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Should we teach only abstinence in sexuality education?

Why all the fuss?

Schools have become a battleground in the nation’s culture wars. In the fight over the hearts, minds-and libidos-of our nation’s teenagers, the latest skirmish involves sex education. The question is not whether education about sexuality belongs in the schools (there is well nigh universal accord on this score),¹ but rather, how to approach the topic. “Just say no” is the answer, at least according to a growing number of champions of “abstinence only” curricula. Abstinence-only approaches include discussions of values, character building and refusal skills, while avoiding specific discussions of contraception or safer sex. Comprehensive sexuality education begins with abstinence but also acknowledges that many teenagers will choose to have sex and thus need to be aware of the consequences and how to protect themselves. Such programs include instruction in safe sex behavior, including use of condoms and other contraceptives.² The abstinence-only sex education movement has been propelled by the persistent but mistaken belief that comprehensive sexuality education itself somehow seduces teenagers into sexual activity. By this reasoning it follows that schools should either ignore the issue or discuss sexuality only in terms of fear and disease. The casualties in this war are teenagers themselves, denied information about how to prevent pregnancy or sexually transmitted diseases in the highly likely event that they have sexual intercourse.

Policy developments

Abstinence-only proponents got a big boost when, as part of the federal welfare reform legislation, Congress earmarked $50 million dollars per year for the next five years for abstinence-only school programs. Eight specific criteria have been established for programs, including the mandate that their “exclusive purpose” be teaching the “social, psychological and health gains” to be realized from abstinence. The block grant requires 75 percent matching funds from other public or private sources, for an annual total of more than $87 million.³ Every state in the union applied for the federal abstinence funding. Some expect to use it only for children in early grades or for media campaigns, a strategy which avoids putting a teacher in the position of being unable to answer a question about birth control or barrier methods of protection from high school students.⁴

Abstinence for whom? until when?

Abstinence-only curricula typically seek to encourage abstinence from sexual activity until marriage. In support of this goal, abstinence proponents use arguments that fly in the face of both science and human experience. The federal abstinence provisions include the statement: “Sexual activity outside the context of marriage is likely to have harmful psychological and physical effects.” This conclusion is as unsubstantiated as it is startling, in light of the statistic that 93 percent of American men and 80 percent of American women between ages 18 and 59 were not virgins on their wedding night.⁴ In the debate over the role for abstinence in sexuality education, little pain is taken to avoid the distinction, for example, between abstinence for 12 or 13-year olds versus 17 or 18-year-olds. Few could argue with a near exclusive focus on abstinence for young children. For older teens, sexuality education needs to be relevant for the substantial share of adolescents who choose to have sex. Two thirds (66%) of American high school seniors have had sex.⁵ Pleas to abstain from sex until marriage must also be considered in light of the current average age at which Americans first tie the knot (approximately 24 for women and 26 for men).⁶ Moreover, the exhortations to avoid sex until marriage have little, if any, meaning for gay teens.

Great expectations?

The sex education debate sometimes grows so heated as to lose a sense of proportion. Great expectations are heaped on school-based programs. Most teaching is assessed by measuring its impact on knowledge rather than behavior outside of the classroom.⁷ It is a tall order to establish the relationship between classroom sex education and changes in behaviors such as delays in initiating intercourse or increases in contraceptive use. Classroom instruction must be factored into the conflicting mix of influences from peers, parents, churches and a media barrage of pro-sex messages. If all young people had safe and secure lives, a “just say no” message by itself might be useful. But for most, risk taking is part of a constellation of internal and external influences. A 1995 national survey reported that 16% of girls whose first intercourse was before age 16 reported that initiation of intercourse was not voluntary. School-based programs by definition also fail to reach many of those at highest risk, such as “runaway” or “throwaway” youth.⁹ Abstinence-only or abstinence plus? The best sex education begins with abstinence as a starting point, both encouraging it for young people who are not ready for sex and supporting those who choose it for whatever reason. Abstinence-only proponents have criticized more comprehensive approaches for focusing only on “plumbing,” sending “mixed messages” and ignoring values. Clearly, the best sex education programs address more than the biology of sex and risk (although kids are owed the basic facts on how their bodies work and how to protect themselves against unintended pregnancy and sexually transmitted diseases). So far, abstinence-only programs have failed to meet scientific tests of proven effectiveness. A recent review found only six published studies in the peer-reviewed literature examining abstinence-only programs.¹⁰ None was found effective, in part due to poor evaluation; one was clearly ineffective. If the federal government is going to fund approaches absent any proof of significant program effects, state officials who accept federal dollars should insist that the programs be thoroughly and rigorously evaluated. The new quarter billion dollar federal program for abstinence-only teaching furthers a religious and political, not a public health agenda.¹¹ Political agendas and discomfort with teen sexuality obstruct the ability to conduct research on which programs work best in preventing HIV and unintended pregnancies. It is not enough to agree on what adults would like young people to hear. Delivery of politically palatable-rather than effective-curricula may serve the interest of adults, but will cheat many young people.

What really works?

For all their antipathy, abstinence-only advocates and comprehensive sexuality education proponents share common goals: the prevention of unintended pregnancies, HIV and other STDs. A number of comprehensive sex education curricula examined in rigorous studies have achieved modest delays in sexual intercourse, reductions in number of partners, and increases in contraceptive use. A national review outlined a variety of elements of effective programs: tailoring to the age and experience of the audience; focus on risky sexual behavior; sound theoretical foundation; provision of basic facts about avoiding risks of unprotected sex; acknowledgement of social pressures to have sex; and practice in communication, negotiation and refusal skills.¹⁰ The guardians of quality education, including teachers, parents, school boards, and legislators have a duty to consider more than the leanings of one advocacy group or another. Credible, objective evidence about the ability of specific programs to achieve their goals is essential. Decision makers need to separate value questions from questions of effectiveness in sex education, and find the common ground.

Says who?

