Sexual Behaviors of US Women at Risk of HIV Acquisition: A Longitudinal Analysis of Findings from HPTN 064

Food Is Medicine for Human Immunodeficiency Virus: Improved Health and Hospitalizations in the Changing Health Through Food Support (CHEFS-HIV) Pragmatic Randomized Trial

BACKGROUND

Policy support for "food is medicine"-medically tailored meals or groceries to improve health-is rapidly growing. No randomized trials have heretofore investigated the benefits of medically tailored food programs for people with human immunodeficiency virus (PWH).

METHODS

The CHEFS-HIV pragmatic randomized trial included PWH who were clients of Project Open Hand (POH), a San Francisco-based nonprofit food organization. The intervention arm (n = 93) received comprehensive medically tailored meals, groceries, and nutritional education. Control participants (n = 98) received less intensive (POH "standard of care") food services. Health, nutrition, and behavioral outcomes were assessed at baseline and 6 months later. Primary outcomes measured were viral nonsuppression and health-related quality of life. Mixed models estimated treatment effects as differences-in-differences between arms.

RESULTS

The intervention arm had lower odds of hospitalization (odds ratio [OR], 0.11), food insecurity (OR, 0.23), depressive symptoms (OR, 0.32), antiretroviral therapy adherence <90% (OR, 0.18), and unprotected sex (OR, 0.18), as well as less fatty food consumption (β = -.170 servings/day) over 6 months, compared to the control arm. There was no difference between study arms in viral nonsuppression and health-related quality of life over 6 months.

CONCLUSIONS

A "food is medicine" intervention reduced hospitalizations and improved mental and physical health among PWH, despite no impact on viral suppression.

CLINICAL TRIALS REGISTRATION

NCT03191253.

A Cross-Biomeasure Study to Optimize Antiretroviral Adherence Estimation

BACKGROUND

Incomplete adherence to daily tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) reduces effectiveness. Adherence biomeasures (ie, drug concentrations in biological specimen) are more accurate than self-report. TDF/FTC's intracellular active metabolites (tenofovir-diphosphate; TFVdp and FTC-triphosphate; FTCtp) can be quantified in different types of blood samples to estimate adherence. To optimize adherence estimation, we investigated approaches to measure TFVdp and FTCtp in 4 blood matrices.

METHODS

Twelve HIV-negative, healthy volunteers were enrolled in a single-center, open-label, 3-phase, directly observed therapy study. LC-MS/MS methods quantified TFVdp/FTCtp in dried blood spots, volumetrically accurate microsampling, upper layer packed cells, and peripheral blood mononuclear cells (PBMCs). Noncompartmental analysis estimated half-lives and accumulation ratios. Correlations characterized relationships between clinical variables and exposure. Regression models were fit to determine concentrations associated with <4 and ≥4 doses/week; correct classification percentages were determined.

RESULTS

Terminal half-life estimates of 3-4 vs 15-22 days distinguished between moderate-term (FTCtp in all samples; TFVdp in PBMCs) versus long-term (TFVdp in red blood cell-containing matrices) measures. Model-derived thresholds accurately categorized <4 and ≥4 doses/week when including both metabolites for 14- and 28-day dosing periods (81%-91% and 82%-85%, respectively). Within each classification and regression trees analyses containing both moderate- and long-term measures, dried blood spots exhibited highest accuracy to predict stable (74%-94%) and changing (42%-47%) adherence patterns.

CONCLUSIONS

We demonstrate higher accuracy of moderate-term biomeasures to classify adherence over a 14-day period compared with long-term biomeasures to classify adherence over a 28-day period. Combined moderate- and long-term biomeasures predicted stable and changing adherence patterns, with dried blood spots exhibiting highest accuracy.

Socio-economic status and adherence to HIV preventive and therapeutic interventions: exploring the mediating role of food insecurity among men who have sex with men and transgender and non-binary persons from Brazil

INTRODUCTION

Brazil offers free-of-charge antiretroviral therapy (ART) for people living with HIV (PLWH) as well as oral pre-exposure prophylaxis (PrEP) through its national health system. Adherence to ART and to PrEP is essential to achieving the expected benefits of virologic suppression and prevention of HIV acquisition, respectively. Brazil has experienced worsening social inequalities, exacerbated by the COVID-19 pandemic, leading to increases in food insecurity especially among vulnerable populations. We explored whether food insecurity mediated the association of socio-economic status on adherence to ART/PrEP.

METHODS

Adult men who have sex with men (MSM) and transgender and non-binary persons (TGNB) living in Brazil (May-September/2021) voluntarily participated in a cross-sectional online study advertised on dating apps and social media. Participants living with HIV reporting ART use and participants with HIV-negative status reporting daily oral PrEP use were eligible for the analysis. Self-report of ART adherence was measured by the WebAd-Q instrument (3-items/past week) plus a visual analogue scale. Self-report of PrEP adherence was measured by the number of days the person took PrEP in the past week. The 8-item Brazilian Scale of Food Insecurity (EBIA) was used to measure food insecurity (higher scores indicate more severe food insecurity). Two structural equation models were used to assess the direct and indirect effects of variables on ART adherence among PLWH and on PrEP adherence among people using PrEP.

