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Internet

How does the Internet affect HIV prevention?

why the Internet?

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

does the Internet contribute to risk?

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

can the Internet help in prevention?

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

what’s being done?

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

what needs to be done?

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

Says who?

1. Chiasson MA, Parsons JT, Tesoriero JM, et al. HIV behavioral research online.Journal of Urban Health. 2006;83:73-85. 2. Madden M, Lenhart A. Online dating. Report prepared by the Pew Internet and American Life Project. March 2006. 3. Liau A, Millett G, Marks G. Meta-analytic examination of online sex-seeking and sexual risk behavior among men who have sex with men. Sexually Transmitted Diseases. 2006;33:576-584. 4. Rebchook G, Curotto A, Kegeles S. Exploring the sexual behavior and Internet use of chatroom-using men who have sex with men through qualitative and quantitative research. Presented at the 2003 National HIV Prevention Conference, Atlanta, GA. 5. McFarlane M, Bull SS, Rietmeijer CA. The Internet as a newly emerging risk environment for sexually transmitted diseases. Journal of the American Medical Association. 2000;284:443-446. 6. Klausner JD, Wolf W, Fischer-Ponce L, et al. Tracing a syphilis outbreak through cyberspace. Journal of the American Medical Association. 2000;284:447-449. 7. Tashima K, Alt E, Harwell J, et al. Internet sex-seeking leads to acute HIV infection: a report of two cases. International Journal of STD and AIDS. 2003;14:285-286. 8. Bolding G, Davis M, Hart G, et al. Gay men who look for sex on the Internet: is there more HIV/STI risk with online partners? AIDS. 2005;19:961-968. 9. McKirnan D, Houston E, Tolou-Shams M. Is the Web the culprit? Cognitive escape and Internet sexual risk among gay and bisexual men. AIDS and Behavior. 2006. 10. Wohlfeiler D, Potterat JJ. Using gay men’s sexual networks to reduce sexually transmitted disease (STD)/human immunodeficiency virus (HIV) transmission. Sexually Transmitted Diseases. 2005;32:S48-52. 11. Carballo-Dieguez A, Miner M, Dolezal C, et al. Sexual negotiation, HIV-status disclosure, and sexual risk behavior among Latino men who use the internet to seek sex with other men. Archives of Sexual Behavior. 2006;35:473-481. 12. Davis M, Hart G, Bolding G, et al. Sex and the Internet: gay men, risk reduction and serostatus. Culture, Health and Sexuality. 2006;8:161-174. 13. Curotto A, Rebchook G, Kegeles S. Opening a virtual door into a vast real world: Community-based organizations are reaching out to at-risk MSM with creative, online programs. Paper presented at: STD/HIV Prevention and the Internet; August 27, 2003; Washington D.C. 14. Weldon JN. The Internet as a tool for delivering a comprehensive prevention intervention for MSM Internet sex seekers. Paper presented at: 2003 National HIV Prevention Conference; July 27-30, 2003, 2003; Atlanta, GA. depts.washington.edu/poweron/ 15. Bowen AM, Horvath K, Williams ML. A randomized control trial of Internet-delivered HIV prevention targeting rural MSM. Health Education Research. 2006.www.wrapp.net 16. Mimiaga MJ, Tetu A, Novak D, et al. Acceptability and utility of a partner notification system for sexually transmitted infection exposure using an internet-based, partner-seeking website for men who have sex with men. Presented at the International AIDS Conference, Toronto, Canada. 2006. Abstr #THPDC02. 17. Klausner JD, Levine DK, Kent CK. Internet-based site-specific interventions for syphilis prevention among gay and bisexual men. AIDS Care, 2004;16:964-970. 18. Levine D, Klausner JD. Lessons learned from tobacco control: A proposal for public health policy initiatives to reduce the consequences of high-risk sexual behavior among men who have sex with men and use the Internet. Sexuality Research and Social Policy. 2005;2:51-58.
Prepared by Greg Rebchook PhD, Alberto Curotto PhD, CAPS and Deb Levine, ISIS January 2007. Fact Sheet #63E Special thanks to the following reviewers of this fact sheet: Anne Bowen, Cari Courtenay-Quirk, Jonathan Elford, Charles King, Jeff Klausner, Mary McFarlane, Greg Millett, Frank Strona. Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. To receive Fact Sheets via e-mail, send an e-mail to [email protected] with the message “subscribe CAPSFS first name last name.” ©January 2007, University of CA.
Resource

Red Internet

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

¿por qué Internet?