Kaiser Family Foundation. The Kaiser Survey on Americans and AIDS/HIV. Menlo Park, CA: 1998. 2. National Institutes of Health. Interventions to Prevent HIV Risk Behaviors. Consensus Development Conference Statement . Washington, D.C.:1997; Feb. 11-13. 3. Block Grant Guidance for the Abstinence Education Provision of the 1996 Welfare Law P.L. 104-193. For more information, contact: Department of Health and Human Services, PHS/HRSA/MCHB/OD/CB-18-20, 5600 Fishers Lane, Rockville, MD 20857, (301) 443-0205. 4. Associated Press. Sex education that teaches abstinence wins support. New York Times. July 23,1997;A19. 5. Centers for Disease Control and Prevention. Youth risk behavior surveillance-United States , 1995. Morbidity and Mortality Weekly Report. 1996;45(No. SS-4):1-86. 6. The Alan Guttmacher Institute. Sex and America’s Teenagers. New York, 1994. http://www.agi-usa.org/ 7. Kirby D. Sex and HIV/AIDS education in schools . British Medical Journal. 1995;311:403. 8. National Center for Health Statistics. National Survey of Family Growth, cycle IV : 1990 telephone reinterview. Hyattsville, MD: US Department. of Health and Human Services; 1995. 9. Rotheram-Borus MJ, Koopman C, Haignere C, et al. Reducing HIV risk behaviors among runaway adolescents . Journal of the American Medical Association. 1991;266:1237-1241. 10. Kirby D. No Easy Answers: Research Findings on Programs to Reduce Teen Pregnancy . Washington, DC: National Campaign to Prevent Teen Pregnancy; 1997. 11. Ehrhardt AA. Our view of adolescent sexuality-a focus on risk behavior without the developmental context . American Journal of Public Health. 1996;86:1523-1525. Resources: The Alan Guttmacher Institute 120 Wall Street New York, NY 10005 (212) 248-1111 http://www.agi-usa.org/ Centers for Disease Control and Prevention Division of Adolescent and School Health 4770 Buford Highway, NE MS-29 Chamblee, GA 30341 (770) 488-3251 https://www.cdc.gov/healthyyouth/index.htm Sexuality Information and Education Council of the United States (SIECUS) 130 West 42nd Street, Suite 350 New York, NY 10036 (212) 819-9770. http://www.siecus.org National School Boards Association 1680 Duke Street Alexandria, VA 22314 (703) 838-6722 Contact: Brenda Z. Greene http://www.nsba.org

Prepared by Chris Collins* and Jeff Stryker* *CAPS, UCSF September 1997. Fact Sheet #30E 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]. © September 1997, University of California

¿Debemos enseñar “solo-abstinencia” en la educación sexual?

¿por qué tanto alboroto?

Las escuelas se han convertido en el campo de batalla cultural de la nación. En la lucha por conquistar el corazón, mente — y líbidos — de nuestra juventud, la última contienda incluye la educación sexual. La pregunta no radica en que si la escuela es el lugar apropiado para enseñar educación sexual (en esto todos estamos de acuerdo),¹ más bien es, como abordar el tema. Con solo decir “no” se soluciona el problema, al menos esto es lo que cree una cantidad creciente de campeones del currículum basado en solo-abstinencia. Con la abstinencia se trata el tema de los valores morales, se contruye el carácter y se aprende a decir “no”, siempre y cuando se evite el tema de los anticonceptivos o el sexo seguro. Una educación sexual completa comienza con la abstinencia, pero además toma en cuenta que muchos jóvenes van a decidir tener sexo, por lo tanto tienen que saber las consecuencias y la manera de protegerse a si mismos. Estos programas incluyen la instrucción sobre el comportamiento sexual seguro, incluyendo el uso del condón y de otros anticonceptivos.² El movimiento de educación sexual basado en solo-abstinencia tiene su origen en la constante y errada creencia de que una educación sexual completa de alguna forma induce a la juventud a iniciar la actividad sexual. A causa de este razonamiento, las escuelas deben ignorar el tema o relacionar la sexualidad con el temor y la enfermedad. En esta guerra los perdedores siguen siendo los jóvenes, ya que se les niega información sobre como evitar los embarazos o las enfermedades de transmisión sexual en caso de que tengan relaciones sexuales, lo cual es muy probable.

políticas en desarrollo

Los proponentes de solo-abstinencia obtuvieron su mayor logro cuando como parte de la ley de Reforma Federal de Bienestar Social, el congreso designó 50 millones de dólares anuales por cinco años consecutivos a programas de solo-abstinencia en las escuelas. Existen ocho elementos específicos que estos programas deben cumplir, uno de estos mandatos es que el “propósito exclusivo” del programa sea el de demostrar la ganancia social, psicológica y de salud que se obtiene por medio de la abstinencia. Este tipo de fondos requiere que se recaude el 75% de la cantidad otorgada a través de fuentes públicas o privadas, para un total de $87 millones de dólares anuales.³

abstinencia, ¿para quién? y ¿Hasta cuándo?

Generalmente, el currículum de solo-abstinencia promueve abstenerse de la actividad sexual hasta el matrimonio. Para lograr esta meta, los proponentes de la abstinencia usan argumentos que pasan por alto ante la ciencia y la experiencia del ser humano. Una de las provisiones federales en cuanto a la abstinencia establece que la actividad sexual fuera del matrimonio puede ocasionar daños físicos y psicológicos. Esta conclusión resulta tan carente de validez como sorprendente si tomamos en cuenta las estadísticas que señalan que el 93 por ciento de los hombres y el 80 por ciento de las mujeres entre los 18 y 59 años de edad no eran vírgenes en su noche de bodas.⁴ En el debate acerca del papel que desempeña la abstinencia en la educación sexual, poco se hace para lograr la distinción, por ejemplo, entre los programas de abstinencia para los de 12 a 13 anõs versus los de 17 o 18 años. Todos están de acuerdo que la abstinencia se les debe enseñar a niños pequeños. Para los adolescentes mayores, la educación sexual debe ser relevante a la cantidad sustancial de adolescentes que deciden tener relaciones sexuales. Dos tercios (66%) de los adolescentes en su último año escolar han tenido relaciones sexuales.⁵ Al pedir la abstinencia sexual hasta el matrimonio, se debe tomar en cuenta el promedio actual de las edades en que los Norteamericanos contraen matrimonio por primera vez (aproximadamente 24 años en la mujer y 26 para el hombre).⁶ Es más, pedirles a los hombres gay que eviten el sexo hasta el matrimonio, tiene poco significado, si acaso lo tiene.

¿grandes expectativas?

