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Woman

What are US women’s HIV prevention needs?

are women at risk?

Yes. HIV is taking an increasing toll on women and girls in the US. In 1985, women comprised 8% of all AIDS cases in the US, while by 2005, women made up 27% of all AIDS cases. In 2005, women accounted for 30% of all new HIV infections. Of these, 60% occurred among African Americans, 19% among Whites, 19% among Hispanics, and 1% each among Asian/Pacific Islanders and American Indian/Alaska Natives.

who are women most affected by HIV?

African American and Hispanic women in particular are disproportionately affected by HIV/AIDS. Although African American and Hispanic women comprise only 23% of the total female population in the US, in 2005 they accounted for 79% of all new HIV infections (African American women: 60%, Hispanic women: 19%). Accordingly, in 2004 HIV infection was the leading cause of death for Black women (including African American women) aged 25-34 years. Younger women are also affected by HIV/AIDS. In recent years, the largest number of HIV/AIDS diagnoses among women occured in women 15-39 years old. In 2005, young women represented 28% of AIDS cases among young men and women aged 20-24.

what places women at risk?

Most women are infected with HIV through heterosexual contact, especially women with injection drug using partners. In 2005, 80% of all new infections in women were from heterosexual contact. Women are more likely than men to acquire HIV via sexual intercourse, due to greater exposed surface area in the female genital tract. Injection and non-injection drug use places women at an increased risk for HIV and is strongly linked to unsafe sexual practices. Approximately 20% of new HIV cases in women is related to injection drug use. Women who use crack cocaine may also be at high risk of sexual transmission of HIV, particularly if they sell or trade sex for drugs. Sexually transmitted infections (STIs) other than HIV can increase the likelihood of getting or transmitting HIV. In the US, chlamydia and gonorrhea (both asymptomatic) are the most commonly reported STIs, with highest rates in women of color and young women and adolescents. Sexual abuse (both childhood and adult) and domestic violence play a substantial role in placing women at risk for HIV infection. In the US, annually 2.1 million women are raped and 4 million become victims of domestic violence; of these women, more than 10,000 rape victims and 79,000 violence victims require hospitalization. Women who report early and chronic sexual abuse are seven times more likely to engage in HIV-related risk behaviors compared to women without trauma history. Women disproportionately suffer from poverty, in particular women of color who are affected by HIV. Because of this, women are less likely than men to have health insurance and access to quality healthcare or prevention services. Approximately two-thirds of women with HIV in the US have an annual income of less than $10,000. Poverty can increase HIV risks such as exchanging sex for money, shelter, or drugs. In a survey of young and low-income women in California, women who reported sex work were more likely to have syphilis, herpes, hepatitis C, and a history of sexual abuse. Abuse, violence and poverty can all lessen a woman’s power to negotiate condom use or choose safer partners. They also can lead to psychological distress, such as depression, anxiety and post-traumatic stress disorder (PTSD). Having relationships that overlap in time (concurrent partners) can increase women’s risk of HIV transmission. Concurrency is more likely to occur among women who are not married, are young adults and are poor.

what can help?

Involving male partners. For women to protect themselves from HIV, they must not only rely on their own skills, attitudes, and behaviors regarding condom use, but also on those of their male partner. Often, men and women in relationships may find intimacy to be more important than protection against HIV. Involving women’s partners in HIV prevention programs can help strengthen intimacy and trust and improve sexual communication and negotiation, including asking about past and current partners. Support from other women. Many prevention programs for women offer groups to reduce women’s isolation and allow women to support each other and normalize safer behaviors. Greater social support can increase self esteem and allow women to make healthier choices. A program in Washington DC helped build support and empowerment for HIV+ African American women by holding educational groups during shared meals and providing small gifts (along with condoms) as incentives or thank-yous. Help with non-HIV factors. Women at risk for HIV face many behavioral and structural challenges beyond HIV: poverty and economic strain, unemployment, violence and unhealthy gender relations, migration, STIs, drug use, and caring for children and family members. HIV prevention programs for women should provide transportation, child care, nutritious food and compensation such as money, phone or store cards or gift packs. Programs should provide up-to-date referrals for employment, housing, medical care and mental health services trauma, abuse and depression.

what is being done?

Currently 17 women-specific interventions exist that have been approved by the CDC as best evidence or promising evidence or are part of the Diffusion of Effective Behavioral Interventions (DEBI) project: CHOICES, Communal Effectance-AIDS Prevention, Female and Culturally Specific Negotiation, Project FIO, Project SAFE, RAPP, SiHLE, SISTA, Sisters Saving Sisters, Sister to Sister, WHP, WiLLOW, Women’s Co-op, Condom Promotion, Insights, Safer Sex, and SEPA. The Women’s Leadership and Community Planning project in San Francisco, offered a 2-day training for women with HIV in California who want to take greater leadership roles in state Planning Councils. At the training, women network with each other, as well as learn skills in public speaking, decision-making, and conflict management. Women stay in touch through monthly conference calls. After the first training, 6 of 13 women moved into leadership positions on their local or state Councils. Respeto/Proteger: Respecting and Protecting our Relationships is an HIV prevention program for Latino teen mothers and fathers in Los Angeles, CA. Developed and tested with a community agency and academic researchers, the program recognizes risks young women face, including poverty, drug and alcohol use, history of STIs and physical or sexual abuse. The six-session intervention focuses on healing the wounded spirit and builds on feelings of maternal and paternal protectiveness using cultural and traditional teachings.

what needs to be done?

Because women are more likely to get HIV from their male partners, programs that target men (especially IDUs) will have a beneficial impact on women. Needle exchange and drug treatment strategies are critical. Public health agencies need to raise awareness about sexual abuse and domestic violence to not only help men and women develop the skills to prevent it, but also to curb its effect on the HIV epidemic. HIV testing campaigns that target women and women-friendly testing sites are also needed. Behavioral and structural HIV prevention interventions for women continue to be necessary, given the lack of evidence from biomedical interventions (microbicides, vaccines). However, research needs to continue on how women can protect themselves with an accessible, affordable, comfortable and discrete tool for safer sex. Although research has highlighted the subpopulations of women most affected by HIV/AIDS, it is even more important to translate and materialize study findings into tangible public health programs and effective policies. Interventions that address sexuality, family, culture, empowerment, self-esteem, and negotiating skills, as well as interventions located in varying community settings are especially valuable.

Says who?

