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Profilaxis pre-exposición (PrEP)

¿Cómo ayuda la Profilaxis Pre-Exposición (PrEP) a prevenir el VIH?

Elaborado por Pamela DeCarlo y Kimberly Koester | May 2017

¿Qué es PrEP?

La Profilaxis Pre-Exposición (conocida como PrEP) es un método preventivo basado en el uso de medicamentos para personas que no viven con el VIH pero que están preoupadas por el riesgo de adquirirlo. Actualmente, PrEP consiste en tomar una pastilla del medicamento Truvada una vez al día de forma consistente. [1]

Las normas clínicas para PrEP recomiendan hacer una prueba del VIH y análisis de las funciones del hígado antes de comenzar a tomar el medicamento. Mientras estén tomando el medicamento, las personas deben hacerse análisis para detectar y tratar, si hiciera falta, infecciones transmitidas sexualmente (ITS) cada tres meses, la prueba para el VIH cada seis meses y análisis de las funciones del hígado de acuerdo a lo indicado por el médico. Cualquier ITS, así como la infección por el VIH, deben tratarse de inmediato.

¿Funciona PrEP?

¡Sí! PrEP puede prevenir la transmisión del VIH siempre y cuando el medicamento se administre de forma consistente todos los días. Las dosis diarias de PrEP reducen el riesgo de contraer el VIH a través del sexo en un 90%. Para las personas que se inyectan drogas, se reduce el riesgo en más de un 49%. [2]

En un estudio realizado por los investigadores de Kaiser Permanente con 972 pacientes observados durante tres años, ninguno de los pacientes que tomaban PrEP contrajo el VIH; pero dos personas que dejaron el tratamiento tras perder su seguro médico sí contrajeron el virus. [3] En la clínica Magnet en San Francisco, CA, no ha habido ninguna nueva infección por el VIH entre los 1.996 pacientes inscriptos en el programa de PrEP. [4]

PrEP evita la transmisión de manera distinta según se trate de sexo vaginal o de sexo anal. En las pruebas clínicas del iPrEX, se logró evitar la transmisión del virus por la vía anal administrándose el medicamento de 4 a 5 veces por semana. [5] Un ensayo clínico con mujeres cisgénero concluyó que la utilización del medicamento de 6 a 7 veces por semana evita la transmisión por la vía vaginal. [6]

¿Es segura PrEP?

Totalmente. La mayoría de las personas que toman PrEP no experimentan efectos secundarios. Los efectos secundarios que puede producir en algunas personas generalmente son leves y de corta duración. Los efectos secundarios más comunes son náuseas, trastornos digestivos, problemas del hígado y pérdida ósea. Según una investigación, PrEP es generalmente más segura que la aspirina. [7]

¿Hay otros beneficios de PrEP?

PrEP puede aportar beneficios para la salud mental. Varios estudios y muchos profesionales de la salud que administran PrEP indican que el uso de PrEP parece reducir el estrés y la ansiedad provocadas por el riesgo de contraer el VIH. Por lo mismo, puede potencialmente aumentar la intimidad y el gozo sexual. Algunas personas comentan que después de comenzar PrEP pudieron tener relaciones sexuales sin miedo de contraer el VIH por primera vez en su vida. Otras expresan esperanza para el futuro y optimismo en sus relaciones amorosas. [8,9]

PrEP puede fomentar la autonomía. PrEP es el primer método de prevención del VIH confiable que promueve de una forma relativamente fácil el tener un rol activo para  prevenir el VIH. Por la relativa facilidad de su uso, PrEP fomenta condiciones de autonomía en la prevención del VIH, ya que para tomarla no es necesario informar o mostrar nada a nadie ni negociar con la pareja y no se aplica durante las relaciones sexuales. [10]

PrEP puede facilitar el acceso a los servicios médicos. Muchos programas de PrEP se destinan a personas jóvenes y saludables, un sector de la población que suele no tener seguro médico y no acudir a servicios médicos. Considerando que PrEP requiere de análisis frecuentes y los medicamentos se entregan por receta, varios programas están capacitando a navegadores de PrEP que ayudan a los pacientes a inscribirse en un seguro médico, a buscar formas para pagar los medicamentos y a encontrar profesionales de la salud. Los navegadores promueven la adherencia al tratamiento y a las citas médicas y también ayudan a encontrar otros servicios de asistencia social que pueden contribuir a mantenerse saludable.

¿Cómo puede mejorarse el acceso a PrEP?

Eliminando barreras estructurales. Al igual que otros medicamentos y programas de conductas preventivas, PrEP sólo funciona cuando se administra de acuerdo a las indicaciones médicas. Muchas personas usan PrEP con un alto grado de motivación para tomar el tratamiento, por lo que parecería que cuestiones estructurales más que personales pueden ser barreras para la adherencia. Algunas de estas barreras incluyen el costo de los medicamentos y de los servicios clínicos o de laboratorio, la dificultad de encontrar profesionales dispuestos a recetar los medicamentos sin juzgar y de acudir a una clínica cada tres meses, así como temores derivados de experiencias estigmatizantes previas o de la percepción del estigma relacionado con el VIH.

Reduciendo los costos. El costo de los medicamentos de PrEP oscila entre $1.200 y $1.500 dólares al mes. Aunque la mayoría de los seguros, incluido Medicaid, cubre estos gastos, algunos requieren altos copagos y desembolsos. Cambios de empleo o de seguro pueden ocasionar lapsos durante los cuales resulta difícil costear los medicamentos. Algunos Estados y Gilead (la empresa que produce Truvada) tienen programas de asistencia financiera para estos casos. [11]

Incrementando el uso de navegadores. Los navegadores de PrEP trabajan en una variedad de establecimientos médicos, tanto privados como públicos, para hacer llegar los servicios de PrEP al público y para facilitar el acceso al seguro médico y a otros programas que ayudan con los costos.

Incrementando el conocimiento y aceptación entre los profesionales. Algunos profesionales desconocen PrEP o se sienten incómodos al recetar el medicamento a sus pacientes. A veces pueden tener conceptos erróneos sobre la eficacia del tratamiento o suponer que sus pacientes no adherirán al tratamiento. [12] Los prejuicios acerca de raza, género, sexualidad, edad, uso de condones y de drogas pueden hacer que los profesionales no ofrezcan o receten PrEP a algunos pacientes. Una investigación demostró que es más factible que los profesionales receten PrEP a hombres homosexuales con parejas seropositivas y menos probable que la receten a personas heterosexuales y a personas que se inyectan drogas. [13]

Considerando inequidades de salud. Aunque el uso de PrEP aumentó un 500% entre 2013 y 2015, aún persisten disparidades. Actualmente, sólo un pequeño porcentaje de las personas que podrían beneficiarse de PrEP usan el tratamiento. El uso ha aumentado poco entre afroamericanos, latinos, mujeres y la población joven. [14]

¿Qué se está haciendo?

Existe una variedad de clínicas de atención primaria, para las ITS y el VIH, centros de planificación familiar, farmacias, sitios web, doctores, enfermeros practicantes y farmacéuticos que ofrecen servicios de PrEP.

