Responding to HIV/AIDS in Our Communities
by Paula Toynton, M.Ed.

Although the prevalence of HIV/AIDS in the United States makes up only 3.2% of the global epidemic, it remains a serious, continuous, and for some populations, a growing health crisis in our communities. For example, did you know that there are neighborhoods in the U.S. for which the HIV prevalence rates greater than 25%, like those found in Sub-Saharan Africa? Since school nurses often are the health gatekeepers for individual children, families, and communities, you also present a key opportunity for response to this crisis.

Explore this site to learn your local epidemic profile and to understand what can be done to prevent infection and to encourage testing and diagnosis so that people in your community will benefit from care and treatment. Today testing is easier, new medicine and diagnostics have made treatment of HIV a chronically manageable disease, and we know more about what changes risk behavior.

Our goal is to help you build an "HIV/AIDS Go Box" that will ensure your readiness to respond to the HIV issues you might face. Included is basic information for talking about HIV and AIDS, numerous Internet links to make certain that you have the latest information and resources at your finger tips, as well as a summary of critical best practices. This information is offered to assist you in dealing with a highly stigmatized health topic.

Start by clicking on one of the headings below.

I. Understanding HIV and AIDS: Start with a True/False quiz of basic information everyone should know, followed by detailed answers. A great exercise for everyone. Good facts to know and tell.

II. HIV/AIDS "Go Box": Build a resource file that includes: 1) your community epidemiological profile to help you define your focus and role; 2) basic fact sheets for youth; 3) community and internet health and social service resources for referral; and 4) HIV/AIDS and sexual health educational materials and activities.

III. Best Practices for Prevention, Risk Assessment, and Motivational
Interviewing: Learn the key elements for risk assessment readiness and best practices for discussing HIV facts, risk, counseling and testing and care and treatment, as well as developing readiness through motivational strategies to encourage people to take action.

IV. Resources: Access useful and up-to-date HIV/AIDS Internet resources quickly. Links will provide a complete listing of those referenced throughout the web site, sorted by purpose and content for quick access. Local resources for counseling and testing, prevention and care and treatment, as well as national educational and epidemiological data are included.

I. Understanding HIV and AIDS: A True and False Quiz     Back to top

These are basic facts everyone should know. Read through the True/False

statements below to test your knowledge. Then read the detailed answers to

learn more about each issue.

1.	HIV is found throughout every region of the world	TRUE / FALSE
2.	Effective treatment has raised the number of people living with HIV in the United States to 1.2 million	TRUE / FALSE
3.	New infection rates have remained level for over a decade at 40,000 new cases a year, with increases in some populations	TRUE / FALSE
4.	25% of people living with HIV remain undiagnosed and are believed to be responsible for a significant percent of new infections	TRUE / FALSE
5.	In 2005, Black/African American and Latino/Hispanic individuals experienced nearly 80% of US AIDS diagnosis in 2005. Poverty being the greatest common denominator.	TRUE / FALSE
6.	In the U.S., sexual transmission is responsible for most new adolescent HIV infections	TRUE / FALSE
7.	In 2002, teen girls represented 51% of AIDS cases reported among 13-19 year olds	TRUE / FALSE
8.	Black/African American teens represent 65% of cases reported among 13-19 year olds; Latino/Hispanic teens represent 20%	TRUE / FALSE
9.	The CDC says that latex condoms, when used consistently and correctly, are highly effective in preventing the sexual transmission of HIV.	TRUE / FALSE
10.	Human sexuality education lowers the incidence of HIV and other sexually transmitted diseases in youth	TRUE / FALSE

Answers: Understanding HIV and AIDS

1. True
The HIV/AIDS epidemic has already claimed more than 25 million lives and another 39.5 million people are currently estimated to be living with HIV/AIDS worldwide. HIV/AIDS cases have been reported in all regions of the world, but most people living with HIV/AIDS (95%) reside in low- and middle-income countries, where most new HIV infections and AIDS-related deaths occur. The nations of sub- Saharan Africa have been hardest hit, followed by the Caribbean; there is also concern about the epidemic in parts of Eastern Europe and Asia. HIV is the leading cause of death worldwide (among those aged 15-59). It is considered a threat to the economic well-being, social, and political stability of many nations.
http://www.kff.org/hivaids/upload/3030-08.pdf