1. Kaiser Family Foundation. Women and HIV/AIDS in the United States. Policy Fact Sheet. July 2007. 2. Centers for Disease Control and Prevention. Cases of HIV infection and AIDS in the United States and Dependent Areas, 2005. HIV/AIDS Surveillance Report. 2007;17. 3. Centers for Disease Control and Prevention. HIV/AIDS fact sheet: HIV/AIDS among women. June 2007. 4. National Institute of Allergy and Infectious Diseases at National Institutes of Health. Research on HIV infection in women. 2006. 5. Theall KP, Sterk CE, Elifson KW, et al. Factors associated with positive HIV serostatus among women who use drugs: continued evidence for expanding factors of influence. Public Health Reports. 2003;118:415-424. 6. Sangani P, Rutherford G, Wilkinson D. Population-based interventions for reducing sexually transmitted infections, including HIV infection. Cochrane Database of Systematic Reviews. 2004; 2:CD001220. 7. Weinstock H, Berman S, Cates W. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspectives in Sexual and Reproductive Health. 2004;36:6-10. 8. Koenig LJ, Moore J. Women, violence, and HIV: A critical evaluation with implications for HIV services. Maternal and Child Health Journal. 2000;4:103-109. 9. Wyatt GE, Myers HF, Loeb TB. Women, trauma, and HIV: an overview. AIDS and Behavior. 2004;8:401-403. 10. Bozzette SA, Berry SH, Duan N, et al. The care of HIV-infected adults in the United States. HIV Cost and Services Utilization Study Consortium. New Engand Journal of Medicine. 1998;339:1897-1904. 11. Cohan DL, Kim A, Ruiz J, et al. Health indicators among low income women who report a history of sex work: the population based Northern California Young Women’s Survey. Sexually Transmitted Infections. 2005;81:428-433. 12. Adimora AA, Schoenbach VJ, Bonas DM, et al. Concurrent sexual partnerships among women in the United States. Epidemiology. 2002;13:320-327. 13. Prosper! The Women’s Collective, Washington DC. 14. Dworkin SL, Ehrhardt AA. Going beyond “ABC” to include “GEM”: critical reflections on progress in the HIV/AIDS epidemic. American Journal of Public Health. 2007;97:13-18. 15. Centers for Disease Control and Prevention. Updated Compendium of Evidence-Based Interventions, 2007. 16. Women’s Leadership and Community Planning project, CompassPoint, San Francisco, CA. 17. Lesser J, Koniak-Griffin D, Gonzalez-Figueroa E, et al. Childhood abuse history and risk behaviors among teen parents in a culturally rooted, couple-focused HIV prevention program. Journal of the Association of Nurses in AIDS Care. 2007;18:18-27. 18. Landovitz RJ. Recent efforts in biomedical prevention of HIV. Topics in HIV Medicine. 2007;15:99-103.

Prepared by Roshan Rahnama, CAPS April 2008. Fact Sheet #4ER Special thanks to the following reviewers of this fact sheet: Abby Charles, Beth Freedman, Bridget Hughes, Winifred King, Linda Koening, Maureen Miller, Adeline Nyamathi, Nancy Padian, Kate Perkins, Gina Wingood, Gail Wyatt, Toni Young. 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.” ©April 2008, University of CA.

Resource

Mujeres

¿Qué necesitan las mujeres en la prevención del VIH en EEUU?

¿corren riesgo de contraer el VIH?

Sí. El VIH afecta a cada vez más mujeres y muchachas en EEUU. En 1985, las mujeres componían el sólo el 8 % de los casos de SIDA en EEUU, en comparación con el 27 % en el año 2005. Para el 2005, las mujeres ya representaban el 30 % de las nuevas infecciones por VIH, de las cuales el 60 % eran afroamericanas, el 19 % caucásicas, el 19 % hispanas y el 1 % asiáticas/isleñas del Pacífico e indígenas americanas/nativas de Alaska, respectivamente.

¿qué mujeres son más afectadas por el VIH?

El VIH/SIDA afecta desproporcionadamente a las mujeres afroamericanas y las hispanas. Aunque estos dos grupos componen sólo el 23 % de la población femenina de EEUU, en el año 2005 representaban el 79 % de los casos nuevos de infección por VIH (afroamericanas: 60 %, hispanas: 19 %). En el 2004 la infección por VIH fue la primera causa de muerte entre mujeres negras (incluidas las afroamericanas) entre 25 y 34 años de edad. El VIH/SIDA también afecta a mujeres más jóvenes. En años recientes, el mayor número de diagnósticos de VIH/SIDA entre mujeres se dio en las que tenían entre 15 y 39 años de edad. En el 2005, las mujeres jóvenes representaban el 28 % de los casos de SIDA entre mujeres y hombres de 20 a 24 años de edad.

¿qué pone en riesgo a las mujeres?

La mayoría de las mujeres contraen el VIH por medio del contacto heterosexual, especialmente si su pareja se inyecta drogas. En el 2005, el 80 % de las nuevas infecciones entre mujeres se debían al contacto heterosexual. Las mujeres son más propensas que los hombres a adquirir el VIH durante el coito debido a que, dentro del tracto genital femenino, una mayor superficie queda expuesta. El consumo de drogas (inyectables o no inyectables) aumenta el riesgo que corren las mujeres de contraer el VIH y está fuertemente vinculado a las prácticas sexuales riesgosas. Aproximadamente el 20 % de los nuevos casos femeninos de VIH se relaciona con el uso de drogas inyectables. Las consumidoras de cocaína en roca (crack) también pueden correr un riesgo elevado de transmisión del VIH, en particular si venden o intercambian el sexo por drogas. Las infecciones de transmisión sexual (ITS) que no sean el VIH pueden aumentar las posibilidades de adquirir o de transmitir el VIH. En EEUU, la clamidia y la gonorrea (ambas infecciones asintomáticas) son las ITS que se reportan con mayor frecuencia, con las tasas más altas entre las mujeres no caucásicas, las mujeres jóvenes y las adolescentes. El abuso sexual (en la niñez y en la edad adulta) y la violencia doméstica juegan un papel fundamental en aumentar el riesgo de contraer el VIH. Cada año 2.1 millones de mujeres son violadas y cuatro millones son víctimas de la violencia doméstica en EE.UU.; de estas mujeres, más de 10,000 mujeres violadas y 79,000 de las víctimas de abuso requieren hospitalización. Las mujeres que han sufrido abuso sexual desde temprana edad y en forma crónica son siete veces más propensas a participar en conductas que las ponen en riesgo de contraer el VIH que otras mujeres sin antecedentes de trauma. Las mujeres sufren desproporcionadamente de la pobreza, en particular las mujeres no caucásicas con VIH, lo cual reduce sus posibilidades de tener seguro médico y acceso a servicios médicos o preventivos de alta calidad. En EEUU, unos dos tercios de las mujeres con VIH tienen ingresos anuales por debajo de $10,000. La pobreza puede aumentar los riesgos de VIH tales como el intercambio del sexo por dinero, alojamiento o drogas. Entre las mujeres jóvenes y de bajos ingresos encuestadas en California, las que afirmaron haber hecho trabajo sexual tenían tasas más altas de sífilis, herpes, hepatitis C y antecedentes de abuso sexual. El abuso, la violencia y la pobreza pueden minar el poder de la mujer a la hora de negociar el uso de condones o de escoger parejas sexualmente más seguras. También pueden llevar a problemas psicológicos como la depresión, la ansiedad y el trastorno de estrés postraumático (PTSD en inglés). Tener parejas concurrentes puede incrementar el riesgo de contraer el VIH y es más común entre las mujeres jóvenes solteras pobres.

