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What works in HIV prevention

We Know What Works in HIV Prevention -Why Aren’t We Doing More of It?

What have we learned?

Fifteen years ago, the first AIDS cases were diagnosed among 5 gay men in Los Angeles, CA. Since then, AIDS has spread to over half a million people in the US and is the leading cause of death for all Americans aged 25-44. Fifteen years have also seen great leaps in understanding how to prevent the spread of HIV. But these fifteen years have not seen the widespread implementation of effective HIV prevention programs in the US. If we know what works, why aren’t we doing more of it? HIV prevention does not have to be perfect to be effective. Epidemiological models have shown that simply cutting rates of risky behavior in half can halt the epidemic.1 The programs listed below are some of the interventions that have shown signs of success and should be replicated, even without 100% reduction in risk behavior.

What has shown signs of working?

The majority of the estimated 41,000 annual new HIV infections in the US are occurring among injection drug users (IDUs), their sexual partners, and their offspring.2 We know what works to prevent the spread of HIV among IDUs: starting HIV prevention efforts when rates of HIV are still low, providing sterile injecting equipment through needle exchange programs and over-the-counter pharmacy sales, conducting community outreach to IDUs, and providing drug treatment on demand.3 In Tacoma, WA, where prevention efforts for IDUs began in 1988, the prevalence of HIV among IDUs has remained steady at 3-4%. In New York City, NY, where prevention efforts for IDUs met with early opposition, HIV among IDUs increased from 10% to more than 50% in five years.3 Connecticut implemented the ideal HIV prevention program: it cost the state nothing and was highly effective. A partial repeal of needle prescription and drug paraphernalia laws resulted in dramatic reductions in needle sharing, and increases in pharmacy purchase of syringes by IDUs. Sharing dropped from 52% to 31% after the new laws, pharmacy purchase rose from 19% to 78%, and street purchase fell from 74% to 28%.4 Gay and bisexual men account for a majority of total current HIV infections, and 25% of annual new infections in the US.2 We know what intervention strategies work for gay and bisexual men: small group counseling and skills training, peer outreach, counseling and testing, hot lines, media programs, and community interventions. One effective program in several medium-sized towns trained the most popular people in social settings to deliver AIDS risk-reduction messages to friends and acquaintances in gay bars. As a result, fewer gay men practiced unprotected sex.5 Another successful program promoted a norm for safer sex among young gay men through a variety of social, outreach and small group activities such as dances, picnics, and volleyball games. As a result, rates of unprotected intercourse dropped from 40% to 31%.6 One fourth of all new HIV infections in the US occur in young people under the age of 22. We know what works for adolescents: effective sex education programs in schools. Although the popular belief is that teaching kids about sex will lead to promiscuity, in fact, the opposite is true. A comprehensive review of 23 school-based programs found that teens who received specific AIDS education were less likely to engage in sex, and those who did were more likely to have sex less often and use contraception.7 Sex education is most effective when it is begun before students have initiated sexual activity. A program in Oakland, CA, used peer educators to teach seventh graders about sexuality and HIV/AIDS. After one year, students in the program were less likely to initiate activities such as deep kissing, genital touching, and sexual intercourse.8 Voluntary HIV testing and treatment with AZT for HIV-positive pregnant women reduced the risk of maternal-fetal HIV transmission by two-thirds in clinical trials.9 Long-term effects on mother and child have yet to be determined.

How is prevention being held back?

