The time has come for common ground on preventing sexual transmission of HIV

Trends and country-level variation in age at first sex in sub-Saharan Africa among birth cohorts entering adulthood between 1985 and 2020

BACKGROUND

Debuting sexual intercourse marks exposure to pregnancy or fatherhood and sexually transmitted infections (STIs), including HIV. In sub-Saharan Africa (SSA), sexual debut varies according to cultural, religious, and economic factors, and encouraging delay has been a longstanding component of behavioural HIV prevention strategies. Age at first sex (AFS) is routinely collected in national household surveys, but data are affected by reporting biases, limiting utility to monitor trends and guide sexual health interventions.

METHODS

We collated individual-level data from nationally-representative household surveys to analyse timing and national trends in AFS in 42 SSA countries. We used a log-skew-logistic distribution to characterize the time to AFS in a Bayesian spatio-temporal model, providing estimates of the sexual debut rate by sex, age, time, and country. We statistically adjusted for reporting biases by comparing AFS reported by the same birth cohorts in multiple survey rounds, allowing different reporting biases by sex and country.

RESULTS

Median AFS in 2015 ranged from 15.8 among Angolan women to 25.3 among men in Niger. AFS was younger for women than men in 37/40 countries. The gap was largest for Sahel region countries and minimal in southern African countries. The distribution of female AFS was asymmetric with half debuting sex in an age range of 3.9 years [IQR 3.4-5.0 across countries]. Median AFS increased slightly between 1985 and 2020, ranging 0.84 years [IQR 0.11-1.55] and 0.79 [IQR -0.23-1.98] for females and males, respectively. The gender gap changed little over time in most countries. Female teens often reported higher AFS compared to when asked in their late twenties while male teens reported lower AFS; both sexes recalled a higher AFS in older ages compared to their thirties.

CONCLUSIONS

AFS increased slightly in most SSA countries, but changes were modest relative to large and persistent variation between countries and sexes, indicating relatively entrenched socio-cultural practices around sexual debut. Sexual health, family planning, and HIV/STI prevention services should adapt to local practices rather than focusing interventions to change AFS. These estimates for rates of sexual debut provide data to guide programmatic prioritization and implementation of sexual health services.

Religiosity and Sexual Initiation Among Hispanic Adolescents: The Role of Sexual Attitudes

Introduction: Religiosity and sexuality present numerous interconnections. Little is known regarding the specific causal pathways between each religiosity dimension and sexual behavior. The objectives of this study were (1) to explore the relationship between religiosity (measured through attendance at religious services, salience, and prayer) and sexual initiation in adolescents and (2) to establish the role of sexual permissiveness as mediator of the impact produced by religiosity in sexual initiation. Methods: This study analyzes data from an ongoing school-based international study examining what young people feel and think about relationships, love, and sexuality. An anonymous, self-administered online questionnaire was developed in Spanish. A total of 4,366 students, aged 14-18, completed the questionnaire. A final sample of 2,919 questionnaires was analyzed. Two unconditional logistic regression models were fit with religiosity variables and possible confounders as independent variables (with and without permissiveness, respectively). The dependent variable was sexual initiation. A final path analysis was performed to further understand the results. Results: Our study highlights that, in predominantly Catholic and Spanish-speaking countries, the fact of attending church and praying may greatly contribute to postponing sexual relations during adolescence, even independently of their attitudes on sexual permissiveness. Conversely, the effect of salience on sexual initiation seems to be fostered only through the mediation of sexual permissiveness. Our findings point to an indirect effect of the three religiosity dimensions (and in particular, religious salience) through permissive attitudes. Conclusion: Religiosity could be a relevant factor to explain sexual initiation during adolescence.

A Practical Guide to Gynecologic and Reproductive Health in Women Undergoing Hematopoietic Stem Cell Transplant

Optimum care of female transplant recipients requires gynecologic care at several stages through the allogeneic hematopoietic stem cell transplantation (HCT) process. Sex-based considerations in women post-HCT span gynecologic sequelae of transplant along with assessment and maintenance of optimal sexual and gynecologic health. Pre-HCT, managing menstruation and abnormal uterine or genital bleeding, considering fertility preservation, and assessing for sexually transmitted infections, including human papillomavirus (HPV)-related disease and cervical cancer, enhance women's health. While inpatient during transplant when women are thrombocytopenic, menstrual bleeding requires suppression. Whenever graft-versus-host disease (GVHD) is assessed, screening for genital GVHD merits consideration. After the first 100 days, periodic assessments include obtaining a menstrual history, assessing ovarian function, and reviewing current hormonal use and contraindications to hormonal methods. Regular assessment for primary ovarian insufficiency, dyspareunia, and intimacy guides provision of contraception and hormone replacement options. As part of ongoing screening for genital GVHD and HPV-related disease, including sexually transmitted infections, periodic pelvic examinations are performed. Once successful long-term survival is achieved, planning for fertility may be considered. This article offers a comprehensive approach to these aspects of gynecologic care of patients throughout the trajectory of HCT and beyond into survivorship. We review the effects of HCT treatment on sexual health, ovarian function, and resulting menstrual changes and fertility challenges. Identification, treatment, and prevention of subsequent malignancies, including breast cancer, are discussed, with a focus on regular assessment of genital HPV disease and GVHD in long-term follow-up.

AIDS Clinical Research in Spain-Large HIV Population, Geniality of Doctors, and Missing Opportunities

The first cases of AIDS in Spain were reported in 1982. Since then over 85,000 persons with AIDS have been cumulated, with 60,000 deaths. Current estimates for people living with HIV are of 145,000, of whom 20% are unaware of it. This explains the still high rate of late HIV presenters. Although the HIV epidemic in Spain was originally driven mostly by injection drug users, since the year 2000 men having sex with men (MSM) account for most new incident HIV cases. Currently, MSM represent over 80% of new yearly HIV diagnoses. In the 80s, a subset of young doctors and nurses working at Internal Medicine hospital wards became deeply engaged in attending HIV-infected persons. Before the introduction of antiretrovirals in the earlier 1990s, diagnosis and treatment of opportunistic infections was their major task. A new wave of infectious diseases specialists was born. Following the wide introduction of triple combination therapy in the late 1990s, drug side effects and antiretroviral resistance led to built a core of highly devoted HIV specialists across the country. Since then, HIV medicine has improved and currently is largely conducted by multidisciplinary teams of health care providers working at hospital-based outclinics, where HIV-positive persons are generally seen every six months. Antiretroviral therapy is currently prescribed to roughly 75,000 persons, almost all attended at clinics belonging to the government health public system. Overall, the impact of HIV/AIDS publications by Spanish teams is the third most important in Europe. HIV research in Spain has classically been funded mostly by national and European public agencies along with pharma companies. Chronologically, some of the major contributions of Spanish HIV research are being in the field of tuberculosis, toxoplasmosis, leishmaniasis, HIV variants including HIV-2, drug resistance, pharmacology, antiretroviral drug-related toxicities, coinfection with viral hepatitis, design and participation in clinical trials with antiretrovirals, immunopathogenesis, ageing, and vaccine development.

The Sooner, the Worse? Association between Earlier Age of Sexual Initiation and Worse Adolescent Health and Well-being Outcomes

This cross-sectional study assesses the association between age of sexual initiation during adolescence and a selection of well-being outcomes regarding that first relationship. High-school adolescents from El Salvador (2,686) and from Peru (3,399) replied to a paper-pencil questionnaire. Those who were sexually initiated replied to several questions regarding their age at sexual initiation, condom use, satisfaction and reasons/circumstances for that sexual relationship. Approximately 19% of participants were sexually initiated (n = 1,179). After retaining participants with valid responses and with sexual initiation ages between 13 and 17, the final sample for this paper consisted of 996 sexually initiated participants (526 Salvadorians and 470 Peruvians). Multiple logistic regression analyses showed that those who initiated sex at earlier ages had worse outcomes compared to those who initiated at older ages. Specifically, they had lower odds of having used a condom, of having good memories of that experience and of having had that first relationship because they were in love. Conversely, they had higher odds of having had that first sexual relationship as a result of peer pressure (“Most of my friends already had sex”), because of partner pressure (“I was afraid to lose him/her,” “My partner told me he/she would leave me” or “I did not know how to say no to a person who insisted”), or as a consequence of different forms of impaired autonomy (“I was under the influence of alcohol or drugs” or “As a consequence of seeing sexual images”). Results show that sex at earlier ages is associated with worse adolescent health and well-being outcomes.

Male condom use, multiple sexual partners and HIV: a prospective case-control study in Kinshasa (DRC)

In the Democratic Republic of Congo no previous studies have assessed the factors associated with different patterns of condom use and with multiple sexual partners, and the association between condom use simultaneously taking into account multiple sexual partnerships, and HIV infection. We carried out a prospective case-control study. From December 2010 until June 2012, 1630 participants aged 15-49 getting HIV Voluntary Counseling and Testing in a hospital in Kinshasa were selected. Cases were new HIV diagnosis and controls were HIV-negative participants detected along the study period. We recruited 274 cases and 1340 controls that were interviewed about HIV-related knowledge, attitudes and behaviours. Among cases there was a high prevalence of multiple lifetime and concurrent sexual partnerships (89.8% and 20.4%, respectively) and most cases never used condoms with only 1.5% using them consistently. Condom use and multiple partnerships were associated with male, single and high-educated participants. An association was found between multiple lifetime partners and 'any condom use' (OR = 2.99; 95%CI: 2.14-4.19) but not with consistent use. Both having two or more multiple concurrent sexual partners or not using condoms were variables similarly and highly associated to HIV risk. The association found between having two or more concurrent sexual partners and HIV was slightly higher (OR = 3.58, 95%CI:2.31-5.56) than the association found between never condom use and HIV (OR = 3.38, 95%CI:1.15-9.93). We found a high prevalence of multiple lifetime sexual partners and an extremely high prevalence of inconsistent condom use, both strongly associated with HIV seropositivity. Local programmes would benefit from comprehensive interventions targeting all behavioural and sociocultural determinants.

HIV Prevention: The Key to Ending AIDS by 2030

There is no viable substitute for re-energizing, funding and supporting culturally attuned, locally staffed HIV advocacy and prevention programmes, especially in resource poor settings. The evidence that such interventions are effective remains compelling; and although the cost implications are not negligible, the medium to long-term outcomes must be regarded not as complementary, but as integral, to biomedical interventions. The success of the anti-retroviral drugs upscale has enabled a noticeable improvement in AIDS related morbidity and mortality in the recent years; yet the underlying dynamics of the epidemic remains undetermined by the rate at which new infections are taking place in relation to the number of AIDS deaths. While the rate of new HIV infections is stabilising in some of the hardest hit countries, it remains far too high and the future cost of maintaining an ever-expanding pool of people reliant on daily drugs for survival is unsustainable. Countries must exercise caution in continuing to focus on treatment as a 'quick fix' to end AIDS as a public health concern. HIV is a socially culturally induced crisis and, as such, a variety of measures are needed simultaneously to appeal to different people, groups and circumstances.

Safe-sex belief and sexual risk behaviours among adolescents from three developing countries: a cross-sectional study

OBJECTIVES

This study intends to evaluate whether the belief that condoms are 100% effective in protecting against HIV infection is associated with sexual risk behaviours among youth.

METHODS

A cross-sectional study was performed in representative samples of high-school students in the Philippines, El Salvador and Peru. Participants completed a self-administered questionnaire. Students were asked about the risk of HIV transmission if one has sex using condoms. They were also asked to indicate whether they had ever had sexual relations and whether they used a condom in their first sexual relation. The sample was composed of 8994 students, aged 13-18.

RESULTS

One out of seven adolescents believed condoms are 100% effective (safe-sex believers). Those adolescents were 82% more likely to have had sex than those without such belief, after adjusting for confounders (OR=1.82; 95% CI 1.51 to 2.21). On the contrary, no association was found between risk perception and condom use. Subgroup and sensitivity analyses produced similar results.

CONCLUSIONS

This is, to the best of our knowledge, the first study conducted specifically to evaluate this phenomenon and that has used the same questionnaire and the same data collection protocol in three different developing countries from Asia, Central and South America. These results reasonably suggest that there could be an association between safe sex beliefs and sexual initiation. Longitudinal studies are needed to better understand this possible association as it could influence how to better promote sexual health.

Social factors associated with the knowledge about HIV of the immigrants from China, Latin America, the Maghreb and Senegal in the Basque Country (Spain)

The objective of this study was to identify the social factors that explain the differences in knowledge with regards to HIV/AIDS among immigrants in the Basque Country (Spain). We conducted a cross-sectional study based on information obtained in the Basque Health Survey for 754 immigrants from: 86 China, 368 Latin America, 237 the Maghreb and 74 Senegal. Odds ratios (95% CI) were calculated from logistic regression models to measure the degree of association between inadequate knowledge regarding transmission, prevention and places where HIV testing is offered, and the independent variables. We found that this inadequate knowledge is associated with place of birth, sex, a lower level of education, immigration status, difficulties in understanding Spanish, and not receiving advice about AIDS in primary care. These findings indicate that initiatives must be developed to promote equity in the provision of healthcare through clinical guidelines, including details of the specific needs of different groups of immigrants and considering gender issues.

Informing youth about the age of sexual initiation using means or percentages

The common statistical indicator "mean age of first sex" can be misinterpreted by youth to indicate that most of their peers of the same age are sexually initiated, when this is not usually the case. This can jeopardize efforts to delay sexual initiation. University students were randomly assigned to one of two versions of an anonymous survey. They were asked to estimate how common sexual initiation was at a given age upon being presented with statements with different wordings, such as the "mean age of first sex" or "proportions of youth at different ages having had sex." Their interpretations were compared using logistic regression. Students who were assigned surveys using the indicator "mean age" of sexual initiation had higher odds of overestimating the extent of sexual initiation compared to those assigned surveys using percentages as the indicator, even after adjusting for student's sex and degree. We encourage the use of the "percentage" of youth, at different ages, who are sexually initiated as a more reliable indicator.

Demographic and health surveys indicate limited impact of condoms and HIV testing in four African countries

Condom promotion and HIV testing for the general population have been major components of HIV prevention efforts in sub-Saharan Africa's high prevalence HIV epidemics, although little evidence documents their public health impact. Recent enhancements to the large, population-based demographic and health surveys (DHS) and AIDS information surveys (AIS) allow use of these data to assess the population-wide impact of these strategies. We analysed the latest DHS and AIS data from four sub-Saharan African countries with high prevalence, heterosexually transmitted HIV epidemics (Côte d'Ivoire, Swaziland, Tanzania and Zambia; N = 48 298) to answer two questions: 1) Are men and women who use condoms less likely to be HIV-infected than those who do not?; and 2) Are men and women who report knowing their HIV status more likely to use condoms than those who do not? Consistent condom use was associated with lower HIV infection rates for Swazi men but with higher HIV infection rates for women in Tanzania and Zambia; it made no significant difference in the other five sex/country subgroups analysed. Inconsistent condom use was not significantly associated with HIV status in any subgroup. Knowing one's HIV status was consistently associated with higher rates of condom use only among married people who were HIV-positive, even though condom use in this group remained relatively low. Effects of knowing one's HIV status among other subgroups varied. These results suggest that condoms have had little population-wide impact for HIV/AIDS prevention in these four countries. HIV testing appears to be associated with increased condom use mainly among people in stable partnerships who test positive. HIV testing and condom promotion may be more effective when targeted to specific groups where there is evidence of benefit rather than to general populations.

Condom use around the globe: how can we fulfil the prevention potential of male condoms?

Despite a global epidemic of sexually transmissible infections and the availability and endorsement of condoms as an effective intervention, the overall use of condoms remains low. This review explores various challenges and opportunities to fully realizing the prevention potential for condoms.

The Global Fund's resource allocation decisions for HIV programmes: addressing those in need

BACKGROUND

Between 2002 and 2010, the Global Fund to Fight AIDS, Tuberculosis and Malaria's investment in HIV increased substantially to reach US$12 billion. We assessed how the Global Fund's investments in HIV programmes were targeted to key populations in relation to disease burden and national income.

METHODS

We conducted an assessment of the funding approved by the Global Fund Board for HIV programmes in Rounds 1-10 (2002-2010) in 145 countries. We used the UNAIDS National AIDS Spending Assessment framework to analyze the Global Fund investments in HIV programmes by HIV spending category and type of epidemic. We examined funding per capita and its likely predictors (HIV adult prevalence, HIV prevalence in most-at-risk populations and gross national income per capita) using stepwise backward regression analysis.

RESULTS

About 52% ($6.1 billion) of the cumulative Global Fund HIV funding was targeted to low- and low-middle-income countries. Around 56% of the total ($6.6 billion) was channelled to countries in sub-Saharan Africa. The majority of funds were for HIV treatment (36%; $4.3 billion) and prevention (29%; $3.5 billion), followed by health systems and community systems strengthening and programme management (22%; $2.6 billion), enabling environment (7%; $0.9 billion) and other activities. The Global Fund investment by country was positively correlated with national adult HIV prevalence. About 10% ($0.4 billion) of the cumulative HIV resources for prevention targeted most-at-risk populations.

CONCLUSIONS

There has been a sustained scale up of the Global Fund's HIV support. Funding has targeted the countries and populations with higher HIV burden and lower income. Prevention in most-at-risk populations is not adequately prioritized in most of the recipient countries. The Global Fund Board has recently modified eligibility and prioritization criteria to better target most-at-risk populations in Round 10 and beyond. More guidance is being provided for Round 11 to strategically focus demand for Global Fund financing in the present resource-constrained environment.

[Sexual risk factors among European young people]

The sexual transmission of the human immunodeficiency virus (HIV) and other sexually transmitted infections (STI) in Europe are still rising. In order to prioritize STI prevention strategies in Europe, it is important to describe the prevalence of different sexual risk factors for STIs among European young people. We carried out a systematic review of published articles and studies performed by European institutions. A total of 21 articles and 10 studies were identified. The data shows an increase in early sexual initiation and the number of sexual partners. Young people who use condoms inconsistently ranged from 15 to 20%. The observed risk factors are: unawareness about other STIs different from HIV, being in favour of casual sex, wrongly believing that some measures are effective in avoiding HIV, not being aware of the risks from having multiple sexual partners and unawareness about the sexual transmission of HIV. The data suggests the need to improve the information addressed to youth.

"Being faithful" in a sexual relationship: perceptions of Tanzanian adolescents in the context of HIV and pregnancy prevention

Little is known about what adolescents think about faithfulness and partner reduction for HIV prevention (the "B" in the ABC HIV prevention behavior change strategy), including how they understand its implementation within relationships. In addition, because adolescents face the twin threats of HIV and unintended pregnancy, it is important to understand how adolescents may integrate their thinking on pregnancy prevention if they are using faithfulness or partner reduction as their HIV prevention strategy. This study gathered evidence by conducting 20 focus group discussions (FGDs) with 158 adolescents, aged 14-20. The FGDs were stratified by sex, age, current school attendance, rural or urban residence, and marital status. Results showed that the vast majority of groups felt that "B" messages are important and relevant for unmarried (as well as married) youth to hear for HIV prevention, but the messages need to be explicit (e.g., "being faithful means having only one tested sexual partner at a time"). Faithful relationships are perceived as ideal in terms of romantic expectations and HIV prevention, but were considered unrealistic if the relationship had a power imbalance. Adolescents acknowledged the risks of multiple partners and a few recognized that concurrent partnerships are riskier than serial partnerships. Condoms were given as the primary method for pregnancy prevention among youth, yet faithfulness was usually seen as precluding condom use and many youth considered condom use as evidence of a lack of faithfulness. Overall, adolescents recognized that practicing fidelity is complex. Young people need life skills education for how to establish and maintain faithful relationships with one tested partner and how to integrate condom use for pregnancy prevention within that relationship. Programs also need to more explicitly address the issues of trust and repeat HIV testing within "faithful" relationships which is an uncomfortable but necessary reality for many adolescents.

Condoms, HIV and the Roman Catholic Church

For decades, the Roman Catholic Church opposed use of condoms to prevent spread of sexually transmitted infections (STI) because of their contraceptive effect. In 2009, Pope Benedict XVI said that widespread use of condoms could worsen the situation, a position rejected as 'unscientific'. Recently, however the Pontiff stated that because the Church considers acts of prostitution and homosexuality to be gravely immoral and disordered, in such specific cases use of a condom might become an initial step in the direction of a moralization leading to an assumption of responsibility and a new awareness of the meaning of sexuality. In doing so, he reaffirmed his belief that condoms cannot solve the problem of STI spread, stressing the Church's position that modern societies no longer see sexuality as an 'expression of love, but only as a sort of drug that people administer to themselves'. The new Papal position has been widely applauded, but made conservative Catholics unhappy. A dialogue with the Church now seems possible: Does concentrating on condoms hinder the effectiveness of other strategies? What are the respective roles of condoms and other approaches to prevent infection spread? Does a special situation exist in Africa requiring specific and focused interventions?

A surprising prevention success: why did the HIV epidemic decline in Zimbabwe?

Daniel Halperin and colleagues examine reasons for the remarkable decline in HIV in Zimbabwe, in the context of severe social, political, and economic disruption.

It's not just who you are but where you live: an exploration of community influences on individual HIV status in rural Malawi

Approximately 1 million people are infected with Human Immunodeficiency Virus (HIV) in Malawi. Despite efforts aimed at changing individual risk behaviors, HIV prevalence continues to rise among rural populations. Both previous research and the Political Economy of Health framework suggest that community-based socio-economic factors and accessibility may influence HIV transmission; however, these community factors have received little empirical investigation. To fill this gap, this research uses data from a nationally representative probability sample of rural Malawians combined with small area estimates of community socio-economic and accessibility data in logistic regression models to: 1) reveal relationships between community factors and individual HIV status; 2) determine whether these relationships operate through individual HIV risk behaviors; and 3) explore whether these associations vary by gender. Community socio-economic factors include relative and absolute poverty; community accessibility factors include distance to roads, cities, and public health facilities. Individual HIV risk behaviors include reported condom use, sexually transmitted infections, multiple partnerships, and paid sex. Results show that higher community income inequality, community proximity to a major road, and community proximity to a public health clinic are associated with increased odds of HIV for women. For men, community proximity to a major road and community proximity to a public health clinic are associated with increased odds of HIV infection. These direct relationships between community factors and individual HIV status are not mediated by individual HIV risk behaviors. The Political Economy of Health frames the discussion. This study provides evidence for expanding HIV prevention efforts beyond individual risk behaviors to consideration of community factors that may drive the HIV epidemic in rural Malawi.

Will circumcision provide even more protection from HIV to women and men? New estimates of the population impact of circumcision interventions

BACKGROUND

Mathematical modelling has indicated that expansion of male circumcision services in high HIV prevalence settings can substantially reduce population-level HIV transmission. However, these projections need revision to incorporate new data on the effect of male circumcision on the risk of acquiring and transmitting HIV.

METHODS

Recent data on the effect of male circumcision during wound healing and the risk of HIV transmission to women were synthesised based on four trials of circumcision among adults and new observational data of HIV transmission rates in stable partnerships from men circumcised at younger ages. New estimates were generated for the impact of circumcision interventions in two mathematical models, representing the HIV epidemics in Zimbabwe and Kisumu, Kenya. The models did not capture the interaction between circumcision, HIV and other sexually transmitted infections.

RESULTS

An increase in the risk of HIV acquisition and transmission during wound healing is unlikely to have a major impact of circumcision interventions. However, it was estimated that circumcision confers a 46% reduction in the rate of male-to-female HIV transmission. If this reduction begins 2 years after the procedure, the impact of circumcision is substantially enhanced and accelerated compared with previous projections with no such effect-increasing by 40% the infections averted by the intervention overall and doubling the number of infections averted among women.

CONCLUSIONS

Communities, and especially women, may benefit much more from circumcision interventions than had previously been predicted, and these results provide an even greater imperative to increase scale-up of safe male circumcision services.

ABC for AIDS prevention in Guinea: migrant gold mining communities address their risks

Contrary to expectation when compared with other migrant mining zones of sub-Saharan Africa, the nation of Guinea has a comparatively low and stable HIV rate. In addition, the regions with the largest gold, diamond, and bauxite mining operations report the lowest HIV rates within the country. This research set out to explain practices and beliefs within gold mining communities near Siguiri, Guinea--the highest-producing gold mining zone in the country--that may contribute to this phenomenon, particularly as they relate to the Abstinence, Be faithful, use a Condom approach to AIDS prevention. Structured interviews on a randomly selected sample of 460 adults and regular visitation to 16 pharmacies and health clinics within the mining zone yielded data showing that abstinence and condom use are minimally practiced for AIDS prevention. Instead, faithfulness to partners was overwhelmingly reported as the method of choice for AIDS avoidance. In addition, this research explored ways in which local conceptions of fidelity differed from those generally understood in other contexts, including engagement in short-term marriages at the gold mining sites.

Defining HIV risk and determining responsibility in postsocialist Poland

Drawing on 15 months of ethnographic research on HIV prevention programs in Poland, I explore the consequences of the shift from models of HIV prevention that emphasize "risk groups" and AIDS blame, to models that focus on "risky behaviors" and universal risk. The centrality of choice making and individual risk management in these models suggests objective risk assessment free from moralizing arguments. The Polish national prevention strategy shifted to focus on choice making, address all risk groups, and include concrete prevention strategies. This shift created a backlash that resulted in the reassertion of moral arguments about risk and risk groups that positioned those most vulnerable to HIV outside the purview of prevention efforts. AIDS organizations working with marginalized, "morally problematic" populations used the label "at risk" to legitimize claims to resources. They enacted a model of risk reduction in which the relevant actor is the individual buffeted by social forces; behavior change, and therefore HIV risk reduction, is a long process because of myriad forms of vulnerability clients face. Despite efforts to reconceptualize risk, organizations positioned the individual as the locus of HIV prevention interventions, rather than attempting to address the social context that shapes risk.

AIDS-related knowledge and sexual behaviour among married and previously married persons in rural central Mozambique

HIV prevalence in central Mozambique is the highest in the country with high urban rates impacting on the rural areas. To identify potential factors influencing the spread of HIV in three sparsely populated districts in southern Sofala province, 847 married and previously married persons were surveyed for their knowledge, practices and beliefs regarding HIV/AIDS and STIs. 21.9% and 6.5% of males and females, respectively, were engaged in casual sexual partnerships in the past year. Being male, married, educated, and having genital discharge and ulcers in the last year were significantly associated with risky sexual activity. Risky behaviour was significantly associated with being Catholic or Protestant when compared with those from Zionist churches. Knowledge of ABC prevention strategies and condom usage was significantly associated with being male, married, having an STI in the past year, and being educated, particularly at the secondary level (Grade 8+). Attitudes and behaviour were influenced by cultural and religious involvement, as well as sex and marital status. It is imperative that prevention strategies take into account the cultural, economic and religious conditions present in rural African settings to create HIV prevention programmes that are culturally relevant and acceptable to the participants.

Relationships, love and sexuality: what the Filipino teens think and feel

BACKGROUND

In order to achieve a change among teens' sexual behavior, an important step is to improve our knowledge about their opinions concerning relationships, love and sexuality.

METHODS

A questionnaire including topics on relationships, love and sexuality was distributed to a target population of 4,000 Filipino students from third year high school to third year college. Participants were obtained through multi-stage sampling of clusters of universities and schools. This paper concentrates on teens aged 13 to 18.

RESULTS

Students reported that they obtained information about love and sexuality mainly from friends. However, they valued parents' opinion more than friends'. They revealed few conversations with their parents on these topics. A majority of them would like to have more information, mainly about emotion-related topics. Almost half of respondents were not aware that condoms are not 100% effective in preventing STIs or pregnancies. More girls, compared to boys, were sensitive and opposed to several types of sexism. After adjusting for sex, age and institution, the belief of 100% condom effectiveness and the approval of pornography and sexism were associated with being sexually experienced.

CONCLUSION

There is room for further encouraging parents to talk more with their children about sexuality, specially aspects related to feelings and emotions in order to help them make better sexual choices. Indeed, teens wish to better communicate with their parents on these issues. Condoms are regarded as safer than what they really are by almost half of the participants of this study, and such incorrect knowledge seems to be associated with sexual initiation.

Northern Uganda and paradigms of HIV prevention: the need for social analysis

In settings of armed conflict, traditional HIV prevention programmes that promote risk avoidance via abstinence and fidelity and risk reduction via condom use and needle exchange are not viable. In such contexts, HIV risk depends less on personal choice than on exposure to physical, emotional and structural violence. War in northern Uganda has created three realities (internally displaced people's camps, night commuters and child abductions) which increase vulnerability to HIV transmission. Based upon this analysis of northern Uganda, we offer a conceptual framework for HIV transmission in conflict settings that recognizes the importance of local and global context in creating vulnerability to HIV infection. This framework is then used to delineate strategies for HIV prevention in northern Uganda, namely the provision of a safe physical environment and access to education, medical and psychological support, and the promotion of conflict resolution strategies and human rights law.

Coming to terms with complexity: a call to action for HIV prevention

A quarter of a century of AIDS responses has created a huge body of knowledge about HIV transmission and how to prevent it, yet every day, around the world, nearly 7000 people become infected with the virus. Although HIV prevention is complex, it ought not to be mystifying. Local and national achievements in curbing the epidemic have been myriad, and have created a body of evidence about what works, but these successful approaches have not yet been fully applied. Essential programmes and services have not had sufficient coverage; they have often lacked the funding to be applied with sufficient quality and intensity. Action and funding have not necessarily been directed to where the epidemic is or to what drives it. Few programmes address vulnerability to HIV and structural determinants of the epidemic. A prevention constituency has not been adequately mobilised to stimulate the demand for HIV prevention. Confident and unified leadership has not emerged to assert what is needed in HIV prevention and how to overcome the political, sociocultural, and logistic barriers in getting there. We discuss the combination of solutions which are needed to intensify HIV prevention, using the existing body of evidence and the lessons from our successes and failures in HIV prevention.

Analysis of content about sexuality and human reproduction in school textbooks in Spain

OBJECTIVES

The spread of sexually transmitted infections (STIs) inadolescents and teenage pregnancy rates are increasing. A decrease in the average age of youth's first sexual experience has also been noted. Sexual education programmes in schools have an important role to play in addressing these issues. The objective of this study was to analyse the content of textbooks in the areas of sexuality and human reproduction in order to evaluate the extent to which these textbooks promote healthy reproductive lifestyles, as well as avoidance of risk behaviour among adolescent students.

STUDY DESIGN

Descriptive study of the content of school textbooks.

METHODS

The study sample consisted of 12 textbooks (approximately 80% of all the textbooks used in Spanish secondary schools) which were edited in 2002. Content analysis evaluated the extent to which these books demonstrated reliable scientific information about: (a) condom effectiveness; (b) consequences, prevention and treatment of STIs; (c) family planning methods; (d) assisted reproductive technologies; and (e) the promotion of healthy reproductive lifestyles.

RESULTS

All textbooks presented inaccurate information in the areas studied. One hundred and fifty one quotes were identified that facilitated incomplete perception of sexuality or risky behaviour. On average, 12.6 incorrect messages were identified in each textbook.

CONCLUSIONS

The textbooks examined are neither appropriate nor sufficiently comprehensive for adolescent education on issues of sexuality. Results suggest a need for alternative textbooks based on better scientific evidence. It is essential that textbooks empower adolescents to make healthy decisions through the promotion of useful life skills that provide a more integrated concept of sexuality. There is a need for approaches to sexual education to integrate values commonly held by parents of the youth that use such texts.

"What worked?": the evidence challenges in determining the causes of HIV prevalence decline

It seems natural to ask "what worked" when looking at nations achieving HIV prevalence declines. Yet this seemingly benign question is fraught with complexity and often poorly understood. This article presents a framework to comprehend the areas in which evidence is needed to assess the policy causes of HIV success. To truly explain what national policies "worked," in addition to HIV prevalence data, evidence or estimates are needed on HIV incidence trends, associated behavior changes, implemented interventions promoting those changes, and policies driving those interventions. Rarely, however, are there conclusive data for these components, as illustrated by the continuing debates around "what worked" in Uganda's HIV success. Unfortunately, within such debates, the understanding of the nature of the evidence requirements is often lost. Only by understanding the nature of the evidence, and how pieces of evidence fit together, can we truly reach evidence-based agreement and draw appropriate lessons of "what worked" in any case of HIV/AIDS prevention.

Understanding the impact of male circumcision interventions on the spread of HIV in southern Africa

Background

Three randomised controlled trials have clearly shown that circumcision of adult men reduces the chance that they acquire HIV infection. However, the potential impact of circumcision programmes – either alone or in combination with other established approaches – is not known and no further field trials are planned. We have used a mathematical model, parameterised using existing trial findings, to understand and predict the impact of circumcision programmes at the population level.

Findings

Our results indicate that circumcision will lead to reductions in incidence for women and uncircumcised men, as well as those circumcised, but that even the most effective intervention is unlikely to completely stem the spread of the virus. Without additional interventions, HIV incidence could eventually be reduced by 25–35%, depending on the level of coverage achieved and whether onward transmission from circumcised men is also reduced. However, circumcision interventions can act synergistically with other types of prevention programmes, and if efforts to change behaviour are increased in parallel with the scale-up of circumcision services, then dramatic reductions in HIV incidence could be achieved. In the long-term, this could lead to reduced AIDS deaths and less need for anti-retroviral therapy. Any increases in risk behaviours following circumcision , i.e. ‘risk compensation’, could offset some of the potential benefit of the intervention, especially for women, but only very large increases would lead to more infections overall.

Conclusions

Circumcision will not be the silver bullet to prevent HIV transmission, but interventions could help to substantially protect men and women from infection, especially in combination with other approaches.

Ethics, ideology, and reproductive health policy in the United States

The 1994 International Conference on Population and Development held in Cairo recognized the centrality of reproductive health to human rights and development. Progress on the Cairo agenda has slowed for numerous reasons, however. The United States, once an enthusiastic promoter of this agenda and still the world's leading reproductive health donor, has revised its reproductive health policies radically since the 2000 presidential election of George W. Bush. This study examines how policies have been reconfigured in five key reproductive health areas, sparking controversy both in the United States and internationally. These categories are the content of sex education, access to emergency contraception and to abortion services, condom effectiveness, and HIV/AIDS prevention. The analysis presented here elucidates how ideological considerations have superseded public health and ethical concerns and reflects on health and ethical consequences.

Why circumcision is a biomedical imperative for the 21(st) century

Circumcision of males represents a surgical "vaccine" against a wide variety of infections, adverse medical conditions and potentially fatal diseases over their lifetime, and also protects their sexual partners. In experienced hands, this common, inexpensive procedure is very safe, can be pain-free and can be performed at any age. The benefits vastly outweigh risks. The enormous public health benefits include protection from urinary tract infections, sexually transmitted HIV, HPV, syphilis and chancroid, penile and prostate cancer, phimosis, thrush, and inflammatory dermatoses. In women circumcision of the male partner provides substantial protection from cervical cancer and chlamydia. Circumcision has socio-sexual benefits and reduces sexual problems with age. It has no adverse effect on penile sensitivity, function, or sensation during sexual arousal. Most women prefer the circumcised penis for appearance, hygiene and sex. Given the convincing epidemiological evidence and biological support, routine circumcision should be highly recommended by all health professionals.

Are condoms the answer to rising rates of non-HIV sexually transmitted infections? Yes

Consistent condom use can reduce the spread of HIV, and Markus Steiner and Willard Cates believe condoms are the answer to other sexually transmitted infections. But Stephen Genuis argues that a more comprehensive approach is needed

Migrant Latino day laborers and intentions to test for HIV

This cross sectional study utilized convenience sampling to investigate the HIV testing intentions of 290 sexually active, male, migrant Latino day laborers, 18 years old or older. The findings indicate that day laborers are indeed at risk for HIV. Nearly two-thirds of the men intended to test for HIV in the next year. Men who were at higher risk of infection from their sexual encounters with female partners were more likely to intend to test, as were men making less money and men who did not perceive themselves to be at risk. Men who attended high school or beyond, and reported using a condom with casual female partners, were much more likely to intend to test than men who did not attend school and reported no such condom use. The prevalence of high risk sex and the low rates of condom use have implications for the increased transmission of HIV.

The future of HIV prevention: control of sexually transmitted infections and circumcision interventions

Prevention and control of sexually transmitted infections (STIs) has proven effective in reducing HIV infection when treatment is available promptly for symptomatic persons in conditions of an emerging epidemic. Biologically, it is assumed that reduced genital tract inflammation reduces infectiousness for HIV as well as reducing susceptibility in HIV-uninfected persons. Male circumcision has been demonstrated effective in reducing risk for HIV infection in three separate trials from South Africa, Kenya, and Uganda. Global expansion of STI treatment and male circumcision programs are vital tools for control of HIV infection; current evidence is reviewed and research priorities are presented.

Decreased condom breakage and slippage rates after counseling men at a sexually transmitted infection clinic in Jamaica

PURPOSE

Our objective was to evaluate condom failure (breakage and slippage) rates before and those during a trial that provided instructions on correct condom use.

METHOD

Our analysis was based on 314 men who presented with urethral discharge at Jamaica's largest sexually transmitted infection clinic and were enrolled into our 6-month trial.

RESULTS

Participants reported breaking 18.5% (95% confidence interval=12.8-24.1%) of their condoms during the 7 days prior to the screening visit and having 3.5% (95% confidence interval=1.2-5.7%) of their condoms slip off completely. After the condom counseling provided during the screening visit, breakage rates decreased (p<.05) and remained below 10% throughout the trial. During in-depth interviews, the men who reported frequent condom failures cited (1) improper storage/exposure to heat, (2) improper handling while putting on condoms and (3) use of lubricants/improper lubricants as the possible reasons for their high failure rates.

CONCLUSION

Although the rates of reported condom breakage and slippage decreased significantly after counseling, we need to improve the quality of condom counseling to further reduce failure rates.

Going beyond "ABC" to include "GEM": critical reflections on progress in the HIV/AIDS epidemic

A considerable number of studies have sought to identify what factors accounted for substantial reductions in HIV seroprevalence after several countries deployed "ABC" (abstinence, be faithful, condom use) strategies. After much public discourse and research on ABC success stories, the Joint United Nations Programme on HIV/AIDS 2004 epidemic report indicated that nearly 50% of infected people worldwide were women, up from 35% in 1985. In light of the feminization of HIV/AIDS, we critically assess the limitations of ABC strategies. We provide 3 additional prevention strategies that focus on gender relations, economics, and migration (GEM) and can speak to the new face of the epidemic. Pressing beyond ABC, GEM strategies provide the basis for a stronger central platform from which national efforts against HIV/AIDS can proceed to reduce transmission risks.

Reproductive Health Policies in President Bush's Second Term: Old Battles and New Fronts in the United States and Internationally

The current Bush Administration has made dramatic changes in US domestic and international reproductive health policies. This paper discusses the issues involved in some of these changes, and it considers likely developments in this area during the remainder of George W. Bush's second term. The first section of the paper defines the term reproductive health and presents a framework for classifying reproductive health policies. The second section examines changes that the Administration has made in domestic family planning policies. The third section looks at analogous changes in American assistance for reproductive health internationally. The final section considers the implications of these trends for future policy and women's health.

Male circumcision, religion, and infectious diseases: an ecologic analysis of 118 developing countries

Background

Both religious practices and male circumcision (MC) have been associated with HIV and other sexually-transmitted infectious diseases. Most studies have been limited in size and have not adequately controlled for religion, so these relationships remain unclear.

Methods

We evaluated relationships between MC prevalence, Muslim and Christian religion, and 7 infectious diseases using country-specific data among 118 developing countries. We used multivariate linear regression to describe associations between MC and cervical cancer incidence, and between MC and HIV prevalence among countries with primarily sexual HIV transmission.

Results

Fifty-three, 14, and 51 developing countries had a high (>80%), intermediate (20–80%), and low (<20%) MC prevalence, respectively. In univariate analyses, MC was associated with lower HIV prevalence and lower cervical cancer incidence, but not with HSV-2, syphilis, nor, as expected, with Hepatitis C, tuberculosis, or malaria. In multivariate analysis after stratifying the countries by religious groups, each categorical increase of MC prevalence was associated with a 3.65/100,000 women (95% CI 0.54-6.76, p = 0.02) decrease in annual cervical cancer incidence, and a 1.84-fold (95% CI 1.36-2.48, p < 0.001) decrease in the adult HIV prevalence among sub-Saharan African countries. In separate multivariate analyses among non-sub-Saharan African countries controlling for religion, higher MC prevalence was associated with a 8.94-fold (95% CI 4.30-18.60) decrease in the adult HIV prevalence among countries with primarily heterosexual HIV transmission, but not, as expected, among countries with primarily homosexual or injection drug use HIV transmission (p = 0.35).

Conclusion

Male circumcision was significantly associated with lower cervical cancer incidence and lower HIV prevalence in sub-Saharan Africa, independent of Muslim and Christian religion. As predicted, male circumcision was also strongly associated with lower HIV prevalence among countries with primarily heterosexual HIV transmission, but not among countries with primarily homosexual or injection drug use HIV transmission. These findings strengthen the reported biological link between MC and some sexually transmitted infectious diseases, including HIV and cervical cancer.

Sexual behaviour in context: a global perspective

Research aimed at investigating sexual behaviour and assessing interventions to improve sexual health has increased in recent decades. The resulting data, despite regional differences in quantity and quality, provide a historically unique opportunity to describe patterns of sexual behaviour and their implications for attempts to protect sexual health at the beginning of the 21st century. In this paper we present original analyses of sexual behaviour data from 59 countries for which they were available. The data show substantial diversity in sexual behaviour by region and sex. No universal trend towards earlier sexual intercourse has occurred, but the shift towards later marriage in most countries has led to an increase in premarital sex, the prevalence of which is generally higher in developed countries than in developing countries, and is higher in men than in women. Monogamy is the dominant pattern everywhere, but having had two or more sexual partners in the past year is more common in men than in women, and reported rates are higher in industrialised than in non-industrialised countries. Condom use has increased in prevalence almost everywhere, but rates remain low in many developing countries. The huge regional variation indicates mainly social and economic determinants of sexual behaviour, which have implications for intervention. Although individual behaviour change is central to improving sexual health, efforts are also needed to address the broader determinants of sexual behaviour, particularly those that relate to the social context. The evidence from behavioural interventions is that no general approach to sexual-health promotion will work everywhere and no single-component intervention will work anywhere. Comprehensive behavioural interventions are needed that take account of the social context in mounting individual-level programmes, attempt to modify social norms to support uptake and maintenance of behaviour change, and tackle the structural factors that contribute to risky sexual behaviour.

Wealth and sexual behaviour among men in Cameroon

Background

The 2004 Demographic and Health Survey (DHS) in Cameroon revealed a higher prevalence of HIV in richest and most educated people than their poorest and least educated compatriots. It is not certain whether the higher prevalence results partly or wholly from wealthier people adopting more unsafe sexual behaviours, surviving longer due to greater access to treatment and care, or being exposed to unsafe injections or other HIV risk factors. As unsafe sex is currently believed to be the main driver of the HIV epidemic in sub-Saharan Africa, we designed this study to examine the association between wealth and sexual behaviour in Cameroon.

Methods

We analysed data from 4409 sexually active men aged 15–59 years who participated in the Cameroon DHS using logistic regression models, and have reported odds ratios (OR) with confidence intervals (CI).

Results

When we controlled for the potential confounding effects of marital status, place of residence, religion and age, men in the richest third of the population were less likely to have used a condom in the last sex with a non-spousal non-cohabiting partner (OR 0.43, 95% CI 0.32–0.56) and more likely to have had at least two concurrent sex partners in the last 12 months (OR 1.38, 95% CI 1.12–1.19) and more than five lifetime sex partners (OR 1.97, 95% CI 1.60–2.43). However, there was no difference between the richest and poorest men in the purchase of sexual services. Regarding education, men with secondary or higher education were less likely to have used a condom in the last sex with a non-spousal non-cohabiting partner (OR 0.24, 95% CI 0.16–0.38) and more likely to have started sexual activity at age 17 years or less (OR 2.73, 95% CI 2.10–3.56) and had more than five lifetime sexual partners (OR 2.59, 95% CI 2.02–3.31). There was no significant association between education and multiple concurrent sexual partnerships in the last 12 months or purchase of sexual services.

Conclusion

Wealthy men in Cameroon are more likely to start sexual activity early and have both multiple concurrent and lifetime sex partners, and are less likely to (consistently) use a condom in sex with a non-spousal non-cohabiting partner. These unsafe sexual behaviours may explain the higher HIV prevalence among wealthier men in the country. While these findings do not suggest a redirection of HIV prevention efforts from the poor to the wealthy, they do call for efforts to ensure that HIV prevention messages get across all strata of society.

Was the "ABC" approach (abstinence, being faithful, using condoms) responsible for Uganda's decline in HIV?

BACKGROUND TO THE DEBATE

Uganda is one of the few African countries where rates of HIV infection have fallen, from about 15 percent in the early 1990s to about five percent in 2001. At the end of 2005, UNAIDS estimated that 6.7 percent of adults were infected with the virus. The reasons behind Uganda's success have been intensely studied in the hope that other countries can emulate the strategies that worked. Some researchers credit the success to the Ugandan government's promotion of "ABC behaviors"--particularly abstinence and fidelity. Uganda receives funds from the United States President's Emergency Plan for AIDS Relief, which promotes the ABC approach with a focus on abstinence-driven public health campaigns. Other researchers question whether the ABC approach was really responsible for the decline in HIV infection. Critics of the ABC approach also argue that by emphasizing abstinence over condom use, the approach leaves women at risk of infection, because in many parts of the world women are not empowered to insist on abstinence or fidelity.