Muchas agencias en los Estados Unidos han creado programas de PrEP para ayudar a difundir el tratamiento, sobre todo en sectores menos atendidos, como hombres negros y latinos gay, mujeres transgénero y los jóvenes. Estas agencias incluyen Callen-Lorde Community Health Center, Chicago PrEP Working Group, HIVE, Philly FIGHT, and Houston Area Community Services.[15] En Seattle, WA, las farmacias comunitarias de Kelley-Ross cuentan con centros One-Step PrEP donde los pacientes pueden hablar con un farmacéutico, recibir recetas de PrEP, hacer análisis de seguimiento y recoger medicamentos en un solo lugar. Además, Kelley-Ross ayuda a los pacientes con el seguro médico. Un 98% de sus pacientes recibe PrEP de manera gratuita.

Otros programas, como Nurx.com (disponible en 11 Estados), distribuyen los medicamentos de PrEP via telesalud. Los interesados se registran en la página web y contestan algunas preguntas para ser luego canalizados a una clínica cercana para realizarse la prueba de VIH, de ITS y de funciones del hígado. Una vez que un médico analiza los resultados, los medicamentos de PrEP se entregan a domicilio o en una farmacia cercana.

Ya que puede resultar difícil encontrar profesionales de la salud que manejen PrEP, hay tres servicios (pleasePrEPme.org, pleasePrEPme.global y PrEPlocator.org) que ofrecen directorios de profesionales públicos y particulares. Ahí se pueden buscar servicios de navegación y profesionales que reciban pacientes sin seguro.

¿Qué debe hacerse?

Cuando aparecen nuevos medicamentos para el público, también frecuentemente se visualizan disparidades en la salud, ya que sectores de la población menos atendidos pueden no conocen los nuevos medicamentos, no tener acceso a ellos o verlos con recelo. PrEP presenta una oportunidad para considerar y reducir esas disparidades.

Aunque muchos profesionales son promotores entusiastas de PrEP entre sus pacientes, otros pueden obstaculizan su acceso. Los profesionales a favor de PrEP suelen incluir al paciente en la toma de decisiones, proporcionándoles información precisa sobre PrEP y confíando en la capacidad del paciente de tomar decisiones que favorezcan su propia salud.

Nuevos medicamentos y métodos en desarrollo para la aplicación y monitoreo de PrEP podrían reducir barreras al acceso. Estos incluyen nuevos medicamentos de acción más prolongada, que se administran por vía intravenosa, microbicidas vaginales y rectales y anillos vaginales, así como autoexámenes para el VIH y las ITS. [16]

Ante el panorama cambiante del cuidado de la salud y la política sanitaria en los Estados Unidos, se necesita continuar abogando por el acceso y el financiamiento de PrEP.

¿Quién lo dice?

  1. CDC. Preexposure prophylaxis for the prevention of HIV infections in the United States—2014: a clinical practice guideline. Atlanta, GA: US Department of Health and Human Services, CDC, US Public Health Service; 2014. CDC fact sheet for providers
  2. CDC. PrEP 101 Consumer Info Sheet. 2016.
  3. Volk JE, Marcus JL, Phengrasamy T, et al. No new HIV infections with increasing use of HIV preexposure prophylaxis in a clinical practice setting. Clin Infect Dis. 2015;61:1601-1603.
  4. Gibson S, Crouch P-C, Hecht J, et al. Eliminating barriers to increase uptake of PrEP in a communitybased clinic in San Francisco. 21st International AIDS Conference. July 2016. Durban, South Africa. Abstract FRAE0104.
  5. Anderson PL, Glidden DV, Liu A, et al. Emtricitabine-Tenofovir concentrations and preexposure prophylaxis efficacy in men who have sex with men. Science Trans Med. 2012:4;151-
  6. Baeten JM, Donnell D, Ndase P, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med. 2012;367:399-410.
  7. Kojima N, Klausner JD. Is emtricitabine-tenofovir disoproxil fumarate pre-exposure prophylaxis for the prevention of human immunodeficiency virus infection safer than aspirin? Open Forum Infect Dis. 2016 Jan 6;3(1):ofv221.
  8. Koester K, Amico RK, Gilmore H, et al. Risk, safety and sex among male PrEP users: time for a new understanding. Culture, Health & Sexuality. 2017.
  9. Golub SA, Radix A, Hilley A, et al. Developing and implementing a PrEP demonstration/ implementation hybrid in a community-based health center. 11th International Conference on HIV Treatment and Prevention Adherence, May 9-11, 2016, Fort Lauderdale, FL. ADH9_OA409.
  10. Seidman D, Weber S. Integrating PrEP for HIV prevention into women’s health care in the United States. Obstetrics and Gyn. 2016;127:37-43.
  11. CDC. Paying for PrEP. 2015.
  12. Elion R, Coleman M. The preexposure prophylaxis revolution: from clinical trials to routine practice: implementation view from the USA. Curr Opin HIV AIDS. 2016;11:67-73.
  13. Adams LM, Balderson BH. HIV providers’ likelihood to prescribe pre-exposure prophylaxis (PrEP) for HIV prevention differs by patient type: a short report. AIDS Care. 2016;8:1154-1158.
  14. Bush S, Magnuson D, Rawlings MK, et al. Racial characteristics of FTC/TDF for Pre-exposure Prophylaxis(PrEP) users in the US #265. ICAAC 2016. Boston, MA; June 16-20, 2016.
  15. http://hivprepsummit.org/index.php/prep-resources/
  16. Mayer KH. PrEP 2016: What will it take to generate demand, increase access, and accelerate uptake? 11th International Conference on HIV Treatment and Prevention Adherence, May 2016, Fort Lauderdale, FL. ADH11.

Gracias a Leah Adams, Pierre Crouch, Rick Elion, Nathan Fecik, Jayne Gagliano, Barbara Green-Ajufo, Colleen Kelley, Jeffry Klausner, Daryl Mangosing, Alan McCord, Karishma Oza, Rupa Patel, Jim Pickett, Rebecca Sedillo, Dominika Seidman, Aaron Siegler, Jill Tregor, Jonathan Volk y Shannon Weber por revisar esta hoja informativa. Kimberly Koester está afiliada a California HIV/AIDS Policy Research Centers (CHPRC).

Agradecemos la reproducción y la difusión de esta hoja, siempre que sea de manera gratuita y que se cite a la University of California San Francisco. ©2017, University of CA. Preguntas y comentarios pueden enviarse a [email protected]. 

Esta publicación es un producto de un Centro de Investigación sobre la Prevención con el apoyo de los Centros de Control y Prevención de Enfermedades (Cooperative Agreement Number 5U48DP004998).

Resource

Intervenciones estructurales

¿Qué papel juegan las intervenciones estructurales en la prevención del VIH?

¿qué son las intervenciones estructurales?