The US government still bans the use of federal funds for needle exchange programs, even though six government-sponsored reports have shown that those programs help stop the spread of HIV and do not lead to increased drug use. Similarly, ten states and the District of Columbia still have laws requiring a doctor’s prescription to buy a syringe, even though four government-sponsored studies have recommended repealing those laws.10 Meanwhile, drug treatment centers frequently have long waiting lists, and fewer than 15% of IDUs in the US are in treatment at any given time.11 In recent years, many states have passed laws that restrict sex education. For example, eight states require or recommend teaching that homosexuality is not an acceptable lifestyle, even though gay teens are at highest risk for HIV and most in need of education. Twenty-six states require abstinence instruction, even though a review of abstinence programs showed no proof of effectiveness in delaying the onset of intercourse.7 Only 14 of the 26 states also require sex education curricula to include information on contraception, sexually transmitted diseases and HIV.12 Funding for HIV prevention has not always flowed where it is most needed. For example, in California in 1991, gay and bisexual men accounted for 88% of all AIDS cases, yet received only 5% of total state spending on prevention.13 Success preventing maternal-fetal transmission has prompted the federal government to recommend universal counseling and voluntary HIV testing to all pregnant women. However, getting tested does not guarantee treatment if a women should test positive. A study of publicly funded HIV test sites found that almost half of all clients had no health insurance, and racial minorities were more likely to be uninsured.14 Lack of insurance may block many women from preventive services such as prenatal care. Prevention programs that have been evaluated and shown to be effective are sometimes perceived as too complicated or expensive to work “in the field.” Researchers and service providers can collaborate to better understand how to adapt effective programs to different populations, and to determine the cost-effectiveness of programs.

What can we do?

The federal government needs to repeal the ban on funding for needle exchange programs. State governments need to repeal needle prescription and paraphernalia laws. Federal and state governments need to dramatically increase methadone maintenance programs, as well as drug treatment programs for cocaine and crack. State governments should pass laws requiring all children to receive explicit and age-appropriate sexuality, drug, and HIV/AIDS education in schools that includes discussions of homosexuality and contraception. State health departments and their Community Planning groups need to prioritize funding for prevention programs that more accurately reflect the epidemiology of HIV in their communities. Highest priority should be given to programs for populations with the greatest need: IDUs in and out of treatment; gay and bisexual men who are young, substance users, and men of color; female partners of IDUs; and high-risk youth. The federal government needs to ensure early access to care and treatment for those who test positive. New medications and therapies can be prohibitively expensive for those without health insurance. Recent advances in HIV treatment can dramatically lower the amount of HIV virus during early phases of infection, which may reduce the risk of transmission. In the future, good HIV treatment may be key for HIV prevention. A comprehensive HIV prevention strategy uses many elements to protect as many people at risk for HIV as possible. Prevention does not have to be perfect to make a difference. We know what works in HIV prevention. We need to apply that knowledge more completely, more fairly, and more consistently. Prepared by Thomas J. Coates, PhD and Pamela DeCarlo

Says Who?

1. Blower SM, McLean AR. Prophylactic vaccines, risk behavior change, and the probability of eradicating HIV in San Francisco . Science. 1994;265:1451-1454. 2. Holmberg SD. The estimated prevalence and incidence of HIV in 96 large US metropolitan areas . American Journal of Public Health. 1996;86:642-654. 3. Des Jarlais DC, Hagan H, Friedman SR, et al. Maintaining low HIV seroprevalence in populations of injecting drug users . Journal of the American Medical Association. 1995;274:1226-1231.
  • Contact: Don Des Jarlais 212/387-3870 X3808.
4. 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.
  • Contact: Beth Weinstein 203/509-7800.
5. Kelly JA, St. Lawrence JS, Stevenson LY, et al. Community AIDS/HIV risk reduction: the effects of endorsements by popular people in three cities . American Journal of Public Health. 1992;82:1483-1489.
  • Contact: Jeff Kelly 414/287-4680.
6. Hays RB, Rebchook, GM, Kegeles SM. The Mpowerment project: a community-level HIV prevention intervention for young gay and bisexual men . American Journal of Public Health. 1996;86:1-8.
  • Contact: Susan Kegeles 415/597-9159.
7. Kirby D, Short L, Collins J, et al. School-based programs to reduce sexual risk behaviors: a review of effectiveness. Public Health Reports. 1994;109:339-360. 8. Ekstrand ML, Siegel D, Nido V, et al. Peer-led AIDS prevention delays initiation of sexual behaviors among US junior high school students. Presented at 11th International Conference on AIDS, Vancouver, BC. 1996.
  • Contact: Maria Ekstrand 415/597-9160.
9. Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment . New England Journal of Medicine. 1994;331:1173-1180. 10. Lurie P, Drucker E. An opportunity lost: estimating the number of HIV infections due to the US failure to adopt a national needle exchange policy. Presented at 11th International Conference on AIDS, Vancouver, BC. 1996. 11. Wiley J, Samuel M. Prevalence of HIV infection in the USA . AIDS. 1989;3(Suppl. 1):71-78. 12. Sexuality Education in America: A State-by-State Review. Report prepared by the NARAL Foundation. Washington, DC: 1995. 13. Lee PR, Franks P, Haynes-Sanstad K, et al. HIV Prevention in California: HIV Education and Prevention Evaluation. Report prepared for the Office of AIDS, California Department of Health Services, 1993. 14. Valdiserri RO, Gerber AR, Dillon BA, et al. Clients without health insurance at publicly funded HIV counseling and testing sites: implications for early intervention . Public Health Reports. 1995;110:47-52.
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]. ©1996, University of California
Resource

Lo que funciona en la prevención

Si sabemos lo que funciona al prevenir el VIH — ¿porqué no sacamos mayor provecho?

¿qué hemos aprendido?

Hace quince años, en Los Angeles, CA, se diagnosticaron los primeros 5 casos de SIDA entre hombres homosexuales. Desde entonces el SIDA se ha extendido a más de medio millón de personas en los EEUU y actualmente es la causa líder de muertes entre los Norteamericanos de 25 a 44 años de edad. Estos quince años han sido testigos del gran avance logrado tratando de entender como detener esta enfermedad. Sin embargo, en estos quince años no se ha visto la implementación de programas eficaces de prevención a gran escala en las tareas de prevención del VIH en los EEUU. Si sabemos lo que funciona, ¿porqué no lo ponemos a prueba? No es necesario que la tarea de prevención sea perfecta para ser efectiva. Los modelos epidemiológicos demuestran que el simple hecho de reducir por mitad el número de conductas de riesgo puede detener esta epidemia.1 Los programas que a continuación mencionamos son algunas de las intervenciones que han dado muestras de eficacia y que deberían ser replicadas aunque no se haya obtenido un 100% en la reducción de las conductas de riesgo.

¿cuáles programas parecen funcionar?

Se estima que la mayoría de los 41,1000 nuevos casos anuales de infección con VIH son atribuidas a los Usuarios de Drogas Intravenosas (UDIs), a sus parejas sexuales y a su descendencia.2 Ya sabemos como detener la transmisión del VIH entre los UDIs: comenzar las tareas de prevención apenas se registren los primeros brotes de infección, proveer el material que se usa para inyectarse esterilizado por medio de los programas de intercambio de jeringuillas o a través de las farmacias, crear programas capaces de reclutar a los UDIs en esta lucha, y proveer programas de rehabilitación de drogas de acuerdo a las circunstancias.3 En Tacoma Washington, ciudad donde los esfuerzos de prevención para los UDIs empezaron en el año 1988, la prevalencia del VIH entre los ellos se ha mantenido entre el 3-4%. En la ciudad de Nueva York, en donde los esfuerzos de prevención para los UDIs encontraron resistencia en sus inicios, nos encontramos con un incremento del 10% hasta más del 50% en cinco años.3 Connecticut implementó el programa ideal de prevención del VIH: sin costo alguno al estado y con resultados sumamente positivos. Esto se logro haciendo un simple cambio sustancial a las leyes que giran en torno a la paraphernalia y a la compra de jeringas lo cual produjo una dramática reducción en el uso de jeringas usadas y un incremento en las ventas de jeringas nuevas entre los UDIs. A raíz de la implementación de estas nuevas leyes se observó una reducción en el uso de jeringas usadas del 52% al 31%, la venta en las farmacias subió del 19% al 78%, y las ventas en las calles cayeron del 74% al 28%.4 Actualmente, el hombre gay y/o bisexual cuenta con la mayoría de los casos de infección con VIH, y con el 25% anual de nuevas infecciones en los EEUU. Sabemos cuales son las estrategias de intervención que funcionan entre el hombre gay y bisexual: pequeños grupos de apoyo, la práctica de ciertas destrezas o la creación de estas, proveer consejería, pruebas del VIH y programas de recultamiento llevados a cabo por miembros del grupo en cuestión, líneas telefónicas de asistencia, programas televisivos e intervenciones a nivel comunitario. Uno de los programas exitosos fue implementado en varias ciudades de tamaño mediano. En este programa se entrenó a las personas más populares del ámbito social para transmitir mensajes de reducción de riesgo en bares de homosexuales. Debido a esto, se redujeron las relaciones sexuales sin protección.5 Otro de los programas exitosos usó la estrategia de promover una norma o patrón de conducta por medio de fiestas, días de campo y juegos de voliból. Esto ocasionó un descenso en las relaciones sexuales sin protección del 40% al 31%.6 Un cuarto de todas las nuevas infecciones en los EEUU ocurre entre los jóvenes menores de 22 años. Sabemos cuales son las estrategias para tratar el caso de los adolescentes: los programas eficaces de educación sexual en las escuelas. En una revisión a 23 programas implementados en las escuelas se descubrió que aquellos jóvenes que participaron en estos programas estaban menos propensos a participar en actividades sexuales y aquellos que estaban teniendo relaciones sexuales lo hacían con menos frecuencia usando métodos anticonceptivos.7 La prueba voluntaria del VIH y el tratamiento con AZT a las mujeres embarazadas VIH positivas redujo en dos tercios el riesgo de transmisión del VIH de la madre al feto.8 Aunque los efectos secundarios que esta medicina ocasiona aún están por verse.

