Gender roles and HIV sexual risk vulnerability of Roma (Gypsies) men and women in Bulgaria and Hungary: an ethnographic study

Levels of HIV Testing Among Young Men Who Have Sex with Men in Bulgaria: Very Low Testing by Ethnic Minority Roma (Gypsy) Men

Little is known about HIV testing among young men who have sex with men (MSM) in Southeastern European countries, nor about differences in testing by young ethnic majority and young Roma MSM, the region's most disadvantaged minority population. 271 young MSM (153 non-Roma and 118 Roma) were recruited in Sofia, Bulgaria and completed measures of HIV testing, psychosocial characteristics related to testing, sexual behavior, and substance use. While 74% of ethnic majority MSM had an HIV test (and 56% had multiple prior tests), only 4% of Roma MSM had ever been tested. Roma MSM had lower knowledge about HIV testing, perceived greater barriers and weaker social norms for testing, and held more negative testing attitudes and intentions. Although all had male partners, no Roma MSM self-identified as gay and most reported transactional sex. Efforts are urgently needed to increase HIV testing uptake by young Roma MSM.

Why don't segregated Roma do more for their health? An explanatory framework from an ethnographic study in Slovakia

Objectives

The health status of segregated Roma is poor. To understand why segregated Roma engage in health-endangering practices, we explored their nonadherence to clinical and public health recommendations.

Methods

We examined one segregated Roma settlement of 260 inhabitants in Slovakia. To obtain qualitative data on local-level mechanisms supporting Roma nonadherence, we combined ethnography and systematic interviewing over 10 years. We then performed a qualitative content analysis based on sociological and public health theories.

Results

Our explanatory framework summarizes how the nonadherence of local Roma was supported by an interlocked system of seven mechanisms, controlled by and operating through both local Roma and non-Roma. These regard the Roma situation of poverty, segregation and substandard infrastructure; the Roma socialization into their situation; the Roma-perceived value of Roma alternative practices; the exclusionary non-Roma and self-exclusionary Roma ideologies; the discrimination, racism and dysfunctional support towards Roma by non-Roma; and drawbacks in adherence.

Conclusions

Non-Roma ideologies, internalized by Roma into a racialized ethnic identity through socialization, and drawbacks in adherence might present powerful, yet neglected, mechanisms supporting segregated Roma nonadherence.

Electronic supplementary material

The online version of this article (10.1007/s00038-018-1134-2) contains supplementary material, which is available to authorized users.

Attitude and practice of family planning methods among Roma women living in northern Turkey

Objective

This study aims to investigate the attitude and practice of family planning (FP) methods among Roma women living in northern Turkey.

Methods

A total of 120 Roma women living in northern Turkey participated in this descriptive study. Data were collected using a questionnaire. The scale of FP attitude was used.

Results

The mean age of participants was 28.9 ± 1.8. Among the participants, 37.5% (45/120) were primary school graduates, 70.8% (85/120) were unemployed, 73.4% (88/120) were in a consensual marriage and 94.2% (113/120) had children. The majority or 85.8% (103/120) of the participants stated that they used FP methods. Intrauterine device (57.4%, 69/120) and withdrawal method (22.3%, 27/120) were the most frequently used FP methods.

Conclusions

The rates at which Roma women use FP were high. Their attitudes towards FP tended to be negative and the methods used were primarily related to females.