2. True
HIV testing is important for both prevention and treatment efforts. HIV-related mortality rates rose steadily through the 1980's, peaking in 1994-1995. Since then, the age-adjusted HIV death rate has declined by more than 70%, including a 4% decline between 2002 and 2003, largely due to highly active antiretroviral therapy (HAART), but also to the decrease in annual new HIV infections in the 1990s compared to the prior decade. In 2003, HIV was the 6th leading cause of death for those aged 25-44, down from #1 in 1995.
http://www.kff.org/hivaids/upload/3029-071.pdf

3. True
Annual HIV incidence is down from its peak of more than 150,000 in the 1980s to approximately 40,000 new infections per year today. However, it has remained at this level for more than a decade and recent analyses suggest a potential rise among some populations.
http://www.kff.org/hivaids/upload/3029-071.pdf

4. True
The majority of persons who are aware of their HIV infection substantially reduce sexual behaviors that might transmit HIV after they become aware that they are infected. In a meta-analysis of findings from eight studies, the prevalence of unprotected anal or vaginal intercourse with uninfected partners was on average 68% lower for HIV-infected persons who were aware of their status than it was for HIV-infected persons who were unaware of their status.
http://www.cdc.gov/mmwR/preview/mmwrhtml/rr5514a1.htm

5. True
Racial and ethnic minorities have been disproportionately affected by HIV/AIDS since the beginning of the epidemic, and now represent the majority of new AIDS cases (71%) and people living with AIDS (64%) in 2005.
http: //www.kff.org/hivaids/upload/3029-071.pdf

6. True
An estimated half of all new HIV infections occur in people under age 25. Most young people are infected through sex.
http://www.kff.org/youthhivstds/upload/U-S-Teen-Sexual-Activity-Fact-Sheet.pdf

7. True
In 2002, girls represented 51% of HIV cases reported among 13-19 year olds, compared to 30% of cases reported among people over age 25 that same year.
http://www.kff.org/youthhivstds/upload/U-S-Teen-Sexual-Activity-Fact-Sheet.pdf

8. True
Among youth, minorities and teen girls have been particularly hard hit by HIV/AIDS. Young Black/African Americans represented 65% of AIDS cases reported among 13-19 year olds in 2002; Latino/Hispanic teens represented 20%. Having sex with men is the leading risk behavior for young black/African American and Latino/Hispanic men/boys.
http://www.kff.org/youthhivstds/upload/U-S-Teen-Sexual-Activity-Fact-Sheet.pdf

9. True
Latex condoms, when used consistently and correctly, are highly effective in preventing transmission of sexually transmitted diseases including HIV, the virus that causes AIDS. In addition, correct and consistent use of latex condoms can reduce the risk of other sexually transmitted diseases (STDs), including discharge and genital ulcer diseases. While the effect of condoms in preventing human papillomavirus (HPV) infection is unknown, condom use has been associated with a lower rate of cervical cancer, an HPV-associated disease.
http://www.cdc.gov/nchstp/od/condoms.pdf

10. True
UNAIDS Review, commissioned in 1997 by the Joint United Nations Program on HIV/AIDS (UNAIDS), examined 68 reports on sexuality education from France, Mexico, Switzerland, Thailand, the United Kingdom, the United States, and various Nordic countries. The review found 22 studies that reported that HIV and/or sexual health education delayed the onset of sexual activity, reduced the number of sexual partners, or reduced unplanned pregnancy and STD rates. The review also found that education about sexual health and/or HIV does not encourage increased sexual activity.
http://www.siecus.org/pubs/fact/fact0007.html

II. HIV/AIDS "Go Box":     Back to top

Build a resource file that includes: 1) your community epidemiological profile to help you define your focus and role; 2) basic fact sheets for youth; 3) community health and social service resources for referral; and 4) HIV/AIDS and Sexual Health Educational Materials and Activities.

Please follow the Internet links provided to create a "Go Box" that will serve your local needs.

Your State and Community Epidemiological Profile

• http://www.cdc.gov/hiv/topics/surveillance/resources/
  reports/2005report/webaddress.htm
  
  
Note, the level of statistical detail varies by state. You may have to contact your local health department for more regional data.

History of HIV/AIDS Interactive Timeline

• http://www.kff.org/hivaids/timeline/hivtimeline.cfm
  

Fact Sheets and Other Resources for Youth

• http://www.kff.org/hivaids/youth.cfm
  

• http://www.cdc.gov/hiv/resources/factsheets/youth.htm

Sexual Health and Healthy Sexuality for Youth

• Sex etc. newsletter and website
  
• Gay, Lesbian and Transgender Youth (GLBTY)

Care and Treatment: The Ryan White CARE Act
http://hab.hrsa.gov/programs/MetropolitanGrantAreas/
The CARE Act programs work with cities, States, and local community-based organizations to provide services to more than 500,000 individuals each year who do not have sufficient health care coverage or financial resources for coping with HIV disease. The majority of CARE Act funds support primary medical care and essential support services. A smaller but equally critical portion is used to fund technical assistance, clinical training, and research on innovative models of care. The CARE Act, which was first authorized in 1990, is currently funded at $2.06 billion.


HIV/AIDS Hotlines
http://www.thebody.com/hotlines/national.html
This is a list of various National Hotlines for HIV and AIDS, as well as related issues.

Counseling and Testing Services
http://www.cdc.gov/hiv/topics/testing/resources/qa/testing_locations.htm
This CDC site answers questions about testing; it also serves as a link for locating testing services nearest you.

Red Cross HIV Prevention Education for Youth
http://www.redcross.org/services/hss/youth/aids.html
All of the American Red Cross HIV/AIDS programs provide opportunities for reaching youth. Videos, brochures, workbooks, comic books, and other materials have been developed to encourage young people and the adults in their lives to openly discuss HIV prevention. The American Red Cross approach involves providing age-appropriate HIV/AIDS education from an early age through adolescence and young adulthood.

Interventions for Youth at High Risk for Acquiring HIV
http://www.effectiveinterventions.org/
Researched behavioral interventions are available in some regions. Contact your local health department to learn what is available in your region. The link below describes these interventions.

General HIV/AIDS Disease and Treatment Information
Life Cycle of the Virus and How Treatment for HIV Works
http://www.aidsmeds.com/articles/hiv_life_cycle_5014.shtml

Stages of HIV Disease Progression without Treatment
http://www.sfaf.org/aids101/hiv_disease.html

Pill Chart
http://www.aids-etc.org/pdf/p02-et/et-03-00/nw_pillchart.pdf

III. Best Practices for Prevention, Risk Assessment,

and Motivational Interviewing:

     Back to top

Personal risk assessment for HIV/AIDS and other STDs requires several steps of readiness building. You may or may not be able to complete an assessment based upon where your student is in the process. Outlined below are key elements for risk assessment readiness and best practices for discussing HIV facts, risk, counseling and testing and care and treatment, as well as developing readiness through motivational strategies that encourage people to take action. Suggested applications of these practices in the school setting have been included.

Seven Key Elements
CAIR Center for AIDS Intervention Research
http://www.mcw.edu/display/router.asp?docid=215

According to Jeffrey A. Kelly, PhD (Medical School of Wisconsin, Behavioral Psychology, Center for AIDS Intervention Research) there are 7 key elements for risk assessment and readiness to change behavior.

1) Knowledge of risk
2) Personalization of risk
3) Efficacy of prevention behaviors and self's ability to change behavior
4) Motivation to change risk behavior
5) Behavioral skills: communication (intra and interpersonal), safer sex, safer drug use
6) Cognitive behavioral problem solving skills
7) Support (intra and interpersonal support)


To read more see J. Kelly's book:
Changing HIV Risk Behavior: Practical Strategies


Application for School Nurses:
Kelly's "Seven Key Elements" offer a checklist. Each "element" builds on the next to develop readiness for an at-risk youth or your community to look at HIV. Used in conjunction with Motivational Counseling (see below), they provide a guide for effective needs assessments with at-risk youth.


Diffusion of Effective Behavioral Interventions (DEBI)
Science-based, community-and group-level HIV prevention interventions
http://www.effectiveinterventions.org/

The Diffusion of Effective Behavioral Interventions (DEBI) project was designed to bring science-based, community-and group-level HIV prevention interventions to community-based service providers and state and local health departments. The goals are to enhance the capacity to implement effective interventions at the state and local levels, to reduce the spread of HIV and STDs, and to promote healthy behaviors.


Application for School Nurses:
DEBIs are a possible referral resource in your area; the website above provides detailed descriptions of DEBIs. To see if DEBIs are provided in your area, contact your local or state health department.


Screening and Treatment for Sexually Transmitted Diseases (STDs) as Prevention for HIV
Testing and treatment of sexually transmitted diseases (STDs) can be an effective tool in preventing the spread of HIV, the virus that causes AIDS. An understanding of the relationship between STDs and HIV infection can help in the development of effective HIV prevention programs for persons with high-risk sexual behaviors. Individuals who are infected with STDs are at least two to five times more likely than uninfected individuals to acquire HIV if they are exposed to the virus through sexual contact.
http://www.cdc.gov/std/hiv/STDFact-STD&HIV.htm


Application for School Nurses:
Sexually active students should be referred for STDs screening and testing.


Routine (not mandatory) Opt-Out verses Opt-In HIV Screening
The CDC recommends HIV screening for patients in all health-care settings after the patient is notified that testing will be performed unless the patient declines (opt-out screening).
http://www.cdc.gov/mmwR/preview/mmwrhtml/rr5514a1.htm

Evidence for the Opt-Out Approach to HIV Screening
The chance that HIV infection is transmitted from a mother who is HIV infected to her child during pregnancy can be reduced to 2 percent or less (fewer than 2 out of every 100). This is possible because of better medicines available to treat HIV. Prior to new anti-HIV treatments, the incidence of mother-to-child transmission was 25%. But first, the pregnant woman and her doctor must know if she is infected with HIV.

In the November 15, 2002, Morbidity and Mortality Weekly Report (MMWR), CDC published information on recent prenatal HIV testing rates in the United States and Canada. The report looked at HIV prenatal testing rates when different testing approaches were used. There are two ways to do voluntary HIV testing:


• Opt-in:
  
  • Pregnant women are given pre-HIV test counseling.
    
  • They must agree to get an HIV test, usually in writing.
    
• Opt-out:
  
  • Pregnant women are told that an HIV test will be included in the standard group of prenatal tests (that is to say, tests given to all pregnant women), and that they may decline the test.
  • Unless they decline, they will receive an HIV test.
    

Statistics published in the MMWR showed that in eight states using the opt-in approach in 1998-1999, testing rates ranged from 25% to 69%. In Tennessee, which uses an opt-out approach, the testing rate was 85%. This and other information on prenatal HIV testing suggests that, of the voluntary approaches to prenatal HIV testing, more women are tested with the opt-out approach.
The opt-out approach offers the best chance that people will routinely be tested for HIV because it de-stigmatizes testing. Two-thirds of people who know their HIV status will reduce or eliminate their risk of transmission to others. Treatment will lower viral load and reduce the risk of transmission to others for those people living with HIV/AIDS (PLWHA) who have difficulty reducing their risk behavior.


Application for School Nurses:
Opt-out Strategies could be used in school-wide efforts to provide risk assessment and counseling to all youth. This would avoid stigmatization of at-risk youth and increased awareness among those not identified as at-risk. Most importantly, it will help channel students at risk to appropriate resources.

In addition, school nurses may have to explain "routine testing" to students and their families who have encountered routine testing in their health care.



Risk Assessment Questionnaire
Assess Your Risk for HIV & Other Sexually Transmitted Diseases
http://www.thebody.com/surveys/sexsurvey.html

Thebody.com is a one-stop resource for practical HIV/AIDS news, information and resources written by experts, as well as various Internet resources. In the survey section, an anonymous test for individuals to discover their risk for HIV or other sexually transmitted diseases (STDs) is offered. This is a learning tool as well as a risk assessment tool. Participants should answer these questions as honestly as they can in order to rule out whether they have possibly been exposed to HIV or other sexually transmitted diseases. Rick Sowadsky, MSPH, Senior Communicable Disease Specialist for the Nevada State Health Division AIDS Program, created the survey. If you have any questions about HIV or other STD prevention, please visit The Body's Safe Sex and Prevention Section.


Application for School Nurses:
Often people like to assess their risks before contemplating testing. This on-line resource offers a confidential assessment opportunity that does not require you to interview the student. The assessment results explain the benefits or risks associated with certain answers and suggest next steps for those who might need testing. Either you or a local counseling and testing professional could be available for debriefing the results. Motivational Counseling Strategies (below) can help the student define the importance of the results and their confidence to take next steps. These strategies will also help you determine what the student might need so that you can make appropriate and effective referrals.


Motivational Interviewing Strategies and Skills

Moving People into Testing, Prevention and Care Motivational Interviewing has become the standard of practice used in counseling to help people change and take action.
http:// www.motivationalinterview.org/clinical/whatismi.html

"Our best current definition is this: Motivational Interviewing (MI) is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. Compared with nondirective counseling, it is more focused and goal-directed. The examination and resolution of ambivalence is its central purpose, and the counselor is intentionally directive in pursuing this goal."


(Stephen Rollnick, Ph.D., & William R. Miller, Ph.D.)
At its most distilled, MI involves clarifying a goal with the client, assessing the importance given by the client to that goal and the level of confidence the client has in achieving his/her goal. Importance and confidence are measured on a scale of 1 (not at all important/no confidence) to 10 (top importance and complete confidence). The interviewer then explores any ambivalence, starting with the positive, "Why do you give it a 4 and not a 1?" This evokes statements of confidence and importance. The follow-up question is, "What do you need to give it an 8? Or 6?" The answer will focus on gaps in the key elements (see Kelly above) or barriers to taking action that then can become the common ground for the counselor and client to work on achieving the client's goal.
Miller and Rollnick's book, Motivational Interviewing:second edition
is recommended if you want to know more.


Application for School Nurses:
The description offered above describes an effective way to have a difficult conversation. It allows you to direct the conversation but with the student's implicit permission given by his/her stated goal - your touchstone. Focus is on positive motivations and student strengths. Motivational interviewing allows for clarification of misunderstandings or other barriers so that you can make appropriate and effective referrals.

IV. Resources     Back to top

General Information

The Body.com
Thebody.com is a one-stop resource for practical HIV/AIDS news, information and resources written by their own experts, as well as various Internet resources. Written in plain language, the site offers both prevention and treatment information and links to other HIV/AIDS resources. Note: Most of the content is for people living with HIV/AIDS (PLWHA).

Kaiser Family Foundation
http://www.kff.org/hivaids/
The Henry J. Kaiser Family Foundation is a non-profit, private operating foundation focusing on the major health care issues facing the nation. The Foundation is an independent voice and source of facts and analysis for policymakers, the media, the health care community, and the general public. Find up-to-date Epidemiological Data (global to state levels) in various presentations (Tables, Graphs and Charts). Also fact sheets on HIV/AIDS by area, population demographics and risk factors.

