Prevention with Positives

Introduction

The Benefits of Prevention with Positives

Most HIV-infected youth want to know how to avoid transmitting the virus to others. They also want to protect themselves from acquiring other sexually transmitted infections (STIs) or drug-resistant virus, but they frequently do not understand the risks associated with STIs and HIV transmission. Although information alone cannot be expected to change sexual and drug-use patterns, culturally competent providers can help patients understand the transmission risk of certain activities and provide guidance to help them reduce risky behaviors. This aspect of care is called prevention with positives (PWP).

Young people may benefit tremendously from PWP services. Many adolescents engage in risk-taking behaviors as a normal part of their development, and sexual experimentation is a common aspect of this process. Reducing the risk behaviors of young HIV-infected patients will not only benefit their own health but also contribute toward achieving the nation's longstanding public health goal of reducing the annual number of new infections.

Providers who have ongoing relationships with HIV-infected youth possess a unique opportunity to offer screening, deliver prevention information, and encourage and support positive behavior change as part of care and treatment. This module is designed to support providers by offering specific information and resources for engaging in customized risk-reduction counseling that is culturally and developmentally appropriate for youth.

Learning Objectives

Upon completion of this module, providers will be able to:

1. Integrate culturally competent prevention counseling into their care for HIV-infected patients, especially youth from communities of color.
2. Address the range of sexual risk-reduction behaviors specific to HIV-infected youth, including partner disclosure, abstinence, safer sex, and reducing substance use.
3. Describe 3 ways that STIs can facilitate the transmission of HIV.
4. Assess their own values and understand how personal values can affect the quality of prevention counseling delivered to HIV-infected patients.
5. Describe aspects of culture that support sexual risk reduction among HIV-infected youth.

Instructions

• The course may be navigated either by selecting the "Next Page" button at the bottom of each screen, or by using the course outline buttons in the left navigation column.

• All users will be asked to complete a final evaluation to help the sponsors assess the value of the course.

Authors

Deborah Royal, RN, ANP, MSN

Deborah Royal, RN, MS, ANP, has been a nurse practitioner at the East Bay AIDS Center (EBAC) in Oakland, California, since 2002. She is currently working on a grant, SAMSHA Integrated Mental Health and HIV Treatment Project, as the project nurse practitioner. In addition, she is involved with several community services, including the 2007 African American Health Summit Committee, Bay Area Black United Fund, Alameda County Office of AIDS Planning Council, Working Group for the Ryan White Care Act, Family Care Network Leadership Council, Infection Control Committee Alta Bates-Summit Medical Center, and the Women's Services Task Force. She is also the chair of the Prevention for Positives Task Force, Alameda County. She has a master's degree in nursing from the University of California San Francisco and a BS degree from San Francisco State University.

Peggy Macy, MSW

Peggy Macy, MSW, has worked with children and teens with HIV since 1990, serving as a clinical social worker in the Pediatric HIV/AIDS Program of Children's Hospital and Research Center in Oakland, California. Her work with patients includes sexuality education (puberty, healthy relationships, safer sex, HIV disclosure, body image, sexual orientation, and gender identity issues), and she has developed a variety of therapeutic interventions to promote resilience. These include individual and group activities to foster hope, build self-esteem, increase understanding of HIV, manage stigma, and encourage good health decisions.

Peggy Macy has designed and led classes on the topics of prevention for positives and sexuality education for infected and affected teens at an HIV summer camp, Camp Sunburst. She also teaches a comprehensive sexuality curriculum, "Our Whole Lives," to adolescents in her community. She has given numerous talks, including presentations at national and international conferences, on issues faced by children and youth with HIV.

Patients and Providers: The PWP Team

Understanding At-Risk Patient Populations

As discussed in previous modules, an estimated 25% to 50% of new HIV infections each year occur among young people aged 13 to 24. Health care providers are faced with several trends that are increasing the numbers of HIV-infected youth in their practices. First, a large cohort of perinatally infected adolescents is now transitioning from pediatric to adolescent medical settings. Second, HIV-infected adults often acquire the virus during adolescence, and there is now more outreach and HIV case finding among this age group. Third, improvements in treatment and care are allowing people with HIV infection to lead more normal lives.

Of the estimated 184,991 adult and adolescent HIV infections diagnosed during 2001-2005, more (51%) occurred among Blacks/African Americans than among all other racial/ethnic populations combined. Most (62%) new diagnoses occurred among persons aged 25-44; in this age group, Blacks/African Americans accounted for 48% of new diagnoses. Although adult and adolescent Blacks/African Americans accounted for 13% of the population in the 33 states for which data are available during 2001-2005, they accounted for 50.5% of the 184,991 new HIV/AIDS diagnoses; Whites accounted for 72% of the population and 29.3% of diagnoses; Latinos accounted for 13% of the population and 18.2% of diagnoses. Among racial/ethnic populations, Blacks/African Americans accounted for the largest percentages of cases diagnosed in both males (43.9%) and females (67.2%).

Although Asian Americans and Pacific Islanders (AA/PIs) account for approximately 1% of the HIV cases in the 33 states with long-term, confidential name-based HIV reporting, the AA/PI population in the United States is growing. In fact, increases in HIV diagnosis rates (the estimated annual percentage change) from 2001 to 2004 were greatest among AA/PI women (14.3) and men (8.1) in comparison with other racial/ethnic groups.

To understand how prevention efforts should be focused, it is useful to know how the virus is most often transmitted to youth:

1. Unprotected sex
2. Intravenous drug use
3. Perinatal infection

Providers should be aware of key societal and disease-related risk factors that are known to contribute to the elevated rates of HIV transmission among youth. Among these is a history of trauma such as physical or sexual abuse. Research has demonstrated that the chances someone will engage in behaviors that put them at risk of HIV infection are increased when the person has experienced a trauma.1 These behaviors include unprotected sex, use of alcohol, and exchanging sex to meet survival needs.2 Understanding these issues can aid in anticipating barriers to risk reduction and in designing prevention efforts that are tailored to each patient's individual set of risk factors.

Patients and Providers: The PWP Team

Understanding Yourself: Values Clarification from a Cultural Perspective

Despite efforts on the part of most health care providers to uphold the principle of objectivity, each individual retains personal values that can influence how they respond to patients. Sometimes, such values are very apparent and are easily articulated. Other times, they exist at a deeper level, and providers may not recognize the influence these values have on their behavior and judgments. Further, one's values may change in response to life experiences, and encounters with clients and colleagues may influence certain beliefs without an individual having much of a chance to reflect on those changes.3

The health care system in the United States revolves around a set of mainstream beliefs and values that are not necessarily shared by or applicable to persons with different cultural backgrounds, such as AA/PIs.4 For example, many providers emphasize the individual autonomy and privacy of the patient by teaching self-care and giving information to the patient only. Often, family members are excluded from involvement in the care process, hospital visiting hours are limited, and sleeping accommodations for visitors are not provided.5 Moreover, cultural differences can contribute to miscommunication between provider and patient, which could result in misdiagnosis or inappropriate treatment decisions. For example, misdiagnosis of child abuse can be avoided if health care providers are aware of dermabrasive procedures commonly used within certain Asian communities. Also, miscommunication can greatly reduce trust between the patient and provider, decreasing the patient's cooperation and compliance, two factors that play an important role in HIV prevention and treatment. These problems can hinder the quality of health care and even prevent the patient from seeking care in the future. Lastly, miscommunication can lead to unnecessary diagnostic procedures and delays, both of which can increase health care costs.4

Successful PWP efforts rely heavily on a relationship of trust built between provider and patient. With some patients, this trust can be established in a single visit, whereas others may need several encounters before they feel comfortable. Honesty from providers is an important ingredient for building trust with patients. If patients sense a lack of congruence between a provider's words and feelings, they are likely to have difficulty trusting the provider. Yet, in almost all cases, the essential component of trust can be achieved only within an environment that allows patients to feel secure in the knowledge that any information they share about their risk behaviors will be received in a nonjudgmental and supportive manner.

Sex and drugs are two sensitive issues at the core of PWP efforts. To help patients reduce HIV risk behaviors, providers must be able to comfortably and objectively address topics such as sexual practices, drug use, and parenting--subjects that many people find morally charged and awkward to discuss. Progress toward achieving this goal can be made by implementing the LEARN model (see Toolbox).

Part of effective listening involves recognizing one's own personal and cultural biases, suspending judgment, normalizing the patient's behavior, and understanding that supporting the patient does not imply condoning or agreeing with the patient's behaviors. Value clarification exercises can help providers identify areas of bias that may create barriers to nonjudgmental and active listening. As noted in the introductory module--through the LEARN model--listening to the patient's explanation of the problem, explaining one's own perspective on the problem, and acknowledging the differences between provider and patient are key processes for achieving effective communication.

Making Risk Reduction Work

In 2003, the U.S. Centers for Disease Control and Prevention, the Health Resources and Services Administration, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America put forth the following recommendations to better incorporate HIV prevention efforts into the medical care of persons living with HIV. These recommendations will be explored in greater detail throughout this module.

• Routinely screen for transmission risk behaviors, STIs, and pregnancy.
• Provide brief behavioral risk reduction interventions in the office setting and refer selected higher-risk patients for more intensive prevention interventions.
• Facilitate notification and subsequent counseling of sex and needle-sharing partners of infected persons either by the patient alone, in collaboration with the patient, or through the local health department.

To accomplish these goals, providers should incorporate risk reduction as part of a comprehensive treatment plan (see Toolbox). Any plan to address risk reduction with HIV-infected youth should focus on:

• 1. Sexual risk reduction
• 2. Partner disclosure
• 3. Addressing psychosocial cofactors

Valuing Cultural Competence

Sexual intimacy is a part of the everyday human experience. The nature of sexual relationships is guided by a broad array of cultural values, norms, and guidelines. An exploration of cultural practices and beliefs would reveal a range of acceptable sexual behaviors that are markedly different across groups of people. In some cultures, sexual intimacy is guided by spiritual connection and purpose, whereas in others it may be guided by pleasure or satisfaction. Providers must take the time to learn about their patients' unique perspectives on sexuality. Each culture also has guidelines regarding the level of privacy associated with discussion of sexuality. Thus, providers will need to spend some time learning appropriate ways to talk with their patients regarding sexual matters. These discussions are most productive when there is an established patient-provider relationship based in openness, acceptance, and sincerity. Again, practicing the LEARN model is an ideal tool for successfully exploring the range of acceptable sexual behaviors of patients in a way that allows providers to understand the influence of cultural practices and beliefs.

In many cultures, sex and related issues are not considered proper subjects for discussion. Within such cultures, a person attempting to negotiate safer sex may be considered promiscuous.6 Among persons who are HIV infected, a higher percentage of AA/PIs have an "unknown" mode of transmission compared with those from all other racial groups except Blacks/African Americans.7 This may be the result of reluctance to disclose personal information about their risk behaviors, particularly sexual practices. Resistance to discussion of sexual topics with health care providers can serve to support the stereotype that AA/PIs are not sexually active. The provider may not obtain information related to the client's sexual behaviors, which is important for assessing the client's risk of STIs 4 and HIV risk behaviors.

Participants in a study of HIV-infected AA/PIs indicated a possible link among vulnerabilities created by the immigration process, increased HIV risk behavior, and HIV infection.8 Several participants in a study of undocumented male immigrants believed they were infected with HIV because they frequented sex workers in Southeast Asia during the prolonged period of time they were attempting to make their passage to the United States. Several gay male study participants said they increased their unprotected sexual activity after arriving in the United States because they saw it as a land of sexual freedom. Few of them were properly informed about the risks of HIV infection. AA/PI women in the study were often infected by their boyfriends or husbands after arriving in the United States. A number of participants described having little or no information about HIV and safer sex techniques.

Within American Indian and Alaska Native (AI/AN) cultures, there is a range in perception related to sexual behavior dependent on urban vs rural residence, family values, and religious or spiritual orientation. Engagement with a traditional culture through involvement in community activities appears to have a significant impact on negating substance abuse and high-risk sexual behavior.9 Involvement with family and community, participation in sports activities, and interaction with peers who regularly attend cultural activities tend to reduce the chances of youth being drawn into a "party group." Providers may find additional information about adolescent patients' behavior by taking note of their peers and the activities in which they are involved. Parents of youth can provide information about their own cultural activities and consequently the extent of the extended family's available resources. Discussion of sexuality in particular requires a trusting relationship between the provider and the young patient.

Certain aspects of culture such as social support or spirituality may increase the likelihood that adolescents will engage in safer sex practices and other health enhancing behaviors. Hubbard and colleagues found that among Black/African American young women, higher frequency of engaging in religious or spiritual activities (eg, praying, meditating, attending religious services, or seeking counsel from a spiritual adviser) was associated with higher self-efficacy in communicating with partners about safer sex and STI's and refusing unprotected sexual encounters.10 Similarly, Song and colleagues found that the coping styles of seeking social support and seeking spiritual hope were each associated with better adherence to HIV prevention intervention sessions among HIV-infected youth.11 The WiLLOW program for HIV-infected females demonstrated that a prevention program that includes a gender pride component was successful in reducing the incidence of unprotected vaginal intercourse, Chlamydia, and gonorrhea.12 The women who participated in this program also had greater condom self-efficacy and HIV knowledge.

Rotheram-Borus et al found their CLEAR (Choosing Life: Empowerment, Action, Results) program was an effective prevention intervention for young gay men of color (43% Latino and 26% Black in the study group).13 Participants had some history of illicit drug use. The program includes three modules that focus on improving health and coping with serostatus including treatment adherence; reducing substance abuse and sexual risk behavior; and reducing emotional distress and increasing quality of life. Participants demonstrated a significantly greater proportion of protected sex acts.

Sexual Risk Reduction

Although it is recommended that providers routinely assess their HIV-infected patients for sexual risk behaviors, many providers conduct sexual histories of their patients inconsistently, particularly patients who present without genitourinary complaints.

Young people living with HIV need access to accurate information about HIV and STI transmission to address their concerns about sexuality, dating, disclosure, and transmission risk, and to answer their questions about parenting--and this information should be culturally and linguistically appropriate. In general, they want their health care providers to provide that information and to sensitively ask them personal questions about HIV-related risk behaviors. Although they want these discussions to take place, most youth prefer that providers initiate the discussion.

Among many AA/PI families, males have a higher status than females and older family members have a higher status than younger members.45 When providers meet with family members, it may be tempting to address younger, more Americanized family members, rather than elderly members who do not speak English. If questions are not directed toward the person who has the power to make decisions, the entire family could be insulted and confusion could arise. However, involvement of the patient's family may or may not be appropriate. After an assessment, and when appropriate for the patient's care, the provider should work within the traditional family hierarchy. To correctly identify the head of the family, providers may consult first with the patient.414

Among Blacks/African Americans, family is not defined solely by blood relationship. Often non-blood kin 15 are as influential in an adolescent's life as blood relatives. Adolescent may have been reared by relatives other than their parents or non-blood relatives. This is particularly likely among adolescents with perinatally acquired HIV infection whose parents have died. It may be useful for providers to construct genograms with their patients and identify people the adolescent trusts to help them make decisions. It is important to get a sense of who the adolescent defines as family. From here the provider can take to appropriate steps to involve parents, guardians, and significant family members in discussions about sexuality. These adults may prefer separate sessions with the provider to help them find the words they need to discuss sexuality and safer sex with their teenagers.

In order for these discussions to be effective, patients must feel that their providers will comfortably and supportively engage in dialogue with them about any topic--no matter how risqué or risky that may be. Young people can sense when providers are out of their element discussing sensitive issues and this perception will almost certainly hinder honest communication about risk behaviors. Patients also can be keenly aware of the cultural biases and perspectives of the providers and feel that they do not really understand their community or family contexts. Providers who are uncomfortable talking about sex or drugs, and those who may be reluctant to face their own potential cultural biases, should practice talking about these issues before they initiate risk-reduction discussions with their patients.

Sexual Risk Reduction

Setting the Stage for Risk Reduction

Providers need to set the stage for asking routine screening questions as early as possible in their relationships with patients. Providers can build trust with their patients in the following ways:

Start early in providing culturally sensitive anticipatory guidance to parents and patient.

• When possible, begin addressing sexuality before the patient becomes sexually active. For patients in a provider's continual care since childhood, sexuality discussions are a natural extension of the health education provided at younger ages.
• Begin with safer topics, such as the physical changes of puberty. Respectful of the family's cultural beliefs and traditions, educate the patient and parents about what to expect in terms of sexual, physical, emotional, and social development during puberty and adolescence.
• Although all parents of adolescents and preadolescents benefit from this kind of anticipatory guidance, the information is especially vital for parents and caregivers of youth with HIV, especially perinatally infected youth. When meeting with parents, begin with an exploration of their expectations about their child's sexual activity and anchor the conversation using their expectations as point of departure to impart anticipatory guidance that addresses their views and expectations.

See adolescent patients separately.

• By the time your patient reaches age 12, spend part of the medical appointment alone with him or her. Youth are far less likely to raise concerns and speak candidly if parents or caregivers are present.
• Keep in mind that many adolescents may be embarrassed talking about sexuality, especially with a care provider they have known since early childhood. Do not be discouraged if they appear uncomfortable. Acknowledge that it is a delicate topic and utilize supportive, active listening to build trust.

Clarify issues of confidentiality.

• Thoroughly explain to adolescent patients what information can and cannot be kept confidential from parents, with an emphasis on protecting their confidentiality.
• Become familiar with the confidentiality and consent laws of the state in which the clinic is located.

Begin with neutral topics.

• Make sexuality a routine component of the overall assessment, but allow the teen to "warm up" by starting with more neutral topics, such as home life, school, or job. This approach helps establish rapport while demonstrating care and concern for the patient as a whole person. The HEADSS assessment is an effective assessment tool that starts with "safer" topics before addressing sexuality and other sensitive areas.16

Remember the 4 "Ps" when discussing sexual activity.15

Use the 4 Ps to structure sexuality discussions:

• Partners
• Practices
• Protection
• Prevention

Be a good listener and an "askable" provider.

Active listening skills are crucial when discussing sex, as many youth anticipate being lectured or judged on this topic. Four key active listening skill areas are open-ended questions, nonjudgmental attitude, reflective listening, and self-awareness:

1. Open-ended questions
   Start most questions with what, how, when, or tell me to elicit information while minimizing defensiveness.16 Ask for clarification when necessary and avoid using only medical technical language (eg, fellatio or intercourse instead of descriptive terms like penis in mouth or penis in vagina/anus/butt).
2. Nonjudgmental attitude
   Avoid questions that clearly communicate a preferred answer, such as "You aren't having sex yet, are you?" or "You don't ever have unprotected intercourse, right?" Likewise, beware of nonverbal expressions of judgment, such as shaking one's head while asking a question.
3. Reflective listening
   Paraphrase what the patient has said and repeat it back, checking that it has been understood correctly.17 This validates the patient and builds trust.
4. Self-awareness
   Strive to be conscious of one's own sexuality issues and beliefs, and of potential personal cultural biases. Unexamined opinions and values can be detected easily by patients and frequently come across as judgment or criticism.

Use of empathetic listening skills conveys to patients the provider is "askable," a safe adult with whom to raise concerns--if not at the current visit, perhaps at a future one.

Avoid making assumptions.

• Beware of making assumptions based on sexual stereotypes regarding race, class, gender, sexual orientation, or disability as they relate to sexuality. Do not assume that a teen with HIV has different social or sexual aspirations than noninfected peers. Chronically ill youth are frequently misperceived as being less sexual than their healthy counterparts.18
• Do not assume that a young patient has a heterosexual orientation. Use language that distinguishes between sexual orientation, behavior, and identity. For instance, because many young men who have sex with men do not identify as gay, inquire first about sexual behavior rather than sexual identity. Avoid any labels that are not first used by the patient. Use gender-neutral terms when referring to a teen's sexual partner, until the patient has clarified.
• Avoid assumptions about how much, how often, and what kind of sexual activity patients are having. Seek clarification for vague descriptors such as a lot or very often. Ask, "What does very often mean to you? Is it several times a day? Once a week? Twice a week? A few times a month?"

Maintain a professional yet supportive demeanor.

• Use relaxed and open body language such as frequent hand gestures and verbal acknowledgments (eg, "Uh huh, I hear you."), maintain proper therapeutic distance, avoid awkward or imposing physical settings, and pay attention to patient comfort (eg, the patient is likely to be more comfortable dressed in street clothes instead of an examination gown). Maintaining good eye contact is another important way to be professional yet supportive with many patients, but it should be noted that some may perceive eye contact as offensive or disrespectful.

Make the office or clinic a youth-friendly atmosphere.

• Create a youth-friendly waiting area stocked with a diverse supply of culturally and linguistically appropriate youth-related health materials.
• Offer services during hours that are convenient for youth.
• Make the clinic sensitive to the diversity of the patient population by hiring demographically appropriate front office staff and by reviewing the styles and languages of signage and materials.

Acknowledge sensitive topics.

• If a situation or discussion is awkward, respect a patient's clues that further talk is unwanted. In such cases, providers should acknowledge that preference and suggest the option of further discussion another time.

Ask about sexual health and well-being.

• Do not limit the sexual history assessment to questions that help determine the patient's risk to others. Assessing sexual function and health yields useful clinical information and conveys a sense of caring for the patient's quality of life.
• As with other chronic illnesses, HIV disease can affect normal sexual health.19 For example, decreased sexual interest and arousal is common with a number of potential causes, including fatigue, low mood, medication side effects, lower testosterone levels, gynecologic complications, and poor body image related to wasting or lipodystrophy.

Patients are typically too shy to freely divulge information about their sexual health. They may be more at ease if the discussion is opened with a third-person statement that normalizes the issue, such as, "Many patients have concerns or questions about their sex lives. Do you have any concerns?"

If patients do report sexual problems, such as low libido or difficulty with arousal, ask whether they are using any herbal or over-the-counter treatments.20 Educate about self-care (eg, use of exercise and good nutrition to improve sexual arousal) and consider referral for psychotherapy to address psychological issues.

Explore attitudes about parenthood and pregnancy.

• Do not assume that all HIV-infected teens want to avoid pregnancy or parenthood. As with their uninfected peers, many young women with HIV infection do become pregnant. Although some of these pregnancies are unintentional, others are planned or semiplanned. In most AA/PI cultures, children have obligations to enter into heterosexual marriage and produce children,2122 with sons expected to pass on the family name.234
• For teens expressing interest (or even ambivalence) regarding pregnancy and childbearing, educate about reproductive choices available to HIV-infected and serodiscordant couples (eg, artificial insemination, sperm washing, adoption) and provide preconception counseling.

Educate about sexual health and well-being.

• Remember that the teen patient may lack adequate or accurate information. Children growing up with chronic illnesses typically receive less sexuality information from parents and peers, and education provided in school may be insufficient.24
• Sexuality education can be woven into the risk assessment. Key topics should include:
  • Sexual readiness
  • Ability to choose abstinence
  • Transmission of HIV and other STIs
  • Continuum of risk for different sexual behaviors
  • Effectiveness of condoms and dental dams
  • No-risk choices for sexual expression
  • Contraceptive options and potential interactions between hormonal methods and HIV medications
  • Patients' perceptions and definitions of sexuality and sexual activities

Sexual Risk Reduction

Elements of a Sexual Risk Screening

The standard elements of a sexual risk screening are as easy to remember as who, what, and where. Begin by asking "Are you having sex?" And if the answer is yes, then ask:

• WHO: number and gender(s) of partners and HIV status of partners
• WHAT: type of sex: oral, anal, vaginal (insertive or receptive); condom or barrier use or lack thereof; risk of pregnancy; possibility of coercion (emotional or physical); substance use, if any; associated genitourinary symptoms
• WHERE: meeting venues for sexual partners

When any screening question reveals risks, providers can either provide individualized risk-reduction counseling themselves or refer patients for more intensive counseling and support. If a referral is necessary, it is important to have well-established relationships with providers and organizations known to be youth friendly.

Once the stage has been set for honest communication, it is important to remember that a successful change of risk behavior requires a desire for such change on the part of the patient. The provider may marshal the discussion, but it is the patient who must feel in charge.25 (See Toolbox for Motivational Interviewing Techniques.)

Sexual Risk Reduction

The Basics of Risk Reduction

Begin by asking what the patient knows about HIV and how it is and is not transmitted.

The patient should guide the discussion, starting from the patient's point of view and focusing first on the patient's concerns and questions. It is not unusual for HIV-infected youth to believe that they will never be able to have sex, that they will never want to have sex because of transmission worries, that no one would agree to have sex with them if they were to disclose their status, and that they can never have children. Acknowledge that choosing to not have sex (abstinence) is an option but may not be a lifelong choice, so they will need information on safer sex.

Talk honestly about abstinence.

Although it is tempting to simply congratulate a teen for choosing abstinence, providers should further explore young patients' understanding of abstinence and help them reduce the possibility of risky behavior in the event the planned abstinence lapses:

• Assessing candor
  Determine whether abstinence is a genuine plan or whether the teen is simply saying what he or she thinks the provider wants to hear. Follow-up questions often help to clarify. For example, "What makes you choose abstinence at this point?" "How old do you feel you should be to have intercourse?" "How does your partner feel about abstinence?" "How are you handling sexual urges?" and "Have you thought what you would do if you change your mind?"
• Defining abstinence
  Many adolescents engage in oral or anal sex because they feel these activities preserve their virginity and prevent pregnancy. It is helpful to shift the focus from "maintaining virginity" to reducing risk. Engaging in sexual behaviors that don't involve contact with body fluids (sometimes referred to as "outercourse") is a much safer option than unprotected oral and anal intercourse.
• Encouraging a backup plan
  Help teens strategize how they could stay safe if they were to change their mind in the heat of the moment (eg, keeping condoms handy). Teach that higher rates of unsafe sex occur when teens are unprepared or insufficiently educated.

Ask sexually active patients how they are currently having sex and what risk-reduction plans they have.

Encourage disclosure to partners.

Partner disclosure is difficult for many youth because they worry how their partners will react to the news that they are HIV infected. Common fears are that the partner:

• may reject or abandon them
• may become angry to the point of verbal, emotional, or even physical abuse
• may tell friends and others in the community that they are HIV infected

Delayed partner disclosure is common, but steps should be taken to help patients find supportive people who can assist them in disclosing to sexual or substance-using partners. Once a sexual relationship has begun without disclosure, finding the right time for disclosure becomes increasingly difficult. Over time, the HIV-infected person may worry that it is too late to avoid transmission, especially if condoms have not been used consistently. In such cases, many patients fear that revealing their HIV status may lead to their partners testing positive--and in their minds, a partner's positive result could have dire consequences including guilt, blame, and the end of the relationship.

For many youth, communicating a difficult message is extremely hard to do. Disclosure is probably one of the most difficult conversations for anyone to initiate, but it should be emphasized as an essential part of prevention and possible support. To make the process easier for adolescent patients, providers should inform them of the 3 disclosure options:

• Client disclosure
  In cases where patients feel relatively comfortable with the idea of disclosing their HIV status to their partners on their own, providers should work with them to facilitate that process. It is helpful to have patients identify people in their lives who they feel would be supportive if they knew their status. When those persons are not the partners, encourage patients to disclose to them first in order to build a support system and to practice having the conversation. Then encourage them to inform their sexual partners.
• Provider-assisted disclosure
  If patients want to inform their partners but do not think they can do it alone, providers should offer the option of meeting with the patient and partner together to help the patient inform the partner. This meeting can involve the primary care provider or it can be scheduled with members of the psychosocial staff such as social workers, staff psychologists, or psychiatrists.
• Department of Health disclosure
  If a patient consents to the partner notification process but does not want to be directly involved with the actual disclosure, most health departments (although this varies by state) offer a service whereby they visit reported partners of HIV-infected people face to face and inform them that they may have been exposed to the virus. During this process, the identity of the HIV-infected partner is not revealed, thus the patient's confidentiality is maintained.

Provide options for sexual risk reduction should be provided, including:

• Abstinence
• Intimate touching without exchange of bodily fluids
• Reducing number of partners
• Disclosing status and negotiating sexual practices
• Correctly and consistently using condoms (male and female)
• STI screening and treatment
• Maintaining maximal suppression of HIV through antiretroviral therapy
• Avoiding alcohol, marijuana, party drugs, and other substances that impair good judgment and prevention

Create a welcome atmosphere for discussions about sexual orientation.

An estimated 10% of youth question their sexuality and sexual orientation in the high-school years, so it is important not to risk alienating patients by displaying a bias regarding sexual orientation. Model tolerance to reinforce that there is no single right way to behave sexually and to encourage youth to disclose what they perceive to be "abnormal" differences. Make sure to ask a couple of questions, beginning with, "Have your sex partners been men, women, or both?" If a patient has had same-sex experiences, ask the patient, "Do you consider yourself gay, straight, bisexual, or unsure of your sexual orientation?"

Explain that having unprotected sex puts them at risk of acquiring more HIV or resistant HIV, which may limit future treatment options.

If an HIV-infected woman becomes pregnant, teach about antiretroviral medications that can help prevent mother-to-child transmission of HIV.

Young women should fully understand their family planning, contraception, pregnancy or pregnancy termination, and adoption options, and they should be informed about available healthy sexuality counseling and preconception planning services.

Address the risk continuum of transmission via vaginal, anal, and oral sex.

Patients should be urged to always use condoms during vaginal or anal sex. Although the transmission risk is lower with oral sex than with most other sexual activities, sores in the mouth, burns from crack pipes, lesions around the genitals, gum disease, and concurrent STIs may increase the transmission risks associated with oral sex. Oral sex risks can be even further reduced by not brushing or flossing teeth before engaging in oral sex, and by using barriers such as condoms, dental dams, or plastic kitchen wrap.

Parents can be risk-reduction allies. Providers should assess patients' level of comfort in discussing sex with their parents and facilitate open discussion between them if it is possible. Many parents lack sufficient knowledge about sex and the risks of transmission. Others could use guidance to help them supportively communicate what they know to their children. Providers can build parents' capacity to assist in risk reduction by answering questions and sharing resources (see Toolbox), but attention always should be paid to preserving the patient's confidentiality.

Explain the link between STIs and HIV.

In addition to screening for sexual risk behaviors, all sexually active HIV-infected youth should be screened for symptoms of STIs at every visit and should be given a physical examination every 6-12 months. A standard part of the screening process should be education. Youth need comprehensive information about STIs that includes:

• Local STI epidemiology
• How concurrent STIs increase the amount of HIV virus in infected tissue
• How STIs cause erosions in skin and mucous membranes or inflammation and thus increase the risk of transmission
• How STIs can be completely asymptomatic and can exist for many years without detection
• How viruses such as herpes can be spread even when a person is asymptomatic
• How multiple parts of the body can be infected and result in symptoms such as sore throat, vaginal irritation, abdominal pain, anal discharge, and urinary frequency
• How STIs, even when asymptomatic, can cause infertility in women
• How STI screening and management is easy, painless, and confidential
• How substance use can lead to riskier sexual behaviors including forgoing condom use

Providers should also help patients identify strategies for reducing barriers to safer sex and drug-use behavior. Finally, many young people believe that, because they are already infected with HIV, the risk of acquiring other STIs is not serious. All patients should be educated about the health risks of burdening their bodies with another STI and the potential harm of acquiring more damaging strains of HIV.

In many AA/PI cultures, women are expected to exhibit "modest" behavior.275 Discussions about sex, including negotiating safer sex with a partner, are seen as improper 2128 or as indicative of sexual promiscuity.29 Discussing condom use can be interpreted by a male partner as a sign of distrust of him.4 Women who are comfortable talking about condom use with their partners may still fail to do so because of the cultural tendency to accommodate others. Specifically, an AA/PI woman may avoid raising the topic to prevent her partner from feeling offended or insulted. Because condoms are perceived as causing physical discomfort, she may not approach the topic out of consideration for her partner's needs.28 When providing preventive education to AA/PI women, discuss how to negotiate safer sex with their partners, keeping in mind that condom use requires a male partner's cooperation. Because of the power gap between men and women in many AA/PI communities, such negotiation is especially important for HIV prevention efforts. Encourage the use of the female condom, which gives the woman more control over her sexual life.4 HIV interventions may address the cultural tendency of AA/PI women to accommodate others or take into account their expected role in the family. For example, emphasize that failing to obtain and follow HIV prevention and treatment recommendations can result in an inability to take care of her husband and children.28

Facilitate condom negotiation skills.

Providers can help their patients improve condom negotiation skills by:

• 1. Normalizing anxieties about discussing condoms
  Reassure patients that many people find it difficult and awkward to bring up the topic of condoms with a partner, especially if condoms have not been used in the past.
• 2. Offering tips for condom negotiation
  • Don't wait until the heat of the moment.
  • Be prepared to state your concerns and don't back down.
  • If you haven't used condoms in the past, state what made you change your mind (for example, advice from a friend, magazine, or doctor).
  • Offer to get tested for HIV together.
• 3. Role playing about discussions about condom use with a partner.

  If your partner asks:
  You don't love me enough to have sex without a condom?
  You can say:
  It is because I love you and I love myself that I want to keep us both safe.

  Or, if your partner says:
  You want to use a condom because you've been messing around with other people.
  You can say:
  Before we met, we both had other partners and I want to be sure that neither of us brings anything into the relationship.

Facilitate correct condom use.

Many young people have never been taught how to properly use a condom (see Toolbox for a link to online patient information about condom use). Providers should demonstrate steps for putting on a condom and should offer to supply condoms. Patients should be taught condom "Dos and Don'ts." Most importantly, providers should stress that, when used properly, condoms rarely fail to protect against STIs and pregnancy.

Sexual Risk Reduction

Video: Johnny

The following video shows Johnny, an 18-year-old Latino male who tested HIV positive last month after being notified by the health department that he may have been exposed to HIV by an unnamed sex partner.

Sexual Risk Reduction

Summary Points

• Reassure patients that you talk to everyone about sex and prevention, as young people tend to be egocentric and may think that you have singled them out.
• Acknowledge that talking about sex can be difficult.
• Probe in a nonjudgmental manner to obtain an accurate account of a patient's sexual activity.
• Support abstinence but also ensure that patients know how to have sex safely.
• Teach the "ABCs": Abstinence, Be Faithful, Condom Use.
• Counsel patients about the risks associated with various sexual activities.
• Ask patients to clarify any ambiguous terms, and ascertain that they understand the information you have conveyed.
• Have patients explain why they want to practice safer sex.
• Have patients practice condom negotiation skills with role-playing.
• Frame risk reduction as a responsibility to patients' own health and to the protection of others.

Addressing Psychosocial Cofactors

As discussed in the Psychosocial Issues module, when addressing sexual risk behaviors and decision-making, it is important to consider 3 potential cofactors associated with increased sexual risk behavior among people with HIV: substance abuse, mental illness, and a history of childhood sexual abuse.30

Substance Use

People with HIV have considerably higher rates of substance use compared with the general population.31 In many cases, youth who have been exposed to trauma, racism, discrimination, poverty, and other social problems are at higher risk of engaging in the use of substances as a means of self-medicating. From the perspective of HIV transmission, alcohol and drug use are very significant risk factors that can bring about sexual risk taking as well as the unsafe sharing of needles among injection drug users (IDUs).

The chances of transmitting disease by means of shared syringes are very high. IDUs are at risk of contracting not only HIV but also bloodborne pathogens such as hepatitis B and C, which are far more virulent than HIV and thus easier to transmit. Another concern is the possibility of coinfection with HIV and viral hepatitis. The best way for an IDU to avoid contracting HIV is to stop injecting drugs. Referrals to drug treatment programs can be helpful for users who are ready to quit. However, if recreational drugs, hormones, or steroids are used, sterile needles substantially reduce the risk of HIV infection. If new needles are unavailable, IDUs are advised to avoid sharing needles or other injection drug equipment. In the event that sharing cannot be avoided, needles should be cleaned thoroughly with bleach and water. Providers can help by telling patients how to obtain sterile syringes through exchange programs and pharmacies.

For many HIV-infected youth, sex and drug use are linked activities. Studies have found that young people using substances tend to initiate sex earlier and that sexually experienced teens are more likely to initiate substance use.32 About 9 in 10 young people say their peers use alcohol or drugs before having sex at least some of the time.1 Large numbers of young people report they have engaged in risky sexual behavior while under the influence of drugs and alcohol, including having intercourse without a condom, "going further" sexually than they had planned, and having sex with more partners. Using drugs that cause euphoria (eg, ecstasy, amphetamines) presents an especially high risk of engaging in unsafe sexual activity.

Substances also increase the likelihood of negative sexual experiences and compromise the ability to give sexual consent. Alcohol and drugs also increase the risk of sexual violence, with alcohol implicated in two thirds of date rape incidents.33

It is theorized that some drugs increase HIV transmission rates by means other than lowering judgment and inhibition. Drugs that delay ejaculation (such as amphetamines, nitrates, and crack cocaine) lead to prolonged and more vigorous sexual activity, increasing the risk of trauma to the genitals associated with higher HIV transmission rates.2

Teens are often unaware of the negative effects of substance use on healthy sexual function. Alcohol and narcotics decrease libido, arousal, and orgasm. Although amphetamines initially increase sexual desire, they can cause impotence and long-term sexual dysfunction, which is why patients using amphetamines often seek erectile dysfunction medications such as Viagra, Cialis, and Levitra.

Because of the effects of drug use on judgment and other factors that increase risk-taking behaviors, providers should encourage patients to receive treatment for their substance use issues as part of risk-reduction efforts. See the Psychosocial Issues module for strategies that can help providers address substance use among HIV-infected adolescent populations.

Addressing Psychosocial Cofactors

Mental Health and Neurodevelopmental Disorders

Mental and neurodevelopmental problems are another key cofactor in sexual risk taking. As detailed in the Psychosocial Issues module, youth with HIV have higher rates of mental health and neurodevelopmental disorders compared with their HIV-uninfected peers.4567 The perinatally infected population has an especially high prevalence of neuropsychological deficits caused by the effects of HIV on brain development, sometimes complicated by perinatal alcohol and drug exposure and prematurity. Among the cognitive dysfunctions seen in children with HIV are language disorders, spatial ability problems, memory problems, attention deficits and, sometimes, moderate to severe mental retardation.13

Providers should be aware of the following behavioral and developmental disorders and the ways in which they may impair sexual decision-making and increase the risk of unsafe sex--keeping in mind that not all listed points are true of every youth with a given disorder:

Attention deficit hyperactivity disorder (ADHD)

• impulsivity
• poor foresight
• difficulty learning from mistakes
• sensation-seeking behaviors
• higher risk-taking tendencies, including risky sexual behaviors
• poor interpersonal skills
• high incidence of comorbidities (eg, substance use, mental disorders, and learning problems)

Learning disabilities

• impaired social skills
• difficulty understanding HIV, STI transmission (especially when the mode of teaching/education involves the area of their disability, such as reading for those with dyslexia)
• difficulties with expressive or receptive language
• poor problem-solving skills
• low self-esteem 30

Developmental disabilities or mental retardation

• limited understanding of HIV, STI transmission, reproduction, contraception
• especially vulnerable to sexual coercion
• impaired interpersonal skills, limiting partner disclosure and safer sex negotiation
• sexual "acting out"
• emotional instability
• poor judgment

Depression

• higher rates of unprotected intercourse, multiple sex partners, STIs, trading sex for money or drugs
• depression and poly-drug use leads to greater risks than with depression alone
• self-blame, apathy, and low self-worth decrease motivation for self-protection

Anxiety disorders (eg, social phobia, generalized anxiety disorder)

• heightened interpersonal sensitivity
• social isolation
• hypervigilance
• intense need for secrecy may hinder partner disclosure

Bipolar disorder

• apathy
• sad mood
• hostility
• lack of insight
• social impairment
• reckless behavior
• elated mood
• hypersexuality, inappropriate sexual behaviors
• sleeplessness

Serious mental illness, including bipolar disorder and schizophrenia, is associated with higher risk of becoming a victim of sexual coercion and intimate partner violence. People with serious mental illness are also more likely to have unstable partnerships in high-risk sexual networks, use substances that impair decision-making abilities, and lack the emotional stability, judgment, and interpersonal skills needed to avoid risk.4

For more detailed diagnostic information, consult the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).

Addressing Psychosocial Cofactors

History of Childhood Sexual Abuse

In the United States, it is estimated that more than 30% of females and up to 15% of males in the general population have experienced childhood sexual trauma. Childhood sexual abuse is a significant risk factor for acquiring or transmitting HIV. Studies indicate that up to two-thirds of women with HIV had experienced child or adult sexual abuse.34 Similarly, a study of HIV-infected male and female youth found that up to 40% reported sexual abuse.35 Examples of increased sexual risk taking among abuse survivors include earlier coitus, higher number of partners, less condom use, higher-risk partners, more frequent sexual activity, exchanging sex for drugs or shelter, and combining sex and substance use.101112

Survivors of childhood abuse may experience feelings of powerlessness over sexuality and may have compulsive sex patterns, such as repetition compulsion (reenacting behaviors that led to their trauma). Common gender-specific issues related to childhood sexual abuse are listed below. 36

Posttraumatic stress disorder (PTSD), whether caused by sexual abuse or another trauma, often goes undiagnosed in the primary care setting. Yet, it significantly affects all spheres of a patient's life, including increases in risk-taking behaviors, health care utilization, health complaints, mortality, and morbidity.

If abuse is suspected, providers should:

• Screen for history of trauma, including sexual abuse and PTSD symptoms, either verbally or by using a brief screening tool (see Toolbox for Primary Care PTSD Screening Tool).
• Avoid intentionally eliciting a retelling of the traumatic event, but refer for further mental health evaluation and treatment.
• Validate the patient and show empathy and concern. Educate about the effects of trauma on various aspects of life, including sexual safety (see Toolbox for Culturally Competent Youth & Trauma Fact Sheets).

Pregnancy and Parenting

Whether intentionally or not, many young HIV-infected women become pregnant. Several factors influence pregnancy decisions among young women with HIV.

• With the rate of vertical transmission now quite low, partially as a result of the implementation of protocols for the prevention of mother-to-child transmission (PMTCT) of HIV, the fear of infecting a baby is no longer a deterrent for many HIV-infected women. Current estimates are that only 140 children perinatally infected with HIV are born in the United States annually.7
• Treatment advances have extended life expectancies for HIV-infected patients and improved their quality of life. Now that HIV is no longer perceived as a death sentence, many infected women choose to start families. In fact, some will start families sooner than they otherwise would, hoping to bear and raise children while they are still relatively healthy.
• For some HIV-infected women, becoming a mother represents a chance to overcome their mortality, or to "cheat death." Leaving behind a baby when they die would be a way to leave a piece of themselves--a legacy.
• Within the broader American culture as well as among many racial/ethnic groups, there is a distinct value of pregnancy and childbearing. The emphasis on and availability of infertility treatments attests to this value. Within Black/African American, Latino, AI/AN, and AA/PI communities, family and children are very important. Thus, it is likely that HIV-infected young people within these groups will want to give birth to their own children.

Assess patients' attitudes about parenting and pregnancy, using nonjudgmental questions and active listening. Sample questions are:

• "Do you see yourself having children one day?"
• "How would pregnancy and parenthood affect your life? Your current relationship?"
• "What would you do if you (or your partner) became pregnant?"
• "How do you think your parents (or caregivers) would feel or react if you (or your partner) became pregnant?"

The last question helps identify the choice of pregnancy as a vehicle for rebellion from parents, or possibly as a kind of favor to the parents, to give them a new or substitute baby.

For teens expressing interest (or even ambivalence) regarding pregnancy and childbearing, educate about reproductive choices for HIV-infected and serodiscordant couples (eg, artificial insemination, sperm washing, adoption) and provide preconception counseling.

CASE STUDY:

David

David is a 19-year-old Chinese American. He and his family immigrated to the United States from China when he was 14. Teased in school about his given name, he changed his name to David soon after moving to the United States. He speaks a local Chinese dialect and fluent English with an accent. He lives with his parents, who speak only their local Chinese dialect. Also in the household are his two younger brothers, aged 17 and 15.

David reports having no previous serious illnesses and takes no regular medications. He received all of his immunizations either when he immigrated to the United States or through his doctor while in high school. He was given a skin test for tuberculosis when he was in high school. He doesn't recall whether the result was positive or negative, but he recalls getting an X ray and having to take pills for about 9 months.

About 6 weeks ago, David tested "preliminary HIV positive" at The DL, a community-based organization where free, rapid HIV testing is offered. Following the preliminary positive test result, David returned to The DL clinic where he had blood drawn for a second HIV test, which confirmed that he was infected with HIV.

David was initially upset by the confirmation that he was infected with HIV. He told the counselor that he had convinced himself that the preliminary result was wrong "because Asians don't get HIV." After a couple of weeks, he resigned himself to the diagnosis and reengaged in care to find out what to do next. He met first with the clinic case manager who determined that he was uninsured, but was eligible for the AIDS Drug Assistance Program (ADAP), based on his income. While his application for ADAP is pending, he meets with Dr. Phipps at The DL's HIV primary care clinic.

During the process of documenting his sexual history, David discloses that he uses condoms "about half the time." Dr. Phipps is able to elicit from him that during the previous year he engaged in oral sex and receptive anal intercourse with males. David states that he met "about 20 or 30 men online" during what he calls a "sexual exploration phase" and used drugs with many of these men. However, he claims that he stopped having sex with men several months ago because he is feeling pressure to "get serious" with his Chinese American girlfriend. He says his parents really like her and her family and they are hinting more than usual that it is time he started his own family. He tells Dr. Phipps that they constantly remind him that he is their eldest son and that they would be very proud if he gave them a grandson. David states that he wants to have a son but Dr. Phipps tells him that it would not be a good idea because the risks of his girlfriend and child becoming infected with HIV are too great.

When Dr. Phipps asks whether anyone else knows that he was tested for HIV, he replies, "No, I don't want my situation to be a burden on my family." Moreover, he says that his parents would disown him if they found out how he became infected. He states that they have made homophobic comments in the past such as, "All the perverted homosexuals with AIDS should be killed."

David tells Dr. Phipps that he took the HIV test because he and his girlfriend have had vaginal intercourse without a condom on several occasions. Dr. Phipps asks whether his girlfriend has ever been tested for HIV, and David replies that she has not. When offered a pamphlet on anonymous HIV testing through the health department for his girlfriend, he refuses because he fears that she would immediately suspect that he is HIV infected, as he is the only person she has had sex with. David also tells Dr. Phipps that he is not overly concerned that his girlfriend could be HIV infected because, even though they often did not use condoms, they mostly had anal sex so that she would not become pregnant. Dr. Phipps gives David a flyer on safer sex and other STIs, and tells him to study the information and to try to use condoms every time he has sex.

Following the brief sexual history, Dr. Phipps examines David. A genital examination shows a normal uncircumcised penis, no external lesions suggestive of STIs, and no evidence of hernias or testicular masses. Inspection of the perianal area reveals a couple of raised, verrucous lesions and an old, external hemorrhoid. David reports that he has had those bumps for about a year and that they sometimes get itchy. The remainder of his examination reveals nothing abnormal. David and Dr. Phipps talk about treating the bumps in his anal area and make a plan to do an anal Papanicolaou smear during his next visit. Dr. Phipps recommends a comprehensive panel of blood and urine tests and schedules a follow-up appointment in a couple weeks.

Discussion Questions:

1. What could Dr. Phipps have done to ensure that David has a support system to help him cope with his HIV disease?

• Despite the fact that David believes his family would disown him if they learned that he is infected with HIV, Dr. Phipps should have asked David to think of people in his life who might be supportive if they knew that he was HIV infected. A referral to a mental health professional could help David build a support system so that he can better cope with his disease, take better care of his health, and be more likely to avoid transmitting HIV to others.

2. Given David's situation with his girlfriend, what might have been the best approach for partner notification?

• Dr. Phipps seemed to be in a rush and relied too much on pamphlets from the health department to provide David with options for informing his girlfriend that she may be infected with HIV. A better approach would have been to either coach David so that he could tell his girlfriend alone or offer to meet with David and his girlfriend to deliver the news and offer her HIV testing and support.

3. Were there any signs that David may be misinformed about the risks of HIV transmission via certain sexual activities?

• David's comment that his girlfriend was not at risk because they usually only had unprotected anal sex should have prompted Dr. Phipps to question David more about his sexual activities and his perception of the transmission risks associated with these activities. Again, a pamphlet is no substitute for prevention counseling and it appears that David needs to educated about sexual risk reduction and prevention strategies involving both men and women.

4. How well did Dr. Phipps address David's sexuality?

• David may have stated that his sexual experiences with men were only a phase, but Dr. Phipps should have spent more time with David talking about his sexual identity or made a referral for David to speak to a mental health professional to explore this issue. If David represses parts of his sexuality, it could put him at a higher risk of transmitting HIV to sexual partners of both genders and could put him at greater risk of contracting other STIs.

5. How should Dr. Phipps have answered David's question about parenting?

• Many young adults with HIV want to experience full lives, and for many this includes the joys of parenting. Dr. Phipps should have explained that unprotected vaginal intercourse with his girlfriend would place her at high risk of HIV infection, but that there are technologies available to remove the HIV from his semen and sperm so that she could be artificially inseminated safely. Such a procedure would not only protect her health but also would ensure that their child was born HIV negative.
• If an HIV-infected female patient has the same question, Dr. Phipps should inform her that there are HIV transmission risks associated with carrying a child, but there are extremely effective treatments to prevent a child from becoming infected with a mother's HIV. HIV-infected mothers also should be counseled about healthy feeding choices for their infants, as HIV can be passed through breast milk.

References

1. Kalichman SC, Gore-Felton C. Trauma symptoms, sexual behaviors, and substance abuse: correlates of childhood sexual abuse and HIV risks among men who have sex with men. J Child Sex Abus. 2004;13(1):1-15.
2. Kalichman SC, Simbayi LC. Sexual assault history and risks for sexually transmitted infections among women in an African township in Cape Town, South Africa. AIDS Care. 2004 Aug;16(6):681-9.
3. Ridley CR. Imperatives for ethnic and cultural relevance in psychology training programs. Professional Psychology: Research and Practice. 1985;16(5):611-622.
4. Chodon T. The Role of Culture in HIV/AIDS Health Care -- A Practical Guide for Providers Serving Asian and Pacific Islander Americans. New York, NY: Asian & Pacific Islander Coalition on HIV/AIDS, Inc. 2001.
5. Galanti, G. Caring for Patients from Different Cultures, 2nd edition. Philadelphia: University of Pennsylvania Press. 1997.
6. Yep, GA. Overcoming barriers in HIV/ AIDS education for Asian Americans: Toward more effective cultural communication. In D.C. Umeh (Ed.), Confronting the AIDS epidemic: Cross-cultural perspectives on HIV/AIDS education (pp. 219-230). Trenton, NJ: Africa World Press. 1997.
7. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2005. Vol. 17. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2006.
8. Chin, J., Weiss, L., et al. Looking for a Place to Call Home: A Needs Assessment of Asians and Pacific Islanders Living With HIV/AIDS in the New York Eligible Metropolitan Area, The New York Academy of Medicine; May 2007.
9. Walters KL, Simoni JM, Harris C. Patterns and predictors of HIV risk among urban American Indians. Am Indian Alsk Native Ment Health Res. 2000;9(2):1-21.
10. McCree DH, Wingood GM, DiClemente R, Davies S, Harrington KF. Religiosity and risky sexual behavior in African-American adolescent females. J Adolesc Health. 2003 Jul;33(1):2-8.
11. Song J, Lee MB, Rotheram-Borus MJ, Swendeman D. Predictors of intervention adherence among young people living with HIV. Am J Health Behav. 2006 Mar-Apr;30(2):136-46.
12. Wingood GM, DiClemente RJ, Mikhail I, Lang DL, McCree DH, Davies SL, Hardin JW, Hook EW, Saag M. A randomized controlled trial to reduce HIV transmission risk behaviors and sexually transmitted diseases among women living with HIV: The WiLLOW Program. J Acquir Immune Defic Syndr. 2004 Oct 1;37 Suppl 2:S58-67.
13. Rotheram-Borus MJ, Swendeman D, Comulada WS, Weiss RE, Lee M, Lightfoot M. Prevention for substance-using HIV-positive young people: telephone and in-person delivery. J Acquir Immune Defic Syndr. 2004 Oct 1;37 Suppl 2:S68-77.
14. Fadiman, A. The Spirit Catches You and You Fall Down. A Hmong Child, Her American Doctors, and the Collision of Two Cultures. Farrar, Straus and Giroux: New York. 1997.
15. Boyd-Franklin N. Black Families in Therapy: A Multisystems Approach. New York: Guilford; 1989.
16. Akinbami LJ, Gandhi H, Cheng TL. Availability of adolescent health services and confidentiality in primary care practices. Pediatrics. 2003 Feb;111(2):394-401.
17. Samples CL, Goodman E, Woods E. Epidemiology and Medical Management of Adolescents. In: Pizzo PA, Wilfert C, eds. Pediatric AIDS, 3rd ed. Baltimore: Lippincott Williams & Wilkins; 1998:615.
18. Lyon M, Brasseux C, D'Angelo LJ. Who should I tell? Disclosure of HIV status by infected adolescents. J Adolesc Health. 1999 24:20.
19. Nusbaum MR, Hamilton C, Lenahan P. Chronic illness and sexual functioning. Am Fam Physician. 2003 Jan 15;67(2):347-54.
20. Schouten, JT, Lichtenstein, B. HIV and Sexual Functioning: What's (Not) Up? Seattle Treatment Education Project (STEP) Perspectives. Spring 2002.
21. Yep GA. HIV/AIDS in Asian and Pacific Islander communities in the US: A review, analysis and integration. International Quarterly of Community Health Education 13:293-315. 1993.
22. Inouye, J. The Invisible Disease: HIV/AIDS. In: Asian Americans, Asian Voices: Asian and Asian American Health Educators Speak Out, Zahn L, Editor. 82-105. Jones & Bartlett Publishers. 1999.
23. Matteson, DR. Bisexual and homosexual behavior and HIV risk among Chinese-, Filipino- and Korean-American men. The Journal of Sex Research, 34, 93-104. 1997.
24. Cromer BA, Enrile B, et al.Knowledge, attitudes and behavior related to sexuality in adolescents with chronic disability. Dev Med Child Neurol. 1990 Jul;32(7):602-10.
25. U.S. Census Bureau. Statistical Abstract of the United States: 2006 (125th Edition). Washington: U.S. Census Bureau; 2005.
26. Miller WR, Rollnick S. Motivational interviewing: Preparing people for change, New York: The Guilford Press. 2002.
27. National Asian Women's Health Organization. Communicating Across Boundaries. San Francisco: NAWHO. 1999.
28. Chin D. HIV-related sexual risk assessment among Asian/Pacific Islander American women: an inductive model. Soc Sci Med. 1999 Jul;49(2):241-51.
29. Asian and Pacific Islander American Health Forum (APIAHF). Draft Narrative About Asian and Pacific Islander Gay/Bisexual Men Who Have Sex With Men. San Francisco: APIAHF. 1999.
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31. Substance Abuse and HIV/AIDS in the United States. U.S. Department of Health and Human Services - Health Resources and Services Administration - HIV/AIDS Bureau. June 2006.
32. Santelli JS, Robin L, Brener ND, et al. Timing of Alcohol and Other Drug Use and Sexual Risk Behaviors Among Unmarried Adolescents and Young Adults. Family Planning Perspectives. Volume 33(5). September/October 2001.
33. Youth and Alcohol: Dangerous and Deadly Consequences, Office of the Inspector General, U.S. Department of Health and Human Services, 1992.
34. Cohen M, Deamant C, Barkan S, et al. Domestic violence and childhood sexual abuse in HIV-infected women and women at risk for HIV. Am J Public Health. 2000 April; 90(4): 560-565.
35. Need reference
36. Need reference

Resources

For Providers

Tools

• Case Finding, Primary and Secondary Prevention for Adolescents: Clinical Risk Assessment and Screening Guide. Pennsylvania/MidAtlantic AIDS Education and Training Center. 2006.
• Checklist for HIV Prevention & Treatment Integration
• A Guide to Sexual History Taking with Men who have Sex with Men. California STD/HIV Prevention Training Center. February 2006. Includes questions for adults and teens.
• HEADSS questionnaire with additional questions for for Lesbian, Gay, Bisexual or (LGB) Youth. Psychosocial evaluation tool for adolescents.
• Helping Parents Address an HIV-Positive Child's Sexuality. Guide for address common parental concerns.
• LEARN Model. Cross-cultural communication mneumonic.
• Motivational Interviewing Techniques. Tips from a PWP training curriculum for clinicians.
• Primary Care PTSD Screening Tool. from the National Center for Posttraumatic Stress Disorder, U.S. Department of Veterans Affairs.
• Resources for Developing Abstinence-Based Education Programs. National Center for Education in Maternal and Child Health (NCEMCH) Program Interchange.
• STD/HIV Risk Assessment: A Quick Reference Guide. Mountain-Plains AIDS Education and Training Center.
• Tools for Building Cultural Awareness. From: Transforming the Face of Health Professions Through Cultural & Linguistic Competence Education: The Role of the HRSA Centers of Excellence. March 2005.

Reference Materials

• ABC Guidance #1. For United States Government In-Country Staff and Implementing Partners Applying the ABC Approach To Preventing Sexually Transmitted HIV Infections Within The President's Emergency Plan for AIDS Relief (PEPFAR). Discussion of how best to implement the "ABC" approach in diverse settings and populations. The President's Emergency Plan for AIDS Relief, Office of the U.S. Global AIDS Coordinator.
• Bright Futures: Adolescence. From: Jellinek M, Patel BP, Froehle MC, eds. Bright Futures in Practice: Mental Health-Volume I. Practice Guide. Arlington, VA: National Center for Education in Maternal and Child Health. 2002.
• Best-Evidence Interventions. U.S. Centers for Disease Control and Prevention, Divisions of HIV/AIDS Prevention. Guide to successful HIV/AIDS interventions, listed by target population and methods employed.
• Cultural and Trauma Resources. Fact sheets for working with different populations from the National Child Traumatic Stress Network.
• Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). American Psychiatric Association.
• HIV Transmission and Prevention in Adolescents. Kirby, D. HIV InSite Knowledge Base. 2002.
• Integrating HIV Prevention into the Care of People with HIV. Web listings from HIV InSite, a project of the University of California, San Francisco.
• Prevention with Positives Resources. Web listings from the UCSF AIDS Research Institute.
• Prevention in Positives: A Case Based Workshop for Providers. Shah S, McGowan J, Young S. New York/New Jersey AIDS Education and Training Center. February 2005.
• Prevention With HIV Positive People: What Is It? How to Do It! Institute Manual. Centers for Disease Control and Prevention, National Association of People with AIDS. United States Conference on AIDS. September 2002.

For Adolescents

• AmbienteJoven. Spanish-language Web site for Latino young men who have sex with men (YMSM) and for Latino gay, lesbian, bisexual, transgender and questioning (GLBTQ) youth in the United States and Latin America. Ambiente Joven's peer educators provide culturally relevant information and support on sexual health issues.
• AVERT: Young People's Section. Offers information about young people and HIV/AIDS, as well as birth control and contraception, condoms, sex, sexuality, and puberty. A London-based HIV/AIDS information website.
• It's Your (Sex) Life. Guide to safe and responsible sex for teens from the Henry J. Kaiser Family Foundation. Includes information on HIV/AIDS, pregnancy and contraception, and communicating about sex.
• IWannaKnow. Answers to questions on teen sexual health and sexually transmitted diseases from the American Social Health Association (ASHA).
• Learn More About Condoms. Brief guide from Advocates for Youth.
• My Sistahs. Sexuality and relationship information for young African American, Asian American, Latina, and Native American women, including information on STDs and HIV/AIDS.
• Sex and Sexuality. HIV InSite, University of California, San Francisco. Practical advice for people with HIV.
• Teen Talk. U.S. Department of Health and Human Services. Office of Population Affairs. Advice sheet for youth with an abstinence message
• YouthResource. Is created by and for GLBTQ youth and offers support, community, resources, and peer-to-peer education about sexual health and other issues of concern to GLBTQ youth. Project of Advocates for Youth.

For Parents

• Advocates for Youth: Parents' Sex Ed Center. Fact sheets, videos, expert advice and more for parents wishing to better understand and communicate with their teens.
• Bright Futures: Adolescence. From: Jellinek M, Patel BP, Froehle MC, eds. Bright Futures in Practice: Mental Health-Volume I. Practice Guide. Arlington, VA: National Center for Education in Maternal and Child Health. 2002. This practice guide addresses the parent-teen relationship.
• Planned Parenthood: For Parents. Planned Parenthood. Resources for parents about talking to teens about sex.
• For Parents: Resources. Adolescent Health Working Group. Resource collection cover topics such as talking to teens about sex, pregnancy, health care, drug use, and sexual orientation.
• Parenting Corner. American Academy of Pediatrics website featuring information and materials for parents.
• Talking With Kids About Tough Issues. Website from Children Now and Kaiser Family Foundation. Covers sex, drugs, violence, media, and other issues.