La mayoría de las intervenciones de prevención del VIH tratan con los individuos de a uno por uno. Aún cuando muchas obtienen excelentes resultados, requieren mucho tiempo del personal y benefician a un número limitado de personas. Además, los beneficiarios de las intervenciones pueden sentirse presionados por parte de sus pares (que no reciben las intervenciones) para continuar participando en actividades de alto riesgo. Las intervenciones estructurales modifican o influencian el ambiente social, político o económico de manera que muchas personas se beneficien al mismo tiempo, quizás sin saberlo.1 El término “intervenciones estructurales” significa muchas cosas. Las intervenciones estructurales incluyen programas que efectúan cambios en el campo jurídico (frecuentemente con presión o participación comunitaria) para facilitar las conductas seguras, como la venta libre de jeringas. También pueden enfocarse en el contexto social inmediato de la actividad sexual o inyección de drogas, modificando el entorno físico o normativo en el cual éstas suceden. Como ejemplo tenemos los prostíbulos tailandeses que exigen el uso de condones. Las intervenciones estructurales abarcan también los programas que buscan reducir o eliminar la desigualdad de ingresos, el racismo y otras inequidades y formas de opresión que crean vulnerabilidad al VIH/SIDA.

¿qué estructuras producen riesgo?

¿Cómo podemos identificar las estructuras o procesos sociales, políticos o económicos que deberán modificarse? Por lo general, lo hacemos estudiando la variación natural entre áreas o grupos, o los experimentos naturales en los cuales las condiciones cambian por motivos que no sean intervenciones relacionadas con el VIH. Los estudios de la variación natural (naturally-occurring variation) han demostrado que: 1) los países pobres son los más propensos a tener una epidemia generalizada del VIH; 2) los países con mayor desigualdad de ingresos tienen tasas altas del VIH; 3) las políticas importan: los lugares en donde las jeringas se pueden comprar legalmente tienen tasas menores de prevalencia y de incidencia del VIH entre los usuarios de drogas inyectables (UDI).2 Los estudios sobre experimentos naturales indican que: 1) las transiciones sociales y políticas que de otra manera resultarían provechosas (ej. sucesos de los ’90 como la eliminación del sistema de apartheid en Sudáfrica y la terminación de la dictadura en Indonesia) fueron seguidas por grandes brotes del VIH; 2) las guerras aumentan el VIH, las enfermedades transmitidas sexualmente (ETS), la prostitución, la violación, la esclavitud sexual y el uso arriesgado de alcohol y drogas. También llevan a incrementos en el número de parejas sexuales y en la frecuencia de cambio de pareja sexual.3

¿por qué las intervenciones estructurales?

Muchas veces las intervenciones estructurales abarcan temas que parecen completamente ajenos VIH. Al pensar en la prevención del VIH, por lo general no se considera ni la eliminación de las desigualdades de ingresos la ni de la guerra. Pero estas realidades sociales, políticas y económicas ejercen una influencia enorme sobre las conductas de alto riesgo. Circunstancias sin relación directa con el VIH con frecuencia crean condiciones que promueven la propagación del mismo, haciendo de las intervenciones estructurales una necesidad imprescindible. Por ejemplo, en los años ‘70 el gobierno de la ciudad de Nueva York cerró las estaciones de bomberos en los barrios pobres habitados por grupos minoritarios. Como consecuencia, los incendios incontrolados destruyeron numerosos edificios, lo cual tuvo efectos muy traumáticos sobre la vida social de los residentes. El uso de drogas inyectables (y después de crack), el alcoholismo, el intercambio sexual, las pandillas y la desmoralización, se extendieron ampliamente. Posteriormente se presentaron brotes de ETS, VIH, tuberculosis y muchas otras enfermedades.4 Los gobiernos de los países ricos, incluyendo el de EE.UU., así como los bancos, las grandes empresas y otros integrantes de la élite económica, han perseguido agresivamente una política mundial organizada basada en recortes a la asistencia pública, privatización y competencia. Esto ha provocado el endeudamiento masivo de muchos países en vías de desarrollo, aumentado la desigualdad de ingresos y fomentado la formación de macrociudades en torno a enormes barrios de tugurios. Asimismo, debido a los “programas de ajuste estructural” impuestos por el Fondo Monetario Internacional, muchos países africanos, asiáticos y latinoamericanos se han visto obligados a recortar substancialmente los servicios de salud y educación. Estas políticas y programas han impedido en gran medida la provisión eficaz de intervenciones preventivas, terapias antirretrovirales y otros servicios médicos para las poblaciones infectadas.5,6

ejemplos de intervenciones estructurales

En muchos países, gran número de trabajadores sexuales tiene VIH y otras ETS. Tailandia y la República Dominicana han instituido campañas de “condones al 100%” que exigen a los propietarios de los prostíbulos que hagan cumplir el uso de condones durante todo acto sexual. Las campañas buscan el apoyo de los dueños de prostíbulos, de los trabajadores sexuales y, en cuanto sea posible, de los clientes. Estos programas han limitado considerablemente la transmisión del VIH y de las ETS al modificar el contexto social inmediato de la conducta sexual para reducir los incidentes de sexo sin protección.7,8 Las leyes de la mayoría de los estados de EE.UU. prohíben la posesión o distribución de jeringas, y muchos estados requieren receta médica para comprar jeringas. Consecuentemente, muchos UDI no llevan jeringas consigo por miedo a ser hostigados o detenidos por la policía. Para encontrar una solución jurídica a este problema, la legislatura de Connecticut aprobó la revocación parcial de las leyes sobre la receta de jeringas y la posesión de artículos para el uso de drogas. El resultado fue que los UDI redujeron en forma dramática su uso de jeringas compartidas y compraron más jeringas en farmacias. Después de la entrada en vigor de las nuevas leyes, el uso de jeringas compartidas bajó del 52% al 31%, la compra en farmacias subió del 19% al 78%, y la compra callejera disminuyó del 74% al 28%.9

¿podemos cambiar las políticas dañinas?

No es fácil evitar o terminar las guerras, ni las políticas de desarrollo urbano que perjudican a los pobres y a los grupos minoritarios, ni tampoco las políticas sexuales y de drogas que crean ambientes marginados. Sin embargo, los individuos y las comunidades pueden efectuar cambios. Los movimientos de las bases o comunitarios muchas veces son pasos iniciales necesarios para proceder a intervenciones estructurales más amplias. A veces, incluso la formación de dichos movimientos puede ser una intervención estructural. “Chico Chats,” un programa del Proyecto STOP AIDS en San Francisco, CA, ofreció talleres informativos sobre técnicas de organización y movilización comunitaria. Los participantes formaron un grupo activista llamado ¡Ya Basta! y diseñaron un video y un taller que examinaban el silencio en torno al sexo y la revelación de la homosexualidad en la familia latina. El video se está presentando en comunidades latinas en todo San Francisco.10 Organizaciones comunitarias e individuos de varios estados de EE.UU. con tasas altas de VIH entre los UDI, han creado programas de intercambio de jeringas (PIJ). Muchos PIJ han operado ilegalmente y sin apoyo. Las personas que trabajan en los PIJ y otros grupos de activistas políticos han colaborado con los oficiales públicos para invocar políticas “bajo estado de emergencia” que permitan la existencia legal de los PIJ en muchos estados.11 Los trabajadores/as sexuales de Calcuta recibieron ayuda de las autoridades de salud pública para organizar un sindicato comunitario que les permite insistir a sus clientes sobre el uso de condón. La prevalencia del VIH entre los trabajadores/as sexuales de Calcuta se ha mantenido menor que en otras ciudades de la India.12

¿qué queda por hacer?

