curran, Michael Merson, John Stover, Kwaku Yeboah. 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.

Resource

Mundial

¿Qué sirve mejor para la prevención mundial del VIH?

¿cuál es el cuadro internacional del VIH?

Con más de 39 millones de personas viviendo con el VIH alrededor del mundo, la epidemia del VIH/SIDA es una amenaza para cada aspecto del desarrollo económico global.^1,2 En 2005, más de 4 millones de personas contrajeron el VIH y casi 3 millones murieron de enfermedades relacionadas con el SIDA.² El VIH/SIDA se ubica entre las primeras 10 causas de muerte en los países en vías de desarrollo y es la mayor causa de muerte en el África subsahariana. Aunque el África subsahariana es la región más azotada por el VIH, el virus se va extendiendo con alarmante velocidad a partes de Asia y Europa occidental. El VIH tiene tres modos principales de transmisión: el coito (aproximadamente el 80 % de las infecciones en todo el mundo);³ la exposición a sangre o productos sanguíneos infectados, lo cual incluye el consumo de drogas inyectables; y el contagio de una madre VIH+ a su recién nacido. La comunidad internacional reconoce la urgencia de detener la epidemia del SIDA, pero faltan el financiamiento, la voluntad política, la responsabilidad social y los recursos humanos necesarios. Aunque intervenciones ya conocidas podrían evitar casi dos tercios de las infecciones nuevas proyectadas entre el año 2002 y el 2010, menos de una de cada cinco personas con alto riesgo de infectarse tiene acceso a los servicios más básicos de prevención.⁴

¿cómo se adecua la prevención?

Los estudios sobre la prevención y las experiencias nacionales durante los últimos 20 años sugieren fuertemente que las estrategias alcanzan su mayor eficacia cuando se adecuan cuidadosamente de acuerdo con las características y la etapa de la epidemia en el país o comunidad en cuestión. A pesar de las escasas evaluaciones rigorosas de programas de prevención, las evidencias demuestran que las estrategias adaptadas para reflejar el perfil epidémico regional son las más eficaces y costo-efectivas.⁵

Las epidemias de bajo nivel ocurren en regiones con baja prevalencia del VIH en la población general (< 1%) y también una reducida prevalencia máxima en una población clave (< 5%). Las poblaciones clave incluyen los trabajadores sexuales, los hombres que tienen sexo con hombres (HSH) y los usuarios de drogas inyectables (UDI).
Las epidemias concentradas se dan en regiones en donde la prevalencia del VIH en la población general es menos del 1% y la prevalencia máxima en una población clave excede el 5%.
Las epidemias generalizadas de bajo nivel ocurren en regiones cuya prevalencia del VIH en la población general es del 1-10% y cuya prevalencia máxima en una población clave es del 5% o más.
Las epidemias generalizadas de alto nivel suceden en regiones en donde la prevalencia del VIH en la población general es del 10% o más y la prevalencia máxima en una población clave es del 5% o mayor.

Las siguientes actividades son relevantes para todos los perfiles epidémicos:

Enseñanza sexual en las escuelas
Programas basados en la participación de pares
Información, enseñanza y comunicación (IEC)
Detección y tratamiento de ITS
Pruebas y consejería voluntarias (PCV)
Reducción de daños para los UDI
Vigilancia de las conductas riesgosas, las infecciones de transmisión sexual (ITS) y el VIH
Promoción y distribución de condones, junto con campañas de publicidad social
Prácticas de seguridad para evitar el contacto con sangre
Prevención de la transmisión madre-hijo (TMH) y uso de precauciones universales

epidemia de bajo nivel

La provisión amplia de PCV, detección de ITS y profilaxis postexposición podría no ser costo-efectiva en una epidemia de bajo nivel. En esta situación, como ocurre en Oriente Medio y en el Norte de África, las estrategias de control del VIH/SIDA deben enfatizar:

Intervención individual en poblaciones clave
Uso limitado de los medios masivos para difundir mensajes educativos
Programas de prevención para personas VIH+
PCV disponibles a las poblaciones con los mayores niveles de conducta riesgosa y tasas de infección
Prevención de la TMH entre madres identificadas como VIH+
Solución de las ineficiencias del mercado con respecto a la compra y distribución de condones, incluyendo estrategias como compras al por mayor e incentivos
Consideración de las actitudes comunitarias hacia la actividad sexual, ya que éstas pueden determinar sus reacciones a los materiales de enseñanza sexual.

epidemia concentrada

En una epidemia concentrada, como las que se dan en el Asia Occidental, el Pacífico, Europa, el Asia Central, América Latina, el Caribe y Surasia, las prioridades de prevención deben incluir:

Promoción de las PCV entre las poblaciones clave
Pruebas de VIH para mujeres embarazadas, según el perfil de riesgo individual
Programas de pares que informen a los individuos en riesgo, promuevan conductas más seguras y repartan condones entre poblaciones clave
Programas de intercambio de agujas y de sustitución de drogas para los UDI
Pruebas de detección y tratamiento de ITS para los grupos clave de riesgo