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

¿contribuye Internet al riesgo?

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

¿puede Internet ayudar en la prevención?

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

¿qué se está haciendo al respecto?

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

¿qué queda por hacer?

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

¿Quién lo dice?

1. Chiasson MA, Parsons JT, Tesoriero JM, et al. HIV behavioral research online.Journal of Urban Health. 2006;83:73-85. 2. Madden M, Lenhart A. Online dating. Report prepared by the Pew Internet and American Life Project. March 2006. 3. Liau A, Millett G, Marks G. Meta-analytic examination of online sex-seeking and sexual risk behavior among men who have sex with men. Sexually Transmitted Diseases. 2006;33:576-584. 4. Rebchook G, Curotto A, Kegeles S. Exploring the sexual behavior and Internet use of chatroom-using men who have sex with men through qualitative and quantitative research. Presented at the 2003 National HIV Prevention Conference, Atlanta, GA. 5. McFarlane M, Bull SS, Rietmeijer CA. The Internet as a newly emerging risk environment for sexually transmitted diseases. Journal of the American Medical Association. 2000;284:443-446. 6. Klausner JD, Wolf W, Fischer-Ponce L, et al. Tracing a syphilis outbreak through cyberspace. Journal of the American Medical Association. 2000;284:447-449. 7. Tashima K, Alt E, Harwell J, et al. Internet sex-seeking leads to acute HIV infection: a report of two cases. International Journal of STD and AIDS. 2003;14:285-286. 8. Bolding G, Davis M, Hart G, et al. Gay men who look for sex on the Internet: is there more HIV/STI risk with online partners? AIDS. 2005;19:961-968. 9. McKirnan D, Houston E, Tolou-Shams M. Is the Web the culprit? Cognitive escape and Internet sexual risk among gay and bisexual men. AIDS and Behavior. 2006. 10. Wohlfeiler D, Potterat JJ. Using gay men’s sexual networks to reduce sexually transmitted disease (STD)/human immunodeficiency virus (HIV) transmission. Sexually Transmitted Diseases. 2005;32:S48-52. 11. Carballo-Dieguez A, Miner M, Dolezal C, et al. Sexual negotiation, HIV-status disclosure, and sexual risk behavior among Latino men who use the internet to seek sex with other men. Archives of Sexual Behavior. 2006;35:473-481. 12. Davis M, Hart G, Bolding G, et al. Sex and the Internet: gay men, risk reduction and serostatus. Culture, Health and Sexuality. 2006;8:161-174. 13. Curotto A, Rebchook G, Kegeles S. Opening a virtual door into a vast real world: Community-based organizations are reaching out to at-risk MSM with creative, online programs. Paper presented at: STD/HIV Prevention and the Internet; August 27, 2003; Washington D.C. 14. Weldon JN. The Internet as a tool for delivering a comprehensive prevention intervention for MSM Internet sex seekers. Paper presented at: 2003 National HIV Prevention Conference; July 27-30, 2003, 2003; Atlanta, GA. depts.washington.edu/poweron/ 15. Bowen AM, Horvath K, Williams ML. A randomized control trial of Internet-delivered HIV prevention targeting rural MSM. Health Education Research. 2006.www.wrapp.net 16. Mimiaga MJ, Tetu A, Novak D, et al. Acceptability and utility of a partner notification system for sexually transmitted infection exposure using an internet-based, partner-seeking website for men who have sex with men. Presented at the International AIDS Conference, Toronto, Canada. 2006. Abstr #THPDC02. 17. Klausner JD, Levine DK, Kent CK. Internet-based site-specific interventions for syphilis prevention among gay and bisexual men. AIDS Care, 2004;16:964-970. 18. Levine D, Klausner JD. Lessons learned from tobacco control: A proposal for public health policy initiatives to reduce the consequences of high-risk sexual behavior among men who have sex with men and use the Internet. Sexuality Research and Social Policy. 2005;2:51-58.
Preparado por Greg Rebchook PhD*, Alberto Curotto PhD* and Deb Levine** *CAPS, **ISIS Traducido por Rocky Schnaath Mayo 2007. Hoja de Dato #63S
Resource

Prisons and jails

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

Is prevention in prisons and jails important?

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

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

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

How does incarceration impact HIV risk?

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

What can be done inside?

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

What are transitional interventions?

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

What are next steps?

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

Says who?

