05 – Prevention

How Mental Health Professionals can Promote Prevention

There are many things that mental health professionals can to do promote prevention and discussion about HIV and AIDS.

Here are a few (UNICEF, 2003):

1. Be specific and realistic when discussing risky behaviors and how to change them. As with any risky behaviors, a challenge faced by mental health experts is helping people realize the needs to change the behavior. Although talking about “safe sex” practices is common, it is often times not specific enough to promote a lasting change. Often times their willingness to change sexual behavior (such as consistently using or requesting the use of condoms) depends on their attitudes towards that behavior. Therefore, it is helpful to have conversations about the following issues related to HIV prevention.

1. • Specific behaviors that should be changed, and that are in the control of the individual (not just “safe sex” but what exactly does this mean to the individual?)
   • Your client’s attitudes towards the behavior
   • The impact of the attitudes of others in your client’s life – such as the perception of condom usage among their friends or sexual partners
   • Your client’s ability to perform the behavior

Consider:

• What kinds of interactions have you had with people living with HIV/AIDS?
• What have you heard about HIV/AIDS?
  What do those around you believe or think about HIV/AIDS and those living with the disease?
• How does your background and life experiences influence your perceptions of HIV/AIDS?

Discussion Topics to Promote Prevention

As mental health professionals, we know that clients come to us with a wide variety of questions and concerns. It is likely that at some point you will need to discuss with clients how to lower their risk for sexual transmitted diseases, including but not limited to HIV.

According to HIV.gov (2017), a site run by the US Department of Health and Human Services, here are some behaviors that are recommended. You should discuss these with your clients and lead them towards action-planning for how to enact these behaviors in their own life:

• Choose less risky sexual behaviors.Sexual activities carry different levels of risk for getting or transmitting HIV. HIV is mainly spread by having anal or vaginal sex without a condom or without taking medicines to prevent HIV. Anal sex is the riskiest type of sex for HIV transmission. It’s possible for either partner—the insertive partner (top) or the receptive partner (bottom)—to get HIV, but it is much riskier for an HIV-negative partner to be the receptive partner. Vaginal sex also carries a risk for HIV transmission, but it is less risky than anal sex. Oral sex poses little to no risk of getting or transmitting HIV.

• Use condoms consistently and correctly. When used consistently and correctly, condoms are highly effective in preventing HIV.

• Reduce the number of people you have sex with.The number of sex partners you have affects your HIV risk. The more partners you have, the more likely you are to have a partner with HIV whose viral load is not suppressed or to have a sex partner with a sexually transmitted disease. Both of these factors can increase the risk of HIV transmission

• Talk to your doctor about pre-exposure prophylaxis (PrEP). PrEP is a way for people who do not have HIV but who are at substantial risk of getting it to prevent HIV infection by taking a pill every day. Studies have shown that PrEP is highly effective for preventing HIV from sex if it’s used as prescribed, but PrEP is much less effective when it isn’t taken consistently.

  PrEP should be considered if:

  • you are HIV-negative and in an ongoing sexual relationship with an HIV-positive partner
  • you aren’t in a mutually monogamous relationship with a recently tested, HIV-negative partner and you are
  • a gay or bisexual man who has had anal sex without a condom or has been diagnosed with an sexually transmitted disease (STD) in the past 6 months; or
  • a heterosexual man or woman who does not regularly use condoms during sex with partners of unknown HIV status who at at very high risk of HIV (e.g. people who inject drugs or women who have bisexual male partners).

• Talk to your doctor right away (within 3 days) about post-exposure prophylaxis (PEP) if you’re HIV negative or don’t know your status and think you have been recently exposed to HIV during sex. An example of a possible exposure is if you have anal or vaginal sex without a condom with someone who is or may be HIV-positive, and you are HIV-negative and not taking PrEP. Your chance of exposure to HIV is lower if your HIV-positive partner is taking antiretroviral therapy (ART) consistently, especially if his/her viral load is undetectable. Starting PEP immediately and taking it daily for 4 weeks reduces your chance of getting HIV.

• Get tested and treated for other sexually transmitted diseases (STDs) and encourage your partners to do the same. If you are sexually active, get tested at least once a year. STDs can have long-term health consequences. They can also increase your chance of getting HIV or transmitting it to others. 

• If your partner is HIV-positive, encourage your partner to get and stay on HIV treatment.ART reduces the amount of HIV virus (viral load) in blood and body fluids. If taken consistently and correctly, ART can keep people with HIV healthy for many years, and greatly reduce their chance of transmitting HIV to sex partners.

Prevention for Mixed Status Couples

Another situation you are likely to encounter is a mixed-status couple, in which one partner is HIV positive and the other partner is HIV negative. While there is always a risk of transmitting HIV, there are things that can be done to minimize the risk. The following strategies are provided by AIDS.gov (2017):

For HIV Negative partners:

• Encourage your HIV-positive partner to get and stay onantiretroviral therapy (ART), and support your partner in taking all of his/her HIV medications at the right time. This “medication adherence” will lower your partner’s viral load, keep your partner healthy, and reduce the risk that HIV can be transmitted.
• Use condoms consistently and correctly.When used correctly and consistently, condoms are highly effective in preventing HIV infection, as well as other sexually transmitted diseases (STDs). Both male and female condoms are available.
• Choose less risky sexual behaviors.Oral sex is much less risky than anal or vaginal sex. Anal sex is the highest-risk sexual activity for HIV transmission. If you are HIV-negative, insertive anal sex (“topping”) is less risky for getting HIV than receptive anal sex (“bottoming”). Remember: HIV can be sexually transmitted via blood, semen (cum), pre-seminal fluid (pre-cum), rectal fluid, and vaginal fluid. Sexual activities that do not involve the potential exchange of these bodily fluids (e.g. touching) carry no risk for getting HIV.
• Talk to your doctor about pre-exposure prophylaxis (PrEP). PrEP is a way for people who don’t have HIV to prevent HIV infection by taking a pill every day. The pill contains two medicines that are also used to treat HIV. Along with other prevention methods like condoms, PrEP can offer good protection against HIV if taken every day. The CDC recommends PrEP be considered for people who are HIV-negative and at substantial risk for HIV infection. This includes HIV-negative individuals who are in an ongoing relationship with an HIV-positive partner, as well at others at high risk.
• Talk to your doctor right away (within 3 days) about post-exposure prophylaxis (PEP) if you think you have had a possible exposure to HIV.An example of a possible exposure is if you had anal or vaginal sex with your HIV-positive partner without a condom, and you are not taking PrEP. Your chance of exposure to HIV is lower if your HIV-positive partner is taking ART consistently and correctly, especially if his/her viral load is undetectable. Starting PEP immediately and taking it daily for 4 weeks reduces your chance of getting HIV.
• Get tested for HIV.You should get tested for HIV at least once a year so that you are sure about your HIV status and can take action to keep healthy. Talk to your doctor about whether you may also benefit from more frequent testing (e.g. every 3-6 months).
• Get tested and treated for other STDs and encourage your partner to do the same.If either of you are sexually active outside the partnership, you should get tested at least once a year and talk to your provider about whether more frequent testing is of benefit. STDs can have long-term health consequences. They can also increase your chance of getting HIV.
• Get and stay on antiretroviral therapy (ART).ART reduces the amount of virus in your blood and body fluids. ART can keep you healthy for many years, and greatly reduce your chance of transmitting HIV to your sexual partners if you take it consistently and correctly.
• If you are taking ART, follow your health care provider’s advice.Visit your health care provider regularly and always take your medicine as directed.

Promoting Prevention through Getting the Conversation Started

The prerequisite to almost all of the behaviors that we have discussed so far is effective communication.  It is critical to help our clients feel comfortable and confident having these conversations. So how can we help our clients get these conversations started? The Center for Disease Control and Prevention has some great resources on how to start conversations about issues related to HIV/AIDS. Here are some general tips from the CDC (2017):

• Don’t wait until the heat of the moment to start talking about HIV. It’s better to talk about it earlier rather than later—certainly before you have sex.
• Some men who are living with HIV have suggested that it helps to talk about their status earlier in the relationship rather than later. Disclosing you are HIV-positive after you’ve become close to someone can cause your partner to feel as though you have kept something important from him.
• If you’re looking for a way to start talking, show him this web page. Watch the videos together, talk about the campaign and use it as a way to start the conversation. Approaching the conversation this way doesn’t make it sound like you don’t trust him, but rather you’ve been reading about it, heard about it, were talking to a friend who brought it up, etc., and because you care, you want to make sure you’re both protected.
• Don’t force it. Find the right time and place to have a conversation. You can schedule a time to talk or have spontaneous conversations in a setting where you are comfortable.
• Try scheduling regular check-ins, or ‘talkiversaries.’ The key to a healthy relationship is having an open dialogue throughout the relationship. It can be hard to find the right time to bring these things up. If you agree to schedule them in advance, no one has to wonder about the timing of the conversations.
• A conversation does not have to be face-to-face. Whether you talk, type, or text what is important is that you start the conversation about HIV.

There are also tips available depending on the specific need – such as talking about your status, revealing a HIV positive status, learning that a partner is positive, talking about safe sex options, or living with HIV. A few of these specific tips are highlighted below (CDC, 2017), but you can find a full listing of them here:

Talking about HIV Status:

• I was online earlier and saw a post about the importance of knowing your HIV status. Do you know yours?
• Since the last time you were tested have you had sex or shared needles with anyone?
• I always ask people that I am starting to date about their HIV status. What is your status?

Revealing a HIV positive status

• About a year ago, I found out that I’m HIV-positive. Since then, I’ve been taking HIV medication consistently and correctly. The virus is controlled and at undetectable levels, and I feel good. Let’s start talking about ways to keep each other healthy and safe. When was the last time you were tested for HIV?
• I really like you, and like where this is going, but before we go any further, there’s something I want to tell you. I’m HIV-positive.

Learning that your partner is HIV positive:

• Thanks for telling me you are HIV-positive. I really appreciate you sharing that important information with me. I really like you and I want to make sure that we keep each other healthy. Let’s talk about our options for safer sex.
• I am glad we’re having this conversation. I am relieved you know that I am living with HIV and am thankful that you shared with me that you are HIV-positive, too. Let’s talk about how we can help each other stay healthy.

Talking about safe sex options:

• So we haven’t really talked about it, but can we agree that when the time comes, we’ll use condoms to keep each other safe?
• Maybe we should consider doing things that have a lower chance of getting or transmitting HIV, like oral sex. Doing other things can be fun and are much safer than anal sex.
• I know we just met and we don’t know everything about each other, but you should know that practicing safer sex is really important to me. When is the last time you were tested for HIV and other sexually transmitted diseases?

Reducing Harm for Injecting Drug Users

About 2,500 people in the United States become infected with HIV every year due to drug usage. According to the World Health Organization (2017), here are some precautions that you can discuss with clients who are injecting drug users.

• Needle and syringe programs
• Opioid substitution therapy for people dependent on opioids and other evidence based drug dependence treatment;
• HIV testing and counselling;
• Risk-reduction information and education;
• HIV treatment and care;
• Access to condoms; and
• Management of STIs, tuberculosis and viral hepatitis.

Mother to Child Transmission of HIV

If you encounter a client who is HIV positive and pregnant, it is critical to help the client seek interventions that will reduce the chances of transmitting HIV to the baby. Without intervention, the World Health Organization (2017) estimates that 15-45% of children will be infected with HIV if their mother is HIV positive during pregnancy. However, with interventions, this can be almost completely prevented. A growing numbers of countries are making encouraging headway on reducing mother to child transmission. In fact, a few countries have been formally validated by the World Health Organization for completely eliminating mother to child transmission – including Armenia, Belarus, Cuba, and Thailand.

Parenting and HIV

In recent years, the family has been increasingly recognized as the “front line” in prevention HIV transmission, and providing caregiving for HIV infected members.  Not surprisingly, positive family dynamics are important to helping children and adolescents make wise and safe decisions. Specifically, parenting factors have been shown to be highly related to HIV prevention and risky behaviors in children and young adults. Factors such as parental attentiveness and involvement, effective and supportive communication, and promotion of autonomy are critical for preventing risky behaviors.

Parents are ultimately role models for their children’s attitudes towards sex, sexual behavior, and risky behavior in general. Unlike a sexual education course that is taught over a short period of time, interactions with family members are constant and built over a lifetime. The ways in which parents communicate with their children about sex are very impactful. Frequent parent-child discussions about sexual behaviors and decisions tend to result in children making more responsible decisions about their sexual behavior.

Due to parents’ strong influence as health educators, it is important for mental health professionals to empower and encourage patients to have positive and open parent-child communication, in particular about sex and risky behavior. Similar to positive communication techniques about any other topic, it is important for parents to frame discussions as a two-way street instead of being closed and directive.

Here is an article written by Dr. Michael Carerra (1999), from the Children’s Aid Society, about sexual learning and how parents can provide positive influence to their children on an everyday basis:

Young people need sexuality education and parents, as essential sources of information and role models, can truly influence their children’s sexual development. Two parents, a single parent, a foster parent, a grandparent, or any other adult who cares for and nurtures a young person must assume this task because sexuality education involves crucial family, religious, and cultural values and convictions. Young people inevitably learn about sex and sexuality from their environment anyway, and it is evident that the environment is not always very safe or reliable, so it is up to caring adults to influence their sons’ and daughters’ moral development, healthy decision making abilities, self-esteem, and knowledge of, and comfort with, their own sexuality. A parent really has no choice in this matter. The only choice is whether the job will be done well or poorly.

Learning about sex and sexuality has been long misunderstood by parents. For many, it simply means the hasty presentation of some information on reproduction, like where babies come from, or an anatomy lesson showing that men have a penis and women have a vagina. Others may wait until their child reaches puberty and provide some information on bodily changes, sometimes discussing menstruation, but rarely ever mentioning wet dreams. With very few exceptions, these kinds of discussions are initiated and carried out by the mother or a female in the household. Rarely do fathers provide any direct sexual information to their children, especially their daughters. Many men continue to believe that their interactions with their children are important simply as sex role models and providers. Yet fathers must have a more meaningful role in this process, because they can do much to affect the emotional, social, and sexual development of their children.

Sex, to many people means genital acts, either with a partner or alone. But this definition denies the completeness of our sexuality. Sexuality has to do with being female or male and is conditioned by the cultural and religious views we hold dear. Genital sexual expression can be a very important part of a person’s sexuality but it is a relatively small part of overall sexual learning. The other important elements of sexual learning are body image, gender identity, gender role, family and social role, affection, love, intimacy, relationships, sensuousness and eroticism. All these elements together form the total fabric, the full cloth of sexuality. Accordingly, parents have a wide array of themes and opportunities to discuss sexuality within this context through their daily living with their children.

Talking with them about their clothes and how they look and how their looks make them feel and providing them with your view of the role of women and men in families, in relationships and in society are unthreatening, yet critical sexual learning opportunities. Repetitions of these messages throughout their development and daily adult role modeling will provide the needed emphasis on the specific view a parent wants to convey to their child. Being certain these beliefs are shared and repeated by other adults in the household will help avoid problems with mixed and gender biased messages.

Parents can reinforce holistic sexual learning in their homes by watching almost any TV show with their son or daughter. Invariably, the message for a woman is in order to succeed, she must use her body. That is how she is recognized, receives attention, moves ahead with her friends, and gets ahead in the world of work. This is an example of a social lie that is embedded in every network and cable sitcom, in hip hop music, and in every magazine read by young women. Boys and young also men receive false messages from all the informational sources around them which regularly and strongly indicate that the way males succeed or achieve is through the use of power, force, or wealth. This is also a lie. With every opportunity, parents must assertively challenge these sexuality lies, these untruths about body image, gender and social role, and replace them with the truth. The fundamental truth is that girls and boys succeed by using their brain not their body; they succeed not by their physical appearance or strength but by the strength of their character and their moral core. Parents need to communicate with their children about the truth and then reinforce it daily with a living, authentic example. 

Clearly, these issues are not about reproduction or body parts or the technology of sex; that is not needed here. What is needed is a willingness to regularly challenge what a parent sees as wrong and gently reinforce what is right, always facing and pushing through the natural developmental resistance expressed by young people towards adults whose ideas are different than others’. Staying this course takes time, patience, and endurance, but the benefits to young people are incalculable.

The beginning of wisdom for parents as they move ahead in the critical job of influencing the sexual learning of their children is to make abundantly clear, at every appropriate opportunity, in ways that are individually comfortable, that their child is loved, prized, and valued. This constitutes an extraordinarily powerful sexual message.

Talking with Children: Building Blocks of Prevention

As with any other conversations, discussions about HIV and AIDS must be tailored to the client’s age and developmental stage. As with any work with children in which sexuality is discussed, there is some basic knowledge that children need to understand.

• Building Block 1: Knowledge

  Children first need to understand how their bodies work, what problems they might experience, and how to deal with such problems.

  Examples:

  • How to identify health problems and seek help
  • How to cope with death in the family
  • Facts about sex, sexuality, and gender
  • How to keep the body safe and avoid harmful behaviors

• Building Block 2: Values

  This knowledge is only helpful to the extent that children have attitudes and values that will help them translate this knowledge into skills. Mental health professionals should work with children to equip them with self-confidence and self-esteem to guide their decision making.

  Examples:

  • Self-Control
  • The right to privacy
  • The right to protect oneself
  • Taking responsibility for one’s actions
  • Respect for life
  • Forgiveness
  • Friendliness
  • Non-discrimination towards those who are different
  • A positive and realistic sense of self

• Building Block 3: Life Skills

  We then must work with children to translate their knowledge and values into applicable skills. For example, being able to say no, to resist sexual abusers, to access health services, and to apply critical thinking skills to make positive decision in their lives.

  Examples:

  • Responsible decision making
  • Problem solving
  • Planning for the future
  • Goal setting
  • Conflict resolution
  • Communication skills
  • Assertiveness

Empowering Young People to Protect Themselves

According to UNICEF (2003), here is a summary of what young people need in order to protect themselves:

Knowledge and Information

• About sexuality and sexual and reproductive health, in order that they can understand how their body functions and make informed choices about their behaviour. There is overwhelming evidence showing that the more educated young people are about sexuality and responsible sexual behaviour, the better the chances that they will delay having sexual relations or will protect themselves if they do. It is therefore critical that young people receive guidance and advice about HIV/AIDS before they become sexually active.
• About transmission, risks and prevention of HIV.
• About the choices available to them, including the avoidance of sexual relations before marriage.
• About the economic and social pressures that make girls particularly vulnerable to unwanted or unsafe sex.
• About where to get voluntary and confidential counselling and testing for HIV, information on preventing infection, as well as care, support and medical treatment for those infected.
• About their rights and responsibilities in the context of HIV/AIDS. Skills and Confidence
• To negotiate difficult situations, whether it is refusing unsafe or unwanted sex or resisting peer pressure to use alcohol or drugs.
• To feel that they have the power to protect themselves and to influence others to practice responsible behavior and avoid infection.

Services Oriented to Young People

• That are affordable, welcoming, convenient and sensitive to their needs. Such services can include pre-marital counselling, voluntary and confidential counselling and testing for HIV, control of sexually transmitted infections, materials to prevent HIV infection, including condoms, and services related to the prevention and treatment of drug and alcohol abuse.
• That make available psychological counselling and support for managing grief, stress and discrimination, particularly for young people living with HIV or AIDS.
• That offer ‘peer-to-peer’ counselling, which is often the most effective way to provide education and support for young people. A Safe and Supportive Environment
• That provides unconditional love and support from a caring adult, whether a parent or other family member, trusted teacher or religious leader or designated member of the community.
• That offers young people a place within their faith community to talk openly and without fear of criticism about their feelings about HIV/AIDS, sexuality, death and other issues, whether in a counselling session, youth group or after-school club.
• That gives them a voice and a meaningful role in community decision-making and programs, especially regarding HIV prevention strategies for young people.
• That provides employment skills and opportunities.
• That provides role models for responsible behavior.