Distribución selectiva y promoción de condones entre poblaciones clave, vinculada a las PCV y al tratamiento de ITS. Factores contextuales—tales como el grado de aceptación gubernamental de los programas de intercambio de jeringas, el encarcelamiento de los consumidores de drogas y el hostigamiento de los trabajadores sexuales—probablemente tendrán un efecto considerable sobre la eficacia de los esfuerzos de prevención. El VIH/SIDA se concentra por lo general en poblaciones social y económicamente marginadas en epidemias concentradas, lo cual precisa enfocar los factores socioeconómicos y la estigmatización de las poblaciones clave.

epidemia generalizada de bajo nivel

Aquí, al igual que en algunos países del África subsahariana, las intervenciones selectivas deberán mantenerse o reforzarse. Las intervenciones destinadas a poblaciones más amplias deberán implementarse en forma resolutiva. Entre las prioridades de prevención deben figurar:

Mantener la vigilancia en la población entera, con enfoque en la juventud
Extender la IEC de los medios masivos más allá de la orientación básica
Ampliar la provisión habitual de las PCV y de la detección y tratamiento de ITS más allá de las poblaciones clave
Consolidar la distribución de condones para asegurar el acceso universal
Ofrecer pruebas de detección del VIH a toda mujer embarazada
Ampliar los métodos que involucren a pares y la IEC, con el fin de alcanzar a todas las poblaciones con tasas mayores de ITS y de conducta riesgosa.

Los factores contextuales siguen siendo críticos, pero actualmente imperan los aspectos poblacionales. El más importante probablemente será la condición de la mujer, especialmente con respecto a su capacidad para controlar sus interacciones sexuales, negociar las PCV, protegerse contra el abuso y tener derechos de propiedad como viuda.

epidemia generalizada de alto nivel

En una epidemia generalizada de alto nivel, tal como existe en algunos países del África subsahariana (Botswana y Zimbabwe), es preciso atacar en todos los frentes. Los esfuerzos de prevención deben centrarse en intervenciones de base amplia destinadas a poblaciones concretas y ser capaces de movilizar a la sociedad entera. La prevención debe abarcar:

La provisión universal y rutinaria de las PCV, detección de ITS y tratamiento de las mismas
La distribución gratuita de condones en todo lugar posible
La provisión de PCV para parejas que buscan tener hijos
Consejería para ayudar a las mujeres embarazadas y madres nuevas a tomar decisiones informadas sobre el amamantamiento
La transferencia de métodos individualizados a estrategias masivas innovadoras, acompañadas por evaluaciones de eficacia
La utilización de los medios masivos como herramienta para movilizar a la sociedad y modificar las normas sociales
El uso de espacios que permitan alcanzar a gran número de personas para diversas intervenciones—lugares de trabajo, centros de tránsito, movilizaciones políticas, escuelas, universidades y campamentos militares

En una epidemia generalizada de alto nivel, los factores contextuales como la pobreza y la fragilidad de la infraestructura sanitaria afectarán en forma dramática a la prestación de servicios en todos los niveles. La condición de la mujer se convierte en una preocupación primordial en este ambiente y requiere de acción prioritaria con el fin de alterar radicalmente las normas de género y la vulnerabilidad económica, social, legal y física de las jóvenes y mujeres.

¿qué queda por hacer?

La magnitud y gravedad de la pandemia mundial son un llamado a la acción. La mezcla y distribución adecuada de intervenciones de prevención y tratamiento depende de la etapa de la epidemia en el país en cuestión y del contexto en el que suceda. Sin datos firmes que orienten los objetivos programáticos, las estrategias nacionales tal vez no reflejen las prioridades dictadas por el perfil epidémico determinado, generando así inversiones altamente ineficientes en la prevención y atención del VIH/SIDA. Tal derroche sin duda agrava la escasez de fondos y produce infecciones de VIH innecesarias así como muertes prematuras.

¿Quién lo dice?

Preparado por Nancy Padian PhD*, Stefano Bertozzi,PhD** *Womens Global Health Imperative, UCSF; **Instituto Nacional de Salud Publica, Mexico Traducido por Rocky Schnaath Mayo 2007. Hoja de Dato #62S

Resource

Internet

How does the Internet affect HIV prevention?

why the Internet?

The Internet has become a remarkable social networking tool where people who once were unlikely to meet in the physical world are now only a few key strokes away. It is not surprising that many persons with access to the Internet have used it to find love, companionship and sex.¹ In fact, using the Internet to find sexual partners is a widespread practice among men and women of all ages. About 16 million people say they have used websites to meet other people.² Men who have sex with men (MSM)—whose sexual activities traditionally have been stigmatized—have benefited from the privacy of the Internet, with 40% of gay men reporting that they use the Internet to find sexual partners.³ In online interviews, gay men reported that the Internet has helped them find social support, access resources safely and anonymously, and develop significant personal relationships.⁴ The Internet is important to the HIV prevention field. It is a powerful medium to deliver health and risk-reduction information. Many individuals who engage in risk-taking behaviors use the Internet to meet their sexual partners, and the Internet itself may facilitate such risk-taking behaviors.

does the Internet contribute to risk?