1. PEW Center on the States. One in 31: The long reach of American corrections. March 2009. 2. West HC, Sabol WJ. Prisoners in 2007. Bureau of Justice Statistics Bulletin. 2008. 3. Maruschak L. HIV in Prisons, 2006. Bureau of Justice Statistics Bulletin. 2008. 4. Hammett TM, Harmon MP, Rhodes W. The burden of infectious disease among inmates of and releasees from US correctional facilities, 1997. American Journal of Public Health. 2002 ;92:1789-1794. 5. The Foundation for AIDS Research. HIV in correctional settings: implications for prevention and treatment policy. Issue Brief No 5, March 2008. 6. Golembeski C, Fullilove R. Criminal (in)justice in the city and its associated health consequences. American Journal of Public Health. 2005;95:1701–1706. 7. Hughes T, James Wilson D. Reentry trends in the United States. Bureau of Justice Statistics. 8. Vlahov D, Putnam S. From corrections to communities as an HIV priority. Journal of Urban Health. 2006;83:339-348. 9. Zack B, Kramer K. HIV prevention education in correctional settings. Project UNSHACKLE discussion paper. May 2008. 10. James DJ, Glaze LE. Mental health problems of prison and jail inmates. Bureau of Justice Statistics Special Report. September 2006. 11. HIV transmission among male inmates in a state prison system – Georgia, 1992-2005. Morbity and Mortality Weekly Report. 2006;55:421-426. 12. Seal DW, Margolis AD, Morrow KM, et al. Substance use and sexual behavior during incarceration among 18- to 29-year old men: prevalence and correlates.AIDS and Behavior. 2008;12:27-40. 13. Binswanger IA, Stern MF, Deyo RA, et al. Release from prison—a high risk of death for former inmates. New England Journal of Medicine. 2007;356:157-165. 14. Aral SO, Adimora AA, Fenton KA. Understanding and responding to disparities in HIV and other sexually transmitted infections in African Americans. Lancet. 2008;372:337-340. 15. Freudenberg N. Jails, prisons, and the health of urban populations: a review of the impact of the correctional system on community health. Journal of Urban Health. 2001;78:214-235. 16. World Health Organization. Mental health and prisons. 2005. 17. Tomasino V, Swanson AJ, Nolan J, et al. The Key Extended Entry Program (KEEP): A methadone treatment program for opiate-dependent inmates. The Mount Sinai Journal of Medicine. 2001;68:14-20. 18. Second Chance Act. 19. Wolitski RJ, The Project START study group. Relative efficacy of a multi-session sexual risk-reduction intervention for young men released from prison in 4 states. American Journal of Public Health. 2006;96:1845-1861. 20. Zaller ND, Holmes L, Dyl AC, et al. Linkage to treatment and supportive services among HIV-positive ex-offenders in Project Bridge. Journal of Health Care for the Poor and Underserved. 2008;19:522-531. 21. Jürgens R, Ball A, Verster A. Interventions to reduce HIV transmission related to injecting drug use in prison. Lancet Infectious Diseases. 2009;9:57-66.
Prepared by Barry Zack MPH and Katie Kramer MSW/MPH, The Bridging Group LLC March 2009. Fact Sheet #13R Special thanks to the following reviewers of this Fact Sheet: Tim Flanigan, Nick Freudenberg, Robert Fullilove, Robert Greifinger, Ted Hammett, Bob Hogg, Ralf Jürgens, Beth Justiniano, James Learned, Robin MacGowan, Alex Margolis, Dan O’Connell, Anthony Papa, Robin Pollini, Hugh Potter, Cristine Rodriguez, David Seal, Dan Wohlfeiler, Jeanne Woodford. Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. To receive Fact Sheets via e-mail, send an e-mail to [email protected] with the message “subscribe CAPSFS first name last name.” ©March 2009, University of CA.
Resource

Prisiones

¿Cuál es el papel de las prisiones y cárceles en la prevención del VIH?