No se puede ignorar la relación que existe entre los factores estructurales como la marginalización económica, política y social y entre las conductas que ponen a las personas en riesgo de contraer o transmitir el VIH/SIDA y las ETS.13, 14 Tampoco podemos considerar a las conductas de alto riesgo como si operaran fuera de los contextos social, político y económico. Se necesita un diálogo mas profundo sobre estos temas entre los profesionales del VIH/SIDA. Una manera de reducir posibles consecuencias negativas por el cambio de los factores estructurales, es exigir que por ley que los programas económicos, de desarrollo urbano y de política extranjera realicen anticipadamente “informes científicos sobre el impacto del VIH/SIDA”. Un primer paso posible es que las propias organizaciones de prevención del VIH investigen y publiquen sus propias “informes de impacto.”15 Las instituciones financiadoras deberán tomar en cuenta la amplísima variedad de actividades que constituyen la prevención del VIH. Muchas organizaciones comunitarias responden a todo tema relacionado con el VIH, incluyendo algunos que parecen ajenos. Parte de lo que muchas organizaciones comunitarias atienden diariamente son problemáticas mayores relacionadas con guerra, pobreza, desigualdades sociales (ej. racismo y homofobia) y leyes restrictivas. La ayuda para apoyar y organizar estos esfuerzos puede llevar a la creación de intervenciones estructurales necesarias en la prevención del VIH.

¿quién lo dice?

1. Friedman SR, O’Reilly K. Sociocultural interventions at the community level.AIDS. 1997; 11:S201-S208. 2. Friedman SR, Perlis T, Lynch J, et al. Economic inequality, poverty, and laws against syringe access as predictors of metropolitan area rates of drug injection and HIV infection. 2000 Global Research Network Meeting on HIV Prevention in Drug-Using Populations. Third Annual Meeting Report. Durban, South Africa, July 5 -7, 2000. 147-149. 3. Hankins CA, Friedman SR, Zafar T, et al. Transmission and prevention of HIV and STD in war settings: implications for current and future armed conflicts.AIDS. 2002:16(17):2245-52. 4. Wallace R. Urban desertification, public health and public order: ‘planned shrinkage’, violent death, substance abuse and AIDS in the Bronx. Social Science and Medicine. 1990;31:801-813. 5. Lurie P, Hintzen P, Lowe RA. Socioeconomic obstacles to HIV prevention and treatment in developing countries: the roles of the International Monetary Fund and the World Bank. AIDS. 1995;9:539-546. 6. Farmer P. Infections and Inequalities: the Modern Plagues. University ofCalifornia Press: Los Angeles. 1999. 7. Celentano DD, Nelson KE, Lyles CM, et al. Decreasing incidence of HIV and sexually transmitted diseases in young Thai men: evidence for success of the HIV/AIDS control and prevention program. AIDS. 1998;12:F29-F36. 8. Roca E, Ashburn K, Moreno L, et al. Assessing the impact of environmental-structural interventions. Presented at the International AIDS Conference,Barcelona, Spain. 2002. Abst #TuPeC4831. 9. Groseclose SL, Weinstein B, Jones TS, et al. Impact of increased legal access to needles and syringes on practices of injecting drug users and police officers–Connecticut, 1992-1993. Journal of Acquired Immune Deficiency Syndromes.1995;10:82-89. 10. The STOP AIDS Project. Q Action, ¡Ya Basta! San Francisco, CA. 415/865-0790 x303 11. Gostin LO. The legal environment impeding access to sterile syringes and needles: the conflict between law enforcement and public health. Journal of Acquired Immune Deficiency Syndromes. 1998;18:S60-70. 12. Piot P, Coll Seck AM. International response to the HIV/AIDS epidemic: planning for success. Bulletin of the World Health Organization. 2001;79:1106-1112. 13. Diaz RM, Ayala G, Marin BV. Latino gay men and HIV: risk behavior as a sign of oppression. Focus. 2000;15:1-5. 14. Friedman SR, Aral S. Social networks, risk potential networks, health and disease. Journal of Urban Health. 2001;78:411-418. 15. Friedman SR, Reid G. The need for dialectical models as shown in the response to the HIV/AIDS epidemic. International Journal of Sociology and Social Policy. (in press).

Preparado por Sam Friedman*, Kelly Knight** *National Development and Research Institutes, ** CAPS Traducción Rocky Schnaath Enero 2003. Hoja Informativa 46S

Resource

Gay men (MSM)

What are men who have sex with men’s (MSM) HIV prevention needs?

What do MSM need?

Men who have sex with men (MSM) are not a single homogenous group, but represent a wide variety of people, lifestyles and health needs. From middle class gay men, to homeless runaways, to injection drug users (IDUs) to incarcerated men, MSM have many different identities and associated risks for HIV and other infectious diseases. MSM refers to any man who has sex with a man, whether he identifies as gay, bisexual or heterosexual. Despite success in changing sexual behaviors, MSM continue to be disproportionately affected by HIV/AIDS. MSM account for the largest percentage of persons with AIDS in the US (53%), even as the percentage of AIDS cases among IDUs (25%) and heterosexuals (10%) has increased.1 In 1997, the prevalence rate of HIV for MSM in 4 urban communities was 17% overall, 29% for African-American MSM and 40% for MSM-IDUs.2 HIV is not an issue that exists by itself, but is woven into many aspects of men’s lives. Risk for HIV is embedded in many other core issues such as dating and intimacy, sexual desire and love, as well as alcohol and recreational drug use, homophobia, abuse and coercion, racism and self-esteem.3 HIV prevention programs must be informed by of all these elements

Sexual health

There is not enough sexuality education for young people in the US, and almost no samegender sexuality education. Like many teenagers, young MSM may only learn about sex through distorted media or pornographic images. In general, men in today’s society are pressured to prove their manhood through sexual activity and aggressiveness, while women receive messages on moderation and caretaking. Given this, many MSM face additional challenges learning about dating, intimacy and forming relationships, or about desire, sexual functioning and arousal. Discomfort with one’s sexuality and identity can lead to sexual risk taking.4 In Minnesota, “Man-to-Man: Sexual Health Seminars” are based on the sexual health model. This model assumes that if MSM are more sexually literate, comfortable and competent, they are more likely to be able to reduce risk in the context of sexual behaviors and relationships. The program uses comprehensive sexuality education, cultural specificity and empirical research to help MSM reduce HIV risk long-term. The program was effective in reducing internalized homonegativity and unprotected anal intercourse.5 HIV is not the only sexual health concern for MSM. Other sexually transmitted diseases (STDs) such as herpes and genital warts can negatively affect health and sexuality. Several states have seen an increase in drug-resistant gonorrhea among MSM, making it more difficult to treat.6