¿qué se puede hacer para ayudar?

Involucrar a las parejas masculinas. Para poder protegerse contra el VIH, las mujeres no sólo dependen de sus propias habilidades, actitudes y conductas con respecto al uso de condones, sino también de las de sus compañeros sexuales. En muchas relaciones románticas la intimidad pesa más que la protección contra el VIH. La inclusión de los hombres en los programas de prevención del VIH puede profundizar la intimidad y confianza y mejorar la comunicación y negociación sexual incluyendo las preguntas sobre parejas sexuales anteriores y actuales. Recibir el apoyo de otras mujeres. Muchos programas de prevención para mujeres ofrecen grupos para reducir el aislamiento y permitir el apoyo mutuo entre mujeres y la normalización de prácticas más seguras. Un aumento del apoyo social puede incrementar la autoestima y promover la toma de decisiones más saludables. Un programa en Washington, DC generó apoyo y empoderamiento para mujeres afroamericanas VIH+ por medio de pláticas educativas durante comidas comunales y la provisión de pequeños obsequios (junto con condones) a manera de incentivo o agradecimiento. Ayudar con otros problemas no relacionados con el VIH. Las mujeres vulnerables al VIH encaran muchos desafíos conductuales y estructurales además del VIH: la pobreza y otras dificultades económicas, el desempleo, la violencia y las relaciones de pareja dañinas, la migración, las ITS, el uso de drogas y la necesidad de cuidar de niños y otros familiares. Los programas de prevención del VIH para mujeres deben brindarles transporte, cuidado infantil, alimentos nutritivos y remuneración en forma de comida, tarjetas telefónicas o de tiendas y paquetes de regalos. También deben ofrecer remisiones adecuadas y actualizadas para servicios de empleo, vivienda, atención médica y de salud mental en caso de trauma, abuso y depresión.

¿qué se está haciendo al respecto?

Actualmente existen 17 intervenciones para mujeres las cuales han sido reconocidas por los CDC como ejemplos de “las mejores evidencias” o “evidencias prometedoras” o bien que forman parte del proyecto Diffusion of Effective Behavioral Interventions (DEBI): CHOICES, Communal Effectance-AIDS Prevention, Female and Culturally Specific Negotiation, Project FIO, Project SAFE, RAPP, SiHLE, SISTA, Sisters Saving Sisters, Sister to Sister, WHP, WiLLOW, Women’s Co-op, Condom Promotion, Insights, Safer Sex y SEPA. En San Francisco, el proyecto Women’s Leadership and Community Planningorganiza una capacitación de dos días para mujeres con VIH en California que quieren asumir papeles de mayor liderazgo en los concilios de planificación estatal. En las jornadas de capacitación las mujeres forman redes de contacto, aprenden sobre la pronunciación de discursos, la toma de decisiones y el manejo de conflictos. Ellas se mantienen en contacto por medio de conferencias telefónicas mensuales. Después de la primera capacitación, 6 de las 13 asistentes pasaron a ocupar puestos de liderazgo en sus concilios locales o estatales. Respeto/Proteger: Respecting and Protecting our Relationships es un programa de prevención del VIH para madres y padres adolescentes latinos en Los Ángeles, CA. Creado y probado conjuntamente por una organización comunitaria e investigadores académicos, el programa reconoce los riesgos que las adolescentes afrontan, como la pobreza, el uso de drogas y alcohol, y antecedentes de ITS, abuso físico o abuso sexual. La intervención consiste en seis sesiones destinadas a sanar el espíritu herido y cultivar los sentimientos de protección materna y paterna por medio de enseñanzas culturales tradicionales.

¿qué queda por hacer?

Los programas para los hombres (especialmente los UDIs) también beneficiarán a las mujeres. El intercambio de jeringas y el tratamiento para dejar las drogas son esenciales. Las agencias de salud pública necesitan aumentar la conciencia sobre el abuso sexual y la violencia domestica, no sólo para ayudar a los hombres y a las mujeres a aprender cómo evitarlas, sino también para mitigar sus efectos sobre la epidemia del VIH. También se necesitan campañas de detección del VIH dirigidas sólo a mujeres y sitios de pruebas donde las mujeres se sientan cómodas. Dada la falta de evidencias de intervenciones biomédicas (microbicidas y vacunas) eficaces, persiste la necesidad de brindar intervenciones conductuales y estructurales de prevención del VIH para mujeres. Sin embargo, debe continuar la investigación sobre cómo las mujeres pueden protegerse utilizando una herramienta accesible, económica, cómoda y discreta. Es importante trasladar y concretar los hallazgos de los estudios en programas tangibles de salud pública y en políticas eficaces. Son especialmente valiosas aquellas intervenciones que tomen en cuenta la sexualidad, la familia, la cultura, el empoderamiento, la autoestima y las habilidades de negociación, así como las intervenciones ubicadas en una variedad de ambientes comunitarios.

¿Quién lo dice?