Whether or not the Internet’s unique qualities contribute to risk-taking behaviors is not fully understood. We know that people who use the Internet to meet sexual partners have been found to engage in more risky sexual behavior, be more likely to report a history of STDs, and have greater numbers of sexual partners than those who do not seek sexual partners online.^3,5 In fact, as early as 1999, outbreaks of syphilis among MSM were traced to users of specific chatrooms,⁶ and there are also case reports of HIV transmission from sexual partners met online.⁷ It has been found, though, that men who engage in high-risk behaviors do so regardless of whether they meet their partners online or offline, such as in bars and clubs.⁸ Gay and bisexual men with “psychosocial vulnerabilities” (e.g., safer-sex burnout, depression, and social isolation) may be particularly prone to disengage, or avoid thinking about HIV, in the anonymity of a virtual world where they can meet sexual partners for engaging in high-risk sexual behaviors.⁹ Using the Internet to meet partners outside one’s regular sexual network may also create an environment where sexual mixing between high-risk and low-risk persons occurs.¹⁰ These new, expanded sexual networks can, in turn, increase the rate at which HIV and other STDs are transmitted.

can the Internet help in prevention?

Absolutely. The anonymity of online communication may make it easier to disclose HIV status or discuss safer sex and condom use before meeting in person.¹¹ A study of Latino MSM found they were significantly more likely to engage in sexual negotiation and serostatus disclosure on the Internet than in person. For HIV+ persons, disclosing HIV status online also helps avoid abuse, discrimination or rejection by partners.¹² The Internet also provides a way to find sex partners who like the same things and are willing to take the same amount of risk. It may afford more opportunities to chat with a potential partner before having sex. In online ads, individuals can clearly state that they’re looking for partners who agree to safer sex (such as condom use), and they can more easily avoid meeting those who do not. Similarly, online sex-seeking allows HIV+ persons to disclose their status and find partners of the same serostatus (often called serosorting), especially if they intend not to use condoms.⁸ Just like in the physical world, however, one cannot be fully trusted to give or even know their accurate HIV status, so serosorting may not be a foolproof HIV prevention strategy, and it also risks transmitting other STDs.

what’s being done?

Community-Based Organizations (CBOs), researchers, and health departments—occasionally with the support of online service providers—are using the Internet in creative ways to increase HIV-related awareness and knowledge, and to positively influence attitudes, beliefs, and behaviors. Researchers have used the Internet to recruit participants and to collect data. Internet-based programs have also been used to help people anonymously disclosure their HIV/STD status to past sexual partners. Commonly, CBOs have used e-mail distribution lists or sent outreach workers into popular online meeting venues (such as chat rooms and hook-up sites) to promote their programs, answer questions, deliver educational and safer-sex materials, and encourage dialogue about HIV prevention. A handful of CBOs with dedicated funding created HIV-prevention websites tailored for their communities.¹³ Launched in 2002, PowerOn is a comprehensive site providing access to HIV/AIDS education, support, and referrals to 200 local prevention agencies for the gay, bisexual and transgender community in Seattle/King County, WA. Early PowerOn users showed particular interest in pages about Negotiating Safety Agreements and Putting on a Condom.¹⁴ Wrapp.net provides HIV prevention interventions and resources for MSM in the rural US. One NIMH-funded intervention presented a conversation between an HIV+ and an HIV- gay man who recently engaged in risk behavior. A randomized controlled trial found it was well accepted and improved participants’ HIV risk-reduction knowledge, safer-sex attitudes, beliefs about what will happen as a result of engaging in certain behaviors, and beliefs about how well they can perform a given task.¹⁵ Once computerized online interventions are developed, they can operate cost-effectively around the clock, can be easily modified whenever changes are necessary, and quality control standards can be readily established with little opportunity for human error. Community members with Internet access can use such programs at their convenience and with little risk to their personal privacy. Many health departments are exploring using the Internet for partner notification, disclosure assistance and referrals.¹⁶ InSPOT.org, developed by ISIS, Inc., is a website where men diagnosed with HIV /STDs can send electronic cards to sexual partners to inform them of a potential exposure, conveniently and without intervention by a provider. Cards can be sent anonymously, with or without a personal message. A survey of MSM in San Francisco found that 19% had heard of InSPOT, 5% of those used it to notify a partner and 4% received an e-card. Popular website owners can also participate in HIV prevention and education activities. Craigslist.org agreed to add a health message and link to the San Francisco City Clinic website for users entering the “men seeking men” and the “casual encounters” pages. This addition did not result in a decline in the number of postings or visitors. Manhunt agreed to place ads on the dangers of crystal meth use and the rise in syphilis cases. Gay.com accepted a request to integrate sexual health messages by linking to “Ask Dr. K,” a question-and-answer sexual-health forum.¹⁷

what needs to be done?