El debate sobre la educación sexual, algunas veces crece a niveles fuera de proporción. La mayor parte de la enseñanza se determina midiendo el impacto que el programa ha tenido en el conocimiento, en vez de en la conducta adoptada una vez fuera del salón de clases.⁷ Es imperante establecer la relación entre las clases de educación sexual en el salón de clases y los cambios de conducta tales como el retraso del inicio de las relaciones sexuales o el incremento en el uso de los anticonceptivos. La enseñanza en los salones de clase debe tomar en cuenta la mezcla de influencias de los compañeros(as), de la iglesia , y de una ráfaga de mensajes publicitarios que promueven el sexo. Si todos tuviéramos una vida sana y segura, el simple mensaje de “solo di no” pudiera ser útil. Pero para la mayoría arriesgar forma parte de una constelación de influencias externas e internas. Una encuesta a nivel nacional reveló que el 16% de las chicas que tuvieron su primera relación sexual antes de cumplir los 16 años fue involuntaria.⁸ Los programas con base en las escuelas, por definición, fracasan en alcanzar a aquellos jóvenes que corren mayores riesgos, tales como los que han huído de sus casas y los que son echados de sus casas.⁹

¿solo-abstinencia o abstinencia y algo más?

La mejor educación sexual tiene como punto de partida la abstinencia, promoviéndola entre aquellos que no están listos para tener sexo y apoyando a aquellos que por cualquier razón deciden abstenerse. Claramente, los mejores programas de educación sexual van más allá de la biología del riesgo y del sexo (aún faltaría explicar el funcionamiento básico del cuerpo humano y como protegerse a si mismos de los embarazos no planeados y de las ETS). Hasta hoy, los programas de solo-abstinencia no han podido demostrar cientificamente su efectividad. Un estudio realizado recientemente, encontró que solamente se ha publicado la literatura de seis estudios en revistas evaluadas por expertos en la materia, en los cuales se examinaba la efectividad de los programas de solo-abstinencia.¹⁰ Ninguno de estos programas demostró ser efectivo, en parte debido al inadecuado método de la evaluación; uno de estos era claramente ineficaz. El nuevo cuarto de billón de dólares asignado a programas federales de solo-abstinencia, más que una agenda de salud pública parece más bien política y religiosa.¹¹ Las agendas políticas y la incomodidad del tema de la sexualidad en la juventud obstruyen la habilidad de conducir investigaciones sobre cuales programas son los que funcionan mejor en la prevención del VIH y de los embarazos no planeados. Proclamar currículums agradables al paladar político-en vez de efectivo- puede servir el interés de los adultos, pero defraudar el de muchos jóvenes.

¿qué es lo que realmente funciona?

A pesar de todo, los que abogan por una educación sexual basada en solo-abstinencia y los proponentes de una educación sexual completa, tienen algunas metas en común: la prevención de los embarazos no planeados, evitar la infección con VIH y de otras ETS. Una buena cantidad de curriculums sobre educación sexual completa que fueron examinados a través de rigurosos estudios han logrado un modesto retraso en el inicio de las relaciones sexuales, una reducción en la cantidad de parejas; y un aumento en el uso de anticonceptivos. En una revisión a nivel nacional se señalaron varios elementos de programas eficaces: fueron diseñados de acuerdo a la edad y experiencia de la audiencia; con un enfoque en el comportamiento sexual de riesgo; con una base teórica razonable; ofreciendo información básica sobre como evitar el riesgo de tener sexo sin protección; hacerles notar que la sociedad los empuja a tener sexo; practicar la comunicación, la negociación y las formas de decir no.¹⁰ Los encargados de mantener una educación de calidad, incluyendo a maestros, padres de familia, miembros de juntas directivas escolares, y legisladores tienen el deber de ir más allá de querer favorecer a un grupo sobre otro. Para lograr cumplir las metas específicas de un programa que dice ser efectivo es esencial que la evidencia sea creíble y objetiva. Cuando se trata del tema de la sexualidad es necesario que los que toman las decisiones separen las preguntas sobre valores morales de las de efectividad y encontrar un terreno común.

¿quién lo dice?

Kaiser Family Foundation. The Kaiser Survey on Americans and AIDS/HIV. Menlo Park, CA: 1998. 2. National Institutes of Health. Interventions to Prevent HIV Risk Behaviors. Consensus Development Conference Statement . Washington, D.C.:1997; Feb. 11-13. 3. Block Grant Guidance for the Abstinence Education Provision of the 1996 Welfare Law P.L. 104-193. For more information, contact: Department of Health and Human Services, PHS/HRSA/MCHB/OD/CB-18-20, 5600 Fishers Lane, Rockville, MD 20857, (301) 443-0205. 4. Associated Press. Sex education that teaches abstinence wins support. New York Times. July 23,1997;A19. 5. Centers for Disease Control and Prevention. Youth risk behavior surveillance-United States , 1995. Morbidity and Mortality Weekly Report. 1996;45(No. SS-4):1-86. 6. The Alan Guttmacher Institute. Sex and America’s Teenagers. New York, 1994. http://www.agi-usa.org/ 7. Kirby D. Sex and HIV/AIDS education in schools . British Medical Journal. 1995;311:403. 8. National Center for Health Statistics. National Survey of Family Growth, cycle IV : 1990 telephone reinterview. Hyattsville, MD: US Department. of Health and Human Services; 1995. 9. Rotheram-Borus MJ, Koopman C, Haignere C, et al. Reducing HIV risk behaviors among runaway adolescents . Journal of the American Medical Association. 1991;266:1237-1241. 10. Kirby D. No Easy Answers: Research Findings on Programs to Reduce Teen Pregnancy . Washington, DC: National Campaign to Prevent Teen Pregnancy; 1997. 11. Ehrhardt AA. Our view of adolescent sexuality-a focus on risk behavior without the developmental context . American Journal of Public Health. 1996;86:1523-1525. Recursos: The Alan Guttmacher Institute 120 Wall Street, New York, NY 10005, (212) 248-1111. http://www.agi-usa.org/ Centers for Disease Control and Prevention, Division of Adolescent and School Health, 4770 Buford Highway, NE MS-29, Chamblee, GA 30341, (770) 488-3251.https://www.cdc.gov/healthyyouth/index.htm Sexuality Information and Education Council of the United States (SIECUS), 130 West 42nd Street, Suite 350, New York, NY 10036, (212) 819-9770.http://www.siecus.org National School Boards Association, 1680 Duke Street, Alexandria, VA 22314, (703) 838-6722. Contact: Brenda Z. Greene. http://www.nsba.org

Preparado por Chris Collins* y Jeff Stryker*, Traducción Romy Benard-Rodríguez* *CAPS Abril 1998. Hoja Informativa 30S. versión en PDF

What Are Adolescents’ HIV Prevention Needs?