1. Kaiser Family Foundation. Women and HIV/AIDS in the United States. Policy Fact Sheet. July 2007. 2. Centers for Disease Control and Prevention. Cases of HIV infection and AIDS in the United States and Dependent Areas, 2005. HIV/AIDS Surveillance Report. 2007;17. 3. Centers for Disease Control and Prevention. HIV/AIDS fact sheet: HIV/AIDS among women. June 2007. 4. National Institute of Allergy and Infectious Diseases at National Institutes of Health. Research on HIV infection in women. 2006. 5. Theall KP, Sterk CE, Elifson KW, et al. Factors associated with positive HIV serostatus among women who use drugs: continued evidence for expanding factors of influence. Public Health Reports. 2003;118:415-424. 6. Sangani P, Rutherford G, Wilkinson D. Population-based interventions for reducing sexually transmitted infections, including HIV infection.Cochrane Database of Systematic Reviews. 2004; 2:CD001220. 7. Weinstock H, Berman S, Cates W. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspectives in Sexual and Reproductive Health. 2004;36:6-10. 8. Koenig LJ, Moore J. Women, violence, and HIV: A critical evaluation with implications for HIV services. Maternal and Child Health Journal. 2000;4:103-109. 9. Wyatt GE, Myers HF, Loeb TB. Women, trauma, and HIV: an overview. AIDS and Behavior. 2004;8:401-403. 10. Bozzette SA, Berry SH, Duan N, et al. The care of HIV-infected adults in the United States. HIV Cost and Services Utilization Study Consortium. New Engand Journal of Medicine. 1998;339:1897-1904. 11. Cohan DL, Kim A, Ruiz J, et al. Health indicators among low income women who report a history of sex work: the population based Northern California Young Women’s Survey. Sexually Transmitted Infections. 2005;81:428-433. 12. Adimora AA, Schoenbach VJ, Bonas DM, et al. Concurrent sexual partnerships among women in the United States. Epidemiology. 2002;13:320-327. 13. Prosper! The Women’s Collective, Washington DC. 14. Dworkin SL, Ehrhardt AA. Going beyond “ABC” to include “GEM”: critical reflections on progress in the HIV/AIDS epidemic. American Journal of Public Health. 2007;97:13-18. 15. Centers for Disease Control and Prevention. Updated Compendium of Evidence-Based Interventions, 2007. 16. Women’s Leadership and Community Planning project, CompassPoint, San Francisco, CA. 17. Lesser J, Koniak-Griffin D, Gonzalez-Figueroa E, et al. Childhood abuse history and risk behaviors among teen parents in a culturally rooted, couple-focused HIV prevention program. Journal of the Association of Nurses in AIDS Care. 2007;18:18-27. 18. Landovitz RJ. Recent efforts in biomedical prevention of HIV. Topics in HIV Medicine. 2007;15:99-103.

Preparado por Roshan Rahnama, MPH, CAPS Traducido por Rocky Schnaath Septiembre 2008. Hoja de Dato #4SR

Resource

Women who have sex with women (Lesbians)

What Are Women Who Have Sex With Women’s HIV Prevention Needs?

Are women who have sex with women at risk for HIV?

HIV risk for women who have sex with women (WSW), like for all people, varies depending on what they do. Some WSW may shoot drugs, have sex with men, trade sex for money or drugs, be victims of rape or abuse, have sex with many partners or have artificial insemination. It is important to remember that sexual identity and sexual behavior are not always similar; for example, women who identify as lesbian can also have sex with men, and not all WSW identify as lesbian or bisexual. In this fact sheet, the term “WSW” will cover all these categories, unless a more specific term or definition is offered. Among injection drug users, WSW have higher HIV rates than do women who have sex with men only. A study of female injection drug users (IDUs) in 14 US cities found that, compared to heterosexual women, women who had a female sex partner were more likely to share syringes, to exchange sex for drugs or money, to be homeless and to seroconvert.1 Women who identify as lesbian or bisexual and have sex with men may be at high risk for HIV due to male partnering choices and low condom use. A study of lesbians and bisexual women in San Francisco, CA, found that 81% reported sex with men in the past 3 years. Of those women, 39% reported unprotected vaginal sex and 11% unprotected anal sex.2 In a survey of lesbians and bisexual women in 16 small US cities, among women who were currently sexually active with a male partner, 39% reported sex with a gay/bisexual man and 20% sex with an IDU.3

Is female-to-female transmission possible?

From all we know, there is a small but still unspecified risk of HIV transmission associated with female-to-female sexual practices.4 HIV is found in vaginal fluids and menstrual blood, but the amount of virus has not been adequately measured. Female-to-female sex can include a variety of activities, and the risk relative to all activities is still not known. It is thought that oral sex alone poses a relatively low risk,4 and acts that may result in vaginal trauma, such as sharing sex toys without condoms or digital play with finger cuts or sharp nails, might pose higher risk. To date, there have been no studies that have rigorously examined female-to-female sexual acts or cunnilingus as a risk for HIV transmission, but there are a number of reported cases of transmission.5 Only one study has looked at HIV-discordant lesbian couples (where one woman is infected and the other isn’t). Although this study followed only 10 couples and only over a short period of time, they found no seroconversions.6

What are barriers to prevention?

Social, environmental and economic factors can be a barrier to prevention. WSW who are poor, drug addicted, lack adequate job training, are homeless or who fear violence may turn to prostitution or engage in sex with men for survival.4 Attention to more immediate concerns of food, housing and addiction often takes priority over future concerns of HIV infection. Expectations of heterosexuality and negative social or cultural attitudes towards homosexuality may serve to increase risk behaviors among some WSW. A study in San Francisco, CA, found that young lesbians engaged in high rates of alcohol and drug use, unprotected sex with men and sexual experimentation with young gay men as a way of coping with societal pressures.7 At-risk WSW are often invisible or not recognized within other groups such as crack-smokers and injection drug users, the homeless, commercial sex workers and prisoners. WSW who have sex with men may identify with different communities depending on the gender of their current sex partner. Prevention efforts should take this into account, and recognize that bisexual women may be most effectively reached through programs targeted to high risk heterosexual women.

What’s being done?

Prevention programs that focus specifically on WSW and HIV are still extremely limited, but the following projects have made a difference. The Lesbian AIDS Project (LAP) at GMHC in New York City, NY, provides multiple services to both HIV- and HIV+ WSW. LAP runs groups, safer sex workshops and a hotline. At-risk and HIV+ lesbians on staff provide education and outreach in the community including in women’s prisons and recovery settings.8 In San Francisco, CA, Lyon-Martin Women’s Health Services trained lesbians and bisexual women as peer educators to deliver safer sex information in women’s bars, dance clubs and sex clubs. Affectionately known as the “Safer Sex Sluts,” the peer educators are “dedicated to demolishing denial” by presenting skits, giving workshops and individual consultations and handing out condoms and lubricant.9 A community-based outreach project in Hollywood, CA, targeted street-based high-risk gay, bisexual, lesbian and transgender drug users. Based on a harm reduction model, the program provided support groups, peer counseling, referrals, prevention packages and hygiene kits.10 In Guatemala, a public space for lesbians, transvestites and gay/bisexual men opened to provide a safe environment for self-expression free of alcohol, sex and drugs. The Culture House sponsors creative workshops and classes in pottery, photography, literature, English and French, among others. They also sponsor conferences and round tables on issues such as violations of human rights, attitudes of the Catholic church towards gays and lesbians, staying HIV-negative and legal aspects of AIDS.11

What still needs to be done?