¿comó se limita la prevención?

Hasta hoy, el gobierno Estadounidense no permite el uso de fondos federales para programas de intercambio de jeringas, a pesar de que 6 reportes auspiciados por el gobierno demostraron que estos programas ayudan a detener la transmisión del VIH sin que se haya observado un incremento en el uso de las drogas.9 Simultáneamente, diez estados y el DC tiene hasta hoy leyes que requieren una receta del doctor para comprar jeringas, a pesar de que 4 estudios auspiciados por el gobierno han recomendado abolir estas leyes. Mientras tanto, los centros para el tratamiento de drogas tienen con frecuencia largas listas de espera, y menos del 15% de los UDIs en los EEUU están bajo tratamiento en un momento dado.10 Hasta hace pocos años, muchos estados han logrado crear/pasar leyes que restringen la educación sexual. Por ejemplo, en ocho estados se requiere o se recomienda enseñar que la homosexualidad no es un estilo de vida aceptable en la sociedad a pesar de que los jóvenes gay/homosexuales son los que corren mayor riesgo de contraer el VIH y por lo tanto son los que necesitan más educación. A pesar de que en 26 estados se exige promover la abstinencia en las escuelas, una revisión de estos programas no comprobó la efectividad de estos en cuanto a retrasar las actividades sexuales. Solamente en 14 de los 26 estados se exige como requisito incluir en el currícula de educación sexual información acerca de los anticonceptivos, sobre las enfermedades transmitidas sexualmente y sobre el VIH.11 Los fondos monetarios designados para los esfuerzos de prevención del VIH no siempre se canalizan donde más se necesitan. Por ejemplo, en el estado de California, en el año 1991 en donde el 88% de todos los casos de SIDA era atribuido a hombres homosexuales y bisexuales, solamente designaron el 5% del presupuesto para la prevención en esta población.12 El éxito obtenido al prevenir la transmisión materno-fetal ha provocado que el gobierno federal recomiende servicios de consejería y pruebas voluntaria del VIH a toda mujer embarazada. Eso si, el hecho de hacerse la prueba no garantiza recibir el tratamiento en caso de resultar positiva. Un estudio a los centros públicos donde se hacen pruebas del VIH, encontró que casi la mitad de los clientes no tenían seguro de salud siendo las minorías raciales las que poseían menos posibilidades de tener seguro de salud.13 La falta de un seguro puede impedir que las mujeres reciban servicios preventivos tales como el cuidado prenatal.

¿qué podemos hacer?

El gobierno federal deberá revocar las leyes que impiden que los programas de intercambio de jeringas obtengan fondos para operar. Los gobiernos estatales necesitan revocar las leyes de paraphernalia y de prescripción en cuanto a las jeringas. Ambos gobiernos necesitan incrementar programas de mantenimiento con “Methadone”, asimismo los programas de rehabilitación de drogas como la cocaína y el crack. Los gobiernos estatales deberán implementar leyes que requieran que todo joven reciba educación más explícita sobre la sexualidad, las drogas y el VIH/SIDA de acuerdo con la edad en las escuelas, incluyendo el tema de la homosexualidad y los anticonceptivos. Los departamentos de salubridad del estado y los Grupos Comunitarios de Planeamiento a cargo de distribuir los fondos deberán darle prioridad a los programas de prevención que reflejen con mayor exactitud la epidemiología del VIH en sus comunidades. La mayor prioridad deberá estar centrada en aquellos programas dirigidos a las poblaciones que más lo necesitan: los UDIs dentro y fuera de los programas de tratamiento; hombres homosexuales y bisexuales jóvenes, UDIs y minorías; las parejas femeninas de los UDIs; y los jóvenes que corren alto riesgo. El gobierno federal necesita asegurar el acceso al cuidado médico durante la etapa inicial a aquellas personas que resulten VIH-positivas. El alto costo de los nuevos medicamentos y del tratamiento se hace inaccesible para aquellos que no poseen seguro médico. Los recientes avances en el tratamiento del VIH pueden reducir dramaticamente la cantidad de virus si se hace durante la etapa inicial, lo cual reduce el riesgo de transmisión. En el futuro, un buen tratamiento puede ser la clave para el éxito de los esfuerzos de prevención. Un programa de prevención completo y eficaz utiliza múltiples elementos para proteger a la mayor cantidad de personas a riesgo posible. La estrategia de prevención no necesariamente debe ser perfecta para obtener éxito. Sabemos lo que funciona al hacer prevención. Necesitamos aplicar este conocimiento mas plena, justa, y consistentemente.

¿quién lo dice?

1. Blower SM, McLean AR. Prophylactic vaccines, risk behavior change, and the probability of eradicating HIV in San Francisco . Science. 1994;265:1451-1454. 2. Holmberg SD. The estimated prevalence and incidence of HIV in 96 large US metropolitan areas . American Journal of Public Health. 1996;86:642-654. 3. Des Jarlais DC, Hagan H, Friedman SR, et al. Maintaining low HIV seroprevalence in populations of injecting drug users . Journal of the American Medical Association. 1995;274:1226-1231.

  • Contact: Don Des Jarlais 212/387-3870 X3808.

4. 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.

  • Contact: Beth Weinstein 203/509-7800.

5. Kelly JA, St. Lawrence JS, Stevenson LY, et al. Community AIDS/HIV risk reduction: the effects of endorsements by popular people in three cities . American Journal of Public Health. 1992;82:1483-1489.

  • Contact: Jeff Kelly 414/287-4680.

6. Hays RB, Rebchook, GM, Kegeles SM. The Mpowerment project: a community-level HIV prevention intervention for young gay and bisexual men . American Journal of Public Health. 1996;86:1-8.

  • Contact: Susan Kegeles 415/597-9159.

7. Kirby D, Short L, Collins J, et al. School-based programs to reduce sexual risk behaviors: a review of effectiveness. Public Health Reports. 1994;109:339-360. 8. Ekstrand ML, Siegel D, Nido V, et al. Peer-led AIDS prevention delays initiation of sexual behaviors among US junior high school students. Presented at 11th International Conference on AIDS, Vancouver, BC. 1996.

  • Contact: Maria Ekstrand 415/597-9160.

9. Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment . New England Journal of Medicine. 1994;331:1173-1180. 10. Lurie P, Drucker E. An opportunity lost: estimating the number of HIV infections due to the US failure to adopt a national needle exchange policy. Presented at 11th International Conference on AIDS, Vancouver, BC. 1996. 11. Wiley J, Samuel M. Prevalence of HIV infection in the USA . AIDS. 1989;3(Suppl. 1):71-78. 12. Sexuality Education in America: A State-by-State Review. Report prepared by the NARAL Foundation. Washington, DC: 1995. 13. Lee PR, Franks P, Haynes-Sanstad K, et al. HIV Prevention in California: HIV Education and Prevention Evaluation. Report prepared for the Office of AIDS, California Department of Health Services, 1993. 14. Valdiserri RO, Gerber AR, Dillon BA, et al. Clients without health insurance at publicly funded HIV counseling and testing sites: implications for early intervention . Public Health Reports. 1995;110:47-52.

Preparado por Thomas J. Coates, PhD, Pamela DeCarlo; Traducción Romy Benard-Rodríguez Enero 1997. Hoja Informativa 20S.

Resource

Childhood sexual abuse (CSA)

How does childhood sexual abuse affect HIV prevention?

What is childhood sexual abuse?

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

Does CSA affect HIV risk?

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

What’s being done?

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

What needs to be done?

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

Says who?

1. Green AH. Overview of child sexual abuse. In SJ Kaplan (ed.), Family violence: A clinical and legal guide. Washington, DC: American Psychiatric Press. 1996;73-104. 2. Finkelhor D. The international epidemiology of child sexual abuse. Child Abuse & Neglect. 1994;18:409-417. 3. Roesler TA, McKenzie N. Effects of childhood trauma on psychological functioning in adults sexually abused as children. Journal of Nervous and Mental Disease. 1994;182:145-150. 4. Prillo KM, Freeman RC, Collier C, et al. Association between early sexual abuse and adult HIV-risky behaviors among community-recruited women. Child Abuse & Neglect. 2001;25:335-346. 5. Paul, J. Understanding childhood sexual abuse as a predictor of sexual risk-taking among men who have sex with men: The Urban Men’s Health Study. Child Abuse & Neglect. 2001;125:557-584. 6. Watkins B, Bentovim A. The sexual abuse of male children and adolescents: a review of current research. Journal of Child Psychology & Psychiatry & Allied Disciplines. 1992;33:197–248. 7. Wyatt GE, Guthrie D, Notgrass CM. Differential effects of women’s child sexual abuse and subsequent revictimization. Journal of Consulting and Clinical Psychology. 1992;60:167-173. 8. Morrill AC, Kasten L, Urato M, et al. Abuse, addiction and depression as pathways to sexual risk in women and men with a history of substance use. Journal of Substance Abuse. 2001;13:169-184. 9. Wyatt GE, Myers HF, Williams JK, et al. Does a history of trauma contribute to HIV risk for women of color? Implications for prevention and policy. American Journal of Public Health. 2002;92:1-7. 10. Harvey P, Forehand R, Brown C, et al. The prevention of sexual abuse: Examination of the effectiveness of a program with kindergarten-age children. Behavior Therapy. 1988;19:429-435. 11. Squires J, Persaud DI, Graper JK. HIV and STD prevention counseling for adolescent girls seen in a child abuse clinic. Presented at the 14th International AIDS Conference, Barcelona, Spain. 2002. Abst # TuPeF5249. 12. Group Interventions to Prevent HIV in High Risk Women.www.med.stanford.edu/school/ Psychiatry/PSTreatLab/TraumaStudy.php 13. Mills R, Samuels KD, Bob-Semple N, et al. Breakin the cycle: multigenerational dysfunction in families affected with HIV/AIDS. Presented at the 14th International AIDS Conference, Barcelona, Spain. 2002. Abst #. ThPeE7828. 14. Wyatt GE, Myers H, Longshore D, et al. Examining the effects of trauma on HIV risk reduction: the women’s health intervention. Presented at the International Conference on AIDS, Barcelona, Spain. 2002. Abst# WePeF6853. 15. Paul JP. Coerced childhood sexual episodes and adult HIV prevention. FOCUS. 2003;18:1-4
Prepared by Gail Wyatt PhD, Tamra Loeb PhD, Inna Rivkin PhD, Jennifer Carmona PhD, Dorothy Chin PhD, John Williams MD, Hector Myers PhD, Douglas Longshore PhD and Charlotte Sykora PhD UCLA Women’s Health Project September 2003. Fact Sheet #52E Special thanks to the following reviewers of this Fact Sheet: Ruth Kelley, Jay Paul, Elizabeth Radhert.
Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © September 2003, University of California
Resource

Abuso sexual infantil

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

¿qué es el abuso sexual infantil?

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

¿afecta el riesgo de contraer el VIH?

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

¿qué se está haciendo al respecto?

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

¿qué queda por hacer?

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

¿quien lo dice?

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

HIV/STD/unintended pregnancy

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

Why is it important?

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

Do STDs affect HIV?

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

Are STD and HIV prevention connected?

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

What’s working?

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

What still needs to be done?

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

Says who?

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

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

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

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

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

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

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

December 1997. Fact Sheet #31E

Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Francisco should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National AIDS Clearinghouse at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © December 1997, University of California