Antiretroviral treatment causes improvement in the immunologic status and reduction in the viral load (Erb et al., 2000) thus reducing the incidence of hospitalization and mortality ( Paterson et al., 2000) .Treatment effectiveness however requires a high level of adherence to medication regimens (Vanhove et al., 1996).Missing of even a few doses of antiretroviral medication can lead to drug resistant strains of HIV (Bangsberg et al., 2000).A previous study (Erhabor et al., 2009) to investigate the short-term effect of highly active antiretroviral therapy on the CD4 lymphocyte count of HIV-infected Nigerians at the Haematology Department of the University of Port Harcourt Teaching Hospital involving 70 HIV-infected subjects placed on highly active antiretroviral therapy and thirty HIV-infected yet to start therapy due to unaffordability were monitored as controls. CD4 lymphocyte count was determined at baseline for subjects and controls. Subjects were placed on HAART for 12 weeks while controls that were yet to start therapy were monitored as controls. CD4 lymphocyte count was repeated after 12 weeks and the differences compared statistically. We observed that subjects and control patients did not differ significantly in their CD4 lymphocyte count at baseline (p > 0.05), but after 12 weeks HAART in subjects, there was a mean increase in CD4 count of (39 cells/μl) in subjects, while untreated controls showed a mean decline of (12 cells/μl) p < 0.05. There was a statistically significant variation in the therapy dependent increases in CD4 count of HAART treated subjects based on pretherapeutic baseline CD4 count (χ2 = 180.39, p < 0.05). The HAART dependent increase in CD4 counts was higher in younger subjects 19-28 years (31 cells/μl) compared to older subjects 49-58 years (21 cells/μl) (p = 0.01). Similarly CD4 response was found higher in females compared to males (p = 0.01). Low adherence has been associated with detectable viral load (>500 viral RNA copies/ml of plasma (Ruthbun et al., 2005) and possible cross resistance to other antiretrovirals of the same class (Tchetgen et al., 2001). A previous study (Nwauche et al., 2006) to evaluate the factors militating against adherence to antiretroviral therapy among 187 HIV-infected persons on a combination therapy of two-nucleoside analogue; stavudine and lamivudine and one non-nucleoside nevirapine in the Niger Delta of Nigeria indicated an adherence rate of 49.2%.Factors associated with non-adherence included; cost of antiretrovirals, educational status of subjects, medication adverse effects, occupational factors and high pill burden of prescribed regimen. There is need for universal access to antiretroviral treatment .Cost constraint remains a major limiting factor on adherence particularly in resource-limited settings (Muko et al., 2004). National government particularly those in sub Saharan Africa have prolonged reluctance to provide the best possible treatment citing numerous concerns ranging from cost to the ability of patients to adhere to complex life-long treatment. However South Africa a country with more than 5 million citizens living with HIV has proved the pundits wrong. The prices of antiretrovirals having precipitously plummeted by more than 95% as a result of the South African government developing the political will to take on board the challenge of universal access. This strategic and humanitarian obligation has resulted in an increase in adherence to a high level of more than 90%.The world health organization must remain resolute on the initiative of universal access to antiretroviral treatment particularly in developing countries where paradoxically the greatest HIV disease burden exist but with an insignificant number having

Nigerian government started an ambitious antiretroviral treatment programme, which aimed to supply 10,000 adults and 5,000 children with antiretroviral drugs within one year. An initial \$3.5 million worth of ARVs were to be imported from India and delivered at a subsidized monthly cost of \$7 per person (Odutolu et al., 2006). The programme was announced as Africa's largest antiretroviral treatment programme. By 2004 the programme had suffered a major setback as too many patients were being recruited without a big enough supply of drugs to hand out. This resulted in an expanding waiting list and not enough drugs to supply the high demand. The patients who had already started the treatment then had to wait for up to three months for more drugs, which can not only reverse the progress the drugs have already made, but can also increase the risk of HIV becoming resistant to the ARVs. Eventually, another \$3.8 million worth of drugs were ordered and the programme resumed. Resources needed to provide sufficient treatment and care for those living with HIV in Nigeria are seriously lacking. A study of health care providers found many had not received sufficient training on HIV prevention and treatment and many of the health facilities had a shortage of medications, equipment and materials (Physicians for Human Rights, 2006). The government's National HIV/AIDS Strategic Framework for 2005 to 2009 set out to provide ARVs to 80 percent of adults and children with advanced HIV infection and to 80 percent of HIV-positive pregnant women, all by 2010 (WHO, UNAIDS, UNICEF,2007). However, only 31 percent of people who needed treatment for advanced HIV infection received it in 2009. According to the latest WHO guidelines (2010), which advise starting treatment earlier, HIV treatment coverage is only 21% (WHO, UNAIDS, UNICEF, 2010). As a result of this slow progress the treatment goals were set back to 2015 in the revised framework (2010 to 2015) (NACA, 2009). It has been estimated that the Nigerian government are contributing an insignificant 5 percent of the funds for the antiretroviral treatment programmes (HERFON, 2007). The majority of the funding comes from development partners. The main donors are PEPFAR (the President's Emergency Plan for AIDS Relief), the Global Fund and the World Bank. In 2002, the World Bank loaned US\$90.3 million to Nigeria to support the 5-year HIV/AIDS Programme Development Project (HERFON, 2007). In May 2007 it was announced that the World Bank were to allocate a further US\$50 million loan for the programme (World Bank, 2008). In 2008 PEPFAR provided approximately US\$448 million to Nigeria for HIV/AIDS prevention, treatment and care, (PEPFAR, 2008) the third highest amount out of PEPFAR's 15 focus countries. In the same vein, the Global Fund in 2008 disbursed US\$95 million in funds for Nigeria to expand treatment, prevention, and prevention of mother-to-child transmission programmes (Global fund 2009). Even the availability of financial resources has not brought the number of patients on ART to the level desired particularly in some settings in Africa.

For example the Global fund has put forward US\$1.9 billion in order to scale-up access to ART (UNAIDS 2006). In some settings in Africa, the cost of antiretrovirals does not seem to be the most important constraint of access to ART, as many of the drugs are supplied free of cost to eligible patients through combined efforts by countries and bilateral and multilateral partners. Mozambique, a country with one of the highest HIV/AIDS burden, only 14% of those in need received ART by the end of 2006 (WHO/UNAIDS/UNICEF 2007). Mozambique spent less than 30% of the donor funds earmarked for the health ministry (Nemes et al., 2006).This poor absorptive capacity of the public institutions in

Nigerian government started an ambitious antiretroviral treatment programme, which aimed to supply 10,000 adults and 5,000 children with antiretroviral drugs within one year. An initial \$3.5 million worth of ARVs were to be imported from India and delivered at a subsidized monthly cost of \$7 per person (Odutolu et al., 2006). The programme was announced as Africa's largest antiretroviral treatment programme. By 2004 the programme had suffered a major setback as too many patients were being recruited without a big enough supply of drugs to hand out. This resulted in an expanding waiting list and not enough drugs to supply the high demand. The patients who had already started the treatment then had to wait for up to three months for more drugs, which can not only reverse the progress the drugs have already made, but can also increase the risk of HIV becoming resistant to the ARVs. Eventually, another \$3.8 million worth of drugs were ordered and the programme resumed. Resources needed to provide sufficient treatment and care for those living with HIV in Nigeria are seriously lacking. A study of health care providers found many had not received sufficient training on HIV prevention and treatment and many of the health facilities had a shortage of medications, equipment and materials (Physicians for Human Rights, 2006). The government's National HIV/AIDS Strategic Framework for 2005 to 2009 set out to provide ARVs to 80 percent of adults and children with advanced HIV infection and to 80 percent of HIV-positive pregnant women, all by 2010 (WHO, UNAIDS, UNICEF,2007). However, only 31 percent of people who needed treatment for advanced HIV infection received it in 2009. According to the latest WHO guidelines (2010), which advise starting treatment earlier, HIV treatment coverage is only 21% (WHO, UNAIDS, UNICEF, 2010). As a result of this slow progress the treatment goals were set back to 2015 in the revised framework (2010 to 2015) (NACA, 2009). It has been estimated that the Nigerian government are contributing an insignificant 5 percent of the funds for the antiretroviral treatment programmes (HERFON, 2007). The majority of the funding comes from development partners. The main donors are PEPFAR (the President's Emergency Plan for AIDS Relief), the Global Fund and the World Bank. In 2002, the World Bank loaned US\$90.3 million to Nigeria to support the 5-year HIV/AIDS Programme Development Project (HERFON, 2007). In May 2007 it was announced that the World Bank were to allocate a further US\$50 million loan for the programme (World Bank, 2008). In 2008 PEPFAR provided approximately US\$448 million to Nigeria for HIV/AIDS prevention, treatment and care, (PEPFAR, 2008) the third highest amount out of PEPFAR's 15 focus countries. In the same vein, the Global Fund in 2008 disbursed US\$95 million in funds for Nigeria to expand treatment, prevention, and prevention of mother-to-child transmission programmes (Global fund 2009). Even the availability of financial resources has not brought the number of patients on ART to the level desired

For example the Global fund has put forward US\$1.9 billion in order to scale-up access to ART (UNAIDS 2006). In some settings in Africa, the cost of antiretrovirals does not seem to be the most important constraint of access to ART, as many of the drugs are supplied free of cost to eligible patients through combined efforts by countries and bilateral and multilateral partners. Mozambique, a country with one of the highest HIV/AIDS burden, only 14% of those in need received ART by the end of 2006 (WHO/UNAIDS/UNICEF 2007). Mozambique spent less than 30% of the donor funds earmarked for the health ministry (Nemes et al., 2006).This poor absorptive capacity of the public institutions in

particularly in some settings in Africa.

most countries in Africa shows that there are other factors; health- systems level barriers (insufficient human resources and judicious use of donor funds) and population –level barriers (lack of information about ART, stigmatization and discrimination) may prevent or restrict access to ART.

Antiretroviral treatment causes improvement in the immunologic status and reduction in the viral load (Erb et al., 2000) thus reducing the incidence of hospitalization and mortality ( Paterson et al., 2000) .Treatment effectiveness however requires a high level of adherence to medication regimens (Vanhove et al., 1996).Missing of even a few doses of antiretroviral medication can lead to drug resistant strains of HIV (Bangsberg et al., 2000).A previous study (Erhabor et al., 2009) to investigate the short-term effect of highly active antiretroviral therapy on the CD4 lymphocyte count of HIV-infected Nigerians at the Haematology Department of the University of Port Harcourt Teaching Hospital involving 70 HIV-infected subjects placed on highly active antiretroviral therapy and thirty HIV-infected yet to start therapy due to unaffordability were monitored as controls. CD4 lymphocyte count was determined at baseline for subjects and controls. Subjects were placed on HAART for 12 weeks while controls that were yet to start therapy were monitored as controls. CD4 lymphocyte count was repeated after 12 weeks and the differences compared statistically. We observed that subjects and control patients did not differ significantly in their CD4 lymphocyte count at baseline (p > 0.05), but after 12 weeks HAART in subjects, there was a mean increase in CD4 count of (39 cells/μl) in subjects, while untreated controls showed a mean decline of (12 cells/μl) p < 0.05. There was a statistically significant variation in the therapy dependent increases in CD4 count of HAART treated subjects based on pretherapeutic baseline CD4 count (χ2 = 180.39, p < 0.05). The HAART dependent increase in CD4 counts was higher in younger subjects 19-28 years (31 cells/μl) compared to older subjects 49-58 years (21 cells/μl) (p = 0.01). Similarly CD4 response was found higher in females compared to males (p = 0.01). Low adherence has been associated with detectable viral load (>500 viral RNA copies/ml of plasma (Ruthbun et al., 2005) and possible cross resistance to other antiretrovirals of the same class (Tchetgen et al., 2001). A previous study (Nwauche et al., 2006) to evaluate the factors militating against adherence to antiretroviral therapy among 187 HIV-infected persons on a combination therapy of two-nucleoside analogue; stavudine and lamivudine and one non-nucleoside nevirapine in the Niger Delta of Nigeria indicated an adherence rate of 49.2%.Factors associated with non-adherence included; cost of antiretrovirals, educational status of subjects, medication adverse effects, occupational factors and high pill burden of prescribed regimen. There is need for universal access to antiretroviral treatment .Cost constraint remains a major limiting factor on adherence particularly in resource-limited settings (Muko et al., 2004). National government particularly those in sub Saharan Africa have prolonged reluctance to provide the best possible treatment citing numerous concerns ranging from cost to the ability of patients to adhere to complex life-long treatment. However South Africa a country with more than 5 million citizens living with HIV has proved the pundits wrong. The prices of antiretrovirals having precipitously plummeted by more than 95% as a result of the South African government developing the political will to take on board the challenge of universal access. This strategic and humanitarian obligation has resulted in an increase in adherence to a high level of more than 90%.The world health organization must remain resolute on the initiative of universal access to antiretroviral treatment particularly in developing countries where paradoxically the greatest HIV disease burden exist but with an insignificant number having

Challenges Associated with the Effective Management of HIV

exposed healthcare workers.

blood transfusion practice in Nigeria.

also untold adverse social and economic effects.

*Technical Report.* Abuja, Nigeria: Policy Project.

counselling.