New interventions to address the HIV risks associated with the Internet need to be developed and evaluated. Programs that help people think about their motives for seeking partners online, and Web-based, health-related screening and referral tools may be promising approaches. It is crucial to conduct further evaluations of the efficacy of current online prevention programs before any such interventions and approaches can be deemed successful and worth replicating. Social policies to help prevent Internet-facilitated HIV transmission are also necessary and may come from legislation or from voluntary changes enacted by website operators. Cooperative efforts between online providers, law makers, researchers, program planners and, most importantly, community members could create structural changes to prevent further Internet-facilitated HIV transmissions.¹⁸ Options for policy changes include: public-health warnings on websites; changes to the way hookup sites are advertised; encouraging research to measure behavior change from online interventions and the development of tools on dating or hookup sites that facilitate the discussion of HIV and safer sex; and incentives for website operators to cooperate with public-health and other HIV-prevention efforts.

Says who?

1. Chiasson MA, Parsons JT, Tesoriero JM, et al. HIV behavioral research online.Journal of Urban Health. 2006;83:73-85. 2. Madden M, Lenhart A. Online dating. Report prepared by the Pew Internet and American Life Project. March 2006. 3. Liau A, Millett G, Marks G. Meta-analytic examination of online sex-seeking and sexual risk behavior among men who have sex with men. Sexually Transmitted Diseases. 2006;33:576-584. 4. Rebchook G, Curotto A, Kegeles S. Exploring the sexual behavior and Internet use of chatroom-using men who have sex with men through qualitative and quantitative research. Presented at the 2003 National HIV Prevention Conference, Atlanta, GA. 5. McFarlane M, Bull SS, Rietmeijer CA. The Internet as a newly emerging risk environment for sexually transmitted diseases. Journal of the American Medical Association. 2000;284:443-446. 6. 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. 7. Tashima K, Alt E, Harwell J, et al. Internet sex-seeking leads to acute HIV infection: a report of two cases. International Journal of STD and AIDS. 2003;14:285-286. 8. Bolding G, Davis M, Hart G, et al. Gay men who look for sex on the Internet: is there more HIV/STI risk with online partners? AIDS. 2005;19:961-968. 9. McKirnan D, Houston E, Tolou-Shams M. Is the Web the culprit? Cognitive escape and Internet sexual risk among gay and bisexual men. AIDS and Behavior. 2006. 10. Wohlfeiler D, Potterat JJ. Using gay men’s sexual networks to reduce sexually transmitted disease (STD)/human immunodeficiency virus (HIV) transmission. Sexually Transmitted Diseases. 2005;32:S48-52. 11. Carballo-Dieguez A, Miner M, Dolezal C, et al. Sexual negotiation, HIV-status disclosure, and sexual risk behavior among Latino men who use the internet to seek sex with other men. Archives of Sexual Behavior. 2006;35:473-481. 12. Davis M, Hart G, Bolding G, et al. Sex and the Internet: gay men, risk reduction and serostatus. Culture, Health and Sexuality. 2006;8:161-174. 13. Curotto A, Rebchook G, Kegeles S. Opening a virtual door into a vast real world: Community-based organizations are reaching out to at-risk MSM with creative, online programs. Paper presented at: STD/HIV Prevention and the Internet; August 27, 2003; Washington D.C. 14. Weldon JN. The Internet as a tool for delivering a comprehensive prevention intervention for MSM Internet sex seekers. Paper presented at: 2003 National HIV Prevention Conference; July 27-30, 2003, 2003; Atlanta, GA. depts.washington.edu/poweron/ 15. Bowen AM, Horvath K, Williams ML. A randomized control trial of Internet-delivered HIV prevention targeting rural MSM. Health Education Research. 2006.www.wrapp.net 16. Mimiaga MJ, Tetu A, Novak D, et al. Acceptability and utility of a partner notification system for sexually transmitted infection exposure using an internet-based, partner-seeking website for men who have sex with men. Presented at the International AIDS Conference, Toronto, Canada. 2006. Abstr #THPDC02. 17. Klausner JD, Levine DK, Kent CK. Internet-based site-specific interventions for syphilis prevention among gay and bisexual men. AIDS Care, 2004;16:964-970. 18. Levine D, Klausner JD. Lessons learned from tobacco control: A proposal for public health policy initiatives to reduce the consequences of high-risk sexual behavior among men who have sex with men and use the Internet. Sexuality Research and Social Policy. 2005;2:51-58.

Prepared by Greg Rebchook PhD, Alberto Curotto PhD, CAPS and Deb Levine, ISIS January 2007. Fact Sheet #63E Special thanks to the following reviewers of this fact sheet: Anne Bowen, Cari Courtenay-Quirk, Jonathan Elford, Charles King, Jeff Klausner, Mary McFarlane, Greg Millett, Frank Strona. Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. To receive Fact Sheets via e-mail, send an e-mail to [email protected] with the message “subscribe CAPSFS first name last name.” ©January 2007, University of CA.

Resource

Red Internet

¿Cómo afecta la red Internet en la prevención del VIH?

¿por qué Internet?

