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Adolescents

What Are Adolescents’ HIV Prevention Needs?

Can adolescents get HIV?

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

What puts adolescents at risk?

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

Can education help?

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

Are schools the only answer?

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

What needs to be done?

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

Says who?

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

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

April 1999. Fact Sheet #9ER

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

Resource

Adolescentes

¿Qué necesitan los adolescentes en la prevención del VIH?

¿pueden contraer los adolescentes el VIH?

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

¿cómo se exponen al riesgo?

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

¿puede ayudar la educación?

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

¿sólo en la escuela se encuentra la solución?

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

¿qué queda por hacer?

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

¿quién lo dice?

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

Septiembre 1999. Hoja Informativa 9SR.

Resource

Family

What is the role of the family in HIV prevention?

Why families?

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

How do families affect risk behavior?

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

W hat puts families at risk?

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

What’s being done?

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

What still needs to be done?

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

Says who?

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

Resource

Familia

¿Cuál es el papel de la familia en la prevención del VIH?

¿por qué la familia?

La familia tiene una gran influencia sobre los individuos que puede durar toda la vida. Incluso aquellos que ya no mantienen contacto con su familia, o que nunca lo tuvieron, también están afectados por su ausencia. La mitad de todas las personas con VIH se infectó durante la adolescencia o al entrar en la edad adulta (entre los 15 y 24 años). Las intervenciones dirigidas a las familias lo antes posible en la vida de los niños ayudan a asentar prácticas y relaciones saludables que los mantienen alejados de los riesgos. Para los fines de esta hoja informativa, la familia se define como aquellos individuos con quienes la persona haya crecido: el padre, la madre, los tíos, las tías, los primos, los abuelos o los padres de crianza temporal. Muchas familias también tienen lazos fuertes con la comunidad, la cual se convierte en otra influencia poderosa. No comentaremos sobre las familias de elección, tales como las redes sociales íntimas.

¿cómo influye la familia?

La estructura familiar ayuda a la familia, y particularmente a los hijos, a protegerse de conductas riesgosas sexuales y de consumo de drogas. La unidad familiar y la comunicación entre padres e hijos son fundamentales para asegurar conductas saludables.¹ Asimismo, cuando existe poca unidad familiar y poca confianza para hablar con los adultos en su vida, los jóvenes están más propensos a participar en actividades riesgosas. Los adolescentes que se sienten unidos a su familia y perciben que sus padres están atentos a sus necesidades tienden a postergar la iniciación sexual, a protegerse contra el embarazo y a tener menos embarazos e hijos.^2,3 Dos aspectos clave de la paternidad que influyen en la conducta de los adolescentes son la convicción de que sus padres saben con quiénes andan y adónde van cuando no están en la escuela o en casa.¹ Los jóvenes homosexuales pueden tener muchas dificultades para revelar su identidad si sus familias tienen fuertes creencias religiosas que acentúan la importancia del matrimonio y la reproducción. Los jovencitos pueden temer que sus padres se avergüencen de tener un hijo homosexual o que se decepcionen si no se casan y tienen hijos.⁴ Esto puede conducir a la interiorización del sentimiento de vergüenza y a la disminución del amor propio, lo cual contribuye a las prácticas arriesgadas. Un niño que crece en una familia en la cual el estrés, el alcoholismo, el uso de drogas y la violencia doméstica son habituales puede repetir estos comportamientos al llegar a la edad adulta. Muchos alcohólicos y usuarios de drogas tienen antecedentes familiares de alcoholismo y drogadicción, así como altos niveles de violencia doméstica. Además, a veces son los familiares mismos quienes ofrecen a los jóvenes la primera fumada de marihuana, el primer trago de alcohol o la primera inyección de drogas.⁵ El maltrato físico, el abuso sexual y el descuido muchas veces llevan a prácticas sexuales riesgosas y al uso de drogas durante la adolescencia y la edad adulta. Un estudio de personas que abandonaron el mantenimiento con metadona encontró que durante su niñez el 36% fueron víctimas de abuso sexual, el 60% de maltrato físico, el 57% de maltrato emocional, el 66% de descuido y el 25% de las cuatro experiencias. Las personas con antecedentes de maltrato durante la niñez reportaron un mayor número de parejas sexuales y aquellas que fueron descuidadas tenían más probabilidades de ser VIH positivas.⁶

¿qué pone a las familias en riesgo?

Con frecuencia, las familias que tienen problemas producen niños con problemas. La tensión emocional, la pobreza, la violencia y el abuso de drogas en la familia disminuyen la unidad, comunicación y tolerancia entre la familia. Consecuentemente, estos jóvenes sufren más maltrato y descuido, y participan más en prácticas riesgosas sexuales y de uso de drogas. Los barrios en donde hay pocas oportunidades de trabajo y altos niveles de consumo de drogas y violencia perjudican la conducta sexual de los jóvenes.⁷ El trabajo y el cansancio debido al exceso de trabajo pueden tener un efecto considerable sobre la vida familiar. En todos los niveles económicos, el estrés laboral debilita la unidad y comunicación familiar. Cuando los padres trabajan jornadas largas y se sienten abrumados por el trabajo, no tienen tiempo para sí mismos ni para su familia.⁸

¿qué se está haciendo al respecto?

El Collaborative HIV Prevention and Adolescent Mental Health Project es una intervención centrada en la familia, concretamente en las necesidades de los jóvenes afroamericanos y sus familias que viven en barrios urbanos con altas tasas de infección por VIH. El programa busca 1) abordar temas sobre conducta preadolescente, 2) concentrarse en factores relacionados con el niño, los padres y la familia y 3) emplear métodos que tomen en cuenta e involucren a la familia para reducir las altas tasas de infección por VIH. El programa ofrece grupos familiares, servicios para adolescentes y preadolescentes y enfatiza la importancia de la colaboración comunitaria.⁹ Family to Family es una intervención estructural que fortalece la función de la familia y los lazos familiares. Diseñado para responder a una amplia gama de problemas sociales, el programa busca aumentar la comunicación familiar en una comunidad con altas tasas de violencia, abuso de drogas e infección por VIH. Por medio de grupos familiares y orientación sobre cómo afrontar los retos de la vida, el programa abarca temas como el perdón, la comunicación, la responsabilidad, el trabajo en equipo, las tradiciones familiares y el manejo del hogar.¹⁰ Mientras que muchas escuelas y organizaciones comunitarias han empezado a ofrecer programas de reducción de daños para jóvenes gay/lesbianas/bisexuales/transexuales, existen pocos servicios que ayuden a sus padres. Grupos como Parents, Families & Friends of Lesbians & Gays (PFLAG) les ofrecen apoyo y orientación.¹¹ En San Francisco, CA, una coalición de organizaciones que sirven a hombres latinos gay y bisexuales lanzó una campaña en los medios de comunicación sobre la unidad familiar. Al investigar sobre el tema, la coalición encontró que las mujeres fueron identificadas de manera abrumadora como fuentes de apoyo: madres, hermanas, tías y primas. La campaña, “Las familias cambian, las familias crecen”, empleó carteles que mostraban a una madre que abraza al novio de su hijo, con el título: “Mamá conoció a mi novio, así que ya hay lugar para él también.”¹² Keepin’ it R.E.A.L.!, un programa para adolescentes y sus madres, aumenta los conocimientos de los padres sobre el VIH y la sexualidad así como su confianza para comentar estos temas con sus hijos. El programa brindó a las madres y a los jóvenes oportunidades de convivencia y acercamiento. Las madres también pudieron platicar unas con otras, y después del programa estaban más propensas a entablar una conversación con sus hijos adolescentes sobre el sexo.¹³ Las tareas escolares que piden que los estudiantes hablen con sus padres sobre temas sexuales pueden producir buenos resultados. Las tareas, que son obligatorias, permiten que los padres tengan la conversación con sus hijos sin tener que salir de casa.¹⁴

¿qué queda por hacer?

Aunque muchos programas de prevención del VIH reconocen que las familias juegan un papel importante con respecto a las prácticas riesgosas, pocos ofrecen intervenciones para familias. Además de apoyar a las personas que ya practican conductas arriesgadas, los programas deben apoyar a las familias para impedir las causas subyacentes que llevan a los adolescentes a ponerse en riesgo. Para establecer la comunicación abierta y solidificar la unión familiar, es necesario poner atención especial en alentar a los jóvenes gays y lesbianas a hablar sobre su sexualidad, especialmente en aquellas familias con fuertes creencias sobre la importancia del matrimonio y la reproducción. Se prohíbe a los homosexuales y lesbianas casarse; no todos desean tener hijos y frecuentemente se les prohíbe adoptarlos. Las instituciones comunitarias como las iglesias y las escuelas pueden colaborar con los programas de prevención para conscientizar a sus miembros e inculcarles la tolerancia y la aceptación de identidades sexuales no tradicionales. Con demasiada frecuencia, las mismas comunidades que han sido más afectadas por el uso de drogas, la delincuencia y la pobreza también tienen las mayores tasas de VIH y los menores niveles de apoyo familiar y comunitario. No obstante, las influencias externas negativas muchas veces se pueden superar con la ayuda de una familia unida. Se necesitan programas que fortalezcan a las familias, centros para padres de familia y líneas de ayuda telefónica, así como actividades recreativas y centros comunitarios con supervisión adecuada para que los padres sepan que sus hijos están protegidos cuando están fuera de la casa.

¿quién lo dice?

1. DiClemente RJ, Wingood GM, Crosby R, et al. Parental monitoring: Association with adolescents’ risk behaviors. Pediatrics. 2001;107:1363-1368. 2. Resnick MD, Bearman PS, Blum RW, et al. Protecting adolescents from harm: Findings from the National Longitudinal Study on Adolescent Health. Journal of the American Medical Association. 1997; 278:823-32. 3. Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy, Washington, DC: National Campaign to Prevent Teen Pregnancy, 2001. https://www.tandfonline.com/doi/abs/10.1080/19325037.2001.10603497  4. Newman BS, Muzzonigro PG. The effects of traditional family values on the coming out process of gay male adolescents. Adolescence.1993;28:213-216. 5. Hampton RL, Senatore V, Gullotta TP, editors. Substance abuse, family violence and child welfare. Thousand Oaks, CA: Sage Publications; 1998. 6. Kang SY, Deren S, Goldstein MF. Relationships between childhood abuse and neglect experience and HIV risk behaviors among methadone treatment drop-outs. Child Abuse and Neglect. 2002;26:1275-1289. 7. Averett SL, Rees D, Argys LM. The impact of government policies and neighborhood characteristics on teenage sexual activity and contraceptive use.American Journal of Public Health. 2002; 92:1773-1778. 8. Gallinsky, E. Ask the children: A breakthrough study that reveals how to succeed at work and parenting. Quill Publications. 2000. 9. Madison SM, McKay MM, Paikoff R, et al. Basic research and community collaboration: Necessary ingredients for the development of a family-based HIV prevention program. AIDS Education and Prevention. 2000;12:281. 10. Fullilove RE, Green L, Fullilove MT. The Family to Family program: A structural intervention with implications for the prevention of HIV/AIDS and other community epidemics. AIDS. 2000;14S1:S63-S67. 11. PFLAG. www.pflag.org 12. Freedman B. Great HIV prevention campaigns are not just born. CAPS Exchange. 2000. prevention.ucsf.edu/uploads/CEsummer2000.pdf 13. DiIorio C, Resnicow K, Dudley WN, et al. Social cognitive factors associated with mother-adolescent communication about sex. Health Communications.2000;5:41-51. 14. Kirby D, Miller BC. Interventions designed to promote parent-teen communication about sexuality. New Directions for Child and Adolescent Development. 2002;97:93-110.

Preparado por Lesley Green*, Bob Fullilove*, Pamela DeCarlo** *Community Research Group, Columbia University, **CAPS Traducción Rocky Schnaath Septiembre 2003. Hoja Informativa 49S

Resource

Parents and children

Why is communication important?

Sexual activity begins early for many teens. Almost four of ten (37%) 9th graders have had intercourse, and nearly seven of ten (66%) have had intercourse by 12th grade.¹ Every year three million teens, or almost a quarter (1 out of 4) of all sexually experienced teens, will contract a sexually transmitted disease (STD). Chlamydia is more common among teens than among older men and women, and teens have higher rates of gonorrhea than men and women aged 20-44.² The HIV epidemic in the US is increasingly becoming an epidemic of the young. One fourth of all new HIV infections in the US occur in people under the age of 22, and one half of all new infections occur in people under age 25.³

“I want my daughter to be prepared [for sex and puberty]. I was taken by surprise.” Parent

In spite of these staggering statistics, many parents are unaware of or in denial about their children’s sexual experience. A study of mothers and their adolescent children found that 70% of the mothers believed their sons were virgins, but only 44% of sons actually were (had not yet engaged in sexual intercourse). With daughters, 82% of mothers thought they were virgins, and only 70% of daughters actually were.⁴

Are parents and their kids talking?

Unfortunately, not enough. A survey of pre-adolescents and their parents in a high HIV seroprevalence neighborhood found that parents overestimate how much they talk about HIV. Kids remembered less than one-fourth of HIV discussions parents said occurred. They were most likely to remember talks with the parent that were private.⁵ Parents often think they’re talking to their kids about AIDS, but may be discussing medical facts and not necessarily sexuality or safer sex. A national survey found that mothers of children aged 11 and older rated themselves “unsatisfactory” on talking about issues such as: how to tell when youth are ready to be sexually active (38%), preventing HIV (40%), sexual orientation (47%) and how to use a condom (73%).⁶

“I think it’s sad I can’t talk to my mom about it-but it’s her loss. I can always go other places. I think that is a lot of the problem, because when you go `other places’ sometimes you get the wrong information.” Teen

What is the role of parents?

Parents can influence their children’s actions. At-risk youth in five cities took part in an HIV prevention marketing initiative. They reported that parents exerted substantial influence on sexual behavior in three ways: by communicating with them, by acting as role models and by providing direct supervision.⁷ Contrary to popular opinion, children do look to their parents for guidance. Kids often want to talk to their parents about HIV-related issues, but may find it difficult to do so.⁸ Kids may worry that parents’ disapproval and fears will prevent honest discussion, or that parents lack correct information about HIV.

“I want my boys to be respectful of others and learn to develop a relationship with a person before having sex with them.” Parent

Children learn from parents by watching what they do as well as hearing what they say. Whether parents answer, don’t answer, or get angry at children's questions can show children how to deal with difficult issues. Discussions about healthy relationships should start early and grow more sophisticated as children mature. Early talks with young children about naming body parts accurately, learning how to say no, and taking health precautions can set the stage for later education in HIV prevention and sexuality.

What are barriers to communication?

Talking about issues of sexuality with their children can be a difficult experience for many adults. When many of today’s adults were children, their parents didn’t talk about sexuality and other topics with them. Today’s parents may want to take a different approach with their own children, but have no experience to guide them.

“We didn’t talk about these things when we grew up so I’m not always used to it. I try, and I laugh…the kids are more comfortable with [talking about sex] than I am.” Parent

Youth need to carve out their own autonomy during adolescence. As young people begin to separate from their parents, they may be more resistant to parental advice. Parents may have unfounded concerns about talking to their kids, such as the fear that talking about sex will increase curiosity and cause them to experiment prematurely, or that giving information about birth control is a green light for kids to have intercourse. Some parents fear that talking about homosexuality might influence a child’s sexual orientation. In fact, open discussion with parents can help postpone sexual activity, protect from risky behavior and support the healthy sexual socialization of youth.⁹

What’s working?

In Los Angeles, CA, a program addressing newly arrived immigrant parents found that involving churches and health providers, providing culturally sensitive presenters in the parents’ language, and scheduling meetings during the evenings all helped to attract parents to meetings.¹⁰ Parenting and communicating classes often attract more parents than classes specifically addressing HIV, especially in religious communities. Peer education among parents has been effective. “Talking With Kids About AIDS” trains volunteers to conduct workshops with parents and guardians in a variety of community settings. Parents learn about HIV, practice communication and risk reduction skills and complete homework assignments to discuss HIV with their children. The program significantly enhances parents’ ability to initiate talks with their children.¹¹

“Parents need to inform and guide (and get involved) with their kids more! I think it will help tremendously.” Teen

In Virginia, parent educators were trained to lead HIV information programs for parents of elementary, middle and high school students. These parents also served as resource persons for their community. Word-of-mouth recommendations from parents have been effective in attracting other parents. Parent participants reported they were more likely to talk to their children about HIV/AIDS if they felt knowledgeable on the subject.¹² The Fast Road/El Camino Rapido is a training program for migrant families and educators to help families discuss healthy relationships, practice communication skills, and focus on HIV prevention. The program uses cartoon videos in English and Spanish and drawings with bubbles for spoken words and thoughts. Parents work with other parents and with their children to fill in the blanks and help stimulate discussion.

What needs to be done?

Parent-child communication often has not been a focus of HIV prevention efforts. However, programs that involve all family members, children and adults, in educating about sexuality, values and family life, can be very effective. Programs that are most effective must involve parents and youth in program design and staffing. A comprehensive HIV prevention strategy uses many elements to protect as many people at risk for HIV as possible. Given what is at stake, family members and prevention educators must work together to ensure the future health and safety of our children.

Says who?

1. Centers for Disease Control and Prevention. Youth risk behavior surveillance-United States 1995 . Morbidity and Mortality Weekly Report. 1996;45:64. 2. Eng TR, Butler WT, eds. The Hidden Epidemic: Confronting Sexually Transmitted Diseases . Washington, DC: National Academy Press; 1996. 3. Rosenberg PS, Biggar RJ, Goedert JJ. Declining age at HIV infection in the United States (letter). New England Journal of Medicine. 1994;330:789-790. Miller K. Data from the Family adolescent risk behavior and communication study. Personal communication, Centers for Disease Control and Prevention; 1997. Krauss BJ, Goldsamt L, Pierre-Louis M. How pre-adolescents and their parents talk about HIV in a high HIV seroprevalence neighborhood. Presented at the 11th International Conference on AIDS, Vancouver BC. 1997. Abstract ThD4878. Mothers’ Voices. Mothers speak out on preventing and curing AIDS. Survey conducted by EDK Associates. 1997. Kennedy MG, Bye L, Rosenbaum J, et al. Focus group theme that will shape participatory social marketing interventions in 5 cities. Presented at the 11th International Conference on AIDS, Vancouver BC. 1997. Abstract TuD2882. Heft L, Faigeles B, Hall TL. Where are the parents in HIV education? Adolescents want their parents to talk about HIV. Presented at the 11th International Conference on AIDS, Vancouver BC. 1997. Abstract ThC4431.

Contact: Lisa Heft (415) 487-8088.

Leland NL, Barth RP. Characteristics of adolescents who have attempted to avoid HIV and who have communicated with parents about sex. Journal of Adolescent Research. 1993;8:58-76. Baker C, Rich R, Wulf K. Strategies to involve newly-arrived immigrant parents in HIV education. Presented at the 11th International Conference on AIDS, Vancouver BC. 1997. Abstract TuD2794.

Contact: Claudia Baker (213) 625-6429.

Tiffany J. HIV/AIDS education for parents and guardians: talking with kids about AIDS. Presented at the 9th International Conference on AIDS, Berlin, Germany. 1993. Abstract PO-D13-3716.

Contact: Jennifer Tiffany (607) 255-1942.

Rankin DL. When “just say no” isn’t enough: parents educating parents about AIDS. Presented at the National Conference on Women and HIV, Los Angeles, CA. 1997. Abstract P2.37.

Contact: Daphne Long Rankin (804) 828-2210.

Parent/Child Resources: Advocates for Youth 1025 Vermont Avenue NW Washington, DC 20005 (202) 347-5700 https://advocatesforyouth.org/ American Red Cross AIDS Education Office 8111 Gate-house Road Falls Church, VA 22042 http://www.redcross.org Mothers’ Voices 165 West 46th Street, Suite 701 New York, NY 10036 (888) MVOICES http://www.mvoices.org Planned Parenthood (800) 230-7526 http://www.igc.apc.org/ ppfa/ Sexuality Information and Education Council of the US 130 West 42nd Street, Suite 350 New York, NY 10036 (212) 819-9770 http://www.siecus.org

Prepared by Lisa Heft*, Ann Kurth**, Pamela DeCarlo*** *San Francisco AIDS Foundation, **Mothers’ Voices, ***CAPS September 1997. Fact Sheet #28E

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

Library

Adolescents

What Are Adolescents’ HIV Prevention Needs?

Can adolescents get HIV?

What puts adolescents at risk?

Can education help?

Are schools the only answer?

What needs to be done?

Says who?

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

Adolescentes

¿Qué necesitan los adolescentes en la prevención del VIH?

¿pueden contraer los adolescentes el VIH?

¿cómo se exponen al riesgo?

¿puede ayudar la educación?

¿sólo en la escuela se encuentra la solución?

¿qué queda por hacer?

¿quién lo dice?

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

Family

What is the role of the family in HIV prevention?

Why families?

How do families affect risk behavior?

W hat puts families at risk?

What’s being done?

What still needs to be done?

Says who?

Familia

¿Cuál es el papel de la familia en la prevención del VIH?

¿por qué la familia?

¿cómo influye la familia?

¿qué pone a las familias en riesgo?

¿qué se está haciendo al respecto?

¿qué queda por hacer?

¿quién lo dice?

Parents and children

Why is communication important?

Are parents and their kids talking?

What is the role of parents?

What are barriers to communication?

What’s working?

What needs to be done?

Says who?

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

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