**10. References**

Infection in a Low Income Setting in Sub Saharan Africa: Case Study of Nigeria 175

urgently address the issue of formulation of occupational health policy in Nigeria as well as provision of training on universal precaution, phlebotomy, modifying procedures that have high risk, developing institutional policy for handling of sharps and post-exposure management of healthcare workers, provision of HIV post-exposure prophylaxis for

Blood transfusion continues to be an important route of transmission of HIV particularly in Nigeria among young children and pregnant women following transfusion for malaria associated anaemia and pregnancy-related complications. Nigeria faces several enduring challenges; chronic blood shortages, high prevalence of transfusion-transmissible infections, absence of functional national blood transfusion service, recruitment and retention of voluntary non –remunerated donors. Blood safety remains an issue of major concern in transfusion practice in Nigeria where national blood transfusion services and policies, appropriate infrastructure, trained personnel and financial resources are inadequate to support the running of a voluntary non-remunerated donor transfusion service. This is further aggravated by the predominance of family replacement and commercially remunerated blood donors, rather than regular benevolent, non-remunerated donors who give blood as a result of altruism. We advocate that commercial remunerated donation of blood be discouraged. There is need for unlimited supply of highly sensitive HIV test kits for the testing of donors. Political will and open-mindedness to innovative ways to improve supply and safety of blood are essential to promote more evidence-based approaches to

The development and widespread use of antiretrovirals in the developed world has brought about a transformed perception of HIV/AIDS from a fatal incurable disease to a chronic manageable illness. There is an urgent need for universal access and sustainability of antiretroviral therapy particularly in Nigeria. There is need for supervised medication delivery. Efforts should be made towards simplifying the therapeutic regimens to reduce the pill burden and substitution with treatment combination and strategies that minimize negative adverse effects coupled with the re-intensification of patient's education and

There is concern in the developed world about the ability of Nigeria to effectively manage her HIV epidemic particularly in the midst of her sub-optimal health infrastructure including widespread poverty and a large and sexually active youthful population. The most effective interventions has to be multi-sectoral, with a high-level government commitment to tackle the problem, policy changes resulting from an awareness of the impact of HIV/AIDS on society, and the development of communications and media efforts, health interventions targeting high-risk populations, laboratory and field research, and scientific training. Without effective multi-sectoral intervention on a large scale, Nigeria is likely to experience not only the tragedy of countless lives forever altered by the virus, but

[1] Adebajo SB, Mafeni J, Moreland S, et al (2002). Knowledge, Attitudes and Sexual

[2] Akani CI, Erhabor O (2006). Sero-epidemiology of HIV infection among abandoned babies in Port Harcourt, Nigeria. *Annals of African Medicine, Vol. 5(1): 6 – 9.*

Behaviour among Nigerian Military Concerning HIV/AIDS and STD*: Final*

access. There is an urgent need for universal access and sustainability of antiretroviral therapy particularly in resource-limited settings. There is need for supervised medication delivery. Efforts should be made towards simplifying the therapeutic regimen to reduce the bill burden and substitution with treatment combination and strategies that minimise negative adverse effects, coupled with the re-intensification of patient education and counselling.

#### **9. Conclusion**

Nigeria is the most populous nation in Africa Nigeria is the most populous nation in Africa and is home is home to more than 130 million people. These individuals belong to more than 350 ethnic and linguistic groups, and their country is ranked among the 25 poorest in the world. As many as six million people are already infected with the virus. HIV prevalence rates in some states are as high as 12 percent. At least two million children have been orphaned by AIDS. Health facilities in Nigeria are suboptimal. Nigeria faces many daunting challenges in dealing with its HIV/AIDS epidemic.

Public education must play a key role in the success of prevention programs and increase in the uptake of HIV testing. Behavioural change programs must encourage individuals to reduce their risk of HIV acquisition. The stigmatization and discrimination that have typified societal responses must be dealt with promptly, as they compromise the effectiveness of prevention programs. The early involvement and support of the government in the HIV/AIDS campaign can set the necessary groundwork for a continuing strong leadership that will be critical for initiating and sustaining an effective nationwide prevention program. Stigmatization and discrimination against PLWHAs are common in Nigeria. Often both Christian and Muslim religious leaders view immoral behaviour as the cause of the HIV/AIDS epidemic. PLWHAs often lose their jobs or are denied health care services because of the ignorance and fear surrounding the disease. There is need for increased national campaigns and more visible and vocal societies and support groups for people infected with or affected by HIV as well as education of the public about HIV/AIDS in a bid to dispelling myths and giving the disease a human face.

New methods to detect antibodies to HIV are needed for diagnosis, and although the simple rapid test and the enzyme-linked immunosorbent assay formats have been improved, they remain expensive for Nigerian patients. Furthermore, voluntary counselling and testing (VCT) programs are still based in urban centres, where they remain inaccessible to many Nigerians. Clinical management of HIV infection requires the regular measurement of CD4+ lymphocytes in the blood. Flow cytometric techniques are expensive and require a significant infrastructure to perform. In addition, the measurement of quantities of virus in the blood—known as viral load—is an important clinical parameter to evaluate the severity of disease and to monitor the efficacy of therapy. These expensive laboratory tests require complex technologies not previously used in much of the developing world. Scientists are devising new methodologies that they hope will be as sensitive as existing methodologies yet more cost effective. To accommodate these new and critical diagnostic clinical tools, Nigerian institutions will need ongoing training, capacity building, and infrastructure development. These requisites will grow even more acute as the country scales up its ART program.

Healthcare workers are at risk of acquiring HIV infection occupationally through percutaneous or mucosal exposure to contaminated blood and body fluids. There is need to urgently address the issue of formulation of occupational health policy in Nigeria as well as provision of training on universal precaution, phlebotomy, modifying procedures that have high risk, developing institutional policy for handling of sharps and post-exposure management of healthcare workers, provision of HIV post-exposure prophylaxis for exposed healthcare workers.

Blood transfusion continues to be an important route of transmission of HIV particularly in Nigeria among young children and pregnant women following transfusion for malaria associated anaemia and pregnancy-related complications. Nigeria faces several enduring challenges; chronic blood shortages, high prevalence of transfusion-transmissible infections, absence of functional national blood transfusion service, recruitment and retention of voluntary non –remunerated donors. Blood safety remains an issue of major concern in transfusion practice in Nigeria where national blood transfusion services and policies, appropriate infrastructure, trained personnel and financial resources are inadequate to support the running of a voluntary non-remunerated donor transfusion service. This is further aggravated by the predominance of family replacement and commercially remunerated blood donors, rather than regular benevolent, non-remunerated donors who give blood as a result of altruism. We advocate that commercial remunerated donation of blood be discouraged. There is need for unlimited supply of highly sensitive HIV test kits for the testing of donors. Political will and open-mindedness to innovative ways to improve supply and safety of blood are essential to promote more evidence-based approaches to blood transfusion practice in Nigeria.

The development and widespread use of antiretrovirals in the developed world has brought about a transformed perception of HIV/AIDS from a fatal incurable disease to a chronic manageable illness. There is an urgent need for universal access and sustainability of antiretroviral therapy particularly in Nigeria. There is need for supervised medication delivery. Efforts should be made towards simplifying the therapeutic regimens to reduce the pill burden and substitution with treatment combination and strategies that minimize negative adverse effects coupled with the re-intensification of patient's education and counselling.

There is concern in the developed world about the ability of Nigeria to effectively manage her HIV epidemic particularly in the midst of her sub-optimal health infrastructure including widespread poverty and a large and sexually active youthful population. The most effective interventions has to be multi-sectoral, with a high-level government commitment to tackle the problem, policy changes resulting from an awareness of the impact of HIV/AIDS on society, and the development of communications and media efforts, health interventions targeting high-risk populations, laboratory and field research, and scientific training. Without effective multi-sectoral intervention on a large scale, Nigeria is likely to experience not only the tragedy of countless lives forever altered by the virus, but also untold adverse social and economic effects.

#### **10. References**

174 HIV-Infection – Impact, Awareness and Social Implications of Living with HIV/AIDS

access. There is an urgent need for universal access and sustainability of antiretroviral therapy particularly in resource-limited settings. There is need for supervised medication delivery. Efforts should be made towards simplifying the therapeutic regimen to reduce the bill burden and substitution with treatment combination and strategies that minimise negative adverse effects, coupled with the re-intensification of patient education and

Nigeria is the most populous nation in Africa Nigeria is the most populous nation in Africa and is home is home to more than 130 million people. These individuals belong to more than 350 ethnic and linguistic groups, and their country is ranked among the 25 poorest in the world. As many as six million people are already infected with the virus. HIV prevalence rates in some states are as high as 12 percent. At least two million children have been orphaned by AIDS. Health facilities in Nigeria are suboptimal. Nigeria faces many

Public education must play a key role in the success of prevention programs and increase in the uptake of HIV testing. Behavioural change programs must encourage individuals to reduce their risk of HIV acquisition. The stigmatization and discrimination that have typified societal responses must be dealt with promptly, as they compromise the effectiveness of prevention programs. The early involvement and support of the government in the HIV/AIDS campaign can set the necessary groundwork for a continuing strong leadership that will be critical for initiating and sustaining an effective nationwide prevention program. Stigmatization and discrimination against PLWHAs are common in Nigeria. Often both Christian and Muslim religious leaders view immoral behaviour as the cause of the HIV/AIDS epidemic. PLWHAs often lose their jobs or are denied health care services because of the ignorance and fear surrounding the disease. There is need for increased national campaigns and more visible and vocal societies and support groups for people infected with or affected by HIV as well as education of the public about HIV/AIDS

New methods to detect antibodies to HIV are needed for diagnosis, and although the simple rapid test and the enzyme-linked immunosorbent assay formats have been improved, they remain expensive for Nigerian patients. Furthermore, voluntary counselling and testing (VCT) programs are still based in urban centres, where they remain inaccessible to many Nigerians. Clinical management of HIV infection requires the regular measurement of CD4+ lymphocytes in the blood. Flow cytometric techniques are expensive and require a significant infrastructure to perform. In addition, the measurement of quantities of virus in the blood—known as viral load—is an important clinical parameter to evaluate the severity of disease and to monitor the efficacy of therapy. These expensive laboratory tests require complex technologies not previously used in much of the developing world. Scientists are devising new methodologies that they hope will be as sensitive as existing methodologies yet more cost effective. To accommodate these new and critical diagnostic clinical tools, Nigerian institutions will need ongoing training, capacity building, and infrastructure development. These requisites will grow even more acute as the country

Healthcare workers are at risk of acquiring HIV infection occupationally through percutaneous or mucosal exposure to contaminated blood and body fluids. There is need to

daunting challenges in dealing with its HIV/AIDS epidemic.

in a bid to dispelling myths and giving the disease a human face.

counselling.

**9. Conclusion**

scales up its ART program.

Challenges Associated with the Effective Management of HIV

patients. *AIDS, 14: 499 – 507.*

practice. *JAMA,* 283(9):1175–1182.

Saharan Africa. *JAMA,* 268:1581–1587.

*Medicine International Health,* 5: 3-9.

*Niger J Med, 14(4):419-421.*

Infection in a Low Income Setting in Sub Saharan Africa: Case Study of Nigeria 177

[20] Chandra PS, Deepthivarma S, Manjula V (2003). Disclosure of HIV infection in South

[21] d' Arminio Monforte A, Lepri AC, Rezza G, et al (2000). Insight into reason for

[22] Daniel OJ, Salako AA, Oluwole FA, Alausa OK, Oladapo OT (2004). Human

[23] de Cock KM, Fowler MG, Mercier E, et al (2000). Prevention of mother- to- child HIV

[24] De Cock KM, Soro B, Coulibaly IM, Lucas SB (1992). TB and HIV infection in sub-

[25] De Cock KM and Weiss HA. The global epidemiology of HIV/AIDS (2000). *Tropical*

[26] Diarra A, Kouriba B, Baby M, Murphy E, Lefrere JJ (2009). HIV, HCV, HBV and syphilis

[28] Ejele OA, Nwauche AC, Erhabor O (2004). Highly active antiretroviral therapy

[29] Ejele OA, Nwauche CA, Erhabor O (2005). Seroprevalence of HIV among unemployed

[30] Ejele OA, Nwauche CA, Erhabor O (2005). Seroprevalence of HIV infection among

[31] Elliott AM, Lout N, Tembo G, et al (1990). Impact of Human immunodeficiency virus on TB patients in Zambia, a cross-sectional study. *BMJ,* 301(6749):412–415. [32] Erb P, Battegay M, Zimmerli W, Rickenbach M, Egger M (2000). Effect of antiretroviral

[33] Energy Information Administration (2007).Official energy statistics from the U.S

[34] Erhabor O, Akani CI, Eyindah CE. Reproductive Health Options among HIV-Infected Persons in a Low Income Setting in the Niger Delta of Nigeria. In press [35] Erhabor O, Uko EK, Adias T (2006). Absolute lymphocyte count as a marker for CD4 T-

[36] Erhabor O, Ejele OA, Nwauche CA (2007). Epidemiology and management of

blood donors in Port Harcourt, Nigeria. *Niger J Med; 14(3):287-289.*

volunteer blood donors. *Transfus Clin Biol*, *16(5-6):444-447.*

*Proceedings of the World AIDS conference, Bangkok, 203 – 208.*

infected cohort study. *Arch Intern Med, 160: 1134-1140.*

government. Nigerian energy profile.

Nigerians. Niger J Med,15(1):56-59.

*HIV/AIDS - Research and Palliative Care: 2 1–5.*

[27] Eberstadt N (2002). The future of AIDS. *Foreign Aff,* 81(6); 22-45.

discontinuation of the first HAART regimen in a cohort of antiretroviral naïve

immunodeficiency virus sero-prevalence among newly diagnosed adult pulmonary TB patients in sagamu, Nigeria. *Nigeria Journal of Medicine,* 3(4):393–397.

transmission in resource-poor countries: Translating research into policy and

rate of positive donations among blood donations in Mali: lower rates among

(HAART) in HIV-infected Africans: The question of the optimal time to start.

individuals undergoing pre-employment medical examination in Port Harcourt.

therapy on viral load, CD4 cell count and progression of acquired immunodeficiency syndrome in a community of human immunodeficiency virus-

lymphocyte count: criterion for initiating antiretroviral therapy in HIV infected

occupational exposure to blood borne viral infections in a resource poor setting: the case for availability of post exposure prophylaxis. *Niger J Clin Pract, 10(2):100-104*. [37] Erhabor O, Jeremiah ZA, Adias TC, Okere CE (2010). The prevalence of human

immunodeficiency virus infection among TB patients in Port Harcourt Nigeria.

India: patterns, reasons and reactions*. AIDS Care, 15:207-215.*

[3] Akani CI, Erhabor O, Allagoa DO (2010). Human immunodeficiency virus prevalence in

[4] Akinnawo EO (1995). Sexual networking, STDs, and HIV/ AIDS transmission among

[5] API consensus expert committee. API TB Consensus guidelines (2006). Management of

[6] Azuonwu O, Erhabor O, Frank-Peterside N (2010).HIV Infection in Long-Distance Truck

[7] Azuonwu O, Erhabor O, Obire O. HIV Seroprevalence among military personnel in the

[8] Bangsberg DR, Hetcht FM, Charlebois ED, Zolopa AR, Holodniy M, Sheiner L,

development of drug resistance in an indigent population.*AIDS,14:357-366*. [9] Bakhireva LN, Abebe Y, Brodine SK, et al (2004). Human immunodeficiency

[10] Bangsberg DR, Hetcht FM, Charlebois ED, Zolopa AR, Holodniy M, Sheiner L,

development of drug resistance in an indigent population.*AIDS,14:357-366*. [11] Barnes PF, Bloch AB, Davidson PT, Snider DE Jr (1991). TB in patients with human immunodeficiency virus infection. *N Engl J Med,* 324(23):1644–1650. [12] Barreiro P, Castilla JA, Labarga P, Soriano V (2007). Is natural conception a valid option for HIV-serodiscordant couples? *Human Reproduction, 22(9): 2353-2358.* [13] Batina A, Kabemba S, Malengela R (2007). Infectious markers among blood donors in

[14] Blumberg HM, Burman WJ, Chaisson RE, et al (2003). American Thoracic

[15] Brenan CA, Bodelle P, Coffey R, et al (2008). The prevalence of diverse HIV-1 strains

[16] British HIV Association (BHIVA) (2000). Guidelines for the treatment of HIV-infected

[17] Cameron DW, Heath- Chiozzi M, Danner S, et al (1998). Prolongation of life and

[19] Carroli G, Rooney C, Villar J (2001). How effective is antenatal care in preventing

ritonavir in patients with advanced HIV disease. *Lancet, 351: 543 – 549*. [18] Cantwell MF, Snider DE Jr, Cauthen GM, Onorato IM (1994). Epidemiology of TB in the

Society/Centres for Disease Control and Prevention/Infectious Diseases Society of

was stable in Cameroonian blood donors from 1996 to 2004. *J Acquir Immune Defic*

prevention of AIDS complications in a randomized controlled clinical trial of

maternal mortality and serious morbidity? An overview of the evidence. *Paediatr*

Democratic Republic of Congo (DRC). *Rev Med Brux*, *28(3):145-149.*

America: treatment of TB. *Am J Respir Crit Care Med,* 167:603–662.

adults with antiretroviral therapy. *HIV Med, 1: 76 – 101*.

United States, 1985 through 1992. *JAMA,* 272(7):535–539.

Ethiopian military personnel. *Mil Med, 169(3): 221–226.*

Nigerian police officers. *Health Transit Rev, (Suppl 5):S113–S121.*

*Palliative Care, 2:179–184.*

*India,* 54:219–234.

print].PMID:21584818.

*Syndr,*49(4):432–439.

*Perinat Epidemiol,* 15(1):1–42.

36(4):583-587.

an unbooked obstetric population in the Niger Delta. *HIV/AIDS - Research and*

pulmonary TB, extra-pulmonary TB and TB in special situations. *J Assoc Physicians*

Drivers in a Low Income Setting in the Niger Delta of Nigeria. *J Community Health.*,

Niger Delta of Nigeria. J Community Health.2011 May 17.[Epud ahead of

Bamberger JD, Chesney MN, Moss A (2000).Adherence to protease inhibitor and

virus/acquired immunodeficiency syndrome knowledge and risk factors in

Bamberger JD, Chesney MN, Moss A (2000).Adherence to protease inhibitor and

Challenges Associated with the Effective Management of HIV

to implementation. *AIDS, 24(13): 1975-1982.*

*infections. San Francisco, January – February 2000.*

zidovudine. *N Engl J Med,* 341:385–393.

framework (NSF) 2010-15.

Commission of Nigeria.

unsafe blood in hospitals.

Country Visit Notes. WHO, Geneva.

AIDS disease in people on triple therapy. *Lancet, 353 – 343.*

immunodeficiency virus. *Semin Pediatr Infect Dis,* 4(4):295–308.

confers resistance to ritonavir. *Nat Med, 2: 760 – 766.*

from a rural area of Cameroon. *Medical Journal, 7:119-124.*

Infection in a Low Income Setting in Sub Saharan Africa: Case Study of Nigeria 179

[56] Manjunath JV, Thappa DM, Jaisankar TJ (2002). Sexually transmitted diseases and

[57] Matthews, L. T., Mukherjee, J. S. (2009). Strategies for harm reduction among HIV-

[58] Matthews, L. T., Baeten, J. M., Celum, C., Bangsberg, D. R. (2010). Periconception pre-

[59] Meibohm A, Alexander JR J, Robertson M (2000). Early versus late initiation of

[60] Miller V, Staszewski S, Nisius G, Lepri AC, Sabin C, Phillips AN (1999). Risk of new

[61] Mofenson LM, Lambert JS, Stiehm ER, et al (1999). Risk factors for perinatal

[62] Mofenson LM (2003). Advances in the prevention of vertical transmission of human

[63] Molla A, Korneveva M, Gao Q, et al (1996). Ordered accumulation of mutation in HIV

[64] Moore R, Kemly J, Barlet J, Chiasson R (2000). Start HAART early (CD4 < 350 cells/μl)

*retroviruses and opportunistic infections. San Francisco, January – February 2000.*  [65] Muko KN, Ngwa VC, Chingan LC, Ngwa IG, Shu EN, Meiberg A (2004). Adherence to

[66] National Agency for the Control of AIDS (NACA) (2009). National HIV/AIDS strategic

[67] National Population Commission of Nigeria (1991).  Ministry of Health alerts Nigerians to the transfusion of

[70] Noah D, Fidas G (2000). *The Global Infectious Disease Threat and Its Implications for the*

[71] Nwauche CA, Erhabor O, Ejele OA, Akani CI (2006). Adherence to antiretroviral

[72] Nwokoji UA, Ajuwon AJ (2004). Knowledge of AIDS and HIV risk-related sexual behaviour among Nigerian naval personnel. *BMC Public Health,* 2004; 4:24.

*United States.* Washington, DC: National Intelligence Council, 2000.

Delta of Nigeria. African Journal of Health Sciences, 13 (3-4):13-17.

South India .*International Journal of STD and AIDS, 13:612-617.*

affected couples who want to conceive. *AIDS Behaviour, 13(1), 5-11.*

sexual lifestyles of long –distance truck drivers: A clinic-epidemiologic study in

exposure prophylaxis to prevent HIV transmission: benefits, risks, and challenges

indinavir (IDV) in combination with zidovudine (ZDV) and lamivudine (3TC) in HIV-infected individuals. *Seventh conference on retroviruses and opportunistic*

transmission of human immunodeficiency virus type 1 in women treated with

or later? Evidence for greater effectiveness if started early. *Seventh conference on*

highly active antiretroviral therapy (HAART). A selection of reported case study

*Republic of Nigeria: Analytic Report at the National Level.* Abuja: National Population

(2006).Evaluation of WHO's contributions to 3'by 5':Annex 5:Regional Office and

therapy among HIV-infected subjects in a resource-limited setting in the Niger

[38] Eriki PP, Okwere A, Aisu T (1991). The Influence of human immunodeficiency virus

[39] Erulkar AS, Bello M (2007).The experience of married adolescent girls in northern

[40] Eshleman SH, Mracna M, Guay L, et al (2001). Selection and fading of resistance

[41] European collaborative study (2005). Mother-to-child transmission of HIV infection in the era of highly active antiretroviral therapy. *Clin Infect Dis,* 40(3):458–457. [42] Fasola FA, Kotila TR, Akinyemi JO (2008). Trends in transfusion-transmitted viral infections from 2001 to 2006 in Ibadan, Nigeria. *Intervirology; 51(6):427-431).* [43] Federal Ministry of Health, Nigeria (2009).National Blood Transfusion Service- About

[44] Federal Ministry of Health, Nigeria (2009). Report of the 2008 National HIV

[45] Fleming AF (1988). Sero epidemiology of human immunodeficiency viruses in Africa.

[46] Foster S, Buvé A (1995). Benefits of HIV screening of blood transfusions in Zambia.

[47] Gibney L, Saquib N, Matzger J (2003). Behavioural risk factors for STD/HIV

[48] Harber KD, Pennebaker J (1992). Overcoming traumatic memories. In: Christianson SA, ed. The handbook of emotion and memory. Hillsdale (NJ): Erlbanin, 359-387. [49] Imade GE, Badung B, Pam S, et al (2005). Comparison of a new, affordable flow

[50] Jayaraman S, Chalabi Z, Perel P, Guerriero C, Roberts I (2010). The risk of transfusiontransmitted infections in sub-Saharan Africa. *Transfusion; 50(2):433-442*. [51] Klitzman RL, Kirshenbaum SB, Dodge B, et al 92004). Intricacies and inter-relationships between HIV disclosure and HAART: a qualitative study. *AIDS Care, 16:628-640*. [52] Lallement M (005). Response to the therapy after prior exposure to nevirapine. *3rd IAS*

[53] Lovgren S (2001). African Army hastening HIV/AIDS spread. *Jenda: A Journal of Culture*

[54] Low SY, Eng P (2009). Human immunodeficiency virus testing in patients with newly–

[55] Mandisodza AR, Charuma H, Masoha A, Musekiwa Z, Mvere D, Abayomi A. (2006).

diagnosed TB in Singapore. *Singapore Med Journal,* 50(5):479–481.

2002 and 2003 period. *Afr J Med Med Sci; 35(1):69-72.*

seroprevalence sentinel survey among pregnant women attending antenatal clinic

transmission in Bangladesh trucking industry. *Social Science and Medicine, 56:1411-*

cytometric method and the manual magnetic bead technique for CD4 Tlymphocyte counting in a northern Nigerian setting. *Clin Diagn Lab Immunol,*

*Conference on HIV Pathogenesis and Treatment, Rio de Janeiro, Brazil, July 24–27.*

Prevalence of HIV infection in school based and other young donors during the

transmission (HIVNET 012). AIDS. 2001 Oct 19; 15(15):1951-1957.

132.

us.

*1424.*

12(1):224–227.

*(Abstract TuFo0205).*

*and African Women Studies*; 1, 2.

in Nigeria: 1-46.

Nigeria. The Population Council,1-19.

*Biomed Pharmacother,* 42(5):309–320.

*Lancet*, *22; 346(8969):225-227.*

infection of TB in Kampala, Uganda. *Annual Review of Respiratory Diseases*. , 40:128–

mutations in women and infants receiving nevirapine to prevent HIV-1 vertical

Challenges Associated with the Effective Management of HIV

world. *Stud Fam Plann,* 37(1):41–48.

118-129.

project program.

monitoring treatment. *JAMA,* 288(2):151–153.

epidemic. AIDS Patient Care and STDs, 17:595-600.

multi-factorial problem. Transfusion; 48(6):1256-261.

[96] The Global Fund (2009). Nigeria and the Global Fund.

Clinical Infectious Diseases, 40 (3), 458 – 465).

*Assoc Physicians AIDS Care (Chic Ill) ; 8(1):47-51.*

Programme on HIV/AIDS.UNAIDS, Geneva.

[100] UNAIDS (1998). *AIDS and the Military*. Best Practice Collection. Geneva. [101] UNAIDS (2004). *AIDS Epidemic Update.* Geneva: UNAIDS, December 2004.

Accessed at https://uniformed services.unaids.org on July 8. [103] UNAIDS/WHO (2005). *AIDS Epidemic Update: December 2005.* Geneva: UNAIDS. [104] UNAIDS (2006).Report on the Global AIDS epidemic: May 2006.Joint United Nations

/2008/2008\_Global\_report.asp. Accessed Aug 11, 2010. [106] UNAIDS (2010). UNAIDS reporton the global AIDS epidemic. [107] UNGASS (2010).UNGASS country progress report, Nigeria.

York: United Nations Development Programme: 141.

human development report.

1956.

Infection in a Low Income Setting in Sub Saharan Africa: Case Study of Nigeria 181

[90] Stanton CK, Holtz SA (2006). Levels and trends in caesarean birth in the developing

[91] Stephenson J (2002). Cheaper HIV drugs for poor nations bring a new challenge:

[92] Sugihantono A, Slidell M, Syaifudin A, Pratjojo H, Utami IM, Sadjimin T, et al (2003).

[93] Sunmola AM (2005). Sexual practices, barriers to condom use and its consistent use among long distance truck drivers in Nigeria. AIDS Care, 17:208-211. [94] Tagny CT, Mbanya D, Tapko JB, Lefrère JJ (2008). Blood safety in Sub-Saharan Africa: a

[95] Tchetgen E, Kaplan EH, Friendland GH (2001).Public health consequences of screening

[97] The World Bank (2008). Nigeria receives US million additional funding for HIV/AIDS

[98] Thorne, CN and Patel, D and Fiore, S and Peckham, C and Newell, ML (2005) Mother-

[99] Tounkara A, Sarro YS, Kristensen S, Dao S, Diallo H, Diarra B, Noumsi TG, Guindo O

[102] UNAIDS (2005). Engaging Uniformed Services in the Fight Against HIV/AIDS.

[105] UNAIDS (2008). Uniting the World against AIDS Report on the global AIDS epidemic.

[108] United Nations Development Programme (2004). *Human Development Report.* New

[109] U.S. Bureau of the Census, Population Division (1998). *International Programs Centre HIV/AIDS Surveillance Data.* Washington, DC: U.S. Bureau of the Census. [110] UNDP 92007/2008). Human and income poverty: developing countries. In 2007/2008

[111] Vanhove GF, Schapiro JM, Winters MA, Iversen A, Merigan TC (1996). Patient's

compliance and drug failure in protease inhibitor monotherapy.JAMA, 276:1955-

Available t:http://www.unaids/en/KnowledgeCentre/HIVData/ Global Report

Syphilis and HIV prevalence among commercial sex workers in central Java, Indonesia: Risk-taking behaviour and attitude that may potentiate a wider

patients for adherence to highly active antiretroviral therapy. Journals of AIDS, 26:

to-child transmission of HIV-1 in the era of highly active antiretroviral therapy.

(2009). Seroprevalence of HIV/HBV co-infection in Malian blood donors. *J Int*

[73] Nyobi BM, Kristiansen KI, Bjune G, Muller F, Holm-Hansen C (2008). Diversity of

[74] Odutolu O (2005). Convergence of behaviour change models for AIDS risk reduction in

[75] Odutolu O, Ahonsi BA, Gboun M, Jolayemi OM (2006). AIDS in Nigeria: A nation on

[76] Palella FJ, Delaney KM, Moorman AC, Loveless MO, Fuhrer J, Satten GA, Aschman DJ,

[77] Pandey A, Benara SK, Roy N, Sahu D, Gayle H, et al (2008). Risk behaviour, sexually

[78] Physicians for Human Rights (2006) 'Nigeria: Access to Health Care for People Living

[79] Paterson DL, Swindell S, Mohr J, Bester M, Vergis EN, Squier C, Wagener MM, Singh N

[81] Pieniazek D, Ellenberger D, Janini LM, et al (1991). Predominance of human

[83] Raufu A (2002). Nigeria promises free antiretroviral drugs to HIV positive soldiers. *Br*

[84] Ruthbun RC, Farmer KC, Stephens JR, Lockhard SM (2005). Impact of an adherence

[85] Salawu L, Murainah HA (2006). Pre-donation screening of intending blood donors for

[86] Sarin R (2003). *A New Security Threat: HIV/AIDS in the Military.* Washington, DC: World

[87] Semprini A E, Vucetich A, Hollander L (2004). Sperm washing, use of HAART and role

[88] Semprini, A. E., Fiore, S. (2004) b. HIV and reproduction. *Current Opinion in Obstetrics*

[89] Silver RL, Wortman CB, Crofton C (1990). The role of coping in support provision: the

Tanzania. *AIDS Res Hum Retroviruses,* 24(6):761–769.

Population and Development Studies.

infection. Ann Intern Med, 133:21-30.

Med, 338: 853-860.

with HIV and AIDS.

*Retroviruses,* 15(6):603–608.

*Med J*; 13; 324(7342):870.

study. *Afr J Med Sci; 35(4):453-456.*

*and Gynaecology, 16(3): 257-262.*

25:199-209.

Watch Institute.

*465-470.*

379-426.

sub-Saharan Africa. *Int J Health Plann Manage*, *20(3):239-52*.

survey along national highways in India. AIDS, 22(5):S81-90.

[80] PEPFAR (2008). FY2008 Country profile: Nigeria. Annual report to congress.

[82] Raufu A (2001). AIDS scare hits Nigerian military. *AIDS Anal Afr; 11*(5):14.

human immunodeficiency type 1 subtype in Kegera and Kilimanjaro regions,

the threshold. The National Response to HIV/AIDS. Harvard Center for

Holmberg SD (1998).Declining morbidity among patients with advanced human immunodeficiency virus infection.HIV outpatients study investigation. N Engl J

transmitted infections and HIV among long-distance drivers: a cross-sectional

(2000).Adherence to protease inhibitor therapy and outcomes in patients with HIV

immunodeficiency virus type 2 subtype in Abidjan, Ivory Coast. *AIDS Res Hum*

clinic on behavioural outcomes and virologic response in treatment of HIV infection: a prospective randomized controlled pilot study. Clinical Therapy,

antibodies to infectious agents in a Nigerian tertiary health institution: a pilot

of elective Caesarean section. *Current Opinion in Obstetrics and Gynaecology, 16(6):*

self-presentation dilemma of victims of life Crisis.In: Sarason BR, Sarason IG, Piece GR, eds. Social Support: An International view. New York: John Wiley and Sons:

**10**

*Puerto Rico*

**Prevention Strategies for**

Christine Miranda, Johanna Maysonet,

*Universidad Central del Caribe, School of Medicine*

**Hispanic/Latino Adolescents**

**HIV Infection Risk Reduction Among**

Diana M. Fernández-Santos, Wanda Figueroa-Cosme,

Adolescence is defined as a "period of development characterized by biological, cognitive, emotional and social reorganization with the ultimate goal of adapting to the cultural expectations of becoming an adult" (Lerner & Steinberg, 2004, p. 16). It is also a developmental period associated with sexual debut as well as risk taking practices. Adolescents are in a stage of experimentation and exploration, and in a search of their sexual identity. The use of alcohol and other drugs enhances sexual arousal and performance, increments impulsive risk decision making, and may function as a stimulus for sensation seeking. These factors may synergistically increase the probability of unsafe sexual practices and illicit drug use (*National Institute on Alcohol Abuse and Alcoholism* [Robles 2004). Despite HIV prevention efforts during the past decade, teenagers represent one of the fastest growing groups of newly HIV-infected persons. Sexual transmission accounts for

The physiological, psychological, and social–cultural changes that take place during the adolescence period places this group of young individuals at higher levels of risk to get infected with HIV. These factors contribute to the increment of the newly acquired HIV

Hispanic/Latino adolescents have presented a high incidence of HIV infection for many years. Several research studies have examined the risk factors and scenarios among this group and have developed HIV prevention strategies to lessen HIV infections. Most of these studies have been evaluated within Hispanic/Latino populations residing in the United States. It is relevant to validate and confirm these observations in other countries around the world. However, it is important to develop and test interventions that are directed to

This chapter describes and analyzes the HIV epidemiology, HIV-related risk factors, and prevention strategies for Hispanic/Latino adolescents based on a literature review and our experience with "A Supportive Model for HIV Risk Reduction in Early Adolescent" (ASUMA Project). We will also discuss future implications for the development of strategies

infection seen among adolescents in developing and developed countries.

address HIV infections among other Hispanic/Latino countries.

to address HIV prevention for Hispanic/Latino adolescents.

**1. Introduction**

most cases of HIV during adolescence.

Angel Mayor-Becerra and Robert Hunter-Mellado

### **Prevention Strategies for HIV Infection Risk Reduction Among Hispanic/Latino Adolescents**

Diana M. Fernández-Santos, Wanda Figueroa-Cosme, Christine Miranda, Johanna Maysonet, Angel Mayor-Becerra and Robert Hunter-Mellado *Universidad Central del Caribe, School of Medicine Puerto Rico*

#### **1. Introduction**

182 HIV-Infection – Impact, Awareness and Social Implications of Living with HIV/AIDS

[112] van Leeuwen E, Repping S, Prins J M, Reiss P, van der Veen F. (2009). Assisted

[113] Volberding P (2010). When and where to start: guidelines for the initiation of

[115] WHO/UNAIDS/UNICEF (2007). Towards Universal Access: Scaling up Priority

[116] WHO/UNAIDS/UNICEF (2008). Towards Universal Access: Scaling up Priority HIV/AIDS Interventions in the Health Sector. Progress Report, WHO, Geneva. [117] WHO/UNAIDS/UNICEF (2010). Towards Universal Access: Scaling up Priority HIV/AIDS Interventions in the Health Sector. Progress Report, WHO, Geneva. [118] World Bank (2004). Memorandum of the President of the International Development

[119] World Health Organization (2010). Rapid advice: Revised WHO principles and

[120] Yashioka MR, Schustack A (2001). Disclosure of HIV status: cultural issues of Asian

[121] Yusuph H (2005). Prevalence of HIV infection, in TB patient in Nguru, North Eastern

[122] Zohoun A, Lafia E, Houinato D, Anagonou S (2004). Risk of HIV-1 or 2 infections associated with transfusion in Benin. *Bull Soc Pathol Exot; 97(4):261-264.*

infected man. *Netherland Journal of Medicine, 67(8), 322-327.*

antiretroviral therapy. AIDS Reader, 10: 150 – 155.

[114] WHO (2008).WHO African region: Nigeria.

Federal Republic of Nigeria.

patients. *AIDS Care STDs, 15:77-82.*

Nigeria. *Sahel Medical Journal,* 8(3):65–67.

Geneva.

Aug 11, 2010.

reproductive technologies to establish pregnancies in couples with an HIV-1-

HIV/AIDS Interventions in the Health Sector. Progress Report, April 2007.WHO,

Association and the International Finance Corporation to the Executive Directors on a World Bank Group Second Joint Interim Strategy Progress Report for the

recommendations on infant feeding in the context of HIV.2009.Available at: http://whqlibdoc.who.int/publications/2009/9789241598873\_eng.pdf.Accessed

Adolescence is defined as a "period of development characterized by biological, cognitive, emotional and social reorganization with the ultimate goal of adapting to the cultural expectations of becoming an adult" (Lerner & Steinberg, 2004, p. 16). It is also a developmental period associated with sexual debut as well as risk taking practices. Adolescents are in a stage of experimentation and exploration, and in a search of their sexual identity. The use of alcohol and other drugs enhances sexual arousal and performance, increments impulsive risk decision making, and may function as a stimulus for sensation seeking. These factors may synergistically increase the probability of unsafe sexual practices and illicit drug use (*National Institute on Alcohol Abuse and Alcoholism* [Robles 2004). Despite HIV prevention efforts during the past decade, teenagers represent one of the fastest growing groups of newly HIV-infected persons. Sexual transmission accounts for most cases of HIV during adolescence.

The physiological, psychological, and social–cultural changes that take place during the adolescence period places this group of young individuals at higher levels of risk to get infected with HIV. These factors contribute to the increment of the newly acquired HIV infection seen among adolescents in developing and developed countries.

Hispanic/Latino adolescents have presented a high incidence of HIV infection for many years. Several research studies have examined the risk factors and scenarios among this group and have developed HIV prevention strategies to lessen HIV infections. Most of these studies have been evaluated within Hispanic/Latino populations residing in the United States. It is relevant to validate and confirm these observations in other countries around the world. However, it is important to develop and test interventions that are directed to address HIV infections among other Hispanic/Latino countries.

This chapter describes and analyzes the HIV epidemiology, HIV-related risk factors, and prevention strategies for Hispanic/Latino adolescents based on a literature review and our experience with "A Supportive Model for HIV Risk Reduction in Early Adolescent" (ASUMA Project). We will also discuss future implications for the development of strategies to address HIV prevention for Hispanic/Latino adolescents.

Prevention Strategies for HIV Infection Risk Reduction Among Hispanic/Latino Adolescents 185

2008 (CDC, 2008). Hispanic/Latino living in the U.S. had the second highest HIV infection rate in 2008 (CDC, 2008). Specifically, Puerto Rican born females and male adults held the second and third positions of HIV infections in the U.S. respectively. According to the 2009 YRBSS, Hispanic/Latino students, had the second highest prevalence of having sexual intercourse (49.1%), of which 14.2% reported having four or more partners during their

Until March 2011, the Puerto Rico HIV/AIDS Surveillance Office reported 43,100 cumulative HIV/AIDS cases in Puerto Rico where 50 cases were among adolescents aged 13 to 14 years old and 19,549 (45%) were among adolescents and young adults aged 15-34 years old. This fact indicates that many of these young adults were infected during adolescence since the median incubation between the HIV infection and AIDS diagnosis ranges between 4 to 10 years. In PR, the highest HIV modes of transmission are intravenous drug use (IDU) (46%) followed by heterosexual contact (27%) and men who have sex with men (MSM) (23%) (Puerto Rico HIV/AIDS Surveillance, 2011). Robles et al. (2007) reported an early age of sexual initiation among Puerto Rican adolescents at age 15 (26.8%), where the proportion of sexually active adolescents nearly doubled from elementary to intermediate school and

In general, the adolescent population is a growing vulnerable age group at risk of acquiring the HIV virus. For this reason, future studies with special emphasis on prevention to reduce

Several factors related to HIV infection among adolescents have been studied using an ecological approach. In Hispanic/Latino adolescents, few studies had been performed involving the nature of the interplay between individual, family, and social factors in a

Papalia and Wendkos (1997) define adolescence as a transition period of development between childhood and adulthood. This developmental stage fluctuates between ages 12 and 19 years. Biologically, adolescent's immature reproductive and immune systems make them more vulnerable to infection by various STI pathogens (Cates, & McPheeters, 1997; as cited in Sales, & DiClemente, 2010, p. 2). Offer and Offer (1974) found that one third of adolescents had difficulty facing unexpected events and frequently came back to immature behaviors and were displeased during difficult times. Adolescents frequently use alcohol, cannabis, or tobacco. Recently a new drug known as ecstasy has emerged. Drugs provoke un-inhibited effects in human behavior. Some of the published explanations for the high transmission rates of STI in adolescents include the use of oral contraceptives. That results in unprotected sex, a feeling of invulnerability towards STI, the presence of a non-susceptible

Sensation seeking is a personality factor that could have an important role in HIV risk behavior. Sensation seeking focuses on the need for new and varied experiences through uninhibited behavior, these include dangerous activities, a non-conventional lifestyle, and a

**3. Factors related to HIV infection among Hispanic/Latino adolescents**

lifetime, only preceded by African American students (CDC, 2009).

the HIV/AIDS morbidity and mortality should be conducted.

synergistic manner to decrease HIV infection among them.

belief, and the desire for sensation seeking.

from intermediate to high school.

**3.1 Individual factors**

**3.2 Sensation seeking**

#### **2. Epidemiology of HIV infection among Hispanic/Latino adolescents**

The Human Immunodeficiency Virus (HIV) is a retrovirus transmitted by contact with blood and other body fluids usually via risky behavioral practices incurred during sexual activities, intravenous drugs use, and in the past with the administration of blood products. In 2008, an estimate of 33.4 million people, in which 2.1 million were children under 15 years old, were living with HIV worldwide (Joint United Nations Programme on HIV/AIDS [UNAIDS] & World Health Organization [WHO] 2009).