Prevalence of Chlamydia trachomatis Infection and Its Association with Sexual Behaviour and Alcohol Use in the Population Living in Separated and Segregated Roma Settlements in Eastern Slovakia

The aim of the study was to explore sexual behaviour and the occurrence of Chlamydia trachomatis (CT) infection in the population living in Roma settlements compared to the majority population in Slovakia and to assess the association between alcohol use and sexual behaviour within both populations. A cross-sectional population-based Hepa-Meta study was conducted in Slovakia in 2011. The final sample comprised 452 Roma and 403 non-Roma respondents. The occurrence of CT was detected by direct proof of the pathogen by PCR. The association between alcohol use and the prevalence of risky sexual behaviour were assessed using a logistic regression. First intercourse at age 15 or younger was reported by 27.9% of Roma (vs. 4.5% of non-Roma); 93.4% of Roma (vs. 77.9% of non-Roma) used condom inconsistently, 22.8% of Roma (vs. 43.9% of non-Roma) used a condom for protection from unwanted pregnancies and only 8.8% of Roma (vs. 21.8% of non-Roma) due to protection against infectious diseases. However, Roma reported having had five or more sexual partners less often compared to the majority (11.5% of Roma vs. 20.6% of non-Roma). Binge drinking at least once a month was associated with a higher number of sexual partners in both groups, but not with condom non-use. The prevalence of CT infection in the Roma population was higher (3.8%) compared to non-Roma (2.7%); however, the difference was not statistically significant. Our study found no differences in the prevalence of CT infection between Roma and non-Roma despite differences in sexual behaviour. Roma begin their sexual life earlier and have unprotected sex more often, but on the other hand, they seem to be much more restrained in terms of the number of sexual partners compared to the majority population.

An Assessment of Romani Women's Autonomy and Timing of Pregnancy in Serbia and Macedonia

Background Roma are Europe's largest minority population. Serbia and Macedonia have the greatest proportion of Roma outside of the European Union. Our objective was to examine women's agency and how it related to desired timing of pregnancy among Romani women in Macedonia and Serbia. Methods We surveyed 410 Romani women who had given birth in the last 2 years between November 2012-February 2013 in Serbia and Macedonia using purposeful snowball sampling. Log-Poisson models were used to examine the association between women's inclusion in healthcare decision- making and desired timing of pregnancy. Results Romani women in Macedonia and Serbia were excluded from the labor market, with over 80% being unemployed, approximately 30% had no schooling, and 17% were not included in healthcare decisions. Romani women who were sole decision-makers in relation to their health were 1.4 times more likely to desire the timing of their most recent pregnancy [RRR = 1.4, CI (1.1, 1.8)]. Conclusions Romani women who have great involvement in their own healthcare decisions were more likely to desire the timing of their current pregnancy. Women's inclusion in such important decisions is important and empowerment programs that address gender inequity are needed in Romani communities, particularly for control of timing of pregnancy.

Health-endangering everyday settings and practices in a rural segregated Roma settlement in Slovakia: A descriptive summary from an exploratory longitudinal case study

Background

Research into social root-causes of poor health within segregated Roma communities in Central and Eastern Europe, i.e. research into how, why and by whom high health-endangering settings and exposures are maintained here, is lacking. The aim of this study was to assess the local setup of health-endangering everyday settings and practices over the long-term in one such community. It is the initial part of a larger longitudinal study qualitatively exploring the social root-causes of poor Roma health status through the case of a particular settlement in Slovakia.

Methods

The study, spanning 10 years, comprised four methodologically distinct phases combining ethnography and applied medical-anthropological surveying. The acquired data consisted of field notes on participant observations and records of elicitations focusing on both the setup and the social root-causes of local everyday health-endangering settings and practices. To create the here-presented descriptive summary of the local setup, we performed a qualitative content analysis based on the latest World Health Organization classification of health exposures.

Results

Across all the examined dimensions – material circumstances, psychosocial factors, health-related behaviours, social cohesion and healthcare utilization – all the settlements’ residents faced a wide range of health-endangering settings and practices. How the residents engaged in some of these exposures and how these exposures affected residents’ health varied according to local social stratifications. Most of the patterns described prevailed over the 10-year period. Some local health-endangering settings and practices were praised by most inhabitants using racialized ethnic terms constructed in contrast or in direct opposition to alleged non-Roma norms and ways.