Internet se ha convertido en una herramienta de conexión social que mediante unas pocas tecleadas une a personas que difícilmente se conocerían en el mundo físico. No es sorprendente que muchas personas con acceso a Internet la hayan usado para buscar amor, compañerismo y sexo.¹ De hecho, el uso de Internet para buscar parejas sexuales es una práctica amplia entre hombres y mujeres de todas las edades. Unas 16 millones de personas afirman haber visitado páginas web con el fin de conocer a otras personas.² Los hombres que tienen sexo con hombres (HSH)— una conducta tradicionalmente estigmatizada— se han beneficiado de la privacidad que les ofrece Internet, y un 40 % de los hombres homosexuales informan que usan Internet para conocer a parejas sexuales.³ En entrevistas realizadas en línea, los hombres gay afirmaron que Internet los ha ayudado a encontrar apoyo social, obtener recursos en forma segura y anónima y formar relaciones personales importantes.⁴ Internet es importante en el campo de la prevención del VIH. Es un medio poderoso para brindar información sobre la salud y la reducción de riesgos. Muchos individuos que participan en conductas de riesgo usan Internet para conocer a sus parejas sexuales, y es posible que Internet en sí facilite tales conductas riesgosas.

¿contribuye Internet al riesgo?

No se entiende completamente si las características únicas de Internet contribuyen a las conductas riesgosas o no. Se ha comprobado que las personas que usan Internet para conocer a parejas sexuales tienen conductas más riesgosas, más probabilidades de reportar antecedentes de ITS y mayores números de parejas sexuales que otras personas que no buscan parejas sexuales en línea.^3,5 De hecho, ya desde 1999, se detectaron brotes de sífilis entre HSH mediante rastreo a usuarios de ciertas salas de conversación.⁶ También existen informes de casos de transmisión del VIH entre parejas sexuales que se conocieron en línea.⁷ Sin embargo, se ha encontrado que los hombres que participan en conductas de alto riesgo lo hacen independientemente de si conocieron a sus parejas en línea o de otra manera, como en un bar o club.⁸ Los hombres gay o bisexuales con “vulnerabilidades psicosociales” (p.ej., hartos de practicar el sexo seguro, deprimidos y socialmente aislados) pueden ser especialmente propensos a distanciarse emocionalmente, o a evitar pensar en el VIH, en el anonimato de un mundo virtual que les permite conocer a parejas con el fin de tener sexo de alto riesgo.⁹ El uso de Internet para conocer a parejas fuera de su red social habitual también puede crear un ambiente en el cual ocurre contacto sexual entre personas de alto riesgo y otras de bajo riesgo.¹⁰ Las nuevas redes sexuales expandidas pueden, a su vez, aumentar la frecuencia de transmisión del VIH y otras ITS.

¿puede Internet ayudar en la prevención?

Absolutamente. El anonimato de la comunicación en línea puede facilitar la revelación de la condición de VIH o las conversaciones sobre el sexo más seguro y el uso de condones antes de conocerse personalmente. Un estudio de HSH latinos encontró que eran mucho más propensos a participar en la negociación sexual y de revelar su serocondición en Internet que en persona.¹¹ Para las personas VIH+, la revelación de su condición de VIH en línea también ayuda a evitar el abuso, la discriminación o el rechazo por parte de sus parejas.¹² Internet también facilita la búsqueda de parejas sexuales que compartan los mismos gustos y estén dispuestas a correr el mismo nivel de riesgo. Este medio tal vez ofrece más oportunidades para charlar con una pareja potencial antes de tener sexo. En los anuncios en línea, uno puede exponer claramente que busca parejas que acepten practicar el sexo más seguro (como el uso de condones) y es más fácil evitar quienes no concuerden. Asimismo, la búsqueda sexual en línea permite que las personas VIH+ revelen su condición y encuentren parejas de la misma serocondición (a esto muchas veces se le llama seroselección), especialmente si no piensan usar condones.⁸ Al igual que en el mundo físico, sin embargo, no es posible confiar completamente en que otro le diga o siquiera conozca su condición de VIH exacta, entonces la seroselección tal vez no sea una estrategia infalible de prevención del VIH, y también conlleva el riesgo de transmitir otras ITS.

¿qué se está haciendo al respecto?