Teenagers represent one of the fastest growing groups of newly HIV-infected persons. In 2008, a global estimate of 430,000 new HIV infections occurred among children under the age of 15 (UNAIDS & WHO, 2009). Despite the number and extent of HIV preventive strategies, young people accounted for about 40% of all new adult HIV infections worldwide. (UNAIDS & WHO, 2009). For the vast majority of individuals, sexual relations begin in adolescence, in which the use of illicit drugs and alcohol function as mediators in the adolescents' engagement in sexual risky behaviors.

Until 2008, Latin America occupied the third position in HIV prevalence, accounting for 2 million persons living with HIV/AIDS (UNAIDS & WHO, 2009). UNAIDS and WHO (2009) reported an increase in the number of newly infected children from 6,200 children in 2001 to 6,900 children in 2008. The modes of HIV transmission varied according to the geographic location and the individual's social and cultural backgrounds. Men who have sex with men (MSM) is the predominant transmission mode in North and Latin America, Central and Western Europe, and Oceania; while heterosexual transmission is the highest transmission mode in Africa, Guyana, and in some countries in Central America and the Caribbean (Wilson, Wright, Safrit, & Rudy, 2010).

The Centers for Disease Control and Prevention (CDC, 2008) estimated that 1,106,400 adults and adolescents were living with HIV in the United States at the end of 2006. As of 2009, an approximate of 4.8% (551,455 cases) of the 1,108,611 AIDS cases in the U.S. were adolescents between the ages of 13 and 24 years (CDC, 2009). From 2006 to 2009, an increase in the number of HIV infections among adolescents and young adults living in the U.S. was reported (Centers for Disease Control and Prevention [CDC], 2009). In 2009, most HIV infections and the highest HIV infection rate (36.9 per 100,000 persons) were among persons aged 20 to 24 years (CDC, 2009). For the same year, the incidence rate of HIV infection in the group between 15 and 19 years in the U.S. increased from 9.6 per 100,000 in 2006 to 12.0 per 100,000 (CDC, 2009). Similarly, the incidence rates in the group between 20 and 24 years increased from 28.2 per 100,000 in 2006 to 36.9 per 100,000 in 2009 (CDC, 2009). On the other hand, the rates of adolescents and young adults with AIDS diagnosis increased from 1.9 to 2.2 per 100,000 in the age group between 15 and 19 and from 7.7 to 9.7 per 100,000 in the group 20 to 24 between the years 2006 and 2009 (CDC, 2009).

The CDC Youth Risk Behavior Surveillance System (YRBSS) conducted a survey among junior and high school students from public and private schools in the U.S. mainland and its territories. The 2009 survey results reported that 46.0% of U.S. junior and high school students had sexual intercourse; and among those, 34.2% reported being sexually active during the three months prior to the survey (CDC, 2009). The survey also revealed that twenty-one percent of sexually active students drank alcohol or used illegal drugs before their last sexual intercourse (CDC, 2009).

Furthermore, the number of Hispanic/Latino living with an AIDS diagnosis in the United States and its territories (including PR) increased since 1996 and continued over years until 2008 (CDC, 2008). Hispanic/Latino living in the U.S. had the second highest HIV infection rate in 2008 (CDC, 2008). Specifically, Puerto Rican born females and male adults held the second and third positions of HIV infections in the U.S. respectively. According to the 2009 YRBSS, Hispanic/Latino students, had the second highest prevalence of having sexual intercourse (49.1%), of which 14.2% reported having four or more partners during their lifetime, only preceded by African American students (CDC, 2009).

Until March 2011, the Puerto Rico HIV/AIDS Surveillance Office reported 43,100 cumulative HIV/AIDS cases in Puerto Rico where 50 cases were among adolescents aged 13 to 14 years old and 19,549 (45%) were among adolescents and young adults aged 15-34 years old. This fact indicates that many of these young adults were infected during adolescence since the median incubation between the HIV infection and AIDS diagnosis ranges between 4 to 10 years. In PR, the highest HIV modes of transmission are intravenous drug use (IDU) (46%) followed by heterosexual contact (27%) and men who have sex with men (MSM) (23%) (Puerto Rico HIV/AIDS Surveillance, 2011). Robles et al. (2007) reported an early age of sexual initiation among Puerto Rican adolescents at age 15 (26.8%), where the proportion of sexually active adolescents nearly doubled from elementary to intermediate school and from intermediate to high school.

In general, the adolescent population is a growing vulnerable age group at risk of acquiring the HIV virus. For this reason, future studies with special emphasis on prevention to reduce the HIV/AIDS morbidity and mortality should be conducted.

#### **3. Factors related to HIV infection among Hispanic/Latino adolescents**

Several factors related to HIV infection among adolescents have been studied using an ecological approach. In Hispanic/Latino adolescents, few studies had been performed involving the nature of the interplay between individual, family, and social factors in a synergistic manner to decrease HIV infection among them.

#### **3.1 Individual factors**

184 HIV-Infection – Impact, Awareness and Social Implications of Living with HIV/AIDS

The Human Immunodeficiency Virus (HIV) is a retrovirus transmitted by contact with blood and other body fluids usually via risky behavioral practices incurred during sexual activities, intravenous drugs use, and in the past with the administration of blood products. In 2008, an estimate of 33.4 million people, in which 2.1 million were children under 15 years old, were living with HIV worldwide (Joint United Nations Programme on HIV/AIDS

Teenagers represent one of the fastest growing groups of newly HIV-infected persons. In 2008, a global estimate of 430,000 new HIV infections occurred among children under the age of 15 (UNAIDS & WHO, 2009). Despite the number and extent of HIV preventive strategies, young people accounted for about 40% of all new adult HIV infections worldwide. (UNAIDS & WHO, 2009). For the vast majority of individuals, sexual relations begin in adolescence, in which the use of illicit drugs and alcohol function as mediators in

Until 2008, Latin America occupied the third position in HIV prevalence, accounting for 2 million persons living with HIV/AIDS (UNAIDS & WHO, 2009). UNAIDS and WHO (2009) reported an increase in the number of newly infected children from 6,200 children in 2001 to 6,900 children in 2008. The modes of HIV transmission varied according to the geographic location and the individual's social and cultural backgrounds. Men who have sex with men (MSM) is the predominant transmission mode in North and Latin America, Central and Western Europe, and Oceania; while heterosexual transmission is the highest transmission mode in Africa, Guyana, and in some countries in Central America and the Caribbean

The Centers for Disease Control and Prevention (CDC, 2008) estimated that 1,106,400 adults and adolescents were living with HIV in the United States at the end of 2006. As of 2009, an approximate of 4.8% (551,455 cases) of the 1,108,611 AIDS cases in the U.S. were adolescents between the ages of 13 and 24 years (CDC, 2009). From 2006 to 2009, an increase in the number of HIV infections among adolescents and young adults living in the U.S. was reported (Centers for Disease Control and Prevention [CDC], 2009). In 2009, most HIV infections and the highest HIV infection rate (36.9 per 100,000 persons) were among persons aged 20 to 24 years (CDC, 2009). For the same year, the incidence rate of HIV infection in the group between 15 and 19 years in the U.S. increased from 9.6 per 100,000 in 2006 to 12.0 per 100,000 (CDC, 2009). Similarly, the incidence rates in the group between 20 and 24 years increased from 28.2 per 100,000 in 2006 to 36.9 per 100,000 in 2009 (CDC, 2009). On the other hand, the rates of adolescents and young adults with AIDS diagnosis increased from 1.9 to 2.2 per 100,000 in the age group between 15 and 19 and from 7.7 to 9.7 per 100,000 in the

The CDC Youth Risk Behavior Surveillance System (YRBSS) conducted a survey among junior and high school students from public and private schools in the U.S. mainland and its territories. The 2009 survey results reported that 46.0% of U.S. junior and high school students had sexual intercourse; and among those, 34.2% reported being sexually active during the three months prior to the survey (CDC, 2009). The survey also revealed that twenty-one percent of sexually active students drank alcohol or used illegal drugs before

Furthermore, the number of Hispanic/Latino living with an AIDS diagnosis in the United States and its territories (including PR) increased since 1996 and continued over years until

**2. Epidemiology of HIV infection among Hispanic/Latino adolescents**

[UNAIDS] & World Health Organization [WHO] 2009).

the adolescents' engagement in sexual risky behaviors.

group 20 to 24 between the years 2006 and 2009 (CDC, 2009).

Papalia and Wendkos (1997) define adolescence as a transition period of development between childhood and adulthood. This developmental stage fluctuates between ages 12 and 19 years. Biologically, adolescent's immature reproductive and immune systems make them more vulnerable to infection by various STI pathogens (Cates, & McPheeters, 1997; as cited in Sales, & DiClemente, 2010, p. 2). Offer and Offer (1974) found that one third of adolescents had difficulty facing unexpected events and frequently came back to immature behaviors and were displeased during difficult times. Adolescents frequently use alcohol, cannabis, or tobacco. Recently a new drug known as ecstasy has emerged. Drugs provoke un-inhibited effects in human behavior. Some of the published explanations for the high transmission rates of STI in adolescents include the use of oral contraceptives. That results in unprotected sex, a feeling of invulnerability towards STI, the presence of a non-susceptible belief, and the desire for sensation seeking.

#### **3.2 Sensation seeking**

Sensation seeking is a personality factor that could have an important role in HIV risk behavior. Sensation seeking focuses on the need for new and varied experiences through uninhibited behavior, these include dangerous activities, a non-conventional lifestyle, and a

Prevention Strategies for HIV Infection Risk Reduction Among Hispanic/Latino Adolescents 187

sexual behaviors (DiClemente et al., 2001; Shrier, Harris, Sternberg, & Beardslee, 2001; Shrier, Harris, & Beardslee, 2002; Spencer, Zimet, Aalsma, & Orr, 2002; Parrillo, Freeman,

Adolescents believe that they are invincible from disease, accidents, and death (Hochhauster, 1988). Also, adolescents rely more on peer networks and are more concerned with immediate risks than with long term risks. Mason, Olson, and Parish (1988) indicated that adolescent's attitudes towards risk behaviors often include the denial of any chance of contamination and the adoption of the belief that they are invulnerable. Peltzer (2001) found that the behavioral factors that influence HIV risk among high school seniors in South Africa were attitudes towards the use of condom as well as feeling invulnerable to HIV/AIDS. Since many adolescents do not perceive themselves at risk for HIV infection, they engage in sexual and drug use behaviors that put them at risk not only for HIV infection, but also for unwanted pregnancies, and sexually transmitted infections (Kipke et al., 1990). Hingson et al. (1990) consistently found that even though most adolescents have some information about HIV/AIDS; they still engage in risky sexual behavior. Although adolescents typically perceive HIV as a severe disease, a great deal of variability exists regarding individual perception of susceptibility (DiClemente et al., 2008). Studies have suggested that adolescents who perceive that they are at risk for STIs/HIV tend to engage in less risky sexual behavior than those who do not have these perceptions (Boyer, Shafer, Wibbelsman, Seeberg, Teitle, Lovell, 2000; Sieving, Resnick, Bearinger, Remafedi, Taylor, Harmon, 1997; Zimet, Bunch, Anglin, Lazebnik, Williams, Krowchuck, 1992; as cited in DiClemente,

Alcohol and drug use have been identified as the most important predictors for STDs and HIV infection among high school students; both have strong effects in the age of sexual debut (Schafer et al., 1991). According to a study by the American Federation of AIDS Research (2001), sexual behavior of young people is highly influenced by the use of alcohol and drugs, which in turn negatively affects their decision-making skills and ultimately their behavior. As previously cited, the CDC (2010) reported that 21.6% of adolescents had drunk alcohol or had used drugs before their last sexual intercourse (YRBS, 2010). Kraft and Rise (1999) found a relationship between alcohol consumption and sexual behavior among adolescents.  Among adolescents surveyed in New Zealand, alcohol misuse was significantly associated with unprotected intercourse and sexual activity before age 16 (Fergusson & Lynnskey, 1996). Forty-four percent of sexually active teenagers in Massachusetts said they were more likely to have sexual intercourse if they had been drinking and 17 percent said they were less likely to use condoms after drinking (Strunin & Hingson, 1992). Similar results have been found among Hispanic/Latino adolescents. As previously published, HIV risk behavior (e.g. alcohol use, drugs use, and/or sexual intercourse) was measured among Puerto Rican early-adolescents enrolled in the ASUMA project at baseline. Researchers found that none of them reported

Collier, & Young, 2001; as cited in DiClemente et al., 2008, p. 598).

Crittenden, Rose, Sales, Wingood, Crosby, Salazar, 2008, p. 598).

**3.4 Invulnerability**

**3.5 Risky behaviors**

rejection of monotony (Zuckerman, 1979; Zuckerman 1971). Few studies have demonstrated the relationship between high-risk behavior and sensation seeking among adolescents. Romer & Hennessy (2007) reported that sensation seeking increases adolescent risky behaviors such as the use of alcohol, tobacco, or other drugs. Martin (2002) found that sensation seeking mediates the relationship between pubertal development and drug use in adolescent's males and females. Arnett (1990) found a significant relationship between high sensation seeking scores and sexual relationships without contraception among 145 adolescents in Atlanta. Also, some studies have found a relationship between sensation seeking and alcohol consumption among high school students (Clapper et al., 1994) and first year college students (Johnson & Cropsey, 2010). Erikson (1968) presented a way to understand young people needs in relation to their society. He developed the psychosocial developmental theory, defining seven developmental stages. Adolescence is the stage of identity versus confusion. The most important question in this developmental stage is who am I? Having an identity involves making deliberate decisions related to occupation, sexual orientation, and life philosophy.

Adolescents with high sensation seeking are more receptive to intense or novel stimuli, which make them more likely to engage in HIV risk behaviors (Donohew, Palmgreen, Zimmerman, Harrington, & Lane, 2003; Zucherman, 2007). Zuckerman (2003) affirmed that imparting information alone or using scare tactics are not effective for preventing risky behavior in adolescents with high sensation seeking. Also, Donohew et al. (2003) and Zuckerman (2003) recommended incorporating strategies that enhance self-esteem through cognitive and behavioral interventions to help mediate impulsive decisionmaking and sensation seeking. These strategies teach adolescents skills to resist peer pressure and to exert self-control (e.g. critical thinking and positive decision making). According to Donohew et al. (2003) and Zuckerman (2003) using sensational messages are effective to capture the attention of adolescents with high sensation seeking; such as messages that are "novel, creative, unusual, complex, emotional, graphic, unconventional, fast paced, and suspenseful, with intense sound, hard-edged music and visual effects" (Zucherman, 2006, p. 216).