Definitive research on sexual practices, sexual risks, partnering choices and demographic characteristics of WSW are needed. Effective HIV prevention for WSW must take into account their sexual identity as well as their sexual behavior and drug use activity. Distinguishing WSW by their sexual identity may be crucial in targeting prevention messages. Service providers and health care workers must be sensitized to the needs of WSW and be trained to conduct risk assessments that are not heterosexually biased. Many service providers assume that women who are HIV+ are exclusively heterosexual. If a woman says that she has had sex with a man, most will stop at that first question and don’t proceed to ask if she has also had sex with a woman. Likewise, if a woman reports injection drug use, many will not proceed to sexual behavior questions, assuming drug use is the main risk. This not only affects the care and education a WSW may receive, but also leads to poor documentation on risk behavior forms and inadequate reporting of WSW HIV rates. As a group, WSW have been invisible in the Centers for Disease Control and Prevention (CDC) HIV classification system. While categories of risk groups for men include men who have sex with men, injecting drug use and heterosexual12 contact, among others, there is no category for WSW. Efforts to more clearly identify WSW within the CDC’s current surveillance system are underway.13 Information on the actual number of WSW among AIDS cases will bring to light the need for targeted prevention programs in this population. The most effective prevention message for WSW is still unclear. Some groups contend that we need to focus on what’s causing HIV risk for the majority of WSW—drug use and sex with men—rather than focus on issues of female-to-female transmission. Education and outreach should focus on cleaning or using new needles and using condoms for anal and vaginal sex with men, but a clearer message regarding female-to-female sex must also be established.14 It is unconscionable that after 15 years of the HIV epidemic, HIV+ women still don’t have accurate information about risk in order to know what to do or not do sexually with their female partners. A comprehensive HIV prevention strategy uses a variety of elements to protect as many people at risk as possible. Accurate information on female-to-female sexual transmission and HIV incidence, as well as what factors influence risk taking among WSW, will be key to protecting women who have sex with women.

Says who?

  1. Young RM, Weissman G, Cohen JB. Assessing risk in the absence of information: HIV risk among women injection drug users who have sex with women. AIDS and Public Policy Journal. 1992;7:175-183.
  2. Lemp GF, Jones M, Kellogg TA, et al. HIV seroprevalence and risk behaviors among lesbians and bisexual women in San Francisco. American Journal of Public Health. 1995;85: 1549-1552.
  3. Norman AD, Perry MJ, Stevenson LY, et al. Lesbian and bisexual women in small cities-at risk for HIV? Public Health Reports. 1996;111:347-352.
  4. Mays VM, Cochran SD, Pies C, et al. The risk of HIV infection for lesbians and other women who have sex with women: implications for HIV research, prevention, policy, and services. Women’s Health: Research on Gender, Behavior and Policy. 1996;2:119-139.
  5. Kennedy MB, Scarlett MI, Duerr AC et al. Assessing HIV risk among women who have sex with women: scientific and communication issues. Journal of the American Medical Women’s Association. 1995;50:103-107.
  6. Raiteri R. HIV transmission in HIV-discordant lesbian couples. Presented at the 11th International Conference on AIDS. Vancouver, BC. 1996. Abstract #Tu.C.2455.
  7. Gómez CA, Garcia DR, Kegebein VJ, et al. Sexual identity versus sexual behavior: implications for HIV prevention strategies for women who have sex with women. Women’s Health: Research on Gender, Behavior and Policy. 1996;2:91-109.
  8. Hollibaugh A. LAP Notes. Lesbian AIDS project at GMHC. 1994;2:12.
    • Contact: Io Cyrus, Lesbian AIDS Project (212) 337-3531
  9. Stevens PE. HIV prevention education for lesbians and bisexual women: a cultural analysis of a community intervention. Social Science in Medicine. 1994;39:1565-1578.
    • Contact: Lani Ka’ahumanu (415) 821-3534.
  10. Reback CJ, Watt K. Street drugs, street sex: community-based outreach to gay, bisexual, lesbian and transgender drug users. Presented at the 11th International Conference on AIDS. Vancouver, BC. 1996. Abstract #ThC4670,
    • Contact: Cathy Reback (213) 463-1601.
  11. Martinez LF, Mayorga R, Lorenzana A, et al. The Guatemalan Gay/bisexual and Lesbian Culture House: alternative activities fostering self-esteem, behavioral changes, and AIDS prevention. Presented at the 11th International Conference on AIDS. Vancouver, BC. 1996. Abstract #ThD363.
  12. Warren N. Out of the question: obstacles to research on HIV and women who engage in sexual behaviors with women. SIECUS Report. 1993;October/ November:13-15.
  13. Centers for Disease Control and Prevention. Report on lesbian HIV issues meeting. Decatur, GA; April 1995.
  14. Gorna R. Lesbian safer sex: alarmist or inadequate? Presented at the 11th International Conference on AIDS. Vancouver, BC. 1996. Abstract #ThD244.
    • Contact: (in England) Robin Gorna, Terrence Higgins Trust (011) 44-171-831-0330.
Prepared by Pamela DeCarlo and Cynthia Gómez, PhD January 1997. Fact Sheet #24E Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National AIDS Clearinghouse at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © January 1997, University of California
Resource

Young women

What are young women’s HIV prevention needs?

Are young women at risk for HIV?

Yes. One in five people living with HIV in the US is under the age of 25. Forty percent of these young people are female, with a total of 10,111 young women in the US living with HIV.1 Patterns of HIV infection among young women and men differ considerably. Young women bear the weight of most infections, representing 57% of all HIV cases among 13-19 year-olds, in contrast to 35% of cases among 20-24 year-olds.1 Young African American women are significantly over-represented among HIV+ youth, comprising almost three-fourths (69%) of young women living with HIV. White young women comprise 23% of young women living with HIV, Latinas 6% and Asian/Pacific Islanders and American Indian/Alaska Natives each 1%.1 The reasons why young African American women in particular have such high rates of HIV and other sexually transmitted diseases (STDs) have not been adequately addressed in research. Economic and social inequalities increase young African American women’s vulnerability to HIV infection. Structural racism through discrimination in employment, housing, earning power and educational opportunity can affect their risk for HIV.2

What puts them at risk?