Homophobia, racism and self esteem

Homophobia and racism are prevalent in the US. Internal and external homophobia and racism can lead to low self-esteem, which can lead to increased risk behavior such as sexual aggression, difficulty negotiating safer sex, and drug or alcohol abuse. MSM of color are disproportionately affected by many social and health-related ills such as HIV. African American and Latino MSM are more likely than their White counterparts to engage in high-risk activities and to be HIV-infected. Social and cultural factors may limit the ability of MSM of color to protect themselves from HIV. A study of Latino gay men in urban centers found that men who reported high-risk behavior also reported significantly higher rates of financial hardship, experiences of racism and homophobia, incidence of domestic violence and a history of coercive childhood sexual abuse.7 Hermanos de Luna y Sol, an HIV prevention intervention for Latino gay/bisexual men in San Francisco, CA, deals with the common history of oppression among Latino gay men, including issues of homophobia, machismo, sexual abuse, racism and separation from family and culture.8 In Washington, DC, US Helping US (UHU) is a multi-modal prevention program for Black MSM that addresses the psychological and emotional stress that they may experience as racially and sexually oppressed minorities. UHU provides mental health services, community building and anti-homophobia social marketing.9

Alcohol and recreational drug use

The prevalence of drug use is higher among MSM than among heterosexuals,10 although decreases recently have been noted in all alcohol and drug use categories except amphetamines.11 In many areas of the US, gay bars--often sex-charged environments where alcohol and drugs are prevalent--are the only venues for MSM to meet and socialize with each other. Drug use may vary greatly by region and subculture. Substance use puts MSM at risk for HIV for several reasons: 1) MSM-IDUs are at risk if they share infected injection equipment; 2) substance use is associated with high risk sexual behavior; 3) background HIV prevalence rates are higher for MSM-IDUs and MSM who abuse drugs but do not inject, increasing the likelihood of transmission.12 Substance use can serve as a trigger or an excuse for unprotected sex. Some MSM have trouble having sex without getting high first; others prefer having sex while high, believing recreational drugs increase their libido. For some MSM, drug use provides a sense of community and bonding at gay clubs and circuit parties. A survey of MSM who attend circuit parties found that serodiscordant unprotected anal sex was more likely to occur among men who used amphetamines (speed), Viagra and amyl nitrites (poppers).13 For many MSM-IDUs, drug use, rather than sexual orientation, forms their personal identity. Many MSM-IDUs identify as heterosexual. Too often MSM-IDUs are missed in prevention programs that target MSM but leave out IDUs, or programs that target IDUs but don’t address sexual orientation. MSM-IDUs have high rates of HIV infection, high frequency of unprotected sex and high rates of poverty, addiction and its related social and physical ills.12 The Stonewall Project in San Francisco, CA is a harm reduction program for MSM who use speed. The project provides education and assistance and has been successful at reaching MSM of different sexual and social identities.14 Across the US, several cities have opened social centers for gay men where no alcohol is served and drugs are not allowed. One HIV prevention program for young gay men helps develop community centers where young men can socialize without alcohol.15

What is sexual risk?

The perception of sexual risk for HIV varies among MSM and may change from one sexual situation to another. Throughout the HIV epidemic, MSM have engaged in sophisticated decision-making about what they consider to be risky.16 Some men decide for themselves it is OK to not use a condom if they are the top (insertive partner), if they are having oral sex or if their or their partner’s viral load is undetectable. MSM may make these decisions because the scientific evidence of HIV risk is cloudy, or simply because they are comfortable with some level of risk. HIV prevention programs should help MSM to make realistic and healthy choices based on factual information. MSM have engaged in a hierarchy of strategies for maintaining safer sex that are fluid and context-dependent. Most MSM are able to manage sexual risk with effective strategies such as monogamy with concordant partners, consistent condom use with repeated testing, condom use outside of relationship or abstinence. Other MSM use strategies that are not known to be effective (see above paragraph). A small minority of MSM choose to engage in known risk activities such as unprotected anal intercourse without knowledge of partner serostatus. Unprotected anal intercourse between an HIV+ and an HIV- man remains the greatest risk for HIV transmission among MSM. This has proven to be the biggest challenge for HIV prevention. The intimacy of skin-to-skin contact during intercourse is a powerful and important draw. Many MSM feel their sexual identity, as well as the hard-won goals of gay sexual liberation, are based on having sex--including anal intercourse--in a free and unconstricted manner. A majority of MSM consistently manage sexual risk, yet there is little understanding or research of men who are largely safe, and how their values of nurturance and caretaking, ethics, hopes for collective survival, or relations with friends and community help support them. Only recently have HIV+ MSM been targeted with messages and programs featuring “prevention altruism” that make use of MSM’s strengths. HIV prevention efforts need broader, more emotionally-resonant concepts that build on what is good in MSM’s lives.17

Says who?

  1. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report. 2000;12.
  2. Catania JA, Osmond D, Stall RD, et al. The continuing HIV epidemic among men who have sex with men. American Journal of Public Health. in press.
  3. Seal DW, Kelly JA, Bloom FR, et al. HIV prevention with young men who have sex with men: what young men themselves say is needed. AIDS Care. 2000;12:5-26.
  4. Robinson BE, Bockting W, Rosser BRS, et al. The sexual health model: a sexological approach to long-term HIV risk reduction. Presented at the XIII International Conference on AIDS, Durban, South Africa, July 2000. Abst #ThPeD5613.
  5. Rosser BRS, Bockting WO, Rugg DL, et al. A sexual health approach to long-term HIV risk reduction among men who have sex with men: results from a randomized controlled intervention trial. Presented at the XIII International Conference on AIDS, Durban, South Africa, July 2000. Abst #WePeD4718.
  6. Altman LK. Gonorrhea shows its resistant side; disease control agency tells doctors of new recommendations. Milwaukee Journal Sentinel. October 2, 2000. p. 5G.
  7. Diaz RD, Ayala G, Bein E. Social oppression, resiliency and sexual risk: findings from the national Latino gay men’s study. Presented at the National HIV Prevention Conference, Atlanta, GA, Aug 29-Sep 1, 1999. Abst#287
  8. Díaz RM. Latino Gay Men and HIV: Culture, Sexuality, & Risk Behavior. NY:Routledge. 1998.
  9. Simmons R. Towards developing a comprehensive program for effective HIV prevention among racially oppressed gay men, bisexuals and MSM. Presented at the XIII International Conference on AIDS, Durban, South Africa, July 2000. Abst #TuPeD3839.
  10. Stall R, Wiley J. A comparison of alcohol and drug use patterns of homosexual and heterosexual men: the San Francisco men’s health study. Drug Alcohol Dependency. 1988;22:63-73.
  11. Crosby M, Stall R, Paul J, et al. Alcohol and drug use patterns have declined between generations of younger gay/bisexual men in San Francisco. Drug and Alcohol Dependence. 1998;52:177-182.
  12. Rhodes F, Deren S, Wood MM, et al. Understanding HIV risks of chronic drug-using men who have sex with men. AIDS Care. 1999;11:629-648.
  13. Colfax G, Mansergh G, Vittinghoff E, et al. Drug use and high-risk sexual behavior among circuit party participants. Presented at the XIII International Conference on AIDS, Durban, South Africa, July 2000. Abst #TuPeC3422.
  14. Stonewall Project. 415/502- 1999.
  15. Kegeles SM, Hays RB, Pollack LM, et al. Mobilizing young gay and bisexual men for HIV prevention: a two-community study. AIDS. 1999;13:1753-1762.
  16. Williams AM. Condoms, risk and responsibility. Presented at the HIV Prevention Summit, Half Moon Bay, CA, June 2000.
  17. Nimmons D. In this together: the limits of prevention based on self-interest and the role of altruism in HIV safety. Journal of Psychology & Human Sexuality. 1998;10:75-87

Prepared by Michael Crosby PhD and Pamela Decarlo, CAPS December 2000

Resource

Latino gay men in the US

What are the HIV prevention needs of Latino gay men in the US?