#### **3.3 Self-esteem**

Self-esteem has proven to be a predictor of risk behaviors (e.g. smoking initiation and alcohol use) in adolescents and adults, which predispose them to poor physical health (Birndorf, Ryan, Auinger, & Aten, 2005 as cited in Figueroa, Miranda, Fernandez, Maysonet, & Ramon, 2010, p. 37). Researchers found that Puerto Rican boys were more likely than girls to report high self-esteem in all grades (8th, 10th and 12th) (p < 0.001) (Figueroa, et al., 2010). In grade eigth, 39.2% of boys versus 27.4% of girls reported high self-esteem. Factors common to both - boys and girls- included positive family communication at baseline selfesteem measurement (Figueroa, et al., 2010). An adolescent with low self-esteem can be more exposed to peer pressure than an adolescent with adequate self-esteem. A longitudinal study followed over two years was conducted with seventh grade students, revealed that boys with higher self-esteem were 2.4 times more likely to initiate intercourse, while girls with higher self-esteem were more likely to remain virgin than those with lower self-esteem who were 3 times more likely to initiate intercourse (Sumter, Bokhorst, Steinberg, Westernberg as cited in Figueroa et al., 2010). Low self-esteem, psychological distress, sexual abuse, and depression also place many adolescents at risk to engage in STI/HIV associated sexual behaviors (DiClemente et al., 2001; Shrier, Harris, Sternberg, & Beardslee, 2001; Shrier, Harris, & Beardslee, 2002; Spencer, Zimet, Aalsma, & Orr, 2002; Parrillo, Freeman, Collier, & Young, 2001; as cited in DiClemente et al., 2008, p. 598).

#### **3.4 Invulnerability**

186 HIV-Infection – Impact, Awareness and Social Implications of Living with HIV/AIDS

rejection of monotony (Zuckerman, 1979; Zuckerman 1971). Few studies have demonstrated the relationship between high-risk behavior and sensation seeking among adolescents. Romer & Hennessy (2007) reported that sensation seeking increases adolescent risky behaviors such as the use of alcohol, tobacco, or other drugs. Martin (2002) found that sensation seeking mediates the relationship between pubertal development and drug use in adolescent's males and females. Arnett (1990) found a significant relationship between high sensation seeking scores and sexual relationships without contraception among 145 adolescents in Atlanta. Also, some studies have found a relationship between sensation seeking and alcohol consumption among high school students (Clapper et al., 1994) and first year college students (Johnson & Cropsey, 2010). Erikson (1968) presented a way to understand young people needs in relation to their society. He developed the psychosocial developmental theory, defining seven developmental stages. Adolescence is the stage of identity versus confusion. The most important question in this developmental stage is who am I? Having an identity involves making deliberate decisions related to occupation, sexual

Adolescents with high sensation seeking are more receptive to intense or novel stimuli, which make them more likely to engage in HIV risk behaviors (Donohew, Palmgreen, Zimmerman, Harrington, & Lane, 2003; Zucherman, 2007). Zuckerman (2003) affirmed that imparting information alone or using scare tactics are not effective for preventing risky behavior in adolescents with high sensation seeking. Also, Donohew et al. (2003) and Zuckerman (2003) recommended incorporating strategies that enhance self-esteem through cognitive and behavioral interventions to help mediate impulsive decisionmaking and sensation seeking. These strategies teach adolescents skills to resist peer pressure and to exert self-control (e.g. critical thinking and positive decision making). According to Donohew et al. (2003) and Zuckerman (2003) using sensational messages are effective to capture the attention of adolescents with high sensation seeking; such as messages that are "novel, creative, unusual, complex, emotional, graphic, unconventional, fast paced, and suspenseful, with intense sound, hard-edged music and visual effects"

Self-esteem has proven to be a predictor of risk behaviors (e.g. smoking initiation and alcohol use) in adolescents and adults, which predispose them to poor physical health (Birndorf, Ryan, Auinger, & Aten, 2005 as cited in Figueroa, Miranda, Fernandez, Maysonet, & Ramon, 2010, p. 37). Researchers found that Puerto Rican boys were more likely than girls to report high self-esteem in all grades (8th, 10th and 12th) (p < 0.001) (Figueroa, et al., 2010). In grade eigth, 39.2% of boys versus 27.4% of girls reported high self-esteem. Factors common to both - boys and girls- included positive family communication at baseline selfesteem measurement (Figueroa, et al., 2010). An adolescent with low self-esteem can be more exposed to peer pressure than an adolescent with adequate self-esteem. A longitudinal study followed over two years was conducted with seventh grade students, revealed that boys with higher self-esteem were 2.4 times more likely to initiate intercourse, while girls with higher self-esteem were more likely to remain virgin than those with lower self-esteem who were 3 times more likely to initiate intercourse (Sumter, Bokhorst, Steinberg, Westernberg as cited in Figueroa et al., 2010). Low self-esteem, psychological distress, sexual abuse, and depression also place many adolescents at risk to engage in STI/HIV associated

orientation, and life philosophy.

(Zucherman, 2006, p. 216).

**3.3 Self-esteem**

Adolescents believe that they are invincible from disease, accidents, and death (Hochhauster, 1988). Also, adolescents rely more on peer networks and are more concerned with immediate risks than with long term risks. Mason, Olson, and Parish (1988) indicated that adolescent's attitudes towards risk behaviors often include the denial of any chance of contamination and the adoption of the belief that they are invulnerable. Peltzer (2001) found that the behavioral factors that influence HIV risk among high school seniors in South Africa were attitudes towards the use of condom as well as feeling invulnerable to HIV/AIDS. Since many adolescents do not perceive themselves at risk for HIV infection, they engage in sexual and drug use behaviors that put them at risk not only for HIV infection, but also for unwanted pregnancies, and sexually transmitted infections (Kipke et al., 1990). Hingson et al. (1990) consistently found that even though most adolescents have some information about HIV/AIDS; they still engage in risky sexual behavior. Although adolescents typically perceive HIV as a severe disease, a great deal of variability exists regarding individual perception of susceptibility (DiClemente et al., 2008). Studies have suggested that adolescents who perceive that they are at risk for STIs/HIV tend to engage in less risky sexual behavior than those who do not have these perceptions (Boyer, Shafer, Wibbelsman, Seeberg, Teitle, Lovell, 2000; Sieving, Resnick, Bearinger, Remafedi, Taylor, Harmon, 1997; Zimet, Bunch, Anglin, Lazebnik, Williams, Krowchuck, 1992; as cited in DiClemente, Crittenden, Rose, Sales, Wingood, Crosby, Salazar, 2008, p. 598).

#### **3.5 Risky behaviors**

Alcohol and drug use have been identified as the most important predictors for STDs and HIV infection among high school students; both have strong effects in the age of sexual debut (Schafer et al., 1991). According to a study by the American Federation of AIDS Research (2001), sexual behavior of young people is highly influenced by the use of alcohol and drugs, which in turn negatively affects their decision-making skills and ultimately their behavior. As previously cited, the CDC (2010) reported that 21.6% of adolescents had drunk alcohol or had used drugs before their last sexual intercourse (YRBS, 2010). Kraft and Rise (1999) found a relationship between alcohol consumption and sexual behavior among adolescents.  Among adolescents surveyed in New Zealand, alcohol misuse was significantly associated with unprotected intercourse and sexual activity before age 16 (Fergusson & Lynnskey, 1996). Forty-four percent of sexually active teenagers in Massachusetts said they were more likely to have sexual intercourse if they had been drinking and 17 percent said they were less likely to use condoms after drinking (Strunin & Hingson, 1992). Similar results have been found among Hispanic/Latino adolescents. As previously published, HIV risk behavior (e.g. alcohol use, drugs use, and/or sexual intercourse) was measured among Puerto Rican early-adolescents enrolled in the ASUMA project at baseline. Researchers found that none of them reported

Prevention Strategies for HIV Infection Risk Reduction Among Hispanic/Latino Adolescents 189

This represents a barrier to communicate openly about sexuality and consequently their

DiClemente et al. (as cited in Figueroa et al., 2010) suggested that adolescents that perceived positive family support, family closeness, parental monitoring and parent-adolescent communication are less likely to perform risky sexual behaviors (as cited in Figueroa et al., 2010). Moreover, a study conducted in Puerto Rico by Robles (2007) found that adolescents whose parents reported poor or little communication, monitoring, or control over their children were almost three times more likely to engage in early sexual activity (Robles et al.,

The trend towards peer linkage is high at this stage. Many adolescents start using drugs by curiosity or by peer pressure. The peer group is critical to an adolescent's emotional development and teenagers prefer each other's company to that of their parents. Risk-taking is seen as a way of coping with normal developmental tasks such as exploration, achieving autonomy (Lavery, Siegel, Cousins, & Rusovits, 1993; Millstein & Igra, 1995) and those difficulties that adolescents face when making decisions (Furby & Beyth-Marom, 1992). Peer pressure can be a negative force in the lives of adolescents, often resulting in their experimentation with tobacco, alcohol, illegal drugs and sexual relations. An adolescent with low self-esteem could be more exposed to negative peer pressure than an adolescent with adequate levels of self-esteem. Peer pressure affects the early onset and prevalence of sexual behaviors (Romer et al., 1994). A national representative phone survey among 510 teens between the ages of 12 to 17 found that 83% of males and 89% of females reported that their peers felt an element of extrinsic pressure when asked on sex and relationships; and 41% of males and 31% of females reported that they personally face pressure when it comes

Many studies have identified several risk factors associated with multiple problem behaviors (Biglan, Brennan, Foster & Holder, 2004). Various HIV risk reduction strategies for adolescents have been performed in the United States to mediate biological, cognitive, social, and emotional factors (Biglan et al., 2004). Biglan et al. (2004) stated that effective interventions should address multiple problem behaviors according to the following factors: (1) individual level factors such as mood disorders, anxiety, impulsivity, hyperactivity, attention problems, and early aggression; (2) family level factors such as: absence parental problem solving skills, inconsistent discipline and monitoring, and barriers of parentadolescents communication; and (3) social level factors such as violence, drug and alcohol use and smoking, social stigma, discrimination, lack of health services and public policy to

HIV evidence-based interventions are "behavioral, social, and structural interventions that are relevant to HIV risk reduction have been tested using a methodologically rigorous design, and have been shown to be effective in a research setting" (CDC, 2003). Evidencebased interventions employ several cognitive, social, behavioral, motivational, humanistic

daughters may receive less prevention information.

2007 as cited in Figueroa et al., 2010).

to sex and relationships (SIECUS, 2000).

**4. HIV prevention among adolescents**

enhance HIV risk reduction strategies and programs.

**4.1 Evidence-based interventions**

**3.9 Social factors**

illicit drug use, 26.3% and 1.2% reported alcohol use and sexual intercourse at some point in their lives, respectively (Fernandez et al., 2008). Latinas are 2.8 times more exposed than non-Latina whites to give birth at ages 15-19. Overall, Latinas have the highest pregnancy rate and birthrate among all ethnic groups in the U.S.. Although Latina women initiate sexual intercourse at later ages than non-Latinas, they are less likely to use contraceptives once they start having sex (Stoneas cited in Deardorff, Tschann, Flores, & Ozer, 2010, p. 23). Female virginity was positively associated with women's nonuse of condoms, rather than consistent use, during the first month of their current relationship" (Deardorff et al., 2010). In males, "the importance of satisfying sexual needs increased with the numbers of lifetime and recent sexual partners and with inconsistent condom use in the first month of their relationship" (Deardorff et al., 2010).

#### **3.6 Lack of HIV/AIDS knowledge**

A lack of HIV/AIDS knowledge and inaccurate information are factors that lead to infection with HIV (Alpabio, Asuzu, Fajemilehin, & Ofi, 2008 as cited in Figueroa et al., 2010). A study among Puerto Rican high school students found low HIV/AIDS knowledge and HIV risk behaviors (Mojorele, Brook, & Kachienga as cited in Figueroa et al., 2010). Another study performed in a sample of 7th grade students from Puerto Rico, found that they did not have enough knowledge about transmission modes and preventive behaviors (Morrison et al., 2007 as cited in Figueroa et al, 2010).

#### **3.7 Family factors**

Lescano et al. (2009) identified a set of family cultural factors that have been linked to adolescent risk behavior, these are: acculturation, religiosity, HIV knowledge and sexual communication, gender role and sexual socialization, and parental monitoring practices.

#### **3.8 Communication**

Some studies have demonstrated inadequate HIV/AIDS communication between parents and adolescents. In a study conducted in a neighborhood with high HIV seroprevalence, researchers found that parents overestimate how much they talk about HIV with their children (Krauss et al., 1997). Latino youth that talks with their parents about sex, engage in less sexual activity and are less likely to become pregnant (Adolph, Ramos, Linton, & Grimes, 1995; Gilliam et al., 2007).  Open discussion with parents can help postpone sexual activity, protect them from engaging in risky behaviors, and support the healthy sexual socialization of youth (Leland & Barth, 1993). These findings demonstrate the importance of involving parents in HIV prevention efforts directed to adolescents.

As cited by Dancy et al. (2006), mothers often do not have the correct information to assist their daughters in developing risk-reduction behaviors. The same was reported in the qualitative study with African American females performed by Aronowitz et al. (2007) were mothers admitted that it is uncomfortable to talk about sex with their daughters. In another study by Meneses et al. (2006), Latino and Asian mothers demonstrated the highest levels of discomfort and infrequent communication about sex. Lefkowitz (2007) exposed that conversations between parents and adolescents about sexuality are often difficult for both. This represents a barrier to communicate openly about sexuality and consequently their daughters may receive less prevention information.