While many women face structural barriers that make them vulnerable to HIV, young women face specific barriers. Social and economic inequalities, gender violence, and social position as youth—combined with young women’s particular biological vulnerability—place young women at considerable risk for HIV infection. Over half of all HIV cases among young women do not have an identified risk (they report no or unknown transmission risk), indicating that young women are not aware that they are being exposed to HIV. Of the reported HIV cases with identified risk among young women, 37% are due to heterosexual contact and 7% to injection drug use.1 Twenty-two percent of American children live in families below the poverty level, almost twice the rate in any other industrialized country. Poverty contributes to an environment of high risk for young women, such as being homeless and/or trading sex for money or shelter.3 Sexual transmission of HIV and other STDs from men to young women is easier than to older women due to young women’s developing genital tract. A young woman’s genital tract has a thin single layer of cells that does not transition to a thick multi-layer wall until women are in their early 20s.4 Young women have high rates of STDs, and active STDs can facilitate transmission of HIV. In the US, 15-19 year-old women have the highest rates of gonorrhea and chlamydia. African American women aged 15-19 have gonorrhea rates 24 times higher than young white women.5 Sharing needles and drug preparation equipment is greater among young female IDUs, despite injecting no more than young males. Also, overlapping sexual and injection partnerships have been found to be a key factor in increased injection risk in females.6 One quarter (26%) of lesbian, gay, bisexual, and transgender youth are forced out of their homes upon disclosure of their sexuality. Living on the streets places young women at risk of HIV infection due to exposure through rape, survival sex and injecting drug use.7 Personal histories of physical and sexual abuse and trauma increase vulnerability to high-risk drug use and sexual behavior. A study of young IDUs in Vancouver, Canada, found that those who were HIV+ were more likely to be female, have a history of sexual abuse, engage in survival sex, inject heroin daily and have numerous lifetime sexual partners.8 HIV+ young women (age 13-19) are more likely than their HIV- counterparts to have older sex partners and to use condoms less frequently with them.9 Partnering with older men has perceived and actual benefits for young women, such as financial and emotional security, escape from their current living situation and high status among peers. Older male partners may also present risks, as they are more likely to have had multiple sex partners and be HIV/STD infected, and less likely to use condoms.10

What are facilitators to prevention?

HIV prevention with young women is about so much more than HIV, and must consider the social and economic context of these youths’ lives. Supporting young women as agents of well-being and change in their own lives and in their communities is the foundation of thoughtful HIV prevention. Family and community are important support systems that can protect young women from HIV risk. For example, one study found that young African American women who are involved in community-based Black social organizations are less likely to engage in risky sexual behaviors and more likely to talk to their parents about sexuality and HIV.11

What’s being done?

The Center for Young Women’s Development is a peer-run organization in San Francisco, CA that promotes self-sufficiency, community safety, and youth advocacy among young women aged 14-18 who are involved in the juvenile justice and foster care systems and/or have lived on the streets. The Center provides employment, leadership and training for them to educate others in their community. Equipped with the knowledge and opportunity to train others, these young women are more likely to incorporate these skills into their own lives.12 Sisters for Life, in Washington, DC, is a mentoring program for African American girls aged 9-14 serving three public housing communities in Alexandria, VA. The program builds the life skills of girls, supporting their efforts to develop into healthy, responsible adults who avoid HIV infection, substance abuse and STDs. Sisters for Life promotes academic accomplishments as well as self-worth and self-esteem. It addresses risks surrounding HIV/AIDS indirectly, concentrating on supporting the girls as maturing youth and addressing high-risk behaviors in the larger context of the girls’ lives.13 De Madre a Hija: Protegiendo Nuestra Salud (From Mother to Daughter: Protecting Our Health) is an intergenerational HIV prevention initiative for Latina women. This pilot intervention targets Spanish-speaking Latina mothers of adolescents. It focuses on improving mother-daughter communication across generational and cultural barriers, improving sexual knowledge and comfort, understanding risk, examining gender/sex role attitudes, and building risk reduction skills for both mother and daughter.14

What more needs to be done?

“I want to be able to speak my own language but still be understood.” (Nelly Valesco, 10/16/76 – 10/06/96) Young women must be involved in the planning, design and implementation of HIV prevention programs. In order to be effective, HIV prevention with young women must be conducted within the social and economic context in which they are becoming infected. Because they often experience economic and social disadvantages, education and job training/opportunities are important components of prevention programs. HIV prevention programs that promote community building and involvement can be effective. Programs should incorporate communication and negotiation skills (especially with older men), general sexual and reproductive health information and mental health issues such as healing histories of trauma and abuse. HIV prevention for young women should include access or referrals to STD prevention and treatment, pregnancy prevention and needle exchange services. Programs for hard-to-reach young women who can be most at risk for HIV should be implemented in venues outside of schools, such as youth shelters, shopping malls, detention facilities and recreation/community centers. HIV and other STDs are less of a problem for young women when they are given the skills and opportunities to support themselves.

Says who?

1. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report. US HIV and AIDS cases reported through June 2001 Midyear edition. 2002;13(1). 2. Zierler S, Krieger N. Reframing women’s risk: social inequalities and HIV infection. Annual Review of Public Health. 1997;18:401-436. 3. Prilleltensky I, Nelson G. Promoting Child and Family Wellness: Priorities for Psychological and Social Interventions. Journal of Community Applied and Social Psychology. 2000;10:86. 4. Reid E, Bailey M. Young Women: Silence, Susceptibility and the HIV Epidemic. UNDP HIV and Development Programme, Issue Paper No. 12, 2001. 5. Division of STD Prevention. Sexually Transmitted Disease Surveillance, 1996.Atlanta, GA: U.S. Dept. of Health and Human Services, Centers for Disease Control and Prevention, 1997. 6. Evans JE, Hahn JA, Page-Shafer K, et al. Gender differences in sexual and injection risk behavior among active young injection drug users in San Francisco(The UFO Study) (in press). 7. Clifton CE. The young and the restless. Positively Aware. March/April 2001.https://www.positivelyaware.com/  8. Miller CL, Spittal PM, LaLiberte N, et al. Females experiencing sexual and drug vulnerabilities are at elevated risk for HIV infection among youth who use injection drugs. Journal Of Acquired Immune Deficiency Syndromes. 2002;30:335-341. 9. Sturdevant MS, Belzer M, Weissman G, et al. The relationship of unsafe sexual behavior and the characteristics of sexual partners of HIV infected and HIV uninfected adolescent females. Journal of Adolescent Health. 2001;29:S64-71. 10. Harper GW, Bangi AK, Doll M, et al. Older male sex partners present increased HIV risk for low-income female adolescents: economic, social and cultural influences. Presented at the International Conference on AIDS, July 2002,Barcelona, Spain. #ThPeE7789. 11. Crosby RA, DiClemente RJ, Wingood GM, et al. Participation by African-American adolescent females in social organizations: associations with HIV-protective behaviors. Ethnicity and Disease. 2002;12:186-192. 12. Center for Young Women’s Development. www.cywd.org 13. AIDS Action Committee. What Works in HIV Prevention for Youth. Chapter 4: What Is Working in Local Communities. 2001. Gómez CA, Gómez-Mandic C. Intergenerational HIV Prevention Initiative forLatina Women. Presented at the UCSF Center for AIDS Prevention Studies Conference. April, 2002.