Conclusions

Our summary provides a comprehensive and conveniently structured basis for grounded thinking about the intermediary social determinants of health within segregated Roma communities in Slovakia and beyond. It offers novel clues regarding how certain determinants might vary therein; how they might be contributing to health-deterioration; and how they might be causally inter-linked here. It also suggests racialized ethnically framed social counter-norms might be involved in the maintenance of analogous exposure setups.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4029-x) contains supplementary material, which is available to authorized users.

Female healthcare professionals' behaviour and attitudes in the context of the feminisation of HIV/AIDS: gender vulnerability analysis

In only a few years, HIV/AIDS became a severe public health problem worldwide. More recently, the phenomenon of feminisation has substantially modified the epidemiological profile of the pandemic. Drawing on Grounded Theory, this qualitative, descriptive study examines the adoption of HIV/AIDS prevention measures and practices by women health professionals. Data were acquired by semi-structured interviews of 12 women working as health professionals providing care for HIV-seropositive women. Analysis of the results showed how, as women, the participants felt safe and protected against HIV in a so-called stable relationship, because they relied on factors such as trust in their companion, and perceived themselves as vulnerable and exposed to the risk of sexual contamination. As health professionals, they revealed concerns relating to care for women with HIV, ranging from speculations about how the women were contaminated, to the sensitivity, as women professionals, to put themselves in the place of the women with HIV and, also as professionals, expressed fear of contamination through accidents with biological material. It was concluded that, despite understanding the importance of adopting self-protective HIV-prevention measures and practices, they admitted the existence of vulnerability from occupational rather than sexual risk, and accordingly deployed protective measures against workplace accidents, but failed to use condoms and thus continued to be exposed to HIV in their sexual relations.

How does a group of Iranian youth conceptualize their risky sexual experiences?

Background:

There are restrictions as well as lawful and religious prohibition for sexual relationships in Iranian society.

Objectives:

This study explores the varied experiential reality of Iranian youth and their risky sexual experiences.

Patients and Methods:

Data collection is based on semi-structured interviews with 30 single young men and women. Observation of interactions of youth in different settings has been another source of information. Interviews were microscopically content analyzed.

Results:

The accounts of risky sexual experiences included gendered behavioral, cultural, and cognitive factors. In the re-contextualizing process, these accounts were categorized by two main themes: “gendered sexual script” and “cultural scenarios of interpersonal interactions”. The notion of “male power” was evident in the responses provided by the participants. Women seldom asked for condom use due to limited knowledge about STIs-HIV/AIDS and unpleasant experiences with condoms. Men had limited knowledge about various sexual modes of HIV and STIs transmission and did not use condoms consistently because they had not seen themselves at risk of STIs or HIV as well as their belief about the decrease of sexual pleasure.

Conclusions:

Rising youth awareness, creating a positive attitude, and appropriate knowledge about safe sex practices are seminal. It is also vital to ensure access to gender specific sexual and reproductive health services for youths, empower women, and strengthen their sexual assertiveness as well as the elimination of all forms of gender-based inequalities.

Socioeconomic characteristics of the population living in Roma settlements and their association with health and health-related behaviour

BACKGROUND

The aim of this study was to compare socioeconomic characteristics of the Roma population living in Roma settlements with the majority population. Moreover, it was aimed to assess socioeconomic differences in health and health-related behaviour within the population living in Roma settlements.

METHODS

Data from the cross-sectional HepaMeta study conducted in Slovakia in 2011 were used. The sample consisted of 452 Roma (mean age = 34.7; 35.2% men) and 403 non-Roma (mean age = 33.5; 45.9% men) respondents. Roma in selected settlements were recruited by local Roma community workers. Respondents from the major population were randomly selected from a list of patients from general practitioners. Data were collected via questionnaire, anthropometric measures and analysed blood samples. Differences in socioeconomic characteristics between the population living in Roma settlements and the majority population were tested using the chi-square test. The contribution of selected socioeconomic characteristics on health and health-related behaviour of the population living in Roma settlements was assessed by logistic regression models adjusted for age and gender.

RESULTS

The population living in Roma settlements is characterised by significantly lower socioeconomic standards, and the living conditions are significantly worse compared with the majority. With few exceptions, the study did not confirm any significant association between socioeconomic indicators and health and health-related behaviour within the population living in Roma settlements.

CONCLUSIONS

The deteriorating effect of living in Roma settlement on health and health-related behaviour seems to be immense regardless differences in socioeconomic characteristics or living condition within the settlement population.

High-risk sexual behavior, HIV/STD prevalence, and risk predictors in the social networks of young Roma (Gypsy) men in Bulgaria

Roma (Gypsies), the largest and most disadvantaged ethnic minority group in Europe, are believed to be vulnerable to HIV/AIDS. This study's aim was to examine HIV risk in 6 Roma male sociocentric networks (n = 405 men) in Bulgaria. Participants were interviewed concerning their risk practices and tested for HIV/STDs. High-risk sexual behaviors were common. Over 57% of men had multiple sexual partners in the past 3 months. Over one-third of men reported both male and female partners in the past year. Condom use was low. Greater levels of sexual risk were associated with lower intentions and self-efficacy for using condoms, drug use, having male partners, knowing HIV-positive persons, and having higher AIDS knowledge but no prior HIV testing. Two men had HIV infection, 3.7% gonorrhea, and 5.2% chlamydia. HIV prevention interventions directed toward high-risk social networks of Roma are needed before HIV infection becomes more widely established.

Revisiting the evidence on health and health care disparities among the Roma: a systematic review 2003-2012

OBJECTIVES

To conduct a systematic review of the epidemiological and health service utilization literature related to the Roma population between 2003 and 2012.

METHODS

Systematic review of empirical research related to Roma health and health care utilization published between 2003 and 2012 identified through electronic databases (PsycInfo, Medline, Google Scholar). Methodological rigor was evaluated using a six-point set of design criteria.

RESULTS

We found evidence for lower self-reported health and significantly higher mortality risk for Roma compared to non-Roma, and greater prevalence of health risk factors for Roma children, including environmental risks, low birth weight, and lower vaccination coverage. Studies of non-communicable and infectious disease remain insufficient to make firm conclusions on disparities. Barriers to care include lack of documentation and affordability of care, though more studies on health care utilization are needed.

CONCLUSIONS

Roma youth and adults are in need of programs that reduce health disparities and their increased mortality risk. Reducing exposure to risk factors such as smoking, obesity, and poor living conditions may be a target for interventions. More intervention studies and rigorous evaluations are needed.

HIV-related risk behaviors among Roma youth in Serbia: results of two community-based surveys

PURPOSE

The Roma constitute a large ethnic minority in Serbia, and are one of the poorest and most marginalized groups in Europe. Roma youth may be at high risk for hepatitis C, HIV, and other sexually transmitted infections, but little is known about the prevalence of these infectious diseases, HIV-related knowledge, and risky sexual behaviors in this vulnerable population.

METHODS

We used a respondent-driven sampling to conduct biobehavioral surveys of Roma youth (aged 15-24 years) in Belgrade and Kragujevac, and to document HIV-related knowledge and risky sexual behaviors, health-seeking behaviors, and seroprevalence of HIV, hepatitis C virus (HCV), and syphilis.

RESULTS

Four hundred eleven Roma youth participated in this study. One participant had HIV, four had HCV, and none had syphilis. Risky sexual behaviors were highly prevalent, especially among male subjects: 36.2% (Belgrade) and 45.1% (Kragujevac) had sexual debut before the age of 15 years; 53.9% (Belgrade) and 61.1% (Kragujevac) had more than one sexual partner in the past year; 11.5% (Belgrade) and 4.6% (Kragujevac) reported engaging in commercial sex; and 4.0% (Belgrade) and 3.2% (Kragujevac) reported having anal sex with other men. Among female subjects aged <25 years, 33.5% (Belgrade) and 25.7% (Kragujevac) reported having an abortion. One-quarter of all participants answered all five HIV knowledge questions correctly.

CONCLUSIONS

Fortunately, the current prevalence of HIV, HCV, and syphilis is low; however, the high prevalence of reported risky behaviors suggests that Roma youth in Serbia are at high risk of contracting sexually transmitted infections.

Measles outbreak in Bulgaria: poor maternal educational attainment as a risk factor for medical complications

BACKGROUND

An 8-year era of interrupted indigenous measles transmission in Bulgaria came to an end in April 2009 when a large epidemic occurred that would eventually claim 24,253 cases and 24 deaths; infants, children and young adults of the Roma community were disproportionally affected. Compared with Western Europe, case-fatality rate and proportion of medical complications were uncharacteristically high.

METHODS

To disentangle underlying drivers of the outbreak and reasons for these medical complications, we assembled a number of national ecologic variables as well as regional individual-level data for 206 measles cases, randomly selected from national medical records. We conducted a logit regression analysis of data from individuals with medical complications.

RESULTS

Ecologic socio-economic predictors were not associated with measles cases by region, although the proportion of medical complications differed considerably. Individual-level data from a region with high medical complications revealed that mother's education [odds ratio (OR) 0.79; 95% confidence interval (CI) 0.68-0.92], immunization status of the child (OR 0.28; 95% CI 0.08-0.94) and households declaring an income (OR 0.31; 95% CI 0.10-0.93) decreased the risk for developing severe medical complications such as pneumonia or encephalitis from a measles infection.

DISCUSSION

The extent of this outbreak with a high case-fatality rate and high proportion of medical complications calls for resolute public health action. We found vaccination and maternal education to be crucial conduits of curbing medical complications from measles infections. Ultimately, the goal is measles elimination in Europe by 2015, and these data hint at intervention entry points.

Review of HIV vulnerability and condom use in central and eastern Europe

The epidemiological trend of increasing HIV incidence rates due to sexual transmission in central and eastern Europe has been documented. The current review analysed research articles that report on a wide spectrum of vulnerable populations from this world region. Studies of injection drug users, commercial sex workers, men who have sex with men, adolescents and young adults all reported inconsistent condom use. However, these patterns varied across populations and geographic areas. Populations in former Soviet countries - the most affected by HIV - also often appeared to have lower condom use rates. Intensified, comprehensive and locally tailored measures to curb sexual HIV transmission are urgently needed. Social development programs need to incorporate HIV prevention.

Incidence of infectious diseases and survival among the Roma population: a longitudinal cohort study

BACKGROUND

Roma ethnicity is greatly affected by tuberculosis (TB), AIDS, injecting drugs use (IDU) and imprisonment.

METHODS

We assessed the incidence of several health problems by means of a retrospective cohort study performed in Camp de la Bota, Barcelona (Spain). The 380 individuals included in the 1985 TB outbreak investigation were followed-up until 31 December 2008. One hundred ninety-two subjects (50.5%) were men and 188 (49.5%) women. Information sources included questionnaires taken at the time of this outbreak, a population census and other registries from Barcelona and Catalonia. Cox proportional hazards mixed models were employed in the multivariate survival analysis.

RESULTS

By the end of the follow-up, the survival rate was 79.4%; 50 persons (13.1%) had deceased and 28 (7.3%) had emigrated. The incidence of AIDS was 104 cases per 100 000 person-years of follow-up (pyf), IDU was 240 cases pyf, imprisonment was 642 cases pyf and that of TB was 91 cases pyf. Male survival was lower [hazard ratio (HR) 4.22], when the effect of family was taken into account, than when it was not taken into account (HR 3.67).

CONCLUSIONS

High incidences of AIDS, TB, IDU, imprisonment and poor survival rates have been observed among Roma. Family was found to be an important factor influencing the survival rates: when not considered, the risk of death among men was underestimated.

Some Bulgarian pre-enlargement research trends

AIM

Bulgaria joined the European Union in 2007. This study aims to analyse Bulgarian scientific health output over a five year period before enlargement, highlighting both its interests and concordance with European health recommendations.

METHODS

A bibliometric analysis was undertaken in MEDLINE between 2000 and 2004 according to a year-by-year bibliographic search. The articles were classified by fourteen fields according to the main European Union health report recommendations.

RESULTS

2176 articles were found, distributed as follows: 15.63% in 2000, 20.50% in 2001, 20.63% in 2002, 19.9% in 2003 and 23.25% in 2004. 89.48% of the articles were written in English, 78.81% of the total scientific output was published abroad. Most of the articles were signed by Bulgarian authors and were carried out in Bulgarian research centers.

CONCLUSION

Increased number of articles was noted mainly in the basic research field and global clinical medicine. Bulgarian research priorities generally were aligned with the European Union health recommendations. More sources are recommended to be consulted and more analysis conducted of the Bulgarian research.

Attitudes of adolescent Spanish Roma toward noninjection drug use and risky sexual behavior

Our objective with this study was to analyze the opinions of a potentially socially marginalized group of Spanish Roma adolescents and young adults about noninjection drug use, HIV infection, and risky sexual behavior. Descriptive qualitative research was conducted through focus groups with Roma participants and semistructured interviews with professionals who work with them in areas such as education and health promotion. Results were triangulated by cross analysis among researchers. Declared drug consumption is lower among females than males. The former claim they do not maintain sporadic sexual relations, and link risky sexual practices to being in love and involved in a stable relationship. Males only use condoms in sporadic sexual relations. They attribute their lack of condom use to lost sensitivity, perceiving sex as something uncontrollable, and not having condoms available when using drugs. Results suggest the need to improve actions aimed at preventing the sexual transmission of HIV among the Roma population.

HIV and selected blood-borne and sexually transmitted infections in a predominantly Roma (Gypsy) neighbourhood in Budapest, Hungary: a rapid assessment

We assessed the prevalence of HIV and selected blood-borne and sexually transmitted infections among a convenience sample of 64 residents of Dzsumbuj, a predominantly Roma (Gypsy) neighbourhood in Budapest, Hungary. No cases of HIV were detected, while the prevalence of hepatitis B infection (anti-HBc) was 27% and syphilis prevalence was 2%. Romas (n = 50) were significantly more likely than non-Romas (n = 14) to have HAV antibodies (80% vs. 43%) and less likely to be HBV immunized (anti-HBs only; 6% vs. 29%). Current drug injectors (n = 13) were more likely than non-injectors (n = 51) to have antibodies against HAV (85% vs. 69%) and HCV (85% vs. 8%). While HIV has not been introduced in this population, risk conditions for a potentially explosive HIV epidemic are present. Health care policies should focus on expanding coverage for HAV and HBV immunizations, and access to HIV preventive services needs to be extended to marginalized, mostly minority populations, such as the Roma in Europe.

The HIV type 1 epidemic in Bulgaria involves multiple subtypes and is sustained by continuous viral inflow from West and East European countries

Little is known about the HIV-1 epidemic in Balkan countries. To fill the gap, we investigated the viral genetic diversity in Bulgaria, by sequencing and phylogenetic characterization of 86 plasma samples collected between 2002 and 2006 from seropositive individuals diagnosed within 1986-2006. Analysis of pol gene sequences assigned 51% of the samples to HIV-1 subtype B and 27% to subtype A1. HIV-1 subtype C, F, G, H, and a few putative recombinant forms were also found. Phylogenetic and molecular clock analysis showed a continuous exchange of subtype A and B between Bulgaria and Western as well as other Eastern European countries. At least three separate introductions of HIV-1 subtype A and four of HIV-1 subtype B have occurred within the past 25 years in Bulgaria. The central geographic location of Bulgaria, the substantial genetic heterogeneity of the epidemic with multiple subtypes, and the significant viral flow observed to and from the Balkan countries have the potential to modify the current HIV-1 epidemiological structure in Europe and highlight the importance of more extensive and continuous monitoring of the epidemic in the Balkans.

Intervening to reduce inequalities in infections in Europe

The European Centre for Disease Prevention and Control was founded in response to newly emerging infections such as severe acute respiratory syndrome and avian influenza. However, Europe faces other communicable disease challenges that have proven to be remarkably resilient to public health interventions. We present examples of communicable diseases with inequitable distribution among those with poor educational attainment, low income, or other socioeconomic factors in every European country. Because these findings are incompatible with social justice and fairness, we examine strategic interventions targeting upstream causes of communicable disease transmission keeping in mind 10 indispensable public health functions essential to reach marginalized groups. These interventions have to be tailored to the socio-political context and rely on community-based decision-making and intersectorial collaboration.

Injecting equipment sharing and perception of HIV and hepatitis risk among injecting drug users in Budapest

In central European states, rates of HIV among injection drug users (IDUs) have been low although Hepatitis C (HCV) infection is widespread. The goal of our study was to assess HIV infection, risk perceptions and injecting equipment sharing among IDUs in Budapest, Hungary. Altogether 150 IDUs were interviewed (121 structured interviews between 1999 and 2000 and 29 ethnographic interviews between 2003 and 2004). The majority of them injected heroin (52% and 79%) and many injected amphetamines (51% and 35%). One person tested positive for HIV. Two thirds (68%) shared injecting equipment (syringes, cookers and filters). Some participants said they shared syringes because they were not carrying them for fear of police harassment and that they reused filters as a backup drug supply. In multivariate analysis, sharing of injecting equipment was associated with higher perceived susceptibility to HIV/AIDS, lower self-efficacy for sterile equipment use, higher motivation to comply with peer pressure to use dirty injecting equipment and with having a criminal record. The high levels of injecting risk-behaviors found in this study are a cause for serious concern. Interventions for HIV-prevention need to address not only sharing syringes but also sharing and reusing of other injecting equipment and drug filters.

Prevention of HIV and sexually transmitted diseases in high risk social networks of young Roma (Gypsy) men in Bulgaria: randomised controlled trial

OBJECTIVE

To determine the effects of a behavioural intervention for prevention of HIV and sexually transmitted diseases that identified, trained, and engaged leaders of Roma (Gypsy) men's social networks to counsel their own network members.

DESIGN

A two arm randomised controlled trial.

SETTING

A disadvantaged, impoverished Roma settlement in Bulgaria.

PARTICIPANTS

286 Roma men from 52 social networks recruited in the community.

INTERVENTION

At baseline all participants were assessed for HIV risk behaviour, tested and treated for sexually transmitted diseases, counselled in risk reduction, and randomised to intervention or control groups. Network leaders learnt how to counsel their social network members on risk prevention. Networks were followed up three and 12 months after the intervention to determine evidence of risk reduction.

MAIN OUTCOME MEASURE

Occurrence of unprotected intercourse during the three months before each assessment.

RESULTS

Reported prevalence of unprotected intercourse in the intervention group fell more than in control group (from 81% and 80%, respectively, at baseline to 65% and 75% at three months and 71% and 86% at 12 months). Changes were more pronounced among men with casual partners. Effects remained strong at long term follow-up, consistent with changes in risk reduction norms in the social network. Other measures of risk reduction corroborated the intervention's effects.

CONCLUSIONS

Endorsement and advice on HIV prevention from the leader of a social network produces well maintained change in the reported sexual practices in members of that network. This model has particular relevance for health interventions in populations such as Roma who may be distrustful of outsiders.

TRIAL REGISTRATION

Clinical Trials NCT00310973.

HIV Risk Behavior Patterns, Predictors, and Sexually Transmitted Disease Prevalence in the Social Networks of Young Roma (Gypsy) Men in Sofia, Bulgaria

OBJECTIVES AND GOAL

This research studied predictors of high-risk sexual practices and sexually transmitted disease (STD) prevalence among Roma (Gypsy) men's social networks in Sofia, Bulgaria.

STUDY DESIGN

Fifty-four socially active individuals, approached in Roma neighborhood venues, recruited members (n = 296) of their own networks into the study. Participants completed sociometric and risk behavior interviews and were tested for chlamydia, gonorrhea, syphilis, and trichomonas.

RESULTS

Men had a mean of 7 partners in the past year. Fifty-nine percent had multiple partners in the past 3 months. Seventy-three percent reported recent unprotected vaginal and 51% unprotected anal intercourse. Fifty-nine percent of men had sex with other men in the past year. Twenty-two percent had one of the STDs. The social network to which an individual belonged accounted for 23% to 27% of variance in predicting sexual risk behavior.

CONCLUSIONS

One's social network was the most powerful predictor of HIV risk behavior. HIV/STD prevention interventions directed toward entire social networks are especially promising.

Strong HIV and hepatitis disclosure norms and frequent risk behaviors among Hungarian drug injectors

Ethnographic interviews and focus groups were conducted between May 2003 and January 2004 among injection drug users (IDUs; n=29) in Budapest, Hungary, to assess knowledge related to HIV, hepatitis B (HBV), and hepatitis C (HCV) and norms, attitudes, and behaviors. Participants perceived themselves at low risk for infection with HIV but at high risk for hepatitis through injection but not sexual exposure. They reported strong disclosure norms for HIV and hepatitis infections, while sexual and injection risk behaviors were influenced by trust about partners' self-report of infection status. Injection networks were small, with infrequent syringe sharing among a few close friends. Cookers and drug filters often were shared, and filters were reused as a backup drug supply. Most sexual relationships were monogamous, and condoms were used rarely. Although participant norms supported HIV/HBV/HCV testing, the lack of available behaviors with injection and sex partners who are close friends. Network interventions among IDUs in Hungary should build on disclosure norms and trust to reduce injection and sex risk. Testing services should be expanded and access increased so that IDUs can act on and reinforce their norms for testing.

Marginalized and socially integrated groups of IDUs in Hungary: potential bridges of HIV infection

The discrepancy in HIV rates among Eastern and central European injecting drug users (IDUs) suggests that, in addition to risk behaviors, social contact patterns also play an important role. We identify two groups of IDUs in Budapest, Hungary, marginalized IDUs (M-IDUs) and socially integrated IDUs (SI-IDUs) and compare their HIV/hepatitis B virus (HBV)/hepatitis C virus (HCV) social and risk network characteristics, risk behaviors, and travel patterns. Between May 2003 and January 2004, 29 nontreatment-recruited young IDUs in Budapest participated in ethnographic interviews and focus groups. The mean age was 23.6 years (SD=3.6); eight were female and two Roma/Gypsy. Most injected heroin (n=23) and/or amphetamines (n=10) in the past 30 days. M-IDUs had no legal employment, injected heroin and sniffed glue, and stopped using drugs in treatment/prison. SI-IDUs had regular jobs or were students, injected heroin and sniffed cocaine, and stopped using drugs before exams/tests. Both M-IDUs and SI-IDUs shared injecting equipment on occasion and used condoms rarely. M-IDUs had a large social network of "buddies" and a small risk network of "friends". SI-IDUs had two separate large social networks of "buddies": a M-IDU and a non-IDU network; and a small risk network of "friends". Both groups reported monogamous sexual relationships. M-IDUs traveled within Hungary, whereas SI-IDUs traveled to Western Europe. If an HIV epidemic among IDUs in Hungary is not prevented, SI-IDUs may form a potential "bridge" of HIV infection between high-risk IDU populations and the low-risk general population, whereas M-IDUs may become cores