 Moreover, a study conducted in Puerto Rico by Robles (2007) found that adolescents whose parents reported poor or little communication, monitoring, or control over their children were almost three times more likely to engage in early sexual activity (Robles et al., 2007 as cited in Figueroa et al., 2010).

#### **3.9 Social factors**

188 HIV-Infection – Impact, Awareness and Social Implications of Living with HIV/AIDS

illicit drug use, 26.3% and 1.2% reported alcohol use and sexual intercourse at some point in their lives, respectively (Fernandez et al., 2008). Latinas are 2.8 times more exposed than non-Latina whites to give birth at ages 15-19. Overall, Latinas have the highest pregnancy rate and birthrate among all ethnic groups in the U.S.. Although Latina women initiate sexual intercourse at later ages than non-Latinas, they are less likely to use contraceptives once they start having sex (Stoneas cited in Deardorff, Tschann, Flores, & Ozer, 2010, p. 23). Female virginity was positively associated with women's nonuse of condoms, rather than consistent use, during the first month of their current relationship" (Deardorff et al., 2010). In males, "the importance of satisfying sexual needs increased with the numbers of lifetime and recent sexual partners and with inconsistent condom use in the first month of their

A lack of HIV/AIDS knowledge and inaccurate information are factors that lead to infection with HIV (Alpabio, Asuzu, Fajemilehin, & Ofi, 2008 as cited in Figueroa et al., 2010). A study among Puerto Rican high school students found low HIV/AIDS knowledge and HIV risk behaviors (Mojorele, Brook, & Kachienga as cited in Figueroa et al., 2010). Another study performed in a sample of 7th grade students from Puerto Rico, found that they did not have enough knowledge about transmission modes and preventive behaviors (Morrison et al.,

Lescano et al. (2009) identified a set of family cultural factors that have been linked to adolescent risk behavior, these are: acculturation, religiosity, HIV knowledge and sexual communication, gender role and sexual socialization, and parental monitoring practices.

Some studies have demonstrated inadequate HIV/AIDS communication between parents and adolescents. In a study conducted in a neighborhood with high HIV seroprevalence, researchers found that parents overestimate how much they talk about HIV with their children (Krauss et al., 1997). Latino youth that talks with their parents about sex, engage in less sexual activity and are less likely to become pregnant (Adolph, Ramos, Linton, & Grimes, 1995; Gilliam et al., 2007).  Open discussion with parents can help postpone sexual activity, protect them from engaging in risky behaviors, and support the healthy sexual socialization of youth (Leland & Barth, 1993). These findings demonstrate the importance of involving parents in HIV prevention efforts directed to

As cited by Dancy et al. (2006), mothers often do not have the correct information to assist their daughters in developing risk-reduction behaviors. The same was reported in the qualitative study with African American females performed by Aronowitz et al. (2007) were mothers admitted that it is uncomfortable to talk about sex with their daughters. In another study by Meneses et al. (2006), Latino and Asian mothers demonstrated the highest levels of discomfort and infrequent communication about sex. Lefkowitz (2007) exposed that conversations between parents and adolescents about sexuality are often difficult for both.

relationship" (Deardorff et al., 2010).

**3.6 Lack of HIV/AIDS knowledge**

2007 as cited in Figueroa et al, 2010).

**3.7 Family factors**

**3.8 Communication**

adolescents.

The trend towards peer linkage is high at this stage. Many adolescents start using drugs by curiosity or by peer pressure. The peer group is critical to an adolescent's emotional development and teenagers prefer each other's company to that of their parents. Risk-taking is seen as a way of coping with normal developmental tasks such as exploration, achieving autonomy (Lavery, Siegel, Cousins, & Rusovits, 1993; Millstein & Igra, 1995) and those difficulties that adolescents face when making decisions (Furby & Beyth-Marom, 1992). Peer pressure can be a negative force in the lives of adolescents, often resulting in their experimentation with tobacco, alcohol, illegal drugs and sexual relations. An adolescent with low self-esteem could be more exposed to negative peer pressure than an adolescent with adequate levels of self-esteem. Peer pressure affects the early onset and prevalence of sexual behaviors (Romer et al., 1994). A national representative phone survey among 510 teens between the ages of 12 to 17 found that 83% of males and 89% of females reported that their peers felt an element of extrinsic pressure when asked on sex and relationships; and 41% of males and 31% of females reported that they personally face pressure when it comes to sex and relationships (SIECUS, 2000).

#### **4. HIV prevention among adolescents**

Many studies have identified several risk factors associated with multiple problem behaviors (Biglan, Brennan, Foster & Holder, 2004). Various HIV risk reduction strategies for adolescents have been performed in the United States to mediate biological, cognitive, social, and emotional factors (Biglan et al., 2004). Biglan et al. (2004) stated that effective interventions should address multiple problem behaviors according to the following factors: (1) individual level factors such as mood disorders, anxiety, impulsivity, hyperactivity, attention problems, and early aggression; (2) family level factors such as: absence parental problem solving skills, inconsistent discipline and monitoring, and barriers of parentadolescents communication; and (3) social level factors such as violence, drug and alcohol use and smoking, social stigma, discrimination, lack of health services and public policy to enhance HIV risk reduction strategies and programs.

#### **4.1 Evidence-based interventions**

HIV evidence-based interventions are "behavioral, social, and structural interventions that are relevant to HIV risk reduction have been tested using a methodologically rigorous design, and have been shown to be effective in a research setting" (CDC, 2003). Evidencebased interventions employ several cognitive, social, behavioral, motivational, humanistic

Prevention Strategies for HIV Infection Risk Reduction Among Hispanic/Latino Adolescents 191

small groups discussion) and were delivered in school (Villaruel, Jemmott, & Jemmott, 2006) or community settings (McGraw et al., 2002). The majority of these interventions focused on enhancing adolescents HIV knowledge, self-esteem, emotion and motivational factors, problem solving and decision making skills, autonomy, impulse control and selfcontrol, critical thinking, effective communication and negotiation, social responsibility, values and norms (McGraw et al., 2002; Rotheram-Borus et al., 2009; Villaruel et al., 2006). Some of these theoretical constructs were used to design interventions for reducing HIV risk related behavior among Hispanic/Latino adolescents (e.g., risky sexual behaviors) such as intentions: subjective norms, and control beliefs.  Other interventions have constructed its core components on the socioecological theoretical model, which can be used to address individual, family, community, organizational, and societal determinants of HIV risk infection among Hispanic/Latino adolescents (Biglan et al., 2004). The eco-developmental model along with other social and behavioral models was used to design a Hispanic/Latino adolescent's intervention in Mexico (Gallegos et al., 2006). The outcome of the intervention showed a significant intention of condom use among adolescents in the experimental group (Gallegos et al., 2006). Some effective interventions have incorporated and evaluated the effectiveness of parental involvement as a mean to improve HIV risk practices among their children. Recent research has found high intervention attendance and retention rates among parents involved in HIV prevention programs with their children (Wyckoff et al., 2003). Also, Wyckoff et al. (2003) affirmed that parents are interested and willing to participate in activities directed to improve adolescent communication. Perrino et al. (2000) highlighted the significant contribution of families in the prevention of HIV risk behaviors among adolescents. In recent studies among Hispanic/Latino adolescents in the United States and Mexico, parent-adolescent communication was found to reduce sexual risk behaviors among adolescents (Gallegos et al., 2004; Villaruel, et al., 2006). These findings demonstrate the importance of involving parents in HIV prevention efforts directed to this group. However, many viable organizations and programs are not embracing the inclusion of parents in their HIV prevention efforts because they perceive a degree of difficulty to reach parental involvement. Adolescents recognized the importance of parental advice however they need to feel freedom to choose for themselves. Furthermore, adolescents tend to reject

According to DiClemente and Crittenden (2008) successful programs are based on theoretical or conceptual frameworks and are specifically tailored to a particular subgroup of a population. DiClemente and Crittenden (2008) affirmed that interventions that focus on the development of self-concept, self-esteem, and social competency skills are also effective to reduce risky sexual behaviors among adolescents. Addressing risky behaviors at earlier ages must be proven to be effective in modifying these behaviors and ultimately in preventing diseases (DiClemente & Crittenden, 2008). The development and implementation of culturally appropriate instruments and interventions are key elements in the prevention of disease for a specific population. Rios-Ellis et al. (2008, p.456) affirmed that designing culturally and linguistically appropriate interventions to reduce HIV/AIDS in Hispanic/Latino adolescent "requires an understanding of the many different perceptions, attitudes, and behaviors that deeply influence the Latino culture and values." Effective

the imposition of adults.

and/or existential psychodynamic theoretical models to address the core components of each intervention. Evidence-based interventions have to be implemented exactly as intended and within a context similar to the original intervention. If they are to be adapted and tailored to a different target population the core elements of the intervention need to be maintained.  However, some community interventionists reject the replication with fidelity of an evidence-based program because they tend to customize their programs based on the community needs (Rotheram-Borus et al., 2009).

Kim et al. (1997) and Rotheram-Borus et al. (2009) evaluated and recommended a set of common factors that should be included in the design of effective HIV prevention programs for adolescents: (1) using a theoretical framework to address behavioral change; (2) focusing on the community and/or cultural aspects and issues of target population; (3) including coping skills (e.g., cognitive, affective an behavioral skills) training; (4) addressing environmental barriers; (5) providing skills and tools to support positive community healthy actions. Advocates for Youth (2003, 2006) identified several evidence based programs; known as "Programs that Works." These programs can be accessed through the CDC and the Diffusion of Effective Behavioral Interventions websites (CDC, 2010). Rotheram-Borus et al. (2009, p. 391-394) identified common principles which should be included for effective adolescent HIV prevention interventions program's goals. These include the following:

Several evidence-based interventions were designed and tested among Hispanic/Latino adolescents by using multiple educational strategies (e.g., role play, demonstration, workshops, video/music, projects, simulation, practice, scientific research, assignment,

and/or existential psychodynamic theoretical models to address the core components of each intervention. Evidence-based interventions have to be implemented exactly as intended and within a context similar to the original intervention. If they are to be adapted and tailored to a different target population the core elements of the intervention need to be maintained.  However, some community interventionists reject the replication with fidelity of an evidence-based program because they tend to customize their programs based on the community needs (Rotheram-

Kim et al. (1997) and Rotheram-Borus et al. (2009) evaluated and recommended a set of common factors that should be included in the design of effective HIV prevention programs for adolescents: (1) using a theoretical framework to address behavioral change; (2) focusing on the community and/or cultural aspects and issues of target population; (3) including coping skills (e.g., cognitive, affective an behavioral skills) training; (4) addressing environmental barriers; (5) providing skills and tools to support positive community healthy actions. Advocates for Youth (2003, 2006) identified several evidence based programs; known as "Programs that Works." These programs can be accessed through the CDC and the Diffusion of Effective Behavioral Interventions websites (CDC, 2010). Rotheram-Borus et al. (2009, p. 391-394) identified common principles which should be included for effective adolescent HIV prevention interventions program's goals. These

1. Develop adolescent positive self-esteem. Positive self-esteem and emotion can enhance the adolescent's ability to resist negative peer pressure and to promote self-care. 2. Provide accurate facts. Accurate information can increase HIV/AIDS knowledge and

3. Evaluate options and consequences. Develop adolescent's skills by providing them with

4. Commitment to change. Reinforce vulnerability recognition by reinforcing personal

5. Plan ahead and be prepared. Prepare adolescents with coping skills and avoidance of

6. Practice self-control. Enhance self-control skills that will allow the control of selfemotional states and increment the recognition of situations that might trigger the lack

8. Teach them how to negotiate. Provide them with guidance to enhance verbal and nonverbal negotiation skills and express their desires by enhancing self-care, self-esteem,

9. Focus on their freedom to choose. Interventions should focus on the development of each adolescent's freedom to choose for themselves, thus providing them with skills to

10. Act to help others protect themselves. Enhance their responsibility to value and protect

Several evidence-based interventions were designed and tested among Hispanic/Latino adolescents by using multiple educational strategies (e.g., role play, demonstration, workshops, video/music, projects, simulation, practice, scientific research, assignment,

helps them understand common myths and faulty assumptions.

7. Teach exciting alternatives to avoid high-risk sexual activity.

set voluntary limits that will help them protect their health.

commitment for acting safely through community active participation.

risky situations by enhancing critical thinking and communication skills.

strategies to make informed decisions.

Borus et al., 2009).

include the following:

of control.

their peers.

and positive relationships.

small groups discussion) and were delivered in school (Villaruel, Jemmott, & Jemmott, 2006) or community settings (McGraw et al., 2002). The majority of these interventions focused on enhancing adolescents HIV knowledge, self-esteem, emotion and motivational factors, problem solving and decision making skills, autonomy, impulse control and selfcontrol, critical thinking, effective communication and negotiation, social responsibility, values and norms (McGraw et al., 2002; Rotheram-Borus et al., 2009; Villaruel et al., 2006). Some of these theoretical constructs were used to design interventions for reducing HIV risk related behavior among Hispanic/Latino adolescents (e.g., risky sexual behaviors) such as intentions: subjective norms, and control beliefs.  Other interventions have constructed its core components on the socioecological theoretical model, which can be used to address individual, family, community, organizational, and societal determinants of HIV risk infection among Hispanic/Latino adolescents (Biglan et al., 2004). The eco-developmental model along with other social and behavioral models was used to design a Hispanic/Latino adolescent's intervention in Mexico (Gallegos et al., 2006). The outcome of the intervention showed a significant intention of condom use among adolescents in the experimental group (Gallegos et al., 2006). Some effective interventions have incorporated and evaluated the effectiveness of parental involvement as a mean to improve HIV risk practices among their children. Recent research has found high intervention attendance and retention rates among parents involved in HIV prevention programs with their children (Wyckoff et al., 2003). Also, Wyckoff et al. (2003) affirmed that parents are interested and willing to participate in activities directed to improve adolescent communication. Perrino et al. (2000) highlighted the significant contribution of families in the prevention of HIV risk behaviors among adolescents. In recent studies among Hispanic/Latino adolescents in the United States and Mexico, parent-adolescent communication was found to reduce sexual risk behaviors among adolescents (Gallegos et al., 2004; Villaruel, et al., 2006). These findings demonstrate the importance of involving parents in HIV prevention efforts directed to this group. However, many viable organizations and programs are not embracing the inclusion of parents in their HIV prevention efforts because they perceive a degree of difficulty to reach parental involvement. Adolescents recognized the importance of parental advice however they need to feel freedom to choose for themselves. Furthermore, adolescents tend to reject the imposition of adults.