¿Es importante hacer prevención en las prisiones y cárceles? Definitivamente. EE.UU. tiene la mayor proporción de personas encarceladas del mundo y la cifra sigue en aumento.1 En el 2007 las instituciones correccionales estatales, federales y locales alojaban a 2.4 millones de reclusos.2 Por primera vez más de uno de cada 100 adultos en EE.UU. se encuentra encarcelado.3 En comparación con la población general, los reclusos padecen más enfermedades y problemas de salud; sus tasas de VIH son 2 1/2 veces mayores. En cualquier año dado, un 25% de todas las personas VIH+ en EE.UU. pasa por una institución correccional.4 Las personas encarceladas también tienen tasas más altas de ITS, tuberculosis y hepatitis viral, abuso de alcohol y drogas y enfermedad mental.5 Estas altas tasas de infección en las prisiones y cárceles estadounidenses reflejan el hecho de que la mayoría de los reclusos provienen de zonas pobres y marginadas con poco acceso a servicios de prevención y tratamiento6 y con tasas altas de VIH, ITS y otras enfermedades infecciosas. Los sistemas de justicia penal y de salud pública pueden colaborar para brindar servicios de prevención y tratamiento integrales dentro de estas instituciones y en la comunidad. El encarcelamiento les presenta una ventana de oportunidad para la realización de servicios primarios de prevención, detección y tratamiento así como el establecimiento de enlaces oportunos que faciliten la transición para reclusos con fecha de salida cercana. ¿Cuál es la conexión entre las prisiones/cárceles y la comunidad con respecto al VIH? Por lo menos el 95% de los presos regresa a la comunidad en algún momento.7 El impacto del encarcelamiento y de la enfermedad no se limita a los hombres y mujeres tras las rejas, sino que también repercute en su familias, parejas y comunidades. Se cree erróneamente que el VIH se adquiere en la cárcel o prisión, pero en realidad casi todas las personas VIH+ se infectaron antes de entrar al sistema de justicia penal.8,9 Las personas con antecedentes de enfermedad mental, trauma o abuso físico y sexual, y que no disponen de acceso a servicios de salud mental, pueden auto medicarse con alcohol o drogas. Esta combinación propicia conductas que puedan llevar tanto a la infección por VIH como al encarcelamiento. El 45-65% de los reclusos tiene un diagnóstico de salud mental y hasta el 75% consume drogas o alcohol.10 ¿Cuál es el efecto del encarcelamiento sobre el riesgo de contraer el VIH? Los reclusos pueden tener conductas riesgosas antes, durante y después de ser encarcelados. No obstante, la conducta durante el encarcelamiento puede conllevar un mayor riesgo si no tienen acceso a condónes, jeringas limpias y otras formas de prevención. La actividad sexual (tanto consensual como por coerción), el consumo de alcohol y drogas, la inyección de drogas y el tatuaje pueden poner a los individuos en riesgo de contraer el VIH, otras ITS y la hepatitis viral.11 Un estudio con hombres jóvenes encontró que durante su encarcelamiento el 50% había consumido drogas/alcohol y el 17% había aceptado tener relaciones sexuales con hombres o mujeres.12 La salida de un entorno correccional y el regreso a la comunidad puede ser una etapa de transición estresante que muchas veces conlleva riesgos mayores que el propio encarcelamiento. Los reclusos recién liberados pueden festejar participando en conductas que aumentan su riesgo de contraer el VIH, como beber, drogarse y tener relaciones sexuales. En el estado de Washington un estudio de personas con historial de encarcelamiento encontró un alto riesgo de sobredosis de drogas durante las dos semanas siguientes a su puesta en libertad.13 Existe la percepción errónea de los hombres encarcelados como los responsables de aumentar las tasas de VIH/ITS. El encarcelamiento sí afecta las tasas de VIH/ITS en la comunidad, pero no porque los hombres contraigan estas enfermedades durante el encierro y posteriormente infecten a sus parejas sexuales femeninas cuando son liberados. En cambio, el encarcelamiento disminuye el número de hombres en la comunidad, lo cual perturba las relaciones de pareja estables, altera la proporción hombre-mujer y da lugar a relaciones de pareja concurrentes, o solapadas, de alto riesgo.14 ¿Qué se puede hacer desde adentro? A lo largo de EE.UU. muchas organizaciones de prevención del VIH y departamentos de salud pública colaboran con el sistema de justicia penal para fortalecer la salud de las personas encarceladas y la de sus comunidades. Las organizaciones pueden ofrecer: programas de pares para la prevención, incluyendo la prevención para personas positivas; reducción de daños; atención médica de alta calidad; tratamiento contra el VIH/ITS; tratamientos para la enfermedad mental y la cesación de alcohol y drogas; enlaces a servicios comunitarios previa liberación y ayuda posterior para reintegrarse en la comunidad.10,15 Consejería, pruebas y tratamiento para VIH/ITS/hepatitis/tuberculosis. El encarcelamiento puede ser una oportunidad para ofrecer pruebas de detección y tratamiento a un grupo de individuos con conductas de alto riesgo. Es importante incluir consejería integral previa a la prueba (con un proceso de consentimiento que describa las implicaciones de un resultado positivo o negativo), ya que éstos pueden tener consecuencias dentro de los centros de encarcelamiento, como la limitación de sus opciones de alojamiento, trabajo y privilegios de visita. También se debe proveer tratamiento para los que salgan positivos y orientación sobre la prevención para todos ya sea que resulten VIH positivos o negativos. Tratamiento de salud mental. Las personas encarceladas tienen altas tasas de enfermedad mental. El aglomeramiento, la violencia, el aislamiento otras condiciones de los entornos correccionales perjudican la salud mental. Las prisiones y cárceles pueden ayudar brindando valoraciones clínicas y tratamientos eficaces. Se debe remitir a las personas con trastornos mentales que han cometido delitos menores a servicios de salud mental antes o en lugar de la prisión o cárcel.16 Tratamiento integral contra el abuso de alcohol y drogas. Aunque muchas cárceles y prisiones estadounidenses ofrecen desintoxicación, consejería de profesionales y de pares, grupos de auto ayuda y educación sobre las drogas y el alcohol, muy pocas ofrecen mantenimiento con metadona, por lo que la capacidad de servicio de los programas eficaces de tratamiento contra las drogas está muy lejos de satisfacer la necesidad. En la ciudad de Nueva York, NY, el programa KEEP brinda tratamiento con metadona durante el encarcelamiento y reserva espacios para que los individuos liberados continúen en tratamiento.17 ¿Qué son las intervenciones de transición? Las intervenciones de transición eficaces aseguran que los servicios de prevención y tratamiento proporcionados en las prisiones y cárceles tengan continuidad fuera de éstas. Al entrar en vigor la ley Second Chance Act, muchas comunidades jugarán un mayor papel en la planificación para la transición.17 El proyecto START es la única intervención del Compendium of Evidence-Based Interventions de los CDC destinada a poblaciones encarceladas. START se centra en los clientes (personas recién liberadas de una institución correccional) y les brinda una intervención de 6 sesiones con el fin de reducir su riesgo de VIH, ITS y hepatitis. Basándose en la reducción de daños, START emplea un modelo de prevención con manejo de casos y fomento de la motivación para estimular la reducción de riesgos. Las dos sesiones iniciales preceden a la puesta en libertad y las cuatro finales ocurren después de ésta. Todas incluyen coordinación de remisiones a servicios de vivienda, empleo, desintoxicación de drogas/alcohol, salud mental, jurídicos y prevención de futuros encarcelamientos. START tuvo eficacia para reducir las relaciones sexuales sin protección con jóvenes recién liberados de prisión.18 El proyecto Bridge en Providence, RI, ofrece manejo intensivo de casos para personas VIH+ que salen de la cárcel estatal, quienes son atendidos por un trabajador social y un promotor de salud durante 18 meses. Los participantes se reúnen con ellos una vez por semana durante 12 semanas, luego una vez al mes como mínimo. El proyecto Bridge ha logrado ayudar a personas VIH+ a conseguir y a mantener servicios primordiales después de su puesta en libertad. La investigación ha demostrado que a pesar de tener altos niveles de adicción (el 97%) y de enfermedad mental (el 34%), los participantes recibieron atención médica posterior a su liberación (el 95%), consiguieron vivienda (el 46%) y lograron acceso a servicios de salud mental (el 71%) y de adicción (el 51%).19 ¿Qué queda por hacer? Para triunfar contra el VIH en las prisiones, cárceles y comunidades se requieren estrategias de prevención eficaces (educación por pares, acceso a condones, consejería y pruebas de VIH, etc.) junto con otras estrategias médicas y de tipo estructural que sean exitosas. Algunas estrategias estructurales que han demostrado reducción de VIH/ITS en correccionales son: programas de reducción de daños (provisión de jeringas limpias);21 tratamiento contra alcohol y drogas;17 tratamiento de salud mental;16 tratamiento contra ITS/VIH;5 planes para la transición;19,20 vivienda;5 alternativas al encarcelamiento;15 y reformas con respecto a las condenas y la libertad condicional.1 Es esencial la colaboración entre el sistema de justicia penal (prisión, cárcel, libertad a prueba y condena condicional) y el sistema comunitario de salud pública (servicios sociales y de salud, programas de tratamiento, etc.), y existen varios modelos eficaces. Los programas conjuntos pueden ayudar a resolver problemas de salud pública al tiempo que entienden los retos de priorización de la seguridad y custodia públicas. Si realmente pretendemos reducir las tasas de VIH, ITS y hepatitis en nuestras comunidades, nos incumbe unir fuerzas para crear un espectro continuo de servicios que mejore la prevención, la atención y el tratamiento tanto en las prisiones y cárceles como en las comunidades afectadas desproporcionadamente por el VIH.

¿Quién lo dice?

1. PEW Center on the States. One in 31: The long reach of American corrections. March 2009. 2. West HC, Sabol WJ. Prisoners in 2007. Bureau of Justice Statistics Bulletin. 2008. 3. Maruschak L. HIV in Prisons, 2006. Bureau of Justice Statistics Bulletin. 2008. 4. Hammett TM, Harmon MP, Rhodes W. The burden of infectious disease among inmates of and releasees from US correctional facilities, 1997. American Journal of Public Health. 2002 ;92:1789-1794. 5. The Foundation for AIDS Research. HIV in correctional settings: implications for prevention and treatment policy. Issue Brief No 5, March 2008. 6. Golembeski C, Fullilove R. Criminal (in)justice in the city and its associated health consequences. American Journal of Public Health. 2005;95:1701–1706. 7. Hughes T, James Wilson D. Reentry trends in the United States. Bureau of Justice Statistics. 8. Vlahov D, Putnam S. From corrections to communities as an HIV priority. Journal of Urban Health. 2006;83:339-348. 9. Zack B, Kramer K. HIV prevention education in correctional settings. Project UNSHACKLE discussion paper. May 2008. 10. James DJ, Glaze LE. Mental health problems of prison and jail inmates. Bureau of Justice Statistics Special Report. September 2006. 11. HIV transmission among male inmates in a state prison system – Georgia, 1992-2005. Morbity and Mortality Weekly Report. 2006;55:421-426. 12. Seal DW, Margolis AD, Morrow KM, et al. Substance use and sexual behavior during incarceration among 18- to 29-year old men: prevalence and correlates.AIDS and Behavior. 2008;12:27-40. 13. Binswanger IA, Stern MF, Deyo RA, et al. Release from prison—a high risk of death for former inmates. New England Journal of Medicine. 2007;356:157-165. 14. Aral SO, Adimora AA, Fenton KA. Understanding and responding to disparities in HIV and other sexually transmitted infections in African Americans. Lancet. 2008;372:337-340. 15. Freudenberg N. Jails, prisons, and the health of urban populations: a review of the impact of the correctional system on community health. Journal of Urban Health. 2001;78:214-235. 16. World Health Organization. Mental health and prisons. 2005. 17. Tomasino V, Swanson AJ, Nolan J, et al. The Key Extended Entry Program (KEEP): A methadone treatment program for opiate-dependent inmates. The Mount Sinai Journal of Medicine. 2001;68:14-20. 18. Second Chance Act. 19. Wolitski RJ, The Project START study group. Relative efficacy of a multi-session sexual risk-reduction intervention for young men released from prison in 4 states. American Journal of Public Health. 2006;96:1845-1861. 20. Zaller ND, Holmes L, Dyl AC, et al. Linkage to treatment and supportive services among HIV-positive ex-offenders in Project Bridge. Journal of Health Care for the Poor and Underserved. 2008;19:522-531. 21. Jürgens R, Ball A, Verster A. Interventions to reduce HIV transmission related to injecting drug use in prison. Lancet Infectious Diseases. 2009;9:57-66.
Una publicación del Centro de Estudios para la Prevención del SIDA (CAPS) y el Instituto de Investigaciones sobre SIDA (ARI), Universidad de California en San Francisco (UCSF). Se autoriza la reproducción (citando a UCSF) más no la venta de copias este documento. También disponibles en inglés. Para recibir las Hojas de Datos por correo electrónico escriba a [email protected] con el mensaje “subscribe CAPSFS nombre apellido” ©UCSF 2010
Resource

Rural

What are rural HIV prevention needs?

are rural populations at risk?

Over the years, rural areas, which represent roughly 20% of the US population, have consistently reported 5-8% of all US HIV cases.1 Yet certain rural areas and populations are disproportionately affected—the South and African Americans in particular. There may not be an epidemic of rural HIV/AIDS cases but there are troubling hot spots. The South comprises 68% of all AIDS cases among rural populations.2 In 2000, the rate of new AIDS diagnoses was three times higher for the South than for other rural areas in the US.3 In certain areas of the South, the rate of HIV/AIDS diagnoses is almost as high in rural areas as in urban areas.3 African American men and women represent 50% of rural AIDS cases, Whites 37%, Latinos 9% and American Indian/Alaska Natives 2%.2 African Americans and Latinos are disproportionately affected by HIV in rural areas: In the Northeast, African Americans and Latinos each represent 1% of the rural population, but 25% and 20% of the AIDS cases, respectively.3 Most rural AIDS cases (75%) occur among men.2 However, rates among rural women are increasing, particularly among African American women. Heterosexual transmission accounts for most cases among rural women, whereas injection drug use is the most common transmission category for urban women.2 Among rural men, men who have sex with men (MSM) comprise approximately 60% of rural AIDS cases and injecting drug users (IDUs) about 20%.2 In 2000, in the rural South, 28.5% of men were infected through heterosexual contact.3

what are rural challenges?

In rural areas, HIV prevention and intervention programs have lagged behind urban programs, due to stigmatization of HIV and high risk groups, geographic factors and low overall HIV rates. These three factors combine to make it difficult, financially and practically, to implement rural HIV prevention programs.4 Geographic isolation can hinder access to preventive services for rural residents who have limited access to transportation. Rugged topography and long distances between towns can mean traveling several hours for medical care or social services. This can result in services that are not tailored to specific population needs and delays in delivery of services.5 In addition, isolation can lead to difficulty finding sexual partners and might lead to riskier behaviors when sexual encounters do occur. One study found that rural men are more likely to have sex on their first date than urban men, possibly due to long travel distances and concern that the next chance may be a long time away.6 A powerful stigma remains associated with both HIV/AIDS and homosexuality. Rural MSM may avoid stigma, social hostility and expected violence by hiding their sexuality and assimilating into the heterosexual culture. Rural venues where MSM openly socialize are scarce, resulting in some men seeking sex partners in public sex environments, through the Internet and by regularly traveling to higher seroprevalence areas.4 Rural residents are more likely to live in poverty and less likely to have health insurance than urban residents.7 Without insurance, rural residents are less likely to seek medical care or social services. Rural areas have fewer healthcare providers with HIV expertise and rural HIV+ patients are less likely than urban patients to be on antiretroviral therapy.8 There is limited funding for and access to substance abuse treatment services. Poverty can also increase individual risk such as exchanging sex for money, shelter or drugs. In one study, Black women reported the most common reason for engaging in high risk behaviors was financial dependence on male partners.9

what puts rural populations at risk?

As with all populations, HIV risk depends not on where you live, but on whether you have unprotected sex or share needles with an HIV+ partner, and whether you have access to care, education and prevention services. Rates of sexual partner change and concurrent relationships (having more than one sexual partner at a time) increase the risk of transmission of HIV. A study of rural African Americans with heterosexually transmitted HIV found that more than half had multiple partners, 40% had concurrent partners and 87% believed that their partner had sex with others during their relationship. Concurrency was associated with smoking crack cocaine and incarceration of a sex partner.10 Drug abuse is often seen as an urban problem, but it poses a significant problem in rural areas, methamphetamine in particular.11 One report showed that rural youth are more likely to become substance abusers than urban youth: eighth graders in rural towns are 59% more likely than urban eighth graders to use methamphetamines.12 Substance abuse contributes to risky behaviors such as engaging in unprotected sex, having multiple partners, sharing needles or exchanging sex for drugs.

what’s being done?

The Strong African American Families (SAAF) program is a 7-week prevention intervention designed for African American mothers and their 11-year-old children in rural Georgia. SAAF sought to strengthen parenting skills that would in turn promote positive self-pride and positive sexual body image in their children to help lower their sexual risk behaviors. Mothers reported an increase in targeted parenting behaviors, which increase self pride in their children. Youth reported less intention and willingness to engage in risky behaviors, and a reduction in risky sexual behavior.13 The Wyoming Rural AIDS Prevention Project (WRAPP) piloted an Internet-based intervention for rural MSM that used conversations between an “expert” HIV+ gay man and an “inexperienced” HIV- gay man to deliver basic HIV education and behavior change strategies. The 2 modules lasted 20 minutes and featured dialogues, interactive activities and graphics. Men who participated in the intervention reported increases in knowledge, safer sex outcome expectancies and self-efficacy.14 In rural Arkansas, collaboration between a CBO, the Department of Corrections, the Health Department and Addiction Treatment and Recovery Centers, helped to identify and recruit HIV+ clients engaging in risky sexual and drug-using behaviors. These clients enrolled in the Healthy Relationships Intervention and reported decreased unprotected sex and increased disclosure to family, friends and partners.15 In Mississippi, the Mobile Medical Clinic van travels to rural areas where people are at highest risk for HIV and syphilis, specifically focusing on African Americans. So that they are not seen as the “VD van,” they offer glucose, blood pressure and cholesterol screening. Before the clinic enters a community, they arrange for a local sponsoring organization, like a church or community representative, to ensure that there is support in the community for their presence. They have partnered with local agencies to perform clinical breast exams, PAP smears and dental sealant applications in youth.16

what needs to be done?