Can adolescents get HIV?

Unfortunately, yes. HIV infection is increasing most rapidly among young people. Half of all new infections in the US occur in people younger than 25. From 1994 to 1997, 44% of all HIV infections among young people aged 13-24 occurred among females, and 63% among African-Americans. While the number of new AIDS cases is declining among all age groups, there has not been a comparable decline in the number of new HIV infections among young people.¹ Unprotected sexual intercourse puts young people at risk not only for HIV, but for other sexually transmitted diseases (STDs) and unintended pregnancy. Currently, adolescents are experiencing skyrocketing rates of STDs. Every year three million teens, or almost a quarter of all sexually experienced teens, will contract an STD. Chlamydia and gonorrhea are more common among teens than among older adults.² Some sexually-active young African-American and Latina women are at especially high risk for HIV infection, especially those from poorer neighborhoods. A study of disadvantaged out-of-school youth in the US Job Corps found that young African-American women had the highest rate of HIV infection, and that women 16-18 years old had 50% higher rates of infection than young men.³ Another study of African-American and Latina adolescent females found that young women with older boyfriends (3 years older or more) are at higher risk for HIV.⁴

What puts adolescents at risk?

Adolescence is a developmental period marked by discovery and experimentation that comes with a myriad of physical and emotional changes. Sexual behavior and/or drug use are often a part of this exploration. During this time of growth and change, young people get mixed messages. Teens are urged to remain abstinent while surrounded by images on television, movies and magazines of glamorous people having sex, smoking and drinking. Double standards exist for girls-who are expected to remain virgins-and boys-who are pressured to prove their manhood through sexual activity and aggressiveness. And in the name of culture, religion or morality, young people are often denied access to information about their bodies and health risks that can help keep them safe.⁵ A recent national survey of teens in school showed that from 1991 to 1997, the prevalence of sexually activity decreased 15% for male students, 13% for White students and 11% for African-American students. However, sexual experience among female students and Latino students did not decrease. Condom use increased 23% among sexually active students. However, only about half of sexually active students (57%) used condoms during their last sexual intercourse.⁶ Not all adolescents are equally at risk for HIV infection. Teens are not a homogenous group, and various subgroups of teens participate in higher rates of unprotected sexual activity and substance use, making them especially vulnerable to HIV and other STDs. These include teens who are gay/exploring same-sex relationships, drug users, juvenile offenders, school dropouts, runaways, homeless or migrant youth. These youth are often hard to reach for prevention and education efforts since they may not attend school on a regular basis, and have limited access to health care and service-delivery systems.⁷

Can education help?

Yes. Schools are an important venue for educating teenagers on many kinds of health risks, including HIV, STD and unintended pregnancy. Across the US and around the world, studies have shown that sexuality education for children and young people does not encourage increased sexual activity and does help young people remain abstinent longer. Effective educational programs have focused curricula, have clear messages about risks of unprotected sex and how to avoid risks, teach and practice communication skills, address social and media influences, and encourage openness in discussing sexuality.⁸ In addition, HIV prevention programs that are carefully targeted to adolescents can be highly cost effective.⁹

Are schools the only answer?

No. Young people need to get prevention messages in lots of different ways and in lots of different settings. Schools alone can’t do the job. In the US, many schools are being hampered by laws and funding that prohibit comprehensive sexuality education. The federal government earmarked $50 million per year for school-based abstinence-only programs which emphasize values, character building and refusal skills, but do not discuss contraception or safer sex.¹⁰ Although abstinence programs are effective at delaying the onset of sexual activity, they typically do not decrease rates of sexual risk activity among adolescents the way that safer sex interventions do.¹¹ Youth who are not in school have higher frequencies of behaviors that put them at risk for HIV/STDs, and are less accessible by prevention efforts. A national survey of youth aged 12-19 found that 9% were out-of-school. Out-of-school youth were significantly more likely than in-school youth to have had sexual intercourse, had four or more sex partners, and had used alcohol, marijuana and cocaine.¹² More intensive STD/HIV and substance abuse prevention programs should be aimed at out-of-school youth or youth at risk for dropping out of school. Programs targeting hard-to-reach adolescents at high risk for HIV are necessary in many different venues outside of schools. Programs based in venues such as residential child care facilities, alternative schools and youth detention centers are needed. Peer educators can use an empowerment-oriented approach targeted to youth aged 12-17 to teach about preventing HIV and STDs, and to mobilize and link resources for young people through social and community networks.¹³ Families play an important role in helping teenagers avoid risk behaviors. Frank discussions between parents and adolescent children about condoms can lead teens to adopt behaviors that will prevent them from getting HIV and other STDs. Research has shown that when mothers talked about and answered questions about condom use with their adolescents prior to sexual debut, the adolescents reported greater condom use at first intercourse and most recent intercourse, as well as greater lifetime condom use.¹⁴ The WEHO Lounge in Los Angeles, CA, is a coffee house and HIV testing and information center located between two of the busiest gay discos in town. It offers free confidential oral HIV testing, weekly community forums, peer counseling, drug adherence support groups, free condom distribution and a comprehensive youth and HIV resource library. The Lounge also sells coffee drinks. By placing this resource in the community and adapting it to the needs and habits of young gay men, the program has been highly successful with clients.¹⁵ Project VIDA in Chicago, IL, a community-based service organization, provides HIV prevention for high-risk urban Latina females, ages 12-24. Project VIDA incorporates empowerment and self-care themes into peer-facilitated street/community outreach and group interventions. They act on the belief that it is impossible to separate HIV risks from other cultural, environmental, interpersonal, and intrapsychic stressors that Latina youths face; and that coping skills can help manage the perplexities of these challenges.¹⁶

What needs to be done?