According to DiClemente and Crittenden (2008) successful programs are based on theoretical or conceptual frameworks and are specifically tailored to a particular subgroup of a population. DiClemente and Crittenden (2008) affirmed that interventions that focus on the development of self-concept, self-esteem, and social competency skills are also effective to reduce risky sexual behaviors among adolescents. Addressing risky behaviors at earlier ages must be proven to be effective in modifying these behaviors and ultimately in preventing diseases (DiClemente & Crittenden, 2008). The development and implementation of culturally appropriate instruments and interventions are key elements in the prevention of disease for a specific population. Rios-Ellis et al. (2008, p.456) affirmed that designing culturally and linguistically appropriate interventions to reduce HIV/AIDS in Hispanic/Latino adolescent "requires an understanding of the many different perceptions, attitudes, and behaviors that deeply influence the Latino culture and values." Effective

Prevention Strategies for HIV Infection Risk Reduction Among Hispanic/Latino Adolescents 193

aAIDS Prevention for Adolescents in School; bGet Real about AIDS; cPostponing Sexual Involvement: Human Sexuality & Health Screening; dReach for Health Community Youth Services; eReducing the

Risk Reduction for African American and Latina Adolescent Women ; nProject Save- Sexual Awareness

2008). We also, conducted a workshop for parents of early adolescents from the intervention group. This workshop was adapted from Cornell University's program "Talking with Kids about AIDS: A Program for Parents and Other Adults Who Care" (Fernandez et al., 2009; Fernandez et al., 2008). The parent's workshop focused on developing effective

 School-Based Program Community –Based Program Clinic-Based Program Table 1. Effective programs for Hispanic/Latinos in USA: Impact on Adolescents' Risk for

Safer Choices; gTeen Outreach Program; hAdolescents Living Safely: AIDS Awareness Attitudes &

Poder Latino: A Community AIDS Prevention Program for Inner-City Latino Youth; mHIV

Children's Aid Society-Carrera Program;

Source: Adapted from Advocates for Youth (2008).

for everyone; oTLC: Together Learning Choices

Pregnancy, HIV & STI Programs

California's Adolescent Sibling Prevention Project; j

Risk; f

Action; i

k¡Cuidate!; l

Latino HIV interventions must employ culturally appropriate methods such as the storybased "fotonovelas" and "radionovelas" (Rios-Ellis et al., 2008). Spanish speaking trainers should conduct interventions at schools, community health centers, and community-based organizations in order to positively improve adolescent's HIV knowledge, which in turn lessens HIV/AIDS risk behaviors among Hispanic/Latino adolescents (Rios-Ellis et al., 2008). Also, program developers must address Hispanic/Latino cultural values such as familialism, "machismo", "marianismo", allocentrism, fatalism, power distance, personal space, time orientation, and gender roles" to design interventions that promote Hispanic/Latino parent-adolescent communication as a mean for HIV/AIDS risk reduction strategy among adolescents (Benavides, Bonazzo, & Torres, 2006, p. 92). Villarruel et al. (2006) designed and implemented the "Cuídate!" intervention which addresses Hispanic/Latino cultural factors including familialism and "machismo" to enhance abstinence and condom use in this ethnic group living in United States.

Herbst et al. (2007) examined the overall efficacy of HIV behavioral interventions to reduce HIV/AIDS or STI's risk behaviors among Hispanics in United States and Puerto Rico. Herbst et al. (2007) meta-analysis documented several effective HIV interventions which increase the likelihood of preventive HIV measures such as increasing condom use, reducing unprotected sex, reducing multiple sex partners, and reducing infection of STI. Table 1 shows a list of evidence-based interventions directed for Hispanic/Latino adolescents. Interventions are gender specific since significant differences were seen when targeted interventions for male or females were done as compared to interventions with both genders. (Herbst et al., 2007). According to Gómez and Marín (1996), Marín (2003), and Marín and Gómez (1997), Hispanic females and males might experience discomfort when discussing sexual matters in the presence of persons of the opposite gender.

#### **4.2 A Supportive Model for HIV Risk Reduction in Early Adolescent (ASUMA): A HIV prevention model for Puerto Rican/Hispanic adolescents**

In Puerto Rico we developed, implemented and evaluated an HIV prevention intervention for early adolescents known as "A Supportive Model for HIV Risk Reduction in Early Adolescent" (ASUMA) after a need assessment was performed. ASUMA followed a cohort of 135 Puerto Rican early-adolescents in public and private middle schools (7th to 9th grade). The schools were randomly divided into two groups; interventional and control groups. We developed a theoretical framework that focused on the adolescent's developmental factors and parental support as a mean to reduce HIV risk behaviors. ASUMA's theoretical framework is shown in Figure 1. We theorize that an increase in parental support and adolescent's self-efficacy will lessen HIV risky sexual behaviors. On the other hand, the intervention also focuses on decreasing adolescent's sensation seeking, on increasing HIV/AIDS knowledge and positive attitudes towards HIV/AIDS; which results from a decrease in the sense of invulnerability. Self-esteem among early-adolescents will increase by a decrease in negative peer pressure" (Fernandez et al., 2008).

The ASUMA curriculum design used pragmatic strategies to facilitate the process of active learning including group discussion, audiovisual aids, debates, brainstorming, patient testimony, reflection, and critical thinking (Fernandez et al., 2009). The intervention was centered on the cultural aspects of the target population and in the development of coping skills strategies. We conducted a total of eight workshops that provided information regarding the developmental and HIV risk related factors. The curriculum also included reinforcement of the knowledge and skills gained (Fernandez et al., 2009; Fernandez et al.,

Latino HIV interventions must employ culturally appropriate methods such as the storybased "fotonovelas" and "radionovelas" (Rios-Ellis et al., 2008). Spanish speaking trainers should conduct interventions at schools, community health centers, and community-based organizations in order to positively improve adolescent's HIV knowledge, which in turn lessens HIV/AIDS risk behaviors among Hispanic/Latino adolescents (Rios-Ellis et al., 2008). Also, program developers must address Hispanic/Latino cultural values such as familialism, "machismo", "marianismo", allocentrism, fatalism, power distance, personal space, time orientation, and gender roles" to design interventions that promote Hispanic/Latino parent-adolescent communication as a mean for HIV/AIDS risk reduction strategy among adolescents (Benavides, Bonazzo, & Torres, 2006, p. 92). Villarruel et al. (2006) designed and implemented the "Cuídate!" intervention which addresses Hispanic/Latino cultural factors including familialism and "machismo" to enhance

Herbst et al. (2007) examined the overall efficacy of HIV behavioral interventions to reduce HIV/AIDS or STI's risk behaviors among Hispanics in United States and Puerto Rico. Herbst et al. (2007) meta-analysis documented several effective HIV interventions which increase the likelihood of preventive HIV measures such as increasing condom use, reducing unprotected sex, reducing multiple sex partners, and reducing infection of STI. Table 1 shows a list of evidence-based interventions directed for Hispanic/Latino adolescents. Interventions are gender specific since significant differences were seen when targeted interventions for male or females were done as compared to interventions with both genders. (Herbst et al., 2007). According to Gómez and Marín (1996), Marín (2003), and Marín and Gómez (1997), Hispanic females and males might experience discomfort when

abstinence and condom use in this ethnic group living in United States.

discussing sexual matters in the presence of persons of the opposite gender.

**prevention model for Puerto Rican/Hispanic adolescents**

by a decrease in negative peer pressure" (Fernandez et al., 2008).

**4.2 A Supportive Model for HIV Risk Reduction in Early Adolescent (ASUMA): A HIV**

In Puerto Rico we developed, implemented and evaluated an HIV prevention intervention for early adolescents known as "A Supportive Model for HIV Risk Reduction in Early Adolescent" (ASUMA) after a need assessment was performed. ASUMA followed a cohort of 135 Puerto Rican early-adolescents in public and private middle schools (7th to 9th grade). The schools were randomly divided into two groups; interventional and control groups. We developed a theoretical framework that focused on the adolescent's developmental factors and parental support as a mean to reduce HIV risk behaviors. ASUMA's theoretical framework is shown in Figure 1. We theorize that an increase in parental support and adolescent's self-efficacy will lessen HIV risky sexual behaviors. On the other hand, the intervention also focuses on decreasing adolescent's sensation seeking, on increasing HIV/AIDS knowledge and positive attitudes towards HIV/AIDS; which results from a decrease in the sense of invulnerability. Self-esteem among early-adolescents will increase

The ASUMA curriculum design used pragmatic strategies to facilitate the process of active learning including group discussion, audiovisual aids, debates, brainstorming, patient testimony, reflection, and critical thinking (Fernandez et al., 2009). The intervention was centered on the cultural aspects of the target population and in the development of coping skills strategies. We conducted a total of eight workshops that provided information regarding the developmental and HIV risk related factors. The curriculum also included reinforcement of the knowledge and skills gained (Fernandez et al., 2009; Fernandez et al.,

Source: Adapted from Advocates for Youth (2008).

aAIDS Prevention for Adolescents in School; bGet Real about AIDS; cPostponing Sexual Involvement: Human Sexuality & Health Screening; dReach for Health Community Youth Services; eReducing the Risk; f Safer Choices; gTeen Outreach Program; hAdolescents Living Safely: AIDS Awareness Attitudes & Action; i California's Adolescent Sibling Prevention Project; j Children's Aid Society-Carrera Program; k¡Cuidate!; l Poder Latino: A Community AIDS Prevention Program for Inner-City Latino Youth; mHIV Risk Reduction for African American and Latina Adolescent Women ; nProject Save- Sexual Awareness for everyone; oTLC: Together Learning Choices

School-Based Program Community –Based Program Clinic-Based Program

Table 1. Effective programs for Hispanic/Latinos in USA: Impact on Adolescents' Risk for Pregnancy, HIV & STI Programs

2008). We also, conducted a workshop for parents of early adolescents from the intervention group. This workshop was adapted from Cornell University's program "Talking with Kids about AIDS: A Program for Parents and Other Adults Who Care" (Fernandez et al., 2009; Fernandez et al., 2008). The parent's workshop focused on developing effective

Prevention Strategies for HIV Infection Risk Reduction Among Hispanic/Latino Adolescents 195

esteem, and peer pressure. Vulnerable groups are at risk for HIV infection (Henry J. Kaiser Foundation, 2002). Adolescent girls and young women are prone to have unprotected sex. On the other hand, young men who have sex with men (MSM) perceived stigma and discrimination from others. The intravenous drug users present high invulnerability and sensation seeking. Furthermore, orphaned children of HIV/AIDS parents are at higher risk of abuse and school dropout. Lastly, homeless or sexually exploited children are at risk of prostitution, trafficking, and child pornography (Henry J.

Other important factors to be considered are cultural barriers such as poverty, values, norms and beliefs, and native tongue. According to the U.S. Census Bureau (2010) most of the Hispanic/Latino in the U.S. and Puerto Rico live in poverty. In U.S. limited literacy in English language and acculturation among immigrants represents a barrier to obtaining HIV prevention information (Organista, Carrillo, & Ayala, 2004; as cited in CDC, 2010, p.

Often adolescents face multiple barriers for seeking and receiving STI and HIV testing and treatment due to lack of health insurance, money to pay, transportation, discomfort with facilities and services designed for adults, and concerns about their confidentiality (CDC,

By strategies we refer to intended actions for enhancing health behaviors (CDC, 2003, as cited in McKenzie, Neiger, Thackeray, 2009). Interventions directed to adolescents' individual factors should focus on addressing this stressful period, which is characterized by hormonal, physical, emotional, psychological, and cognitive changes (Alloy, Zhu, & Abramson, 2003, p. 171). Alloy, Zhu, and Abramson (2003, p. 171) emphasized the need to discuss identity, self-image, independence, and intimacy issues among adolescents. Another major issue with adolescents is depression. Depression is associated with impairment in school behavior, academic performance, and family and social relationships (Gotlib, Lewinsohn, & Seeley, 1995; as cited in Alloy, Zhu, & Abramson, 2003). Adolescents with depression may display antisocial, histrionic, dependent, and passive-aggressive personality disorders that could increase HIV risk behaviors in early adulthood (Alloy et al., 2003, p.172). The Cognitive Behavioral Therapy is used to prevent depression in a school setting, by using workshops for teaching effective problem solving and encourage positive activity, to reduce stressful environmental skills among adolescents (Alloy et al., 2003). Furthermore, Alloy et al. (2003) explain that the incorporation of parents in this process can provide

Achieving culturally and linguistically appropriate interventions to reduce HIV/AIDS in Hispanic/Latino adolescent requires comprehending many different perceptions, attitudes and behaviors that are deeply influenced by Latino cultures and values (Rios-Ellis, 2008, p.

**6. HIV prevention strategies for Latino/Hispanic adolescents**

Kaiser Foundation, 2002).

**5.3 Environmental factors**

2004; as cited in Sales, & DiClemente, 2010).

greater benefits for the adolescents.

**6.1 Strategies to address social level factors**

**5.2 Cultural factors**

1299).

communication skills with kids and to increase parents HIV knowledge and attitudes. The early adolescents from the control group only received written educational materials about HIV/AIDS prevention (Fernandez et al., 2009; Fernandez et al., 2008). ASUMA was found to decrease HIV risk behaviors among early adolescents at the Puerto Rico school setting (Fernandez et al., 2008).

Fig. 1. ASUMA theoretical framework.

#### **5. Barriers for HIV prevention among Latino adolescents**

Researchers have identified several barriers that hinder adolescent's modification of HIV/AIDS risk behaviors among Hispanic/Latino adolescents. These barriers have been classified as individual, cultural, and environmental factors.

#### **5.1 Individual factors**