Prepared by Sonja Mackenzie, MS, CAPS October 2002. Fact Sheet #45E Special thanks to the following reviewers of this Fact Sheet: Moher Downing, Cynthia Gomez, Gary Harper, Kayla Jackson, Jen Lee, Beverly Saunders Biddle, Kimberly Page Shafer.

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]. © October 2002, University of California

Resource

Mujeres jóvenes

¿Qué necesitan las mujeres jóvenes para la prevención del VIH?

¿corren riesgo las mujeres jóvenes?

Sí. Una de cada cinco personas con VIH en EE.UU. es menor de 25 años. El 40% de estos jóvenes son mujeres con un total de 10,111 jovencitas en EE.UU. viviendo con VIH.1 Los patrones de infección entre las jóvenes son muy diferentes a los de los jóvenes. Las jovencitas representan una mayoría de un 57% de todos los casos de VIH entre personas de 13 a 19 años de edad, en contraste con el 35% de los casos entre personas de 20 a 24 años.1 Entre las jóvenes VIH+, predominan desproporcionadamente las afroamericanas, que componen casi las tres cuartas partes (69%) de las mujeres jóvenes viviendo con VIH. El 23% de éstas son blancas, el 6% son latinas y las asiáticas/de las islas del Pacífico, y las indígenas/nativas de Alaska componen el 1% respectivamente.1 No se ha realizado suficiente investigación sobre las razones por las cuales las jóvenes afroamericanas en particular tienen tasas tan altas de VIH y de otras enfermedades transmitidas sexualmente (ETS). Las desigualdades económicas y sociales aumentan su vulnerabilidad a la infección por VIH. El racismo estructural (que conduce a la discriminación en el empleo, la vivienda, los salarios y las oportunidades educativas) puede promover su riesgo de contraer el VIH.2

¿qué las pone en riesgo?

Muchas mujeres encuentran obstáculos estructurales que las hacen vulnerables al VIH, pero las jóvenes se enfrentan a otras barreras específicas. Las desigualdades sociales y económicas, la violencia y su posición social como persona joven, en combinación con la vulnerabilidad particular de la mujer joven, ponen a las jovencitas en un riesgo considerable de contraer el VIH. Más de la mitad de todos los casos de VIH entre mujeres jóvenes no se atribuye a ningún riesgo identificado (ellas reportan un riesgo desconocido o ninguno), lo cual indica que ellas no se dan cuenta de que se exponen al VIH. De los casos de VIH reportados entre mujeres jóvenes con un riesgo identificado, el 37% se debe al contacto heterosexual y el 7% al uso de drogas inyectables.1 El 22% de los niños en EE.UU. vive en familias con ingresos por debajo del índice de pobreza, casi el doble de la tasa de pobreza de cualquier otro país industrializado. La pobreza contribuye a crear un ambiente de alto riesgo para las mujeres jóvenes, por ejemplo, la falta de vivienda o la necesidad de tener sexo a cambio de dinero o alojamiento.3 El VIH y otras ETS se transmiten más fácilmente del hombre a la mujer joven que a la mujer mayor, pues los órganos genitales de la joven aún se encuentran en desarrollo. Durante la juventud, el aparato genital tiene sólo una capa delgada de células, la cual no se convierte en barrera gruesa (con la formación de capas adicionales) sino hasta un poco después de los 20 años de edad.4 Las mujeres jóvenes tienen tasas altas de ETS. Una ETS activa puede facilitar la transmisión del VIH. En EE.UU., las mujeres de 15-19 años de edad tienen las tasas más altas de gonorrea y clamidia. Las afroamericanas de 15-19 años tienen tasas de gonorrea 24 veces mayores que las jóvenes blancas.5 Aunque las mujeres jóvenes usuarias de drogas inyectables (UDI) no se inyecten más que los hombres jóvenes UDI, es más frecuente que ellas compartan jeringas y equipos de preparación de drogas. Entre mujeres la práctica de compartir materiales de inyección de drogas con su pareja sexual es un factor clave en el aumento del riesgo al inyectarse.6 La cuarta parte (26%) de los jóvenes gays, lesbianas, bisexuales y transexuales son corridos de su casa al revelar su sexualidad. La vida en la calle pone a las mujeres jóvenes en peligro de contraer el VIH al exponerlas a la violación, al sexo por sobrevivencia y al uso de drogas inyectables.7 Haber sufrido abuso y trauma físico y sexual en el pasado aumenta la vulnerabilidad al uso riesgoso de drogas y a la actividad sexual sin protección. Un estudio de jóvenes UDI en Vancouver, Canadá encontró que quienes eran VIH+ tendían a: ser mujeres, haber sufrido abuso sexual, tener sexo a cambio de drogas, inyectarse diariamente heroína y haber tenido muchas parejas sexuales.8 Las adolescentes (de 13 a 19 años de edad) VIH+ son más propensas que las VIH- a tener parejas sexuales mayores y a un uso infrecuente de condones ellos.9 Tener un compañero sexual mayor ofrece beneficios aparentes y reales para las mujeres jóvenes, tales como la seguridad económica y emocional, la capacidad de salir de su situación de vivienda actual, y el respeto de sus compañeras. Los compañeros mayores también pueden presentar un riesgo, pues es más probable que ellos hayan tenido varias parejas sexuales y por lo tanto estén infectados por VIH u otra ETS. Ellos también son menos propensos a usar condones.10

¿qué es lo que ayuda en la prevención?

