Biomarker validation of reports of recent sexual activity: results of a randomized controlled study in Zimbabwe

Feasibility and safety of cervical biopsy sampling for mucosal immune studies in female sex workers from Nairobi, Kenya

BACKGROUND

There is an urgent need to improve our understanding of the mucosal immuno-pathogenesis of HIV acquisition in the female genital tract, particularly in high-risk women such as female sex workers (FSWs). Cervical biopsy samples offer technical advantages over cytobrush sampling, but there are concerns that this might increase HIV acquisition, particularly if healing is slow and/or women do not abstain from sex during healing.

METHODOLOGY/PRINCIPAL FINDINGS

Cervical biopsy samples and cervico-vaginal swabs for co-infection diagnostics, prostate specific antigen (PSA) and immune studies were collected from 59 women, including HIV seropositive and HIV-exposed seronegative (HESN) FSWs as well as lower risk women from Nairobi, Kenya. A clinical-demographic questionnaire was administered and women were instructed to avoid sexual intercourse, douching and the insertion of tampons for 14 days. All participants underwent a repeat exam to assess healing within the 14 days, and had HIV diagnostics at six months. Cervical sampling was well tolerated, and 82% of participants had healed macroscopically by 5 days. Both self-report and PSA screening suggested high levels of compliance with pre- and post-procedure abstinence. Delayed healing was associated with vulvovaginal candidiasis (VVC) and HESN status. At six-month follow up all low-risk and HESN participants remained HIV seronegative.

CONCLUSION

Cervical biopsy sampling is a safe and well-tolerated method to obtain cervical biopsies in this context, particularly if participants with VVC are excluded. As healing could be delayed up to 11 days, it is important to support (both financially and with rigorous counseling) a period of post-procedure abstinence to minimize HIV risk.

Predicting discordance between self-reports of sexual behavior and incident sexually transmitted infections with African American female adolescents: results from a 4-city study

This study examined correlates of the discordance between sexual behavior self-reports and Incident Sexually Transmitted Infections. African American adolescent females (N = 964) from four U.S. cities were recruited for an HIV/STI prevention trial. Self-reported sexual behaviors, demographics, and hypothesized psychosocial antecedents of sexual risk behavior were collected at baseline, 6-, 12-, and 18-month follow-up assessments. Urine specimens were collected and tested for three prevalent STIs (chlamydia, gonorrhea, trichomonas) at each assessment. Seventeen percent of participants with a laboratory-confirmed STI reported either lifetime abstinence or recent abstinence from vaginal sex (discordant self-report). Lower STI knowledge, belief that fewer peers were engaging in sex, and belief that more peers will wait until marriage to have sex were associated with discordant reports. Discordance between self-reported abstinence and incident STIs was marked among African American female adolescents. Lack of STI knowledge and sexual behavior peer norms may result in underreporting of sexual behaviors.

Change over time (2007-2009) in HIV preventive behaviours, evidence from two serial population-based surveys in rural Zimbabwe

OBJECTIVE

To assess reported HIV knowledge and attitudes, sexual behaviours and HIV testing in Zimbabwe.

METHODS

Representative household surveys of all 18-24 year olds and a proportion of 25-44 year olds were conducted in six purposefully selected rural districts in two provinces in 2007 and 2009. Both surveys used the same methods and questionnaires. We compared differences in reported HIV knowledge, sexual behaviours and HIV testing, controlling for differences in socio-demographics at baseline, using cross-tabulations and multivariate regression analyses.

RESULTS

Analysis was restricted to districts included in both baseline (n = 1891) and mid-term (n = 2746) surveys. Comparisons indicate increased reports of HIV knowledge (35%vs. 22% had high knowledge) and more favourable individual attitudes towards HIV. There was an increase in reported HIV testing (men: 41%vs. 31%, women: 55%vs. 36%) and condom use (men: adjusted odds ratio (AOR) = 1.35, women: AOR = 1.22) and a decrease in number of sexual partners (men: 67%vs. 49% reported 1 partner/previous 6 months, women: 77%vs. 68%).

CONCLUSIONS

As Zimbabwe continues to document declines in HIV prevalence, this analysis offers insight into recent and continuing positive changes in knowledge, attitudes and behaviours among the rural population.

Sexual behavior of HIV-positive adults not accessing HIV treatment in Mombasa, Kenya: Defining their prevention needs

BACKGROUND

HIV spread continues at high rates from infected persons to their sexual partners. In 2009, an estimated 2.6 million new infections occurred globally. People living with HIV (PLHIV) receiving treatment are in contact with health workers and therefore exposed to prevention messages. By contrast, PLHIV not receiving ART often fall outside the ambit of prevention programs. There is little information on their sexual risk behaviors. This study in Mombasa Kenya therefore explored sexual behaviors of PLHIV not receiving any HIV treatment.

RESULTS

Using modified targeted snowball sampling, 698 PLHIV were recruited through community health workers and HIV-positive peer counsellors. Of the 59.2% sexually-active PLHIV, 24.5% reported multiple sexual partners. Of all sexual partners, 10.2% were HIV negative, while 74.5% were of unknown HIV status. Overall, unprotected sex occurred in 52% of sexual partnerships; notably with 32% of HIV-negative partners and 54% of partners of unknown HIV status in the last 6 months. Multivariate analysis, controlling for intra-client clustering, showed non-disclosure of HIV status (AOR: 2.38, 95%CI: 1.47-3.84, p < 0.001); experiencing moderate levels of perceived stigma (AOR: 2.94, 95%CI: 1.50-5.75, p = 0.002); and believing condoms reduce sexual pleasure (AOR: 2.81, 95%CI: 1.60-4.91, p < 0.001) were independently associated with unsafe sex. Unsafe sex was also higher in those using contraceptive methods other than condoms (AOR: 5.47, 95%CI: 2.57-11.65, p < 0.001); or no method (AOR: 3.99, 95%CI: 2.06-7.75, p < 0.001), compared to condom users.

CONCLUSIONS

High-risk sexual behaviors are common among PLHIV not accessing treatment services, raising the risk of HIV transmission to discordant partners. This population can be identified and reached in the community. Prevention programs need to urgently bring this population into the ambit of prevention and care services. Moreover, beginning HIV treatment earlier might assist in bringing this group into contact with providers and HIV prevention services, and in reducing risk behaviors.

Prostate-specific antigen as a biomarker of condom failure: comparison of three laboratory assays and self-reported condom use problems in a randomized trial of female condom performance

BACKGROUND

Prostate-specific antigen (PSA), a biomarker for semen exposure, may provide a more objective measure of condom failure than subject self-reports. Methods for measuring PSA vary and their comparability with respect to assessing condom performance has not been adequately evaluated. This study compared results from three different PSA assays of vaginal samples collected by subjects in a randomized clinical trial which compared the performance of female condoms.

STUDY DESIGN

We selected 30 pairs of pre- and post-coital vaginal samples from subjects who reported condom functionality problems or whose original PSA assay was positive. Samples were retested using three different PSA assays [quantitative enzyme-linked immunoassay (EIA), rocket immune-electrophoresis (RIE) and chromatographic immunoassay (CIA)]. We compared the proportion of condom uses where the post-coital PSA result indicated semen exposure for each of the three assays.

RESULTS

Despite varying levels of sensitivity, the results from all three assays were remarkably consistent. Self-reported condom failures did not correlate well with positive PSA results, suggesting that exclusive reliance on either PSA or user self-report may be inadequate for assessing condom functionality.

CONCLUSION

In combination with user self-report of condom failure, PSA testing provides a reliable, objective marker of condom functionality. Studies based on PSA testing may improve on conventional contraceptive clinical trials by offering a more direct assessment of a condom product's ability to prevent semen exposure.

Sexually Transmitted Infection (STI) screening, case and contact treatment, and condom promotion resulting in STI reduction two years later in rural Malawi

As part of a longitudinal cohort study in rural Malawi in 2000, 469 men and 758 women were asked to respond to a series of surveys, were tested for gonorrhea and chlamydia, and received their results and treatment, if applicable, for themselves and up to 2 partners if positive for either sexually transmitted infection (STI). Two years later, in 2002, 328 men and 525 women were again asked to respond to survey questions, tested again for gonorrhea and chlamydia, and were also tested for HIV--of these, 247 men and 453 women had also given urine samples in 2000. In 2000, the gonorrhea and chlamydia prevalence was 6.2% and 5.8% among men, and 3.6% and 4.9% among women. Two years later, prevalence of gonorrhea and chlamydia was 0.7% and 1.4% among men, and 1.3% and 1.1% among women. Although we did not test for HIV in the first round, the HIV prevalence in 2002 was 19.2%. The implications of the findings are discussed in the context of interventions for STI prevention and to reduce HIV transmission in sub-Saharan Africa.

Women underestimate the age of their partners during survey interviews: implications for HIV risk associated with age mixing in northern Malawi

BACKGROUND

Age mixing may explain differences in HIV prevalence across populations in sub-Saharan countries, but the validity of survey data on age mixing is unknown.

METHODS

Age differences between partners are frequently estimated indirectly by asking respondents to report their partner's age. Partner's age can also be assessed directly by tracing partners and asking them to report their own age. We use data from 519 relationships, collected in Likoma (Malawi), in which both the partners were interviewed and tested for HIV. In these relationships, age differences were assessed both indirectly and directly, and estimates could thus be compared. We calculate the specificity and sensitivity of the indirect method in identifying age-homogenous/age-disparate relationships in which the male partner is less/more than 5 or 10 years older than the respondent.

RESULTS

Women were accurate in identifying age-homogenous relationships, but not in identifying age-disparate relationships (specificity ≈90%, sensitivity = 24.3%). The sensitivity of the indirect method was even lower in detecting partners older than the respondent by 10+ years (9.6%). Among 43 relationships with an HIV-infected partner included in this study, there were about 3 times more age-disparate relationships according to direct measures of partner's age than according to women's reports of their partner's age (17% vs. 46%).

CONCLUSIONS

Women's survey reports of their partner's age significantly underestimate the extent of and the HIV risk associated with age mixing in this population. Future studies of the effect of sexual mixing patterns on HIV risk in sub-Saharan countries should take reporting biases into account.

Telephone-administered motivational interviewing reduces risky sexual behavior in HIV-positive late middle-age and older adults: a pilot randomized controlled trial

By 2014, 50% of all adults living with HIV/AIDS will be 50-plus years of age. This pilot randomized controlled trial assessed the efficacy of two telephone-delivered motivational interviewing (MI) interventions to reduce risky sexual behavior in HIV-infected adults 45-plus years old. Eligible participants reported engaging in at least one occasion of unprotected anal and/or vaginal intercourse in the 3 months prior to study enrollment. Participants were randomly assigned to receive four sessions of telephone-delivered MI, one session of telephone-delivered MI, or no MI. Relative to 4-session MI participants, Controls reported approximately three times as many episodes of unprotected sex at 3- and 6-month follow-up, while 1-session MI participants reported four times as many unprotected sex acts at 3- and 6-month follow-up. No differences in condom use were observed between 1-session MI and Control participants. Additional large-scale studies that evaluate this intervention approach are warranted.

Condom use and sexually transmitted infections among Malagasy sex workers

We evaluated whether use of a short- or longer-term recall period for condom use was superior for assessing risk of acquisition of incident sexually transmitted infection (STI). Female sex workers ( n = 1000) in Madagascar took part in a randomized trial comparing counselling strategies for male and female condom promotion. We explored associations between women's self-reported condom use with clients and non-paying partners and incident STI, examining both short-term recall (last sex act) and longer-term recall (over the past month and year). Self-reported condom use was generally not associated with reduced STI risk, whether measured at the last act or over longer time periods; with clients or non-paying partners; and through unadjusted and adjusted modelling. No condom use measure (short versus longer time periods, with one or both partner types) was strongly predictive of STI, suggesting poor validity.

Prevalence of gonococcal and chlamydial infection in 2009 in 2 populations in a midwestern city

The purpose of this cross-sectional study was to assess the 2009 prevalence of chlamydial and gonococcal infection in 2 populations in a midwestern city in the United States: patients at a public sexually transmitted disease (STD) clinic, and individuals seeking human immunodeficiency virus (HIV) counseling and testing services at an AIDS community organization. We characterized STD prevalence in a random sample of 592 STD clinic patients and a convenience sample of 471 individuals agreeing to STD testing through outreach efforts at the community organization. The STD clinic population was 59% male, 60% black, with 3.1 mean sex partners in the last year. The community organization population was 72% male, 19% black, with a mean of 4.3 partners in the last year. The prevalence of both chlamydial and gonococcal infections was consistently higher in STD clinic patients than at the community organization (18% vs 4%). Prevalence of chlamydial infection was higher than prevalence of gonococcal infection in both populations (chlamydial infection, 3% and 13% at the STD clinic and community organization, respectively; vs gonococcal infection, 1% and 7%, respectively). Factors significantly associated with increased odds of gonococcal/chlamydial infection at the STD clinic include unmarried status, younger age, at least 6 partners in the last year, and unprotected sex in the last year. At the community organization, the only factor significantly associated with increased odds of gonococcal/chlamydial infection was lower educational attainment. Our findings confirm that STD prevalence differs widely by population group. Given these differences, local approaches to STD control should also be carefully targeted to specific subgroups.

Exposé of misleading claims that male circumcision will increase HIV infections in Africa

Despite over two decades of extensive research showing that male circumcision protects against heterosexual acquisition of HIV in men, and that includes findings from large randomized controlled trials leading to acceptance by the WHO/UNAIDS and the Cochrane Committee, opponents of circumcision continue to generate specious arguments to the contrary. In a recent issue of the Journal of Public Health in Africa, Van Howe and Storms claim that male circumcision will increase HIV infections in Africa. Here we review the statements they use in support of their thesis and show that there is no scientific basis to such an assertion. We also evaluate the statistics used and show that when these data are properly analyzed the results lead to a contrary conclusion affirming the major role of male circumcision in protecting against HIV infection in Africa. Researchers, policy makers and the wider community should rely on balanced scholarship when assessing scientific evidence. We trust that our assessment may help refute the claims by Van Howe and Storms, and provide reassurance on the importance of circumcision for HIV prevention.

Do women using long-acting reversible contraception reduce condom use? A novel study design incorporating semen biomarkers

Long-acting reversible contraceptive (LARC) methods are highly effective against pregnancy. A barrier to their widespread promotion can include the concern they will lead reduced condom use and, thus, will put couples at higher risk for sexually transmitted infections (STIs). We review evidence from previous studies of condom "migration" associated with the use of LARC and propose a novel study design to address the two main methodological issues that have limited these earlier studies. Namely, we propose to use a randomized controlled trial design and to use a biological marker of semen exposure for measuring changes in condom use.

Patterns of alcohol consumption among pregnant African-American women in Washington, DC, USA

The objective of this paper is to describe the patterns and associated behaviours related to alcohol consumption among a selected sample of pregnant women seeking prenatal care in inner city Washington DC. Women receiving prenatal care at one of nine sites completed an anonymous alcohol-screening questionnaire. Questions concerned the amount, type and pattern of alcohol consumption. Women were categorised as at no, low, moderate or high risk for alcohol consumption during pregnancy. For comparisons of risk levels of drinking, bivariate associations were examined using Fisher's exact test. Odds ratios (ORs) and 95% confidence intervals (CIs) were also computed. Although 31% of current/recent drinkers stated that they continued to drink during pregnancy, responses to quantity/frequency questions revealed that 42% continued to do so. Women who were at high compared with moderate risk acknowledged that others were worried about their consumption [OR=4.0, 95% CI 1.5, 10.6], that they drank upon rising [OR=6.7, 95% CI 1.8, 26.9], had a need to reduce drinking [OR=3.2, 95% CI 1.3, 8.1] and in the past 5 years had had fractures [OR=4.2, 95% CI 1.0, 17.8] or a road traffic injury [OR=3.4, 95% CI 1.0, 12.2]. Women in the high/moderate compared with low-risk group were more likely to have been injured in a fight or assault [OR=2.7, 95% CI 1.3, 5.6]. This study validated the usefulness of our questionnaire in identifying women who were at risk for alcohol consumption during pregnancy across a range of consumption levels. Using our screening tool, women were willing to disclose their drinking habits. This low-cost method identifies women appropriate for targeting of interventions.

Concurrency revisited: increasing and compelling epidemiological evidence

Multiple sexual partnerships must necessarily lie at the root of a sexually transmitted epidemic. However, that overlapping or concurrent partnerships have played a pivotal role in the generalized epidemics of sub-Saharan Africa has been challenged. Much of the original proposition that concurrent partnerships play such a role focused on modelling, self-reported sexual behaviour data and ethnographic data. While each of these has definite merit, each also has had methodological limitations. Actually, more recent cross-national sexual behaviour data and improved modelling have strengthened these lines of evidence. However, heretofore the epidemiologic evidence has not been systematically brought to bear. Though assessing the epidemiologic evidence regarding concurrency has its challenges, a careful examination, especially of those studies that have assessed HIV incidence, clearly indicates a key role for concurrency.Such evidence includes: 1) the early and dramatic rise of HIV infection in generalized epidemics that can only arise from transmission through rapid sequential acute infections and thereby concurrency; 2) clear evidence from incidence studies that a major portion of transmission in the population occurs via concurrency both for concordant negative and discordant couples; 3) elevation in risk associated with partner's multiple partnering; 4) declines in HIV associated with declines in concurrency; 5) bursts and clustering of incident infections that indicate concurrency and acute infection play a key role in the propagation of epidemics; and 6) a lack of other plausible explanations, including serial monogamy and non-sexual transmission. While other factors, such as sexually transmitted infections, other infectious diseases, biological factors and HIV sub-type, likely play a role in enhancing transmission, it appears most plausible that these would amplify the role of concurrency rather than alter it. Additionally, critics of concurrency have not proposed plausible alternative explanations for why the explosive generalized epidemics occurred. Specific behaviour change messaging bringing the concepts of multiple partnering and concurrency together appears salient and valid in promoting safer individual behaviour and positive social norms.

Association between participant self-report and biological outcomes used to measure sexual risk behavior in human immunodeficiency virus-1-seropositive female sex workers in Mombasa, Kenya

BACKGROUND

Few studies have examined the association between self-reported sexual risk behaviors and biologic outcomes in human immunodeficiency virus (HIV)-1-seropositive African adults.

METHODS

We conducted a prospective cohort study in 898 HIV-1-seropositive women who reported engaging in transactional sex in Mombasa, Kenya. Primary outcome measures included detection of sperm in genital secretions, pregnancy, and sexually transmitted infections. Because 3 outcomes were evaluated, data are presented with odds ratios [OR] and 96.7% confidence intervals [CI] to reflect that we would reject a null hypothesis if a P-value was ≤0.033 (Simes' methodology).

RESULTS

During 2404 person-years of follow-up, self-reported unprotected intercourse was associated with significantly higher likelihood of detecting sperm in genital secretions (OR: 2.32, 96.7% CI: 1.93, 2.81), and pregnancy (OR: 2.78, 96.7% CI: 1.57, 4.92), but not with detection of sexually transmitted infections (OR: 1.20, 96.7% CI: 0.98, 1.48). At visits where women reported being sexually active, having >1 sex partner in the past week was associated with lower likelihood of detecting sperm in genital secretions (OR: 0.74, 96.7% CI: 0.56, 0.98). This association became nonsignificant after adjustment for reported condom use (adjusted OR: 0.81, 96.7% CI: 0.60, 1.08).

CONCLUSIONS

Combining behavioral and biologic outcomes, which provide complementary information, is advantageous for understanding sexual risk behavior in populations at risk for transmitting HIV-1. The paradoxical relationship between higher numbers of sex partners and less frequent identification of sperm in genital secretions highlights the potential importance of context-specific behavior, such as condom use dependent on partner type, when evaluating sexual risk behavior.

Adverse adolescent reproductive health outcomes after pelvic inflammatory disease

OBJECTIVE

To compare longitudinal adolescent and adult reproductive outcomes after pelvic inflammatory disease (PID).

DESIGN

Secondary analysis of longitudinal data from the Pelvic Inflammatory Disease Evaluation and Clinical Health study.

SETTING

A large multicenter randomized clinical trial assessing PID treatment strategies in the United States.

PARTICIPANTS

Eight hundred thirty-one female patients aged 14 to 38 years with a diagnosis of PID.

MAIN EXPOSURE

Adverse longitudinal outcomes were compared in adolescents (≤19 years) and adults (>19 years).

OUTCOME MEASURES

Primary outcome measures included recurrent sexually transmitted infection at 30 days, recurrent PID, chronic abdominal pain, infertility, pregnancy, and times to recurrent PID and pregnancy. Cox proportional hazards modeling was used to examine the effect of young age on times to pregnancy and recurrent PID.

RESULTS

Adolescents were more likely than adults to have positive results of sexually transmitted infection testing at baseline and at 30 days. There were no significant group differences in chronic abdominal pain, infertility, and recurrent PID at 35 or 84 months, but adolescents were more likely to have a pregnancy at both time points. Adjusted hazard ratios (95% confidence intervals) also demonstrated that adolescents had shorter times to pregnancy (1.48 [1.18-1.87]) and recurrent pelvic inflammatory disease (1.54 [1.03-2.30]).

CONCLUSION

Adolescents may require a different approach to clinical care and follow-up after PID to prevent recurrent sexually transmitted infections, recurrent PID, and unwanted pregnancies.

Assessing the reporting of adherence and sexual activity in a simulated microbicide trial in South Africa: an interview mode experiment using a placebo gel

Misreporting of adherence undermines detection of an association between product use and HIV infection in microbicide trials. This study investigates whether, in a placebo trial, audio computer-assisted self-interviewing (ACASI) produces more accurate reporting of adherence and sexual behavior than a face-to-face interview (FTFI). At three South African clinics, 849 women were enrolled and instructed to use applicators filled with placebo gel; participants were randomly assigned to FTFI or ACASI. Behavioral reports were validated through two biomarkers that detect product usage and unprotected sex. For most behaviors, ACASI generated significantly higher reporting, although differences by interview mode appeared to diminish over time. ACASI participants were more likely to report having had sex without gel, but reported and tested applicators did not indicate greater honesty about gel insertion with ACASI. While comparisons of reported unprotected sex with the validated biomarker revealed more agreement with ACASI than with FTFI, differences were small.

Notes on the frequency of routinely collected and self-reported behavioral data in HIV prevention trials

HIV prevention trials typically randomize thousands of participants to active or control intervention arms, with regular (e.g. monthly) clinic visits over one or more years of follow-up. Because HIV infection rates are often lower than 3 per 100 person-years even in high prevalence settings, tens of thousands of clinic visits may take place before the number of infections required to achieve adequate study power has been observed. In addition to clinical outcomes, the multitude of study visits provides an opportunity to assess adherence and related participant behaviors in great detail. These data may be used to refine counseling messages, gain insight into patterns of behavior, and perform supporting analyses in an attempt to obtain more precise estimates of treatment efficacy. Exploratory analyses were performed to assess how our understanding of participant behaviors and their relationships to biological outcomes in two recent prevention trials might have been impacted had the frequency of routine behavioral data collection been reduced from monthly to just months 1, 3, 6, 9, and 12. Results were comparably informative in the reduced case, suggesting that unnecessarily extensive amounts of routine behavioral data may be collected in these trials.

Predictors of unprotected sex among female sex workers in Madagascar: comparing semen biomarkers and self-reported data

Research on the determinants of condom use and condom non-use generally has relied on self-reported data with questionable validity. We identified predictors of recent, unprotected sex among 331 female sex workers in Madagascar using two outcome measures: self-reports of unprotected sex within the past 48 h and detection of prostate-specific antigen (PSA), a biological marker of recent semen exposure. Multivariable logistic regression revealed that self-reported unprotected sex was associated with three factors: younger age, having a sipa (emotional partner) in the prior seven days, and no current use of hormonal contraception. The sole factor related to having PSA detected was prevalent chlamydial infection (adjusted odds ratio, 4.5; 95% confidence interval, 2.0-10.1). Differences in predictors identified suggest that determinants of unprotected sex, based on self-reported behaviors, might not correlate well with risk of semen exposure. Caution must be taken when interpreting self-reported sexual behavior measures or when adjusting for them in analyses evaluating interventions for the prevention of HIV/STIs.

Change in condom and other barrier method use during and after an HIV prevention trial in Zimbabwe

Background

We examined the use of male condoms and the diaphragm following completion of a clinical trial of the diaphragm's HIV prevention effectiveness. In the trial, called Methods for Improving Reproductive Health in Africa (MIRA), women were randomized to a diaphragm group (diaphragm, gel and condoms) or a condom-only control group. At trial exit, all women were offered the diaphragm and condoms.

Methods

Our sample consisted of 801 Zimbabwean MIRA participants who completed one post-trial visit (median lapse: nine months; range two to 20 months). We assessed condom, diaphragm and any barrier method use at last sex act at enrolment, final MIRA and post-trial visits. We used multivariable random effects logistic regression to examine changes in method use between these three time points.

Results and discussion

In the condom group, condom use decreased from 86% at the final trial visit to 67% post trial (AOR = 0.20; 95% CI: 0.12 to 0.33). In the diaphragm group, condom use was 61% at the final trial visit, and did not decrease significantly post trial (AOR = 0.77; 95% CI: 0.55 to 1.09), while diaphragm use decreased from 79% to 50% post trial (AOR = 0.18; 95% CI: 0.12 to 0.28). Condom use significantly decreased between the enrolment and post-trial visits in both groups. Use of any barrier method was similar in both groups: it significantly decreased between the final trial and the post-trial visits, but did not change between enrolment and the post-trial visits.

Conclusions

High condom use levels achieved during the trial were not sustained post trial in the condom group. Post-trial diaphragm use remained relatively high in the diaphragm group (given its unknown effectiveness), but was very low in the condom group. Introducing "new" methods for HIV prevention may require time and user skills before they get adopted. Our findings underscore the potential benefit of providing a mix of methods to women as it may encourage more protected acts.

Assessment of changes in condom use among female sex workers in a prospective cohort study introducing diaphragm use for disease prevention

Changes in the rates of condom use and number of sexual partners were evaluated among 140 female sex workers in Kibera, Kenya, participating in a 6-month study of diaphragm safety and acceptability for prevention of sexually transmitted infections conducted in 2004-2005. Analyses were stratified by partner type. Multivariable Tobit regression modeling was used to assess the association between study visit and proportion of acts protected. Participants completed 140 baseline visits and 390 bimonthly follow-up visits. The mean percentage of coital acts reported as protected by a condom increased from 56% at baseline to 68% at the 6-month visit (P < 0.01). Similar increases were observed for condom use by all partner types. Additionally, the mean number of sexual partners decreased over the study. Furthermore, consistent (i.e., 100%) diaphragm use during follow-up was associated with a higher proportion of coital acts protected by a condom in analyses adjusted for study visit and coital frequency. These findings suggest that, despite concerns that introduction of the diaphragm would result in more risky sexual behaviors, reported condom use increased and number of partners decreased.

A mixed methods and triangulation model for increasing the accuracy of adherence and sexual behaviour data: the Microbicides Development Programme

Background

The collection of accurate data on adherence and sexual behaviour is crucial in microbicide (and other HIV-related) research. In the absence of a “gold standard” the collection of such data relies largely on participant self-reporting. After reviewing available methods, this paper describes a mixed method/triangulation model for generating more accurate data on adherence and sexual behaviour in a multi-centre vaginal microbicide clinical trial. In a companion paper some of the results from this model are presented [1].

Methodology/Principal Findings

Data were collected from a random subsample of 725 women (7.7% of the trial population) using structured interviews, coital diaries, in-depth interviews, counting returned gel applicators, focus group discussions, and ethnography. The core of the model was a customised, semi-structured in-depth interview. There were two levels of triangulation: first, discrepancies between data from the questionnaires, diaries, in-depth interviews and applicator returns were identified, discussed with participants and, to a large extent, resolved; second, results from individual participants were related to more general data emerging from the focus group discussions and ethnography. A democratic and equitable collaboration between clinical trialists and qualitative social scientists facilitated the success of the model, as did the preparatory studies preceding the trial. The process revealed some of the underlying assumptions and routinised practices in “clinical trial culture” that are potentially detrimental to the collection of accurate data, as well as some of the shortcomings of large qualitative studies, and pointed to some potential solutions.

Conclusions/Significance

The integration of qualitative social science and the use of mixed methods and triangulation in clinical trials are feasible, and can reveal (and resolve) inaccuracies in data on adherence and sensitive behaviours, as well as illuminating aspects of “trial culture” that may also affect data accuracy.

Reporting on first sexual experience: The importance of interviewer-respondent interaction

Survey methodologists typically seek to improve data on sensitive topics by standardizing surveys and avoiding the use of human interviewers. This study uses data collected from 90 never-married young adults in rural Malawi to compare reports on first sexual encounters between a standard survey and an in-depth interview. A significant fraction of young women who claimed in the survey to have never been sexually active affirmed sexual experience during the in-depth interview, fielded shortly thereafter. Two elements of the in-depth interview, flexibility and reciprocal exchange, foster trust and more truthful reporting. The findings contradict the long-standing presumption that face-to-face interviews are inherently threatening when the topic is sex.