RESULTS

In total, 1230 PLWH were using ART, and 991 individuals with HIV-negative status were using daily oral PrEP. The median age of PLWH was 37 years (HIV negative: 34 years), most were cismen (98%). More PLWH reported moderate/severe food insecurity (21.7%; HIV negative: 12.9%). Self-report of ART adherence (measured by WebAd-Q, past 7 days) was 55.7% (PrEP adherence: 93.3%). In the two models, socio-economic status had an effect on adherence that was mediated through food insecurity: higher socio-economic status was associated with lower food insecurity, and higher food insecurity was associated with lower adherence.

CONCLUSIONS

Our findings suggest that the provision of socio-economic support could help PLWH and people at higher vulnerability to HIV acquisition by improving their adherence to ART or PrEP, and ultimately populations through decreased HIV transmissions.

HIV Preexposure Prophylaxis With Emtricitabine and Tenofovir Disoproxil Fumarate Among Cisgender Women

Importance

Emtricitabine and tenofovir disoproxil fumarate (F/TDF) for HIV preexposure prophylaxis (PrEP) is highly effective in cisgender men who have sex with men (MSM) when adherence is high (>4 doses/week). Real-world effectiveness and adherence with F/TDF for PrEP in cisgender women is less well characterized.

Objective

To characterize the effectiveness of F/TDF for PrEP and its relationship with adherence in cisgender women.

Design, Setting, and Participants

Data were pooled from 11 F/TDF PrEP postapproval studies conducted in 6 countries that included 6296 cisgender women aged 15 to 69 years conducted from 2012 to 2020. HIV incidence was evaluated according to adherence level measured objectively (tenofovir diphosphate concentration in dried blood spots or tenofovir concentration in plasma; n = 288) and subjectively (electronic pill cap monitoring, pill counts, self-report, and study-reported adherence scale; n = 2954) using group-based trajectory modeling.

Exposures

F/TDF prescribed orally once a day. HIV incidence was analyzed in subgroups based on adherence trajectory.

Main Outcomes and Measures

HIV incidence.

Results

Of the 6296 participants, 46% were from Kenya, 28% were from South Africa, 21% were from India, 2.9% were from Uganda, 1.6% were from Botswana, and 0.8% were from the US. The mean (SD) age at PrEP initiation across all studies was 25 (7) years, with 61% of participants being younger than 25 years. The overall HIV incidence was 0.72 per 100 person-years (95% CI, 0.51-1.01; 32 incident HIV diagnoses among 6296 participants). Four distinct groups of adherence trajectories were identified: consistently daily (7 doses/week), consistently high (4-6 doses/week), high but declining (from a mean of 4-6 doses/week and then declining), and consistently low (less than 2 doses/week). None of the 498 women with consistently daily adherence acquired HIV. Only 1 of the 658 women with consistently high adherence acquired HIV (incidence rate, 0.13/100 person-years [95% CI, 0.02-0.92]). The incidence rate was 0.49 per 100 person-years (95% CI, 0.22-1.08) in the high but declining adherence group (n = 1166) and 1.27 per 100 person-years (95% CI, 0.53-3.04) in the consistently low adherence group (n = 632).

Conclusions and Relevance

In a pooled analysis of 11 postapproval studies of F/TDF for PrEP among cisgender women, overall HIV incidence was 0.72 per 100 person-years; individuals with consistently daily or consistently high adherence (4-6 doses/week) to PrEP experienced very low HIV incidence.

Type of Exchange Sex and Associated Behaviors and Outcomes Among Cisgender Men and Women at Increased Risk for HIV via Heterosexual Transmission in Six U.S. Metropolitan Areas

Exchange sex is associated with sexual risk behaviors and poor outcomes and different types may incur different levels of risk. We assessed risk profiles of different types of exchange sex among non-injecting cisgender men and women who participated in the 2019 National HIV Behavioral Surveillance project at six sites. Six percent of men and 19% of women reported exchange sex in the past year; most engaged in non-commercial exchange sex for drugs/money with smaller percentages reporting formal sex work or non-commercial exchange sex for goods or services other than drugs/money. Exchange sex was associated with sexual risk and prevention behaviors and psychosocial and sexual health outcomes and associations varied by type of exchange sex. Efforts to improve access to STI/HIV testing and PrEP may benefit from tailoring based on type of exchange sex. Findings indicate value in a broader definition of exchange sex with follow-up assessment of exchange sex typology.

Unwanted sexual activity among United States women early in the COVID-19 pandemic

BACKGROUND

Female sexual activity and, accordingly, birth rates tend to decline in times of stress, such as a pandemic. In addition, when resources are scarce or exogenous conditions are threatening, some women may engage in sexual activity primarily to maintain socioeconomic security. Having unwanted sex may indicate sexual activity in exchange for economic security.

OBJECTIVE

This study aimed to describe patterns and correlates of unwanted sex, defined as having sex more frequently than desired, among US women early in the COVID-19 pandemic.

STUDY DESIGN

The National US Women's Health COVID-19 Study was conducted in April 2020, using a nested quota sample design to enroll 3200 English-speaking women (88% cooperation rate) aged 18 to 90 years recruited from a research panel. The quota strata ensured sufficient sample sizes in sociodemographic groups of interest, namely, racial and ethnic subgroups. Patterns of sexual activity, including unwanted sex early in the pandemic, were described. To further elucidate the experiences of women reporting unwanted sex, open-ended responses to an item querying "how the coronavirus pandemic is affecting your sex life" were assessed using conventional content analysis. Logistic regression analyses-adjusting for sociodemographic characteristics, self-reported health, and prepandemic health-related socioeconomic risk factors, including food insecurity, housing instability, utilities and transportation difficulties, and interpersonal violence-were used to model the odds of unwanted sex by a pandemic-related change in health-related socioeconomic risk factors.

RESULTS

The proportion of women who were sexually active early in the pandemic (51%) was about the same as in the 12 months before the pandemic (52%), although 7% of women became active, and 7% of women became inactive. Overall, 11% of sexually active women were having unwanted sex in the early pandemic. The rates of anxiety, depression, traumatic stress symptoms, and each of the 5 health-related socioeconomic risk factors assessed were about 2 times higher among women having unwanted sex than other women (P<.001). Women having unwanted sex were also 5 times more likely than other women to report an increased frequency of sex since the pandemic (65% vs 13%; P<.001) and 6 times more likely to be using emergency contraception (18% vs 3%; P<.001). Women reporting unwanted sex commonly described decreased libido or interest in sex related to mood changes since the pandemic, having "more sex," fear or worry about the transmission of the virus because of sex, and having sex to meet the partner's needs. Among sexually active women, the odds of unwanted sex (adjusting for demographic, reproductive, and health factors) were higher among women with 1 prepandemic health-related socioeconomic risk factor (adjusted odds ratio, 2.0; 95% confidence interval, 1.1-3.8) and 2 or more prepandemic health-related socioeconomic risk factors (adjusted odds ratio, 6.0; 95% confidence interval, 3.4-10.6). Among sexually active women with any prepandemic health-related socioeconomic risk factor, those with new or worsening transportation difficulties early in the pandemic were particularly vulnerable to unwanted sex (adjusted odds ratio, 2.7; 95% confidence interval, 1.7-4.3).

CONCLUSION

More than 1 in 10 sexually active US women was having unwanted sex early in the COVID-19 pandemic. Socioeconomically vulnerable women, especially those with new or worsening transportation problems because of the pandemic, were more likely than others to engage in unwanted sex. Pandemic response and recovery efforts should seek to mitigate unwanted sexual activity and related health and social risks among women.

Structural Barriers to HIV Prevention and Services: Perspectives of African American Women in Low-Income Communities

BACKGROUND

African American women are at a disproportionate HIV risk compared with other U.S. women. Studies show that complex structural and social determinants, rather than individual behaviors, place African American women at greater risk of HIV infection; however, little is known about women's views of what puts them at risk.

AIMS

This study sought to comprehend the perceptions of African American women living in low-income housing regarding the factors that influence both their personal sexual health behaviors and use of HIV prevention services.

METHODS

We conducted seven focus groups with 48 African American women from 10 public housing communities in a small city in the southeastern United States. We analyzed the focus group transcripts using thematic data analysis to identify salient themes and points of interest related to the study aim.

RESULTS

Women identified factors related to the health care system (trustworthiness of the health care system), the external environment (racism, classism, patriarchal structures, and violence/crime), as well as predisposing (health beliefs, stigma, and gender norms), enabling (agency to negotiate gendered power), and need (perceived HIV risk and perceptions of partner characteristics) features of individuals in the population.

CONCLUSION

African American women living in public housing are especially vulnerable to HIV infection due to intersectional discrimination based on racism, classism, gender power dynamics, and community conditions. Our findings confirm the need to develop HIV intervention programming addressing intersectional identities of those making up the communities they plan to address, and being informed by those living in the communities they plan to act on.

Food insecurity as a social determinant of sexual health and substance use independent of poverty status among men who have sex with men in the United States

PURPOSE

To characterize the prevalence of food insecurity among men who have sex with men (MSM) and assess its associations with sexual health measures and substance use, as compared to poverty status.

METHODS

In 2017, 10,049 US MSM were recruited online and completed the American Men's Internet Survey. The survey assessed food insecurity, annual household income and past-year behaviors: condomless anal intercourse (CAI), exchange sex, any illicit substance use other than marijuana, use of methamphetamine, alkyl nitrites or gamma-hydroxybutyrate (GHB), HIV testing and sexually transmitted infection testing and diagnosis. We tested associations between behavioral outcomes and food insecurity or poverty, controlling for demographic characteristics.

RESULTS

The prevalence of food insecurity among AMIS participants was 15.8%. Food insecurity non-response was 2.5% while income non-response was 19.0%. Food insecurity was significantly and positively associated with all behavioral outcomes, while poverty was significantly and positively associated only with exchange sex, any illicit substance use, methamphetamine and GHB use. In models that included both food insecurity and poverty as exposures, food insecurity remained independently positively associated with all behavioral outcomes and the associations for poverty level were null for all outcomes except methamphetamine and GHB use.

CONCLUSIONS

Assessing food insecurity in sexual health and substance use survey research may provide a more robust indicator of economic deprivation and provide insight for HIV and STI prevention interventions.