HIV prevention programs for adolescents must consider the developmental needs and abilities of this age group. Programs should focus on contextual factors that lead young people to engage in higher rates of sexual activity and lower rates of condom use, such as low self-esteem, depression, substance use, gang activity, stress of living in turbulent urban environments, or boredom/restlessness related to unemployment. Any program for adolescents should be interesting, fun and interactive, and involve youth in the planning and implementation. This is especially true for out-of-the-mainstream youth and youth from diverse cultures. Programs for hard-to-reach youth who are most at risk for HIV infection should be implemented in venues outside of schools, such as runaway/homeless youth shelters, shopping malls, detention facilities and recreation/community centers. Adolescents not only need correct information and practice in self-protective skills, but also easy access to condoms in order to keep themselves risk-free.

Says who?

1. Centers for Disease Control and Prevention. Young people at risk-epidemic shifts further toward young women and minorities. Fact sheet prepared by the CDC. July 1998. 2. Eng TR, Butler WT, eds. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: National Academy Press; 1996. 3. Valleroy LA, MacKellar DA, Karon JM, et al. HIV infection in disadvantaged out-of-school youth: prevalence for US Job Corps entrants, 1990 through 1996 . Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 1998;19:67-73. 4. Miller KS, Clark LF, Moore JS. Sexual initiation with older male partners and subsequent HIV risk behavior among female adolescents . Family Planning Perspectives. 1997;29:212-214. 5. UNAIDS. Force for Change: World AIDS Campaign with Young People . Report prepared by UNAIDS, The Joint United Nations Programme on HIV/AIDS for World AIDS Day 1998. 6. Centers for Disease Control and Prevention. Trends in sexual risk behaviors among high school students-United States, 1991-1997 . Morbidity and Mortality Weekly Report. 1998;47:749-752. 7. Rotheram-Borus MJ, Mahler KA, Rosario M. AIDS prevention with adolescents . AIDS Education and Prevention. 1995;7:320-336. 8. UNAIDS. Impact of HIV and sexual health education on the sexual behavior of young people: a review update . Report prepared by UNAIDS, The Joint United Nations Programme on HIV/AIDS for World AIDS Day 1997. 9. Pinkerton SD, Cecil H, Holtgrave D.R. HIV/STD prevention interventions for adolescents: cost-effectiveness considerations . Journal of HIV/AIDS Prevention and Education for Adolescents and Children. 1998;2:5-31. 10. Associated Press. Sex education that teaches abstinence wins support. New York Times. July 23,1997:A19. 11. Jemmott JB, Jemmott LS, Fong GT. Abstinence and safer sex HIV risk-reduction interventions for African-American adolescents: a randomized controlled trial . Journal of the American Medical Association. 1998;279:1529-1536. 12. Centers for Disease Control and Prevention. Health risk behaviors among adolescents who do and do not attend school-United States, 1992 . Morbidity and Mortality Weekly Report. 1994;43:129-132. 13. Zibalese-Crawford M. A creative approach to HIV/AIDS programs for adolescents . Social Work in Health Care. 1997;25:73-88. 14. Miller KS, Levin ML, Whitaker DJ, et al. Patterns of condom use among adolescents: the impact of mother-adolescent communication . American Journal of Public Health. 1998;88:1542-1544. 15. Weinstein M, Farthing C, Portillo T, et al. Taking it to the streets: HIV testing, treatment information and outreach in a Los Angeles neighborhood coffee house. Presented at the 12th World AIDS Conference, Geneva, Switzerland; 1998. Abstract #43125. 16. Harper GW, Contreras R, Vess L, et al. Improving community-based HIV prevention for young Latina women. Presented at the Biennial Meeting of the Society for Community Research and Action, New Haven, CT; June,1999.

Prepared by Gary W. Harper, PhD MPH* and Pamela DeCarlo** *Department of Psychology, DePaul University, **CAPS

April 1999. Fact Sheet #9ER

Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © April 1999, University of California

¿Qué necesitan los adolescentes en la prevención del VIH?

¿pueden contraer los adolescentes el VIH?

Desafortunadamente, sí. Los casos de infección del VIH se incrementan más aceleradamente en los jóvenes. La mitad de todos los casos de VIH se presentan en personas menores de 25 años. De todos los casos de VIH de 1994-1997 en jóvenes de 13-24 años, 44% eran mujeres y 63% Afro-Americanos. Mientras la cifra de nuevos casos de SIDA se reduce en los diferentes grupos de edad, no se ha observado una reducción comparable en la cantidad de nuevas infecciones en los jóvenes.¹ Las relaciones sexuales implican riesgo para un joven, no solo del VIH, sino además para otras Enfermedades de Transmisión Sexual (ETS) y los embarazos no planeados. Actualmente, los adolescentes experimentan tasas alarmantes de ETS. Cada año, tres millones de jovenes entre los 13 y 18 años-es decir, un cuarto de todos con experiencia sexual-contraerán alguna ETS. La clamidia y la gonorrea ocurren con mayor frecuencia entre la juventud que en personas mayores.² En especial, algunas jóvenes Afro-Americanas y Latinas sexualmente activas corren mayor riesgo de infectarse con VIH, especialmente aquellas que provienen de barrios pobres. En un estudio de desertores escolares jóvenes en el “U.S. Job Corps” se descubrió que las jóvenes Afro-Americanas tenían mayores tasas de infección con VIH y que los índices de infección entre las mujeres entre los 16 y 18 años era mayor a las de los hombres jóvenes en un 50%.³ Otro estudio de mujeres adolescentes Afro-Americanas y Latinas reveló que las jóvenes con novios mayores que ellas (3 años mayor o más) corren mayor riesgo de infectarse con el VIH.⁴

¿cómo se exponen al riesgo?

La adolescencia es un período de desarrollo marcado por la curiosidad y la experimentación acompañada de una miríada de cambios emocionales. La conducta sexual y/o el uso de drogas suelen formar parte de esta exploración. Durante esta etapa de crecimiento y cambios, los jóvenes reciben mensajes contradictorios. Por un lado a la juventud se le exhorta a abstenerse sexualmente mientras se les satura de imágenes glamorosas de personajes de cine y televisión teniendo sexo, fumando y tomando. Este doble estándar existe para las chicas-de las que se espera se conserven vírgenes-y los chicos-con la presión de demostrar su hombría por medio de la agresividad y la actividad sexual. En nombre de la cultura, la religión y la moralidad, a la juventud suele negársele el derecho a estar informados sobre el funcionamiento de su cuerpo y los riesgos para la salud para poder protetegerse mejor.⁵ Un reciente sondeo a nivel nacional con jóvenes reveló que de 1991 a 1997, la prevalencia de la actividad sexual disminuyó en un 15% para los estudiantes masculinos, 13% en estudiantes blancos y 11% en estudiantes Afro-Americanos. Sin embargo no se presentó reducción alguna respecto a la experiencia sexual en estudiantes femeninas o en Latinos. Hubo un incremento del uso del condón del 23% en estudiantes sexualmente activos. Sin embargo, solo cerca de la mitad de los estudiantes sexualmente activos usaron condones durante su última relación sexual.⁶ No todos los adolescentes corren el mismo riesgo de infectarse con VIH. La juventud no es un grupo homogéneo, por lo tanto, dentro de esa categoría existen subgrupos que participan en mayor cantidad de actividades sexuales sin protección y abusan de las drogas, lo cual les vuelve más vulnerables al VIH y otras ETS. Esto incluye a jóvenes homosexuales o que experimentan relaciones con personas del mismo sexo, usuarios de drogas, delincuentes juveniles, desertores escolares, vagabundos, desamparados o jóvenes inmigrantes. Alcanzar a este grupo de jóvenes con actividades de prevención se dificulta debido a que no asisten a la escuela regularmente y tienen acceso limitado al sistema de salud u otros servicios similares.⁷

¿puede ayudar la educación?

Si. Las escuelas son un sitio ideal para que los jóvenes aprendan a conocer los riesgos para la salud, incluyendo el VIH, las ETS y los embarazos no planeados. A nivel nacional y global se ha comprobado, por medio de estudios, que la educación sexual a niños y jóvenes no estimula el incremento en la actividad sexual y sí ayuda a la juventud a abstenerse por más tiempo. Los programas educativos exitosos utilizan un curriculó y mensajes claros sobre los riesgos del sexo sin protección y las formas de evitar el riesgo, enseñan y practican la comunicación, tratan el tema de la influencia de la sociedad y de los medios de comunicación, y promueven que se hable del tema de la sexualidad abiertamente.⁸ Adicionalmente, los programas de prevención para adolescentes dirigidos cuidadosamente pueden ser muy efectivos a nivel de costo.⁹

¿sólo en la escuela se encuentra la solución?

No. La juventud necesita recibir mensajes de prevención de formas diversas y en sitios diferentes. Las escuelas por si solas no pueden realizar esta tarea. En los EEUU, a muchas escuelas se les prohibe el uso de fondos federales si utilizan un currículo abierto en cuanto a la sexualidad. El gobierno federal asignó $50 millones anuales a aquellas escuelas cuyos programas están basados en la abstinencia-sin tocar el tema de los anticonceptivos o el sexo seguro.¹⁰ Aunque es cierto que los programas de abstinencia logran retrasar el inicio de la actividad sexual, en general, no reducen la cantidad de actividades sexuales de riesgo de la forma en que lo logran las intervenciones basadas en el sexo seguro.¹¹ Los jóvenes que no asisten a la escuela con mayor frecuencia presentan conductas que les pone a riesgo de contraer VIH/ETS, y tienen menor acceso a programas de prevención. Un sondeo nacional con jóvenes entre los 12 y 19 años de edad reveló que el 9% no asistían a la escuela. Los desertores escolares estuvieron significativamente más propensos a haber tenido relaciones sexuales que los que sí asistían, tenían 4 o más parejas sexuales y habían experimentado con el alcohol, marihuana y cocaína.¹² Deberían crearse programas de prevención más intensivos para los desertores escolares y los que están en riesgo de desertar. Es necesario que los programas dirigidos a los adolescentes que no tienen una vida estable se lleven a cabo en los sitios que ellos frecuentan tales como en centros de detención juvenil y escuelas alternativas. La instrucción impartida por miembros de este mismo grupo puede utilizar el método del empoderamiento, enseñar sobre prevención de VIH, ETS, además de movilizar y anexar recursos para los jóvenes por medio de organizaciones comunitarias y sociales.¹³ El apoyo familiar para que los jóvenes eviten caer en conductas de riesgo es de incalculable valor. Las conversaciones francas sobre condones entre padres e hijos adolescentes puede conducir a los jóvenes a adoptar conductas que les prevendrán de contraer el VIH y otras ETS. Cuando las madres hablan y contestan preguntas sobre el uso del condón previo al iniciamiento sexual, los adolescentes han reportado el uso del condón la primera y última vez que tuvieron sexo, así como un mayor uso del condón durante el transcurso de sus vidas.¹⁴ En Los Angeles, CA, el “WEHO Lounge” es una cafetería y centro de detección e información de VIH localizado entre dos discotecas “gay.” Ofrece pruebas orales de detección del VIH confidenciales, foros comunitarios semanales, consejería impartida por miembros de este grupo, distribución gratuita de condones y una biblioteca juvenil con recursos relacionados al VIH. Este “Lounge” tambien vende cafés. Al colocar este recurso en la comunidad y adaptarlo a la necesidad y hábitos de los hombres jóvenes “gay”, el programa ha tenido un exito fenomenal.¹⁵ El Proyecto VIDA de Chicago, IL, una organización que provee servicios a la comunidad, conduce prevención del VIH a mujeres Latinas entre los 12 y 24 años en riesgo de infección. VIDA recluta y conduce intervenciones dirigidas por miembros de este mismo grupo en las que se incorporan temas como el empoderamiento y la autoestima. Ellos actúan en la creencia de que es imposible separar los riesgos de contraer VIH de las presiones culturales, ambientales, interpersonales e intrasíquicas que enfrentan las jóvenes Latinas; y que es posible vencer estos obstáculos aprendido a manejar situaciones difíciles.¹⁶

¿qué queda por hacer?

Los programas de prevención para adolescentes deben tomar en cuenta las necesidades y habilidades que presenta la edad de este grupo. Los programas deben tener un enfoque en los factores contextuales que contribuyen a que los jóvenes participen en mayor cantidad de actividades sexuales y bajos índices en el uso del condón, tales como la baja auto-estima, la depresión, el uso de drogas, actividades de pandillas, la presión de vivir en ambientes urbanos turbulentos o aburridos ocasionados por la falta de empleo. Cualquier programa para adolescentes debe ser interesante, divertido e interactivo, debe incluir la opinión de los jóvenes en cuanto al diseño e implementación. Esto se aplica especialmente a jóvenes de otras culturas que no forman parte de la gran mayoría. Los programas para jóvenes inestables que corren el riesgo de contraer VIH deben implementarse en otros locales aparte de la escuela, tales como casas de refugio para jóvenes sin hogar o que se han escapado de ellos, centros comerciales, centros de detención, y centros comunitarios. No basta con que los jóvenes reciban la información adecuada ni con practicar las habilidades de auto-protección, es también necesario facilitar el acceso a los condones para poder mantenerles libres de riesgo.

¿quién lo dice?

1. Centers for Disease Control and Prevention. Young people at risk-epidemic shifts further toward young women and minorities. Fact sheet prepared by the CDC. July 1998. 2. Eng TR, Butler WT, eds. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: National Academy Press; 1996. 3. Valleroy LA, MacKellar DA, Karon JM, et al. HIV infection in disadvantaged out-of-school youth: prevalence for US Job Corps entrants, 1990 through 1996 . Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 1998;19:67-73. 4. Miller KS, Clark LF, Moore JS. Sexual initiation with older male partners and subsequent HIV risk behavior among female adolescents . Family Planning Perspectives. 1997;29:212-214. 5. UNAIDS. Force for Change: World AIDS Campaign with Young People . Report prepared by UNAIDS, The Joint United Nations Programme on HIV/AIDS for World AIDS Day 1998. 6. Centers for Disease Control and Prevention. Trends in sexual risk behaviors among high school students-United States, 1991-1997 . Morbidity and Mortality Weekly Report. 1998;47:749-752. 7. Rotheram-Borus MJ, Mahler KA, Rosario M. AIDS prevention with adolescents . AIDS Education and Prevention. 1995;7:320-336. 8. UNAIDS. Impact of HIV and sexual health education on the sexual behavior of young people: a review update . Report prepared by UNAIDS, The Joint United Nations Programme on HIV/AIDS for World AIDS Day 1997. 9. Pinkerton SD, Cecil H, Holtgrave D.R. HIV/STD prevention interventions for adolescents: cost-effectiveness considerations . Journal of HIV/AIDS Prevention and Education for Adolescents and Children. 1998;2:5-31. 10. Associated Press. Sex education that teaches abstinence wins support. New York Times. July 23,1997:A19. 11. Jemmott JB, Jemmott LS, Fong GT. Abstinence and safer sex HIV risk-reduction interventions for African-American adolescents: a randomized controlled trial . Journal of the American Medical Association. 1998;279:1529-1536. 12. Centers for Disease Control and Prevention. Health risk behaviors among adolescents who do and do not attend school-United States, 1992 . Morbidity and Mortality Weekly Report. 1994;43:129-132. 13. Zibalese-Crawford M. A creative approach to HIV/AIDS programs for adolescents . Social Work in Health Care. 1997;25:73-88. 14. Miller KS, Levin ML, Whitaker DJ, et al. Patterns of condom use among adolescents: the impact of mother-adolescent communication . American Journal of Public Health. 1998;88:1542-1544. 15. Weinstein M, Farthing C, Portillo T, et al. Taking it to the streets: HIV testing, treatment information and outreach in a Los Angeles neighborhood coffee house. Presented at the 12th World AIDS Conference, Geneva, Switzerland; 1998. Abstract #43125. 16. Harper GW, Contreras R, Vess L, et al. Improving community-based HIV prevention for young Latina women. Presented at the Biennial Meeting of the Society for Community Research and Action, New Haven, CT; June,1999.

Preparado por Gary Harper, PhD MPH* y Pamela DeCarlo**, Traducción Romy Benard Rodríguez** *Departamento de Psicología, Universidad DePaul, **CAPS

Septiembre 1999. Hoja Informativa 9SR.

What is the role of the family in HIV prevention?

Why families?

Families have great influence over a person, and that influence can last a lifetime. Even people who are no longer or never were in touch with their family are influenced by their absence. One half of all persons with HIV became infected during adolescence or early adulthood (ages 15-24). Working with families as early as possible in children’s lives helps solidify healthy behaviors and relationships, thus preventing risk before it happens. HIV prevention has traditionally focused on the individual and not the family. Yet families can have both positive and negative impact on sexual and drug using behaviors that put a person at risk for HIV. Families are important determinants of adolescent sexual behavior, can affect men and women as they “come out” as gay and lesbian and can affect injection drug users (IDUs) as they gain and lose ties to family throughout the years. For this fact sheet, families are defined as the people you grew up with: fathers, mothers, uncles, aunts, cousins, grandparents or foster parents. Many families have strong ties with the community as well, making the community a strong influence. We will not be discussing families of choice, such as intimate social networks.

How do families affect risk behavior?

Families can help protect themselves and their children from risky sexual and drug using behaviors. Family connectedness and parent child communication are key for ensuring healthy behaviors.¹ Likewise, when families are not connected and adolescents feel they can’t talk to the adults in their lives, there is a greater risk of unhealthy behavior. Adolescents who feel connected to their families and perceive their parents as caring are more likely to postpone their sexual debut, use contraception, have fewer pregnancies and fewer children.^2,3 Two key aspects of parenting that are influential to adolescents are their beliefs that their parents know who they spend time with, and know where they are when they’re not at home or at school.¹ In families with strong religious values and an emphasis on marriage and having children, young gay men can have a hard time coming out to their parents. Young men may fear that having a gay son could cause the family shame, or that they will disappoint their parents by not getting married and having children.⁴ This can lead to internalized shame and low self esteem which contribute to risky behavior. A child who grows up in a family where high stress, alcoholism, substance use and domestic violence are the norm, may repeat that behavior as an adult. Many alcohol and substance abusers have a family history of alcoholism and substance abuse and high levels of domestic violence. In addition, family members sometimes are the ones who give young people their first puff of marijuana, first taste of alcohol or first injection of drugs.⁵ Family childhood physical abuse, sexual abuse and neglect often lead to risky sexual behavior and drug use in adolescence and adulthood. One study of persons who left methadone maintenance found that 36% had experienced sexual abuse as a child, 60% physical abuse, 57% emotional abuse, 66% child physical neglect and 25% all four experiences. Persons with a history of childhood abuse reported more sexual partners and those with physical neglect were more likely to be HIV+.⁶

W hat puts families at risk?