Fact Sheet 28, March 2012

Why focus on Latino gay men?

The ever changing mosaic of Latino demographics in the US creates unique challenges to address health disparities of the population, especially when it comes to HIV prevention needs.  Latinos are the largest and fastest growing ethnoracial minority group in the US, experiencing a 43% growth between 2000 and 20101. Data also show that Latinos are one of the fastest growing populations at risk for HIV transmission:

  • Latino men who have sex with men (MSM*) represent 81% of new infections among Latino men, and 19% among all MSM2,3
  • Latinos are 16% of the US population, but make up 17% of living HIV/ AIDS cases and 20% of new HIV infections each year3
  • Youth (ages 13-29) accounted for 45% of new HIV infections among Latino MSM4

In light of these data there is a need to identify culturally-specific health concerns of Latino gay men so that effective interventions may be developed to address current and prevent future disparities. The US National HIV/AIDS Strategy highlights the call for HIV programs that reduce health inequities among both ethnoracial and sexual minority populations5.  Latino gay men have distinct cross-cultural identities that place them into both prioritized categories6.

What are the prevention challenges?

Most work related to Latino gay men has been based on a sociocultural model of health, which shows that experiences of social discrimination, defined as racism, homophobia and poverty, are strong predictors of mental health outcomes7. Mental health outcomes, such as psychological distress, have been shown to increase sexual risk and decrease sexual resiliency. A recent study of Latino MSM living in New York and Los Angeles8 reported that:

  • Over 40% of the participants reported experiences of both racism and homophobia in the past year
  • Low self-esteem and decreased levels of social support among Latino gay men are associated with increased rates of sexual risk behaviors, including unprotected anal sex
  • Men who had both homophobic and racist experiences were more likely than men who reported no form of discrimination to engage in unprotected anal sex as a bottom, and to also be binge drinkers

Late testing (that is, those individuals who have an AIDS diagnosis within one year of testing HIV-positive) and lack of access to health insurance also create challenges to prevention, treatment and care.

  • 38% of Latinos test late in their illness9.
  • In a study of 21 major US cities, 46% of Latino MSM who tested positive for HIV were unaware of their infection3.
  • HIV+ Latinos are more likely than Whites to postpone care due to issues such as lack of transportation, and more likely to delay initiation of care after their diagnosis9.
  • 24% of Latinos living with HIV/ AIDS are uninsured, compared to 17% of Whites; and only 23% of HIV+ Latinos have private health insurance, compared to 44% of Whites10.

Reviews of research with Latino gay and bisexual men also report that cultural influences and socioeconomic forces impact sexual well being. For example, residency status, HIV-related stigma, machismo, immigration and migration patterns, language, insurance status and educational attainment have all been associated barriers to HIV prevention services and programming11, 12

What other factors affect sexual risk and resiliency?

Latino gay men are often faced with unique socio-sexual situations that place them at risk for HIV transmission. Prior work with MSM populations, including Latino gay men, has documented that various factors are associated with sexual-risk:

  • Serosorting (choosing sexual partners based on perceived HIV status), seropositioning (choosing sexual roles [e.g., top or bottom] based on the perceived HIV status of each partner), and sexual stereotypes and preferences13
  • Alcohol and drug use (including methamphetamine and injection use), as well as having had a history of STDs, like syphilis and gonorrhea14,15
  • High rates of condomless anal sex (“barebacking”) and multiple partners16
  • Childhood sexual abuse and a social context of discrimination17

Defined as adopting cultural ways of mainstream society, work on acculturation suggests that: Latinos who are less acculturated to mainstream US culture are protected by traditional Latino (sexual) values; and that acculturation of US mainstream values serves as a protective barrier because it increases a sense of individualism and self-determination18 Understanding the role of sociocultural factors helps to refine definitions of sexual resiliency among Latino gay men. Innovative work exploring protective factors among Latino gay men notes that: HIV prevalence was higher among US born than non-US born Latinos in San Francisco, while in Chicago the opposite was true19

  • Community involvement moderates sexual risk behaviors20
  • Volunteering with HIV/ AIDS organizations can decrease psychological stressors20

As the majority of these data came from quantitative surveys, more public health focused qualitative studies are needed to further examine the context of the sexual situations in which Latino gay men find themselves, as well as the cultural factors and sexual scripts21 that influence their harm reduction behaviors.

What is being done?

  • Hermanos de Luna y Sol, born out of the Mission District in San Francisco, CA is a longstanding HIV prevention intervention for immigrant Spanish speaking Latino gay and bisexual men that is based on empowerment education and social support, and has been successful in increasing condom use among participants22.
  • Latinos D (based in Queens, NY23) and Somos Latinos Salud (based in Ft. Lauderdale, FL24) are dynamic and promising adaptations of the MPowerment program, an effective community-level, evidence-based HIV intervention for young gay and bisexual men25.
  • SOMOS, a homegrown and culturally responsive NYC-based HIV prevention program, has been shown to lower risk behaviors and decrease number of sexual partners among Latino gay men26.

Still, even with these programs and CDC recommendations to address Latino MSM health disparities, most adaptations of evidence-based interventions have largely been linguistically, but not necessarily culturally, translated versions of established programs.

What are the recommendations?

  • Celebrate the diversity of Latino cultures in programming. Different experiences of historical events, political environments, immigration patterns and regional cultures exist within Latino communities (e.g., Chicanos in Los Angeles, Nuyoricans in New York, Tejanos in San Antonio).
  • Conduct more research on structural and environmental influences on Latino gay men’s sexual health including issues relating to undocumented HIV+ Latinos.
  • Understand that serving populations is not the same as being culturally competent. Including Latino participation does not equate to providing appropriate services.
  • Cultivate Latino gay community collaboration and empowerment by ensuring that Latino gay men participate in local HIV prevention and care planning councils.
  • Develop programs that address the unique concerns of both immigrants and U.S. born Latino gay men. Assuming that all Latino gay men are monolingual Spanish speakers minimizes the needs of bicultural (but not necessarily bilingual) Latino gay men.
  • Reduce gay-related and HIV-related stigmas in Latino communities. Breaking sexual silences will help promote healthy sexual identity development.
  • Work with policy makers and political stakeholders to advocate for sustainable health care access.
  • Highlight social norms and cultural values that enhance sexual resiliency. Focusing solely on risk factors leads to limited insights and opportunities for interventions.
  • Foster programs that address the impact of isolation and identity validation. Lessening stressors that Latino gay men face will improve their overall well-being.

Says who?