Centers for Disease Control and Prevention (CDC)
HIV/AIDS
http://www.cdc.gov/hiv/
HIV/AIDS Frequently Asked Questions (FAQ), fact sheets, epidemiological data, prevention and counseling and testing
SIECUS-the Sexuality Information and Education Council
of the United States
http://www.siecus.org/ SIECUS has served as the national voice for sexuality education, sexual health, and sexual rights for over 40 years. SIECUS provides information and training opportunities for educators, health professionals, parents, and communities across the country to ensure that people of all ages, cultures, and backgrounds receive high quality, comprehensive education about sexuality. We work to provide parents and educators with the information they need on important issues such as sexuality education, youth development, sexual and reproductive health, puberty, abstinence, relationships, sexual orientation, body image, self-esteem, sexually transmitted diseases, HIV/AIDS, unintended pregnancy, and more.

Counseling and Testing
"Revised Recommendations for HIV Testing of Adults, Adolescents and Pregnant Women in Health Care Settings: September 2006"
http://www.cdc. gov/mmwR/preview/mmwrhtml/rr5514a1.htm
New recommendations for human immunodeficiency virus (HIV) testing by health care providers working in the public and private sectors, including those working in hospital emergency departments, urgent care clinics, in-patient services, substance abuse treatment clinics, public health clinics, community clinics, correctional health-care facilities, and primary care settings.

HIV/STD Risk Assessment Survey
http://www.thebody.com/surveys/ sexsurvey.html
Anonymous on-line survey with individualized results

HIV Prevention
Diffusion of Effective Behavioral Interventions (DEBI)
Science-based, community-and group-level HIV prevention interventions
http://www.effectiveinterventions.org/

CAIR Center for AIDS Intervention Research
http://www.mcw.edu/display/router.asp?docid=215

Jeffery A. Kelly's book:
Changing HIV Risk Behavior: Practical Strategies

HIV/AIDS and STDs
http://www.cdc.gov/std/hiv/default.htm
Individuals who are infected with STDs are at least two to five times more likely than uninfected individuals to acquire HIV if they are exposed to the virus through sexual contact. In addition, if an HIV-infected individual is also infected with another STD, that person is more likely to transmit HIV through sexual contact than other HIV-infected persons (Wasserheit, 1992).

50 US State Health Departments List
http://www.cdc.gov/hiv/topics/surveillance/resources/reports/ 2005report/webaddress.htm

US Department of Health and Human Services, Human Resources and Services Administration, HIV and AIDS Bureau (US DHHS, HRSA, HAB)
http://hab.hrsa.gov/
The HIV/AIDS Bureau (HAB) of the Health Resources and Services Administration (HRSA) was formed in August 1997 to consolidate all programs funded under the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act. The CARE Act was signed into law on August 15, 1990, to improve the quality and availability of care for people with HIV/AIDS and their families. Amended and reauthorized in May 1996 and November 2000, the Act is named after the Indiana teenager, Ryan White, who became an active public educator on HIV/AIDS after he contracted the syndrome. He died the same year the legislation was passed.

In serving people and families affected by HIV/AIDS, the Bureau, headed by HRSA Associate Administrator Deborah Parham, Ph.D., RN, has identified four factors that have significant implications for HIV/AIDS care, services and treatment:


• The HIV/AIDS epidemic is growing among traditionally underserved
and hard-to-reach populations.


• The quality of emerging HIV/AIDS therapies can make a difference
in the lives of people living with HIV.


• Changes in the economics of health care are affecting the
HIV/AIDS care network.


• Policy and funding increasingly are determined by outcomes.
Red Cross Health and Safety
http://www.redcross.org/services/hss/hivaids/
The American Red Cross educates people on how to stop the transmission of HIV, encourages people to respond in informed ways to people who have HIV, and helps people apply the facts about HIV to their own behavior. These goals are accomplished through our easy to use educational programs designed to reach a variety of audiences.

The views expressed in this article are those of the author and do not necessarily reflect the views of Johnson & Johnson or Rutgers, The State University of New Jersey. The author assumes no responsibility for any action resulting from the information presented.

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