Las organizaciones comunitarias (CBOs), los investigadores y los departamentos de salud, a veces con el apoyo de los proveedores de servicios en línea, aprovechan Internet creativamente con el fin de aumentar la conciencia y los conocimientos sobre el VIH y para afectar en forma positiva las actitudes, creencias y conductas. Los investigadores han usado Internet para reclutar a participantes y recopilar datos. También se han usado Internet para ayudar a las personas a revelar en forma anónima su condición de VIH/ITS a sus parejas anteriores. Las CBOs frecuentemente han usado listas de distribución de correo electrónico o han enviado a educadores que visitan sitios populares para charlar en línea (salas de conversación, sitios de ligue, etc.) para promover sus programas, contestar preguntas, informar sobre el sexo protegido y otros temas, y para fomentar el diálogo sobre la prevención del VIH. Unas cuantas CBOs con fondos dedicados a este fin crearon sitios web sobre la prevención del VIH.¹³ Lanzado en el 2002, PowerOn es un sitio integral que provee acceso a información, apoyo y recomendaciones a servicios relacionados con el VIH/SIDA a 200 organizaciones locales de prevención para la comunidad gay, bisexual y transgénero del condado de Seattle/King, WA. Los primeros usuarios de PowerOn indicaron especial interés en las páginas sobre la negociación de acuerdos de seguridad y para la colocación correcta del condón.¹⁴ Wrapp.net brinda intervenciones y recursos de prevención del VIH para HSH en las zonas rurales de EE.UU. Una intervención financiada por los NIMH presentó una conversación entre un hombre VIH+ y otro VIH- quienes acababan de participar en conducta riesgosa. Un ensayo controlado aleatorizado encontró que el sitio tenía buena acogida y que mejoró los conocimientos de los participantes con respecto a la reducción de riesgos del VIH, sus actitudes hacia el sexo más seguro, sus creencias sobre las consecuencias de ciertas conductas y sus creencias sobre su capacidad para efectuar ciertas tareas.¹⁵ Una vez creadas, las intervenciones en línea operan en forma económica las 24 horas del día, se pueden modificar fácilmente en el momento necesario y se pueden establecer normas de control de calidad con poca posibilidad de error humano. Personas con acceso a Internet pueden usar estos programas según su conveniencia y con poco riesgo a su intimidad personal. Muchos departamentos de salud exploran las aplicaciones de Internet con respecto a notificación de parejas, ayuda para revelar la serocondición y remisiones a servicios relacionados.¹⁶ InSPOT.org, creado por ISIS, Inc., es un sitio web en el cual, en forma conveniente y sin la intervención del proveedor médico, los hombres diagnosticados con VIH/ ITS pueden enviar tarjetas electrónicas a sus parejas sexuales para informarles de la posible exposición. Las tarjetas se pueden enviar en forma anónima, con o sin un mensaje personal. Los propietarios de sitios web populares también pueden participar en la prevención del VIH. Craigslist.org aceptó agregar un mensaje informativo y un enlace al sitio web de la San Francisco City Clinic para usuarios que visiten las páginas sobre “hombres que buscan a hombres” y “encuentros casuales.” Esta añadidura no produjo una disminución en el número de comentarios colocados ni de visitantes. Manhunt aceptó colocar anuncios sobre los peligros del uso de la metanfetamina cristal y sobre el aumento en los casos de sífilis. Gay.com accedió a una petición de integrar mensajes de salud sexual por medio de un enlace con“Ask Dr. K,” un foro de preguntas y respuestas sobre la salud sexual.¹⁷

¿qué queda por hacer?

Es preciso crear y evaluar nuevas intervenciones que respondan a los riesgos de VIH vinculados con Internet. Los programas que ayuden a las personas a pensar en sus motivos para buscar parejas en línea y las herramientas de detección y remisión en Internet pueden ser abordajes prometedores. Es crucial realizar más evaluaciones sobre la eficacia de los actuales programas en línea antes de determinar que tales intervenciones sean meritorios de ser reproducidos. También se necesitan políticas sociales para ayudar a evitar la transmisión del VIH facilitada por Internet; tales normas pueden lograrse por medios legislativos o por cambios voluntarios efectuados por los propietarios de sitios web. Las colaboraciones entre los proveedores de servicios en línea, los legisladores, los investigadores, los planificadores de programas y, de mayor importancia, los integrantes de la comunidad, podrían generar cambios estructurales que eviten más transmisiones de VIH facilitadas por Internet.¹⁸ Las opciones de cambios normativos abarcan: advertencias de salud pública en los sitios web; cambios en la forma en que se publicitan los sitios de ligue; la promoción de investigaciones que midan los cambios de conducta producidos por las intervenciones en línea y la creación de herramientas en los sitios de ligue y en los sitios para conocer parejas que faciliten las conversaciones sobre el VIH y el sexo más seguro; así como incentivos para los operadores de sitios web para que cooperen con a los esfuerzos de salud pública y de la prevención del VIH.

¿Quién lo dice?

Preparado por Greg Rebchook PhD*, Alberto Curotto PhD* and Deb Levine** *CAPS, **ISIS Traducido por Rocky Schnaath Mayo 2007. Hoja de Dato #63S

Resource

Prisons and jails

What is the role of prisons and jails in HIV prevention?

Is prevention in prisons and jails important?

Absolutely. The US has the highest incarceration rate in the world, and the numbers keep growing.¹ In 2007, the US had over 2.4 million people in state, federal and local correctional facilities.² For the first time, more than 1 in every 100 adults in the US is confined in a jail or prison.¹ Persons in prison and jail have higher rates of many diseases and health problems than the general population.³ HIV rates among incarcerated persons are 2 ½ times higher than in the general population. In any given year, about 25% of all HIV+ persons in the US pass through a correctional facility.⁴ Persons in prison and jail also have higher rates of STIs, tuberculosis and viral hepatitis, as well as substance abuse and mental illness.⁵ These high infection rates in prisons and jails in the US reflect the fact that the majority of persons who are incarcerated come from impoverished and disenfranchised communities with limited access to prevention, screening and treatment services.⁶ These are the same neighborhoods with high rates of HIV, STIs and other infectious diseases. Criminal justice and public health systems can work together to provide comprehensive prevention and treatment inside and outside facilities. Incarceration presents a window of opportunity for primary prevention, screening, treatment and establishing comprehensive, pro-active transitional linkages for persons approaching release and follow-up.

What is the HIV connection between prisons, jails and the community?

At least 95% of persons in prison are released into the community at some point.⁷ The impact of incarceration and disease is not limited to the men and women being locked up, but extends to their families, partners and communities. There is a mistaken belief that men and women acquire HIV inside, when in fact, the vast majority of HIV+ persons in prison and jail enter the criminal justice system HIV+.^8,9 Persons with a history of mental illness, trauma or physical and sexual abuse, who do not have access to mental health services, may self-medicate with substance use. This combination puts them at increased risk for behaviors that may both lead to HIV and land them in jail or prison. Rates of mental health diagnoses for persons in jail and prison are 45-65%, while rates of substance abuse are as high as 75%.¹⁰

How does incarceration impact HIV risk?

Persons in prison and jail may engage in risk behaviors before, during and after incarceration. However, behavior during incarceration may be riskier for those who do not have access to condoms, clean syringes and other prevention tools. Sexual activity (both consensual and coerced), substance use, injecting and tattooing can all put individuals at risk for HIV/STIs and viral hepatitis.¹¹ In one study of incarcerated young men, 50% had used substances and 17% had consensual sex with men or women while confined.¹² Release from correctional settings and re-entry into the community can be a stressful time and often carries higher risks than being incarcerated. Persons released from prison and jail may celebrate their release with HIV risk-related behaviors such as drinking, drug use and sex. Persons released with few resources often return to the same precarious environments where they were arrested. A study of persons formerly incarcerated in Washington found a high risk of drug overdose within the first two weeks of release.¹³ There is a misperception that incarcerated men are responsible for increasing rates of HIV/STIs. Imprisonment does affect HIV/STI rates in the community, but not from men getting infected on the inside and bringing it out to their female sexual partners once they are released. Instead, incarceration decreases the number of men in the community, which disrupts stable partnerships, changes the male-to-female ratio and promotes higher-risk concurrent, or overlapping, partnerships.¹⁴

What can be done inside?

Across the US, many HIV prevention agencies and public health departments are working with the criminal justice system to improve the health of persons who are incarcerated and their communities. Agencies can provide: peer-based prevention programs, including prevention with positives; harm reduction programs; quality health care; treatment for HIV/STIs; treatment for substance abuse and mental illness; links to community services pre-release; help with community reintegration post-release.^10,15 Counseling, testing and treatment for HIV/STI/hepatitis/TB. Incarceration can be an opportunity for screening and treating a group of individuals with high risk behaviors. This should include comprehensive pre-test counseling with a consent process describing the implications of testing positive or negative, as these can have consequences within correctional facilities, such as limiting housing and work assignments, and restricting visiting privileges. It should also include providing treatment for those who test positive and prevention education to those who test positive and negative. Mental health treatment. Persons in prison and jail have high rates of mental illness. Conditions in correctional settings such as overcrowding, violence and isolation have negative effects on mental health. Prisons and jails can help by providing assessment and effective treatment. Persons with mental illness who have committed minor offenses should be diverted to mental health services before or instead of prison or jail.¹⁶ Comprehensive substance abuse treatment. While many jails and prisons in the US offer detoxification, professional and peer counseling, self-help groups and drug and alcohol education, very few offer methadone maintenance. The capacity of effective substance abuse treatment programs falls far short of the need. The KEEP program, based in New York, NY, provides jail-based methadone treatment and dedicated treatment slots to released individuals in the community.¹⁷

What are transitional interventions?

Effective transitional interventions ensure that prevention and treatment services provided on the inside are continued on the outside. Many communities will have an increasing role in transitional planning with enactment of the Second Chance Act.¹⁸ Project START is the only intervention for incarcerated populations in the CDC’s Compendium of Evidence-Based Interventions. Project START is a client-centered, 6-session HIV, STI and hepatitis risk reduction intervention for persons being released from a correctional setting. Based in harm reduction, it uses a prevention case management model and motivational enhancement to encourage risk reduction. The first two sessions are pre-release and the last four are post-release. All sessions include facilitated referrals for housing, employment, substance abuse and mental health treatment, legal issues, and avoiding reincarceration. Research demonstrated that Project START was effective in reducing unprotected sex among young men after their release from prison.¹⁹ Project Bridge in Providence, RI, provides intensive case management for HIV+ persons being released from state prison. Enrollees receive 18 months of case management by a social worker and an outreach worker. Participants meet weekly for 12 weeks, then once a month, at a minimum. Project Bridge is effective in helping HIV+ persons obtain and maintain much needed post-release services. Research showed that despite high levels of addiction (97%) and mental illness (34%), participants received post-release medical care (95%), secured housing (46%), linked to mental health care (71%) and linked to addiction services (51%).²⁰

What are next steps?

Effectively addressing HIV in prisons, jails and communities requires both effective prevention strategies (such as peer education, access to condoms, HIV counseling and testing) and effective structural and medical strategies. Some of the proven effective strategies and policies that can help reduce HIV/STIs in prisons and jails include: harm reduction programs (providing clean syringes);²¹ substance abuse treatment;¹⁷ mental health treatment;¹⁶ STI/HIV treatment;⁵ transitional discharge planning;^19,20 housing;⁵ alternatives to incarceration;¹⁵ and sentencing and parole reform.¹ Collaboration between the criminal justice system (prison, jail, parole and probation) and the community public health system (social services, medical/health clinics, treatment programs, etc.) is essential, and there are several effective models. Building partnerships can help tackle public health issues while understanding the challenges of public safety and custody priorities. If we truly want to decrease rates of HIV, STIs and hepatitis in our communities, we have to work together to create a seamless continuum that will improve prevention, care and treatment both inside prisons and jails as well as in disproportionately affected communities.

Says who?

1. PEW Center on the States. One in 31: The long reach of American corrections. March 2009. 2. West HC, Sabol WJ. Prisoners in 2007. Bureau of Justice Statistics Bulletin. 2008. 3. Maruschak L. HIV in Prisons, 2006. Bureau of Justice Statistics Bulletin. 2008. 4. Hammett TM, Harmon MP, Rhodes W. The burden of infectious disease among inmates of and releasees from US correctional facilities, 1997. American Journal of Public Health. 2002 ;92:1789-1794. 5. The Foundation for AIDS Research. HIV in correctional settings: implications for prevention and treatment policy. Issue Brief No 5, March 2008. 6. Golembeski C, Fullilove R. Criminal (in)justice in the city and its associated health consequences. American Journal of Public Health. 2005;95:1701–1706. 7. Hughes T, James Wilson D. Reentry trends in the United States. Bureau of Justice Statistics. 8. Vlahov D, Putnam S. From corrections to communities as an HIV priority. Journal of Urban Health. 2006;83:339-348. 9. Zack B, Kramer K. HIV prevention education in correctional settings. Project UNSHACKLE discussion paper. May 2008. 10. James DJ, Glaze LE. Mental health problems of prison and jail inmates. Bureau of Justice Statistics Special Report. September 2006. 11. HIV transmission among male inmates in a state prison system – Georgia, 1992-2005. Morbity and Mortality Weekly Report. 2006;55:421-426. 12. Seal DW, Margolis AD, Morrow KM, et al. Substance use and sexual behavior during incarceration among 18- to 29-year old men: prevalence and correlates.AIDS and Behavior. 2008;12:27-40. 13. Binswanger IA, Stern MF, Deyo RA, et al. Release from prison—a high risk of death for former inmates. New England Journal of Medicine. 2007;356:157-165. 14. Aral SO, Adimora AA, Fenton KA. Understanding and responding to disparities in HIV and other sexually transmitted infections in African Americans. Lancet. 2008;372:337-340. 15. Freudenberg N. Jails, prisons, and the health of urban populations: a review of the impact of the correctional system on community health. Journal of Urban Health. 2001;78:214-235. 16. World Health Organization. Mental health and prisons. 2005. 17. Tomasino V, Swanson AJ, Nolan J, et al. The Key Extended Entry Program (KEEP): A methadone treatment program for opiate-dependent inmates. The Mount Sinai Journal of Medicine. 2001;68:14-20. 18. Second Chance Act. 19. Wolitski RJ, The Project START study group. Relative efficacy of a multi-session sexual risk-reduction intervention for young men released from prison in 4 states. American Journal of Public Health. 2006;96:1845-1861. 20. Zaller ND, Holmes L, Dyl AC, et al. Linkage to treatment and supportive services among HIV-positive ex-offenders in Project Bridge. Journal of Health Care for the Poor and Underserved. 2008;19:522-531. 21. Jürgens R, Ball A, Verster A. Interventions to reduce HIV transmission related to injecting drug use in prison. Lancet Infectious Diseases. 2009;9:57-66.

Prepared by Barry Zack MPH and Katie Kramer MSW/MPH, The Bridging Group LLC March 2009. Fact Sheet #13R Special thanks to the following reviewers of this Fact Sheet: Tim Flanigan, Nick Freudenberg, Robert Fullilove, Robert Greifinger, Ted Hammett, Bob Hogg, Ralf Jürgens, Beth Justiniano, James Learned, Robin MacGowan, Alex Margolis, Dan O’Connell, Anthony Papa, Robin Pollini, Hugh Potter, Cristine Rodriguez, David Seal, Dan Wohlfeiler, Jeanne Woodford. Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. To receive Fact Sheets via e-mail, send an e-mail to [email protected] with the message “subscribe CAPSFS first name last name.” ©March 2009, University of CA.