Characteristics associated with HIV and hepatitis C seroprevalence among sexual and injecting partners of HIV positive persons who inject drugs in Nairobi and coastal Kenya

Background

Persons who inject drugs (PWID) have higher HIV and hepatitis C virus (HCV) seroprevalence than the general population in many parts of sub-Saharan Africa (SSA). The seroprevalences of HIV and HCV are also higher in coastal Kenya than in Nairobi. Understanding drivers of regional HIV and HCV variation among PWID in Kenya may inform population-specific prevention interventions.

Methods

Using a cross-sectional study, we defined HIV and HCV seroprevalence among persons identified as sexual or injecting partners of HIV positive PWID in two regions of Kenya and used logistic regression to identify demographic and behavioral characteristics associated with higher seroprevalence.

Results

Among 2386 partners, 469 (19.7%) tested HIV positive and 297(12.4%) tested HCV antibody positive. Partners on the Coast were more likely to live with HIV (seroprevalences: Coast = 23.8%, Nairobi = 17.1%; p < 0.001) and be HCV antibody positive (seroprevalences: Coast = 17.0%, Nairobi = 8.6%; p < 0.001). After adjusting for sex, age, and years injecting and accounting for clustering by site, the higher prevalence of both diseases in the Coast remained significant for HIV (OR 1.68, 95% CI 1.13–2.51) but not for HCV (OR 1.72, 95% CI 0.84–3.74). Compared to those recruited in Nairobi, partners on the Coast were older (Coast = 35 years, Nairobi = 31 years; p < 0.001), more likely to be male (Coast = 77.6%, Nairobi = 61.7%; p < 0.001), to have paid (Coast = 59.2%, Nairobi = 32.8%; p < 0.001) or received (Coast = 44.2%, Nairobi 35.4%; p < 0.001) money for sex, or to have had sex with someone they knew to be HIV positive (Coast 22.0%, Nairobi 10.8%; p < 0.001). Partners who had injected for five or more years had 1.48 times greater odds (95% CI 1.20–1.82) of living with HIV compared to partners who injected less than 5 years and more than twice the odds of HCV (95% CI 1.84–4.11).

Conclusion

HIV and HCV seroprevalence among sexual and injecting partners of PWID was, respectively, 5 times and > 12 times greater than is reported among the general population in Kenya (4% and < 1%, respectively). Providing resources and education will be crucial to reduce exposure and to maintain the lower needle and equipment sharing that we observed compared to other studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07036-8.

The role of food security in increasing adolescent girls' agency towards sexual risk taking: qualitative findings from an income generating agricultural intervention in southwestern Kenya

BACKGROUND

Food insecurity is an important underlying driver of HIV risk and vulnerability among adolescents in sub-Saharan Africa. In this region, adolescents account for 80% of all new HIV infections. The primary purpose of this analysis is to understand perceived mechanisms for how a multisectoral agricultural intervention influenced sexual risk taking among HIV-affected adolescents in southwestern Kenya.

METHODS

We conducted semi-structured, individual interviews with 34 adolescent-caregiver dyads who were participants in Adolescent Shamba Maisha (NCT03741634), a sub-study of adolescent girls and caregivers with a household member participating in the Shamba Maisha trial (NCT01548599), a multi-sectoral agricultural and microfinance intervention. Interviews were audiotaped, transcribed, translated, and analyzed using framework and interpretive description analysis methods.

RESULTS

Adolescents receiving the Shamba Maisha intervention described no longer needing to engage in transactional sex or have multiple concurrent sexual partners as a way to meet their basic needs, including food. Key mechanisms for these effects include greater sexual agency among adolescent girls, and increased confidence and self-efficacy in overcoming existing reciprocity norms and sexual relationship power inequity; as well as staying in school. The intervention also increased caregiver confidence in talking about adolescent sexual reproductive health issues. In contrast, driven primarily by the need for food and basic needs, girls in the control arms described engaging in transactional sex, having multiple sexual partners, being unable to focus in school, getting pregnant or becoming HIV infected.

CONCLUSION

These findings emphasize the need to address food insecurity as a part of structural interventions targeting adolescent HIV risk in low-resource countries. We recommend that future interventions build upon the Shamba Maisha model by combining sustainable agricultural production, with household level interventions that deliberately target gender norms that contribute to unequal power dynamics.

Food Insecurity and Risk Indicators for Sexually Transmitted Infection Among Sexually Active Persons Aged 15-44, National Survey of Family Growth, 2011-2017

OBJECTIVES

Food insecurity is linked to poor sexual health outcomes, especially among persons engaged in sexual behaviors that are associated with the risk of acquiring sexually transmitted infections (STIs). We examined this link using nationally representative data.

METHODS

We used data on adolescents and adults aged 15-44 who reported sexual activity in the past year from 6 years (September 2011-September 2017) of cross-sectional, weighted public-use data from the National Survey of Family Growth. We compared data on persons who did and did not report food insecurity, accounting for demographic characteristics, markers of poverty, and past-year STI risk indicators (ie, engaged in 1 of 4 high-risk activities or diagnosed with chlamydia or gonorrhea).

RESULTS

Respondents who reported at least 1 past-year STI risk indicator were significantly more likely to report food insecurity (females: adjusted risk ratio [ARR] = 1.63; 95% confidence interval [CI], 1.35-1.97; P < .001; males: ARR = 1.46; 95% CI, 1.16-1.85) than respondents who did not report food insecurity. This finding was independent of the association between food insecurity and markers of poverty (≤100% federal poverty level [females: ARR = 1.46; 95% CI, 1.23-1.72; P < .001; males: ARR = 1.81; 95% CI, 1.49-2.20; P < .001]; if the respondent or someone in the household had received Special Supplemental Nutrition Program for Women, Infants, and Children or Supplemental Nutrition Assistance Program benefits in the past year [females: ARR = 3.37; 95% CI, 2.81-4.02; P < .001; males: ARR = 3.27; 95% CI, 2.76-3.87; P < .001]). Sex with opposite- and same-sex partners in the past year was significantly associated with food insecurity (females: ARR = 1.44; 95% CI, 1.11-1.85; P = .01; males: ARR = 1.99; 95% CI, 1.15-3.42; P = .02).

CONCLUSIONS

Food insecurity should be considered a social determinant of health independent of poverty, and its effect on persons at highest risk for STIs, including HIV, should be considered when planning interventions designed to decrease engagement in higher-risk sexual behaviors.

Barriers and Facilitators of Rapid HIV and Syphilis Testing Uptake Among Filipino Transnational Migrants in China

Transnational migrant workers are known to be at high risk for HIV/STIs. This study estimated the point prevalence of HIV/syphilis and examined correlates of HIV/syphilis testing uptake among female migrant domestic workers in Macao, China. Data was obtained from 1363 female Filipino domestic workers who were offered free rapid HIV and syphilis testing. A mixed methods analysis was undertaken to examine correlates of testing and themes about reasons for not testing. Among 1164 women tested, there were no cases of HIV/syphilis observed and 199 (14.6%) refused HIV/syphilis testing. Greater social integration (aOR 1.12; 95% CI 1.02-1.24), having more than one sexual partner (aOR 1.65; 95% CI 1.02-2.65), and longer working hours on the testing day (aOR 0.97; 95% CI 0.94-1.00), were associated with testing uptake. Among those who tested, the majority (> 70%) had never tested before, suggesting the need to improve testing outreach. Qualitative themes about reasons for not testing included low perceived need and insufficient time. Individual and structural testing barriers should be reduced to optimize HIV/STI testing in migrant populations.

Brief Report: PrEP Eligibility Among At-Risk Women in the Southern United States: Associated Factors, Awareness, and Acceptability

BACKGROUND

Among women in the United States, non-Latina black women in the South have disproportionately high rates of new HIV infections but low use of pre-exposure prophylaxis (PrEP). Effective strategies to identify factors associated with PrEP eligibility could facilitate improved screening, offering, and uptake of PrEP among US women at risk of HIV.

SETTING AND METHODS

We applied 2014 CDC criteria for PrEP use to at-risk HIV-negative women enrolled in the Southern US sites (Atlanta, Chapel Hill, Birmingham/Jackson, Miami) of the Women's Interagency HIV Study from 2014 to 2015 to estimate PrEP eligibility and assess PrEP knowledge and acceptability. Factors associated with PrEP eligibility were assessed using multivariable models.

RESULTS

Among 225 women, 72 (32%) were PrEP-eligible; the most common PrEP indicator was condomless sex. The majority of PrEP-eligible women (88%) reported willingness to consider PrEP. Only 24 (11%) PrEP-eligible women had previously heard of PrEP, and only 1 reported previous use. Education level less than high school [adjusted odds ratio (aOR) 2.56; 95% confidence interval (CI): 1.22 to 5.37], history of sexual violence (aOR 4.52; 95% CI: 1.52 to 17.76), and medium to high self-perception of HIV risk (aOR 6.76; 95% CI: 3.26 to 14.05) were significantly associated with PrEP eligibility in adjusted models.

CONCLUSIONS

Extremely low PrEP awareness and use despite a high proportion of eligibility and acceptability signify a critical need to enhance PrEP education and delivery for women in this region. Supplementing CDC eligibility criteria with questions about history of sexual violence and HIV risk self-assessment may enhance PrEP screening and uptake among US women.

The Relationship Between Economic Deprivation, Housing Instability and Transactional Sex Among Women in North Carolina (HPTN 064)

Transactional sex is associated with socioeconomic disadvantage and HIV risk but few studies in the United States (US) have examined both individual and area-level predictors of transactional sex or distinguished transactional sex from sex work. We combined data from HIV Prevention Trials Network 064 study and the US Census to estimate prevalence ratios (PR) for the relationship between census-level and individual measures of economic deprivation and housing instability on transactional sex in 417 women in North Carolina. Increased transactional sex was associated with food insecurity (PR 1.86; 95%; CI 1.57, 2.19), housing instability (PR 1.33; 95% CI 1.11, 1.59), substance abuse (PR 1.90; 95% CI 1.64, 2.19) and partner incarceration (PR 1.32; 95% CI 1.09, 1.61). Census-level indicators were not associated with transactional sex, adjusted for individual-level covariates. Interventions should support housing stability and financial opportunities among southern African American women to reduce HIV risk, particularly among women with incarcerated partners.

Estimating Human Immunodeficiency Virus (HIV) Prevention Effects in Low-incidence Settings

BACKGROUND

Randomized controlled trials (RCTs) for determining efficacy of preexposure prophylaxis (PrEP) in preventing human immunodeficiency virus (HIV) infection have not been conducted among US women because their lower HIV incidence requires impractically large studies. Results from higher-incidence settings, like Sub-Saharan Africa, may not apply to US women owing to differences in age, sexual behavior, coinfections, and adherence.

METHODS

We propose a novel strategy for evaluating PrEP efficacy in the United States using data from both settings to obtain four parameters: (1) intention-to-treat (ITT) and (2) per-protocol effects in the higher-incidence setting, (3) per-protocol effect generalized to the lower-incidence setting, and (4) back-calculated ITT effect using adherence data from the lower-incidence setting. To illustrate, we simulated two RCTs comparing PrEP against placebo: one in 4000 African women and another in 500 US women. We estimated all parameters using g-computation and report risk ratios averaged over 2000 simulations, alongside the 2.5th and 97.5th percentiles of the simulation results.

RESULTS

Twelve months after randomization, the African ITT and per-protocol risk ratios were 0.65 (0.47, 0.88) and 0.20 (0.08, 0.34), respectively. The US ITT and per-protocol risk ratios were 0.42 (0.20, 0.62) and 0.17 (0.03, 0.38), respectively. These results matched well the simulated true effects.

CONCLUSIONS

Our simple demonstration informs the design of future studies seeking to estimate the effectiveness of a treatment (like PrEP) in lower-incidence settings where a traditional RCT would not be feasible. See video abstract at, http://links.lww.com/EDE/B506.

Rethinking Risk, Culture, and Intervention in Collective Sex Environments

This article provides a narrative overview of research on HIV/STI risk and collective sexual behavior based on an inclusive analysis of research on environments where people gather for sexual activity-sex clubs, swingers' clubs, bathhouses, parks, private sex parties, etc. The aim is to analyze how collective sex has been approached across disciplines to promote conversation across paradigms and suggest new lines of inquiry. Attention to context-such as the location of sex-was a necessary redress to universalizing models of sexual risk-taking behavior, leading to insights rooted in the particularities of each environment and its users. However, the identification of ever more precise risk groups or environmental idiosyncrasies eventually becomes theoretically restrictive, leading to an overestimation of the uniqueness of sexual enclaves, and of the difference between any given enclave and the broader social milieu. Using a theoretical framework of transgression to interpret the interdisciplinary literature, similarities in the spatial and social organization of collective sex environments are identified. Insights generated from this complementary perspective are then applied to understandings of collective sex: first, the example of male-female (MF) "swingers" is used to illustrate the need to establish, rather than assume, the distinctiveness of each non-normative sexual enclave, and to broaden the conceptualization of context; second, questions are raised about the practicality of interventions in collective sex environments. Finally, new lines of intellectual inquiry are suggested to shed light not just on collective sex but on sociosexual issues more generally, such as increasing protective sexual health behavior or negotiating consent in sexual encounters.

Food Insecurity, Substance Use, and Sexual Transmission Risk Behavior Among People Living with HIV: A Daily Level Analysis

People living with HIV in poverty have limited tangible and mental resources coupled with competing demands for these resources. Competing demands require individuals to make choices that may be beneficial to them in the short term but not in the long term. Past research has shown that food insecurity is related to sexual risk behaviors among people living with HIV. Individuals who are food insecure may sell sex in order to obtain food or lack of food may lead to a depletion of mental resources to negotiate safe sex. Substance use may also create additional constraints on these already limited resources. The current study tested the relation between food insecurity and day-level sexual risk behavior and the possible mediating role that alcohol/substance use may play. Men and women living with HIV were enrolled in a 28-day prospective study between October 2012 and April 2014 in which they completed daily text message surveys regarding their sex behaviors and substance/alcohol use in the context of sex. A total of 796 participants reported sex on 3894 days. On days in which sex occurred, baseline food insecurity was negatively associated with daily condom use. There was also a significant effect of substance use in the context of sex on the rates of change in condom use over time, and this interaction between substance use and time was a partial mediator of the relation between food insecurity and condom use. Gender did not moderate this mediation. Situation-specific alcohol and drug use should be integrated into interventions that target food insecurity and HIV prevention.

Associations Between Neighborhood Characteristics, Social Cohesion, and Perceived Sex Partner Risk and Non-Monogamy Among HIV-Seropositive and HIV-Seronegative Women in the Southern U.S

Neighborhood social and physical factors shape sexual network characteristics in HIV-seronegative adults in the U.S. This multilevel analysis evaluated whether these relationships also exist in a predominantly HIV-seropositive cohort of women. This cross-sectional multilevel analysis included data from 734 women enrolled in the Women's Interagency HIV Study's sites in the U.S. South. Census tract-level contextual data captured socioeconomic disadvantage (e.g., tract poverty), number of alcohol outlets, and number of non-profits in the census tracts where women lived; participant-level data, including perceived neighborhood cohesion, were gathered via survey. We used hierarchical generalized linear models to evaluate relationships between tract characteristics and two outcomes: perceived main sex partner risk level (e.g., partner substance use) and perceived main sex partner non-monogamy. We tested whether these relationships varied by women's HIV status. Greater tract-level socioeconomic disadvantage was associated with greater sex partner risk (OR 1.29, 95% CI 1.06-1.58) among HIV-seropositive women and less partner non-monogamy among HIV-seronegative women (OR 0.69, 95% CI 0.51-0.92). Perceived neighborhood trust and cohesion was associated with lower partner risk (OR 0.83, 95% CI 0.69-1.00) for HIV-seropositive and HIV-seronegative women. The tract-level number of alcohol outlets and non-profits were not associated with partner risk characteristics. Neighborhood characteristics are associated with perceived sex partner risk and non-monogamy among women in the South; these relationships vary by HIV status. Future studies should examine causal relationships and explore the pathways through which neighborhoods influence partner selection and risk characteristics.

Contribution of Anal Sex to HIV Prevalence Among Heterosexuals: A Modeling Analysis

Anal intercourse is reported by many heterosexuals, and evidence suggests that its practice may be increasing. We estimated the proportion of the HIV burden attributable to anal sex in 2015 among heterosexual women and men in the United States. The HIV Optimization and Prevention Economics model was developed using parameter inputs from the literature for the sexually active U.S. population aged 13-64. The model uses differential equations to represent the progression of the population between compartments defined by HIV disease status and continuum-of-care stages from 2007 to 2015. For heterosexual women of all ages (who do not inject drugs), almost 28% of infections were associated with anal sex, whereas for women aged 18-34, nearly 40% of HIV infections were associated with anal sex. For heterosexual men, 20% of HIV infections were associated with insertive anal sex with women. Sensitivity analyses showed that varying any of 63 inputs by ±20% resulted in no more than a 13% change in the projected number of heterosexual infections in 2015, including those attributed to anal sex. Despite uncertainties in model inputs, a substantial portion of the HIV burden among heterosexuals appears to be attributable to anal sex. Providing information about the relative risk of anal sex compared with vaginal sex may help reduce HIV incidence in heterosexuals.

Associations between neighborhood characteristics and sexual risk behaviors among HIV-infected and HIV-uninfected women in the southern United States

PURPOSE

Neighborhood characteristics shape sexual risk in HIV-uninfected adults in the United States (US). We assess relationships between census tract characteristics and sexual risk behaviors in a predominantly HIV-infected cohort of women living in the Southern US.

METHODS

This cross-sectional multilevel analysis included data from 737 HIV-infected and HIV-uninfected women enrolled in the Women's Interagency HIV Study. Administrative data captured characteristics of census tracts where women lived; participant-level data were gathered via survey. We used principal components analysis to condense tract-level variables into components: social disorder (e.g., violent crime rate), and social disadvantage (e.g., alcohol outlet density). We used hierarchical generalized linear models to assess relationships between tract-level characteristics and condomless vaginal intercourse, anal intercourse, and condomless anal intercourse.

RESULTS

Greater social disorder was associated with less anal intercourse (OR = 0.63, 95% CI = 0.43-0.94) and condomless anal intercourse (OR = 0.49, 95% CI = 0.30-0.80), regardless of HIV status. There were no statistically significant additive or multiplicative interactions between tract characteristics and HIV status.

CONCLUSIONS

Neighborhood characteristics are associated with sexual risk behaviors among women living in the Southern US, these relationships do not vary by HIV status. Future studies should establish temporality and explore the causal pathways through which neighborhoods influence sexual risk.

Social and psychological correlates of unprotected anal intercourse among Hispanic-American women: implications for STI/HIV prevention

Heterosexual anal intercourse is associated with increased risk for HIV and other sexually transmitted infections. Research on the social and psychological risk factors associated with heterosexual unprotected anal intercourse among Hispanic women in the USA is limited. We examined demographic, mental health, relationship power, sexual self-efficacy, self-esteem, acculturation and HIV knowledge as correlates of unprotected anal intercourse among 514 HIV-negative Hispanic women, 18 to 59 years of age, residing in one urban county in southern Florida. In both unadjusted and adjusted results, the likelihood of engaging in unprotected anal intercourse was associated with food insecurity in the past 30 days (adjusted odds ratio [AOR] = 1.57, 95% confidence interval [CI] 1.03, 2.40) and more interpersonal power attributed to the male partner (AOR = 1.63, 95%CI 1.08, 2.45). Not significant, yet of possible importance, were ever having engaged in exchange sex (AOR = 1.96, 95%CI = 0.97, 3.98) and lower HIV knowledge (AOR = 0.80, 95%CI = 0.63, 1.01). Interventions aimed at reducing heterosexual unprotected anal intercourse risk for HIV infection among Hispanic women may benefit by addressing socioeconomic and interpersonal issues, and assessing HIV knowledge and comprehension.

Socioecological factors influencing women's HIV risk in the United States: qualitative findings from the women's HIV SeroIncidence study (HPTN 064)

Background

We sought to understand the multilevel syndemic factors that are concurrently contributing to the HIV epidemic among women living in the US. We specifically examined community, network, dyadic, and individual factors to explain HIV vulnerability within a socioecological framework.

Methods

We gathered qualitative data (120 interviews and 31 focus groups) from a subset of women ages 18–44 years (N = 2,099) enrolled in the HPTN 064 HIV seroincidence estimation study across 10 US communities. We analyzed data from 4 diverse locations: Atlanta, New York City (the Bronx), Raleigh, and Washington, DC. Data were thematically coded using grounded theory methodology. Intercoder reliability was assessed to evaluate consistency of team-based coding practices.

Results

The following themes were identified at 4 levels including 1) exosystem (community): poverty prevalence, discrimination, gender imbalances, community violence, and housing challenges; 2) mesosystem (network): organizational social support and sexual concurrency; 3) microsystem (dyadic): sex exchange, interpersonal social support, intimate partner violence; and 4) individual: HIV/STI awareness, risk taking, and substance use. A strong theme emerged with over 80 % of responses linked to the fundamental role of financial insecurity underlying risk-taking behavioral pathways.

Conclusions

Multilevel syndemic factors contribute to women’s vulnerability to HIV in the US. Financial insecurity is a predominant theme, suggesting the need for tailored programming for women to reduce HIV risk.

Trial registration

Clinicaltrials.gov, NCT00995176

Food insecurity is associated with HIV, sexually transmitted infections and drug use among men in the United States

OBJECTIVE

To examine the population-level association between food insecurity, HIV risk factors, and HIV serostatus among men, the group representing the majority of HIV diagnoses in the United States.

DESIGN

Cross-sectional secondary data analysis using the National Health and Nutrition Examination Survey 1999-2012, a nationally representative survey of the civilian noninstitutionalized US population.

METHODS

Logistic regression with design weights and complex survey commands was used to estimate nationally representative associations between food insecurity and HIV serostatus (primary outcome), herpes simplex virus 2, self-reported sexually transmitted infections (STIs), and past-year illicit drug use among men, adjusting for potential confounders. Food security was measured using the 18-item Household Food Security Survey.

RESULTS

We analyzed data for 9150 men representing 61 million individuals in the United States. Unadjusted HIV prevalence was 1.5% among food insecure men, compared with 0.4% among food secure men (P < 0.001). In adjusted models, food insecure men had over two times higher odds of HIV seropositivity compared with food secure men [adjusted odds ratio (AOR) = 2.10; 95% confidence interval (CI) 1.01-4.37; P < 0.05]. Food insecurity was associated with higher odds of herpes simplex virus 2 seropositivity (AOR = 1.28; 95% CI 1.04-1.57; P < 0.05), self-reported STIs (AOR = 1.54; 95% CI 1.08-2.20; P < 0.05), and illicit drug use (AOR = 1.57; 95% CI 1.14-2.15; P < 0.01). Results were robust to sensitivity analyses restricted to lower incomes.

CONCLUSION

Food insecurity is associated with prevalent HIV, STIs, and illicit drug use among men in the United States. Further research is needed to establish whether and through what mechanisms improved food security may help prevent new HIV infections.

INSTRUMENTS OF HIGH RISK SEXUAL BEHAVIOR ASSESSMENT: A SYSTEMATIC REVIEW

BACKGROUND

Sexual behavior is a complex activity affecting all aspects of human's life. Risky sexual behaviors impose negative outcomes on family, relationships and health. Unsafe sex is the second most leading cause of disability adjusted life years worldwide. Valid and reliable tools for assessment of risky sexual behaviors are necessary for implementing preventive measures.

METHODS

we searched Medline and the Cochrane Library of Systematic Reviews, with the keywords of "risky sexual behavior assessment", "sexual risk assessment", "high risk sexual behavior", "sexual risk taking". By reviewing references of the articles, some complementary studies were added.

RESULTS

Assessment can be performed by questionnaire or non-questionnaire instruments. Questionnaires vary depending on their target population, evaluation of risky sexual behavior as a whole or focusing on an associated risk factor. In order to avoid usual biases in self reports, objective biomarker assessment of unprotected sex are employed. These markers include prostate specific antigen, chromosome Y DNA and Seminogelin.

CONCLUSION

Risky sexual behavior can be assessed by various subjective and objective methods. While self-reports are more feasible, objective methods offer a higher degree of reliability. Further studies for finding more feasible methods of using biomarkers are recommended.

Post-traumatic Stress Disorder Symptoms and Mental Health over Time among Low-Income Women at Increased Risk of HIV in the U.S

Women living in poverty suffer more post-traumatic stress disorder (PTSD) symptoms than do members of the general population; however we know little about factors associated with changes in their PTSD symptoms over time. Using data from HPTN 064, a cohort of women from low-income, high-HIV-prevalence communities across six eastern states (n=1,860), we assessed the prevalence of and changes in PTSD symptoms over 12 months and the effect of potential predictors on symptom acquisition and remission (via the Primary Care-PTSD symptoms scale). Forty-three percent screened positive for PTSD symptoms. Those reporting food insecurity, ongoing abuse, depressive symptoms, or binge drinking were more likely to acquire PTSD symptoms. Those with ongoing abuse or depressive symptoms were less likely to experience PTSD symptom remission. Findings suggest a need to integrate programs to reduce abuse, depression, and economic hardship with those that address sexual health risks among women living in low-income, high-HIV-prevalence neighborhoods.