La prevención del VIH entre mujeres jóvenes abarca mucho más que el VIH, y deberá tomar en cuenta el contexto social y económico de la vida de estas jóvenes. La base de una prevención del VIH bien pensada, consiste en apoyar a las jóvenes para que sean agentes del bienestar y del cambio en su propia vida y en su comunidad. La familia y la comunidad son sistemas de apoyo importantes que pueden proteger a las jovencitas contra el riesgo del VIH. Por ejemplo, un estudio reveló que las jóvenes afroamericanas que participan en organizaciones sociales de la comunidad negra son menos propensas a participar en actividades sexuales riesgosas y más propensas a hablar con sus padres sobre la sexualidad y el VIH.11

¿qué se está haciendo al respecto?

El Center for Young Women’s Development (Centro para el Desarrollo de la Mujer Joven) es una organización dirigida por mujeres jóvenes en San Francisco, CA. que promueve la autosuficiencia, la seguridad comunitaria y la defensa de los derechos de la juventud entre chicas de 14 a 18 años de edad que están involucradas en los sistemas de justicia juvenil o de crianza temporal, o que han vivido en la calle. El centro les brinda empleo, liderazgo y capacitación para que ellas orienten a otras personas en su comunidad. Una vez que tengan los conocimientos y la oportunidad de capacitar a otros, es más probable que estas mujeres jóvenes incorporen estas habilidades a su propia vida.12 Sisters for Life (Hermanas de por Vida), en Washington, DC, es un programa de mentoras para afroamericanas de 9-14 años de edad en tres comunidades de vivienda pública en Alexandria, VA. El programa fortalece las habilidades prácticas de las jovencitas al apoyar sus esfuerzos por llegar a ser adultas sanas y responsables que eviten la infección por VIH, el uso de drogas y alcohol y las ETS. Sisters for Life promueve tanto los logros académicos como el amor propio y la autoestima. El programa abarca el VIH/SIDA en forma indirecta, centrándose en apoyar a las muchachas como jóvenes en vías de maduración y en enfocar las conductas de alto riesgo dentro del contexto más amplio de la vida de cada jovencita.13 De Madre a Hija: Protegiendo Nuestra Salud, es una iniciativa intergeneracional de prevención del VIH entre mujeres latinas. Este programa piloto se destina a las madres hispanohablantes de adolescentes. Su enfoque es ayudar a las participantes a mejorar la comunicación madre-hija por encima de barreras generacionales y culturales, aumentar sus conocimientos sobre el sexo y su confianza para hablar del tema, entender los riesgos para la salud, examinar actitudes sobre los papeles masculinos y femeninos y aumentar las habilidades tanto de las madres como de las hijas para reducir riesgos.14

¿qué queda por hacer?

“Quiero hablar en mi propio idioma y saber que me entenderán.” (Nelly Valesco, 10/16/76 – 10/06/96) Las jóvenes deben ser incluidas en la planificación, diseño y puesta en práctica de los programas de prevención del VIH. Para tener buenos resultados, la prevención del VIH entre mujeres jóvenes deberá realizarse dentro del contexto social y económico en el cual ellas se infectan. Ya que muchas veces ellas tienen desventajas económicas y sociales, las oportunidades educativas y de capacitación laboral son componentes importantes de los programas de prevención. Los programas de prevención del VIH que involucren y fortalezcan a la comunidad pueden lograr cambios positivos. Estos programas deben incorporar información sobre la buena comunicación y la negociación (especialmente con hombres mayores), la salud general y reproductiva, así como ayuda para superar los efectos del trauma o abuso y otras necesidades de salud mental. La prevención del VIH entre las mujeres jóvenes debe incluir acceso o referencias a servicios de prevención y tratamiento de ETS, prevención del embarazo e intercambio de jeringas. Es necesario ofrecer programas para las jóvenes con quienes es difícil establecer contacto y que pueden correr un mayor riesgo de contraer el VIH. Éstos servicios deben ofrecerse en lugares fuera de la escuela, tales como albergues para jóvenes, centros comerciales, centros de detención y centros recreativos o comunitarios. El VIH y otras ETS dejan de ser una gran amenaza para las mujeres jóvenes cuando ellas han adquirido las destrezas y se les han ofrecido oportunidades de apoyarse a sí mismas.

¿quién lo dice?

1. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report. US HIV and AIDS cases reported through June 2001 Midyear edition. 2002;13(1). 2. Zierler S, Krieger N. Reframing women’s risk: social inequalities and HIV infection. Annual Review of Public Health. 1997;18:401-436. 3. Prilleltensky I, Nelson G. Promoting Child and Family Wellness: Priorities for Psychological and Social Interventions. Journal of Community Applied and Social Psychology. 2000;10:86. 4. Reid E, Bailey M. Young Women: Silence, Susceptibility and the HIV Epidemic. UNDP HIV and Development Programme, Issue Paper No. 12, 2001. 5. Division of STD Prevention. Sexually Transmitted Disease Surveillance, 1996.Atlanta, GA: U.S. Dept. of Health and Human Services, Centers for Disease Control and Prevention, 1997. 6. Evans JE, Hahn JA, Page-Shafer K, et al. Gender differences in sexual and injection risk behavior among active young injection drug users in San Francisco(The UFO Study) (in press). 7. Clifton CE. The young and the restless. Positively Aware. March/April 2001. 8. Miller CL, Spittal PM, LaLiberte N, et al. Females experiencing sexual and drug vulnerabilities are at elevated risk for HIV infection among youth who use injection drugs. Journal Of Acquired Immune Deficiency Syndromes. 2002;30:335-341. 9. Sturdevant MS, Belzer M, Weissman G, et al. The relationship of unsafe sexual behavior and the characteristics of sexual partners of HIV infected and HIV uninfected adolescent females. Journal of Adolescent Health. 2001;29:S64-71. 10. Harper GW, Bangi AK, Doll M, et al. Older male sex partners present increased HIV risk for low-income female adolescents: economic, social and cultural influences. Presented at the International Conference on AIDS, July 2002,Barcelona, Spain. #ThPeE7789. 11. Crosby RA, DiClemente RJ, Wingood GM, et al. Participation by African-American adolescent females in social organizations: associations with HIV-protective behaviors. Ethnicity and Disease. 2002;12:186-192. 12. Center for Young Women’s Development. www.cywd.org 13. AIDS Action Committee. What Works in HIV Prevention for Youth. Chapter 4: What Is Working in Local Communities. 2001.https://aac.org/  14. Gómez CA, Gómez-Mandic C. Intergenerational HIV Prevention Initiative forLatina Women. Presented at the UCSF Center for AIDS Prevention Studies Conference. April, 2002.

Preparado por Sonja Mackenzie, MS, CAPS

Traducción Rocky Schnaath Octubre 2002. Hoja Informativa 45S