1 US Census Bureau (2011).  Overview of Race and Hispanic Origin: 2010 – U.S. Census Bureau. 2 CDC. (2011). CDC Fact Sheet: HIV and AIDS among Latinos. https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/Cdc-hiv-latinos-508.pdf. 3 CDC. (2008).  HIV Surveillance in Men Who Have Sex with Men (MSM). https://www.cdc.gov/hiv/group/msm/index.html. 4 Prejean J, et al. (2011). Estimated HIV Incidence in the United States, 2006-2009. PLoS ONE. 5 ONAP. (2010). National HIV/AIDS Strategy: Federal Implementation Plan. https://www.hiv.gov/federal-response/national-hiv-aids-strategy/federal-implementation#:~:text=The%20Federal%20Action%20Plan%20presents,within%203%20to%205%20years. 6 Diaz, RM (1998). Latino gay men and HIV: culture, sexuality, and risk behavior. Routledge. 7 Díaz RM, et al. (2001). The impact of homophobia, poverty, and racism on the mental health of gay and bisexual Latino men: findings from 3 US cities. Am J Public Health. 91(6):927-932. 8 Mizuno Y, et al. (2011). Homophobia and Racism Experienced by Latino Men Who Have Sex with Men in the United States: Correlates of Exposure and Associations with HIV Risk Behaviors. AIDS Behav. [Epub ahead of print] 9 CDC. (2011). HIV Surveillance Report, Vol. 21. 10 RAND. (2011). HIV Cost and Services Utilization Study (HCSUS). http://www.rand.org/health/projects/hcsus.html.\ 11 Zea MC, et al. (2004). Methodological issues in research on sexual behavior with Latino gay and bisexual men.  Am J Community Psychol. 31(3-4):281-291. 12 National Latino AIDS Awareness Day. HIV/ AIDS and Latino/ Hispanic men who have sex with men. 13 Rosenberg ES, et al. (2011). Number of casual male sexual partners and associated factors among men who have sex with men: results from the National HIV Behavioral Surveillance system. BMC Public Health. 25: 11-89. 14 CDC. (2010). HIV among Hispanics/ Latinos. https://www.cdc.gov/hiv/group/racialethnic/hispaniclatinos/index.html15 Balan IC, et al. (2009). Intentional Condomless Anal Intercourse Among Latino MSM Who Meet Sexual Partners on the Internet. AIDS Educ Prev. 21(1): 14-24. 16 Diaz RM et al. (2005). Reasons for stimulant use among Latino gay men in San Francisco: a comparison between methamphetamine and cocaine users. Journal of Urban Health. 82(Supp1): 71-78. 17 Arreola SG, et al. (2009). Childhood sexual abuse and the sociocultural context of sexual risk among adult Latino gay and bisexual men. Am J Pub Hlth. 99 Suppl 2:S432-8. 18 Abraído-Lanza AF, et al. (2005). Do healthy behaviors decline with greater acculturation? Implications for the Latino mortality paradox. Soc Sci Med. 61:1243–1255. 19 Ramirez-Valles J, et al. (2008) HIV Infection, Sexual Risk, and Substance Use among Latino Gay and Bisexual Men and Transgender Persons. American Journal of Public Health. 98: 1036-1042. 20 Ramirez-Valles J (2002). The proactive effects of community inolvment for HIV risk behavior: A conceptual framework. Health Education Research. 17(4): 389-403. 21 Carrillo H, et al. (2008). Risk across borders: Sexual contexts and HIV prevention challenges among Mexican gay and bisexual immigrant men. Findings and recommendations from the Trayectos Study (Monograph). San Francisco: UCSF and SFSU. 22 Hermanas de Luna y Sol.http://sfresourceconnect.org/detail.php?id=41275840  23 Latinos Diferentes. https://www.facebook.com/LatinosD. 24 Latinos Salud – Somos. http://www.latinossalud.org 25 Mpowerment. http://mpowerment.org. 26 Vega MY, et al. (2011). SOMOS: evaluation of an HIV prevention intervention for Latino gay men. Health Educ Res. 26(3):407-418.

Prepared by Gabriel R. Galindo DrPH, UCSF Center for AIDS Prevention Studies Fact Sheet 28, March 2012 Special thanks to the following reviewers of this Fact Sheet: Ana F. Abraido-Lanza, Sonya Arreola, Maricarmen Arjona, George Ayala, Alida Bouris, Hector Carrillo, Rafael Diaz, Lizette Rivera, Ramon Ramirez and Jesus Ramirez-Valles.

Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Francisco should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © July 2012, University of California

Resource

Transgender men

What are transgender men’s HIV prevention needs?

Prepared by Jae Sevelius, CAPS; Ayden Scheim and Broden Giambrone, Gay/Bi/Queer Trans Men’s Working Group, Ontario Gay Men’s Sexual Health Alliance Fact Sheet 67 – Revised September 2015

Who are transmen?

Transgender (‘trans’) is an umbrella term for people whose gender identity and expression do not conform to norms and expectations traditionally associated with their sex assigned at birth. Transgender men, or transmen, are people who were assigned ‘female’ at birth and have a male gender identity and/or masculine gender expression. Transgender people may self-identify and express their gender in a variety of ways and often prefer certain terms and not others. Some who transition from female to male do not identify as transgender at all, but simply as men. In general, transmen should be referred to with male pronouns. However, if you are unsure it is best to respectfully ask a person what terms and pronouns they prefer. Accurate information about the diversity of transmen’s bodies is not widely available. Transmen have different types of bodies, depending on their use of testosterone and gender confirmation surgeries (which may include chest reconstruction, hysterectomy, metoidioplasty, phalloplasty1, etc.; see www.ftmguide.org for further information). Transmen use a broad range of terms and language to identify their sex/gender, describe their body parts, and disclose their trans status to others. For instance, some transmen are not comfortable with the terms ‘vagina’ and ‘vaginal sex’ and may prefer ‘front hole’ and ‘front sex’ or ‘front hole sex’, although this is not true for all transmen. This diversity creates unique needs and barriers for negotiating and adhering to safer sex practices that are not addressed by current HIV prevention programs.

What do we know about HIV and transmen?

The transgender community is diverse and not enough research has been conducted with trans people in general. We have very limited information about transmen in particular. To date, research related to HIV among trans people has almost exclusively focused on transwomen (people who were assigned ‘male’ at birth and have a female gender identity and/or feminine gender expression). However, there is evidence that there is a significant subgroup of transmen that engage in unprotected sex with non-trans men (trans MSM), including some transmen who engage in sex work. Several cities have conducted needs assessments that focus on or are inclusive of transmen and HIV risk, such as Philadelphia, Washington D.C, San Francisco, and the province of Ontario. The few published studies that report HIV rates among samples of transmen have reported 0–3% prevalence.2,4 These rates are self-reported, however, and are based on small, non-representative samples, so we do not have conclusive data about the actual rates. Due to the assumption of low rates of HIV among transmen relative to other high-risk groups, there has not been much research on risk behaviors among transmen. We do know that HIV prevention messages are not reaching most transmen.5 We also know that many trans MSM seek services at gay men’s organizations, where there is little to no education for transmen and their non-trans male partners.4 Providers are generally not trained to identify or serve gay and bisexual transmen in culturally sensitive ways or understand their specific risks and prevention needs.

What don’t we know about HIV and transmen?

We do not have enough information about HIV and transmen. Data collection methods at testing sites do not accurately identify and track transmen or capture their experiences, which contributes to the lack of clarity around HIV rates among transmen. Rates of HIV and sexual risk behaviors among transmen are also not well understood because transmen are often assumed to be primarily having sex with non-trans women. However, transmen, like other men, can be of any sexual orientation and may have sex with different types of partners, including (but not limited to) non-trans men, transgender women, and transgender men.6,7

What puts transmen at risk?