Because resources are limited in rural areas, prevention activities need to be targeted to populations at highest risk, including women and men who have sex with men, African Americans and Latinos, young persons, and alcohol and drug users. Recent immigrants and migrant workers may also be at high risk, especially along the US/Mexico border.4 It is critical to expand and improve care for HIV+ persons in rural areas and provide prevention education in medical settings. Rural healthcare providers need better training and support on HIV clinical care, delivering prevention messages, assessing risk behavior and cultural sensitivity and confidentiality issues.

Says who?

1. Steinberg S, Fleming P. The geographic distribution of AIDS in the United States: is there a rural epidemic? Journal of Rural Health. 2000;16:11-19. 2. Centers for Disease Control and Prevention. HIV/AIDS surveillance in urban and nonurban areas. Slide set. 3. Hall HI, Li J, McKenna MT. HIV in predominantly rural areas of the United States. Journal of Rural Health. 2005;21:245-253. 4. Williams ML, Bowen AM, Horvath KJ. The social/sexual environment of gay men residing in a rural frontier state: implications for the development of HIV prevention programs. Journal of Rural Health. 2005;21:48-55. 5. Castañeda D. HIV/AIDS-related services for women and the rural community context. AIDS Care. 2000;12:549-565. 6. Horvath KJ, Bowen AM, Williams ML. Virtual and physical venues as contexts for HIV risk among rural men who have sex with men. Health Psychology. 2006;25:237-242. 7. National Rural Health Association. HIV/AIDS in rural America: Disproportionate impact on minority and multicultural populations. July 2004. *https://www.ruralhealthweb.org/getattachment/Advocate/Policy-Documents/HIVAIDSRuralAmericapolicybriefApril2014-(1).pdf.aspx 8. Cohn SE, Berk ML, Berry SH, et al. The care of HIV-infected adults in rural areas of the United States. Journal of AIDS. 2001;28:385-392. 9. HIV transmission among Black women–North Carolina, 2004. Morbidity and Mortality Weekly Report. 2005;54:89-94. *https://npin.cdc.gov/publication/mmwr-hiv-transmission-among-black-women-north-carolina-2004 10. Adimora AA, Schoenbach VJ, Martinson FEA, et al. Concurrent partnerships among rural African Americans with recently reported heterosexually transmitted HIV infection. Journal of AIDS. 2003;34:423-429. 11. Kraman P. Drug abuse in America–Rural meth. Trends Alert. March 2004. *csg-web.csg.org/pubs/Documents/TA0403RuralMeth.pdf 12. The National Center on Addiction and Substance Abuse. No place to hide: Substance abuse in mid-size cities and rural America. New York, New York: Columbia University. January 2000. https://eric.ed.gov/?id=ED443618  13. Brody GH, Murry VM, Gerrard M, et al. The Strong African American Families Program: translating research into prevention programming. https://pubmed.ncbi.nlm.nih.gov/15144493/  14. Bowen A, Horvath K, Williams M. Randomized control trial of an Internet-delivered HIV knowledge intervention with MSM. Health Education and Research. In press. *www.wrapp.net 15. Smith AJ, Gaynor H. Advancing HIV prevention in rural Arkansas. Presented at the National HIV Prevention Conference, Atlanta, GA, 2005. Abstract #M1-C1802. *https://www.cdc.gov/hiv/effective-interventions/treat/healthy-relationships?Sort=Priority%3A%3Aasc&Intervention%20Name=Healthy%20Relationships  16. Prevention in rural communities: Mississippi’s Mobile Medical Clinic. NASTAD HIV Prevention Bulletin. March 2006. *All websites accessed May 2006

Prepared by Anne Bowen PhD*, Alan Gambrell MPubAff**, Pamela DeCarlo*** *University of Wyoming, **WordPortfolio, Inc., ***CAPS May 2006 . Fact Sheet #26ER Special thanks to the following reviewers of this Fact Sheet: James Anderson, Janet Arno, Keith Bletzer, Lucy Bradley-Springer, Angeline Bushy, Irene Hall, Rachel Kachur, Bronwen Lichtenstein, Deborah Preston, David Seal, Dale Stratford, Craig Thompson, Mohammad Torabi, Eric Wright. 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]. © May 2006, University of California