Families that have problems often produce children who have problems. Stress, poverty, violence and substance abuse in families leads to less family cohesion, less communication and less tolerance. As a result, teens experience more abuse, neglect and risky drug use and sexual behavior. Neighborhoods with few job opportunities and high levels of drug use and violence have a negative impact on teenage sexual behavior.⁷ Work and feeling overworked can greatly affect family life. At every economic level, work-related stress negatively impacts family cohesion and communication. When parents have long work hours and feel burned out by their jobs, they don’t have enough time for themselves or their families.⁸

What’s being done?

The Collaborative HIV Prevention and Adolescent Mental Health Project is a family-based preventive intervention. The program is based on the needs of urban African American youth and their families living in neighborhoods with high HIV infection rates. It seeks to 1) address pre-adolescent behavior, 2) target specific child, parent, and family factors in preventing HIV risk exposure and 3) address high HIV infection rates through a family-based approach. The program offers multiple family groups, a pre-adolescent component, an adolescent component, and stresses the importance of community collaboration.⁹ Family to Family is a structural intervention that strengthens family functioning and the bonds that connect families to each other. Designed to address a broad range of social issues, the program seeks to increase family communication in a community with high rates of violence, drug abuse and HIV infection. The program uses family groups and life coping skills to address issues such as forgiveness, communication, responsibility, teamwork, family traditions, and household management.¹⁰ While many schools and community agencies have begun to offer risk reduction programs for gay/lesbian/bisexual/transgender (GLBT) youth, there are few programs to help GLBT children and their parents. Groups such as Parents, Families & Friends of Lesbians & Gays (PFLAG) offer support and education.¹¹ In San Francisco, CA, a coalition of agencies serving Latino gay and bisexual men started a media campaign to address family cohesion. In their research they found that women were overwhelmingly identified as a source of support: mothers, sisters, aunts and cousins. The campaign “Families Change, Families Grow/Las Familias Cambian, Las Familias Crecen,” used posters showing a mother hugging her adult son’s boyfriend with the caption, “Mom got to know my boyfriend, now there’s a place for him too.” Keepin’ it R.E.A.L.!, a program for adolescents and their mothers, works to increase parental knowledge about HIV and sexuality issues and increase comfort discussing these issues with their children. The program gave mothers and teens a chance to interact and bond, as well as gave mothers a chance to communicate with each other. Women in the program were more likely to talk to their adolescents about sex. School classes that give homework assignments for students to talk to their parents about sexual topics can be effective. The assignments are required, and parents don’t have to go anywhere, but can talk to their children at home.

What still needs to be done?

Families need support to increase communication and build strong bonds as early as possible. Many HIV prevention programs acknowledge that families play a large role in determining risk behavior, but few programs offer interventions for families. In addition to supporting persons who are already engaged in risky behaviors, programs should support family members so that risk behavior doesn’t have cause to start. To establish open communication and solidify family bonds, special care must be taken to encourage gay and lesbian youth to talk about their sexuality, especially in families with strong values regarding the importance of marriage and bearing children. Gays and lesbians are prohibited by law from marrying, may not wish to have children and are often prohibited from adopting children. Community institutions such as churches and schools can work with prevention programs to educate their members and instill tolerance and acceptance of diverse sexual identities. Too often, communities hardest hit by drug use, crime and poverty also have the highest rates of HIV and the lowest rates of family and community support. However, negative outside influences can often be overcome with the help of a strong family. Family strengthening programs, parenting centers and hotlines are needed. Well monitored recreational activities and community centers are also necessary so that parents can know their children will be safe when not at home.

Says who?

1. DiClemente RJ, Wingood GM, Crosby R, et al. Parental monitoring: Association with adolescents’ risk behaviors. Pediatrics. 2001;107:1363-1368. 2. Resnick MD, Bearman PS, Blum RW, et al. Protecting adolescents from harm: Findings from the National Longitudinal Study on Adolescent Health. Journal of the American Medical Association. 1997; 278:823-32. 3. Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy, Washington, DC: National Campaign to Prevent Teen Pregnancy, 2001. 4. Newman BS, Muzzonigro PG. The effects of traditional family values on the coming out process of gay male adolescents. Adolescence.1993;28:213-216. 5. Hampton RL, Senatore V, Gullotta TP, editors. Substance abuse, family violence and child welfare. Thousand Oaks, CA: Sage Publications; 1998. 6. Kang SY, Deren S, Goldstein MF. Relationships between childhood abuse and neglect experience and HIV risk behaviors among methadone treatment drop-outs. Child Abuse and Neglect. 2002;26:1275-1289. 7. Averett SL, Rees D, Argys LM. The impact of government policies and neighborhood characteristics on teenage sexual activity and contraceptive use.American Journal of Public Health. 2002; 92:1773-1778. 8. Gallinsky, E. Ask the children: A breakthrough study that reveals how to succeed at work and parenting. Quill Publications. 2000. 9. Madison SM, McKay MM, Paikoff R, et al. Basic research and community collaboration: Necessary ingredients for the development of a family-based HIV prevention program. AIDS Education and Prevention. 2000;12:281. 10. Fullilove RE, Green L, Fullilove MT. The Family to Family program: A structural intervention with implications for the prevention of HIV/AIDS and other community epidemics. AIDS. 2000;14S1:S63-S67. 11. PFLAG. www.pflag.org 12. Freedman B. Great HIV prevention campaigns are not just born. CAPS Exchange. 2000. prevention.ucsf.edu/uploads/CEsummer2000.pdf 13. DiIorio C, Resnicow K, Dudley WN, et al. Social cognitive factors associated with mother-adolescent communication about sex. Health Communications.2000;5:41-51. 14. Kirby D, Miller BC. Interventions designed to promote parent-teen communication about sexuality. New Directions for Child and Adolescent Development. 2002;97:93-110. Prepared by Lesley Green*, Bob Fullilove*, Pamela DeCarlo** *Community Research Group, Columbia University, **CAPS April 2003. Fact Sheet #49E Special thanks to the following reviewers of this Fact Sheet: Roberta Downing, Beth Freedman, Doug Kirby, Mary McKay, Lydia O’Donnell, Birdy Paikoff, Pam Woody.

Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © April 2003, University of California