In one study, a majority of trans MSM reported not using condoms consistently during receptive anal and/or frontal (vaginal) sex with non-trans male partners and low rates of HIV testing and low perception of risk.4 In urban areas where HIV prevalence rates among non-trans MSM are estimated to be 17-40% and STI rates are increasing, trans MSM who engage in unprotected receptive anal and/or frontal (vaginal) intercourse with non-trans MSM may be especially vulnerable to HIV/STIs.8,9 Transmen may face complicated power and gender dynamics in their sexual relationships with non-trans men.4 For some trans MSM, having sex with a non-trans gay male partner is a powerful validation of their gay/queer male identity, especially in the early years of transition, and may be more important than insisting on condom use. Some transmen who use testosterone have reported increased sex drive and increased interest in sex with non-trans men after beginning hormone use, which may contribute to their willingness to take sexual risks.4,10 Transmen on testosterone and/or who have had a hysterectomy may have frontal (vaginal) dryness, which increases their risk for frontal (vaginal) trauma during penetration, thus increasing their risk for STIs, including HIV.10 Low self-esteem may contribute to sexual risk-taking among transmen. Rates of depression, substance use, and suicide attempts are high in this population, but multiple barriers exist to accessing culturally competent support and treatment.3,11 Drug and alcohol use is a major risk factor for every community, regardless of their gender identity. Transmen may use alcohol or drugs to enhance sexual experiences or help to relieve anxiety about their bodies during sex.4 Some transmen may feel pressure to use drugs in order to fit into some gay men’s communities or subcultures. Although we have very little information about needle sharing for hormone or drug use among transmen, it may also be a risk factor for some.

What can help?

Online dating. Many transmen meet their non-trans male sexual partners on the Internet. Meeting partners through personal ads may allow transmen to describe their body and gender identity upfront (if they choose to do so) and discuss safer sex with potential partners before meeting in person.4 Educational materials for non-trans partners. Transmen’s non-trans male partners often do not have experience with transmen nor access to education about sex with transmen, which can lead to misconceptions about safer sex. For non-trans gay men, safe sex often simply means condom use with anal sex and they may not be aware of the risks associated with frontal (vaginal) sex. See the next section for information on available materials. Greater visibility in the gay community. Gay and bisexual men need to be educated about the presence of transmen in their community. Increasing visibility and knowledge about transmen may help create a welcoming environment, help increase inclusivity, and help transmen feel more powerful in their relationships with non-trans men.7

What’s being done?

tm4m (tm4m.org) is a San Francisco-based project for transmen who play with men (or want to). They provide information, education, and support to transmen who have sex with men through monthly educational workshops and discussion groups, informational materials and continuously working to foster acceptance and build community. tm4m is a collaborative effort co-sponsored by Eros, Trannywood Pictures and TRANS:THRIVE (a program of the API Wellness Center). The Gay/Bi/Queer Trans Men’s Working Group in Ontario has conducted a needs assessment with trans MSM, developed a sexual health resource12, and a website at www.queertransmen.org. They are also providing training and consultation about trans MSM inclusion for prevention workers serving gay men across the province. All Gender Health Online is a study exploring the sexual health of non-transgender men who have sex with transgender people. The results will be used to develop an online intervention to prevent the spread of HIV and promote the sexual health of transgender people and their partners. The STOP AIDS Project in San Francisco, CA strives to include transmen in their programming and community education. They include transgender men in their mission statement and have changed their data collection methods to better reflect varying bodies and gender identities in gay men’s communities.

What needs to be done?

We need to implement more inclusive data collection methods to better capture subgroups of transgender people. HIV prevention and care providers should not assume that all men they see were assigned ‘male’ at birth. You cannot tell if a guy is trans just by looking at him. The best method for data collection is a two-part question: 1) ask about current gender identity and 2) ask what sex was assigned at birth.13 If unsure, programs should ask transmen for their preferred name and pronoun and use those terms. If rates of HIV among transmen are indeed low, we now have the opportunity to engage in true prevention work to keep those numbers low. Gaining a better understanding of transmen’s risk behaviors and the different ways that they protect themselves will aid in providing appropriate and effective HIV prevention education to transmen and their sexual partners.

Says who?

1. It is important to note that few transmen have fully functional penises, primarily due to the relatively low rates of surgical success, high rates of complications, and the extremely high cost. 2. Herbst J, Jacobs E, Finlayson T, et al. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: A systematic review.AIDS and Behavior. 2007. 3. Clements-Nolle K, Marx R, Guzman R, et al. HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: Implications for public health intervention. American Journal of Public Health. 2001;91:915-921. 4. Sevelius J. ‘‘There’s no pamphlet for the kind of sex I have’’: HIV-related risk factors and protective behaviors among transgender men who have sex with non-transgender men. Journal of the Association of Nurses in AIDS Care. 2009;20:398-410. 5. Hein D, Kirk M. Education and soul-searching: The Enterprise HIV prevention group. In: Bockting W, & Kirk, S., editor. Transgender and HIV: Risks, prevention, and care. Binghamton, NY: The Haworth Press; 2001. p. 101-117. 6. Schleifer D. Make me feel mighty real: Gay female-to-male transgenderists negotiating sex, gender, and sexuality. Sexualities 2006;9(1):57-75. 7. Bockting W, Benner A, Coleman E. Sexual identity development among gay and bisexual female-to-male transsexuals: Emergence of a transgender sexuality. Archives of Sexual Behavior. 2009;38(5). 8. Colfax G, Coates T, Husnik M, Huang Y, Buchbinder S, Koblin B, et al.Longitudinal patterns of methamphetamine, popper (amyl nitrite), and cocaine use and high-risk sexual behavior among a cohort of San Francisco men who have sex with men. Journal of Urban Health. 2005;82:i62-i70. 9. CA Department of Health Services. California HIV counseling and testing annual report: January – December 2003. Sacramento, CA: Office of AIDS; 2006. 10. Gorton N, Buth J, Spade D. Medical therapy and health maintenance for transgender men: A guide for health care providers: Lyon-Martin Women’s Health Services; 2005. 11. Newfield E, Hart S, Dibble S, Kohler L. Female-to-male transgender quality of life. Quality of Life Research 2006;15(9):1447-57. 12. Gay/Bi/Queer Transmen’s Working Group of the Ontario Gay Men’s HIV Prevention Strategy. Primed: The Back Pocket Guide for Transmen & The Men Who Dig Them. Toronto, Ontario; 2007. 13. Center of Excellence for Transgender HIV Prevention. Recommendations for Inclusive Data Collection of Trans People in HIV Prevention, Care, and Services. San Francisco, CA: University of California, San Francisco; 2009. www.transhealth.ucsf.edu

Special thanks to the following reviewers of this Fact Sheet: Walter Bockting, AJ King, Niko Kowell, Dan Lentine, Vel McKleroy, Sarah Morgan, Emily Newfield, David Schleifer, Hale Thompson, Erin Wilson.   Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. To receive Fact Sheets via e-mail, send an e-mail to [email protected] with the message “subscribe CAPSFS first name last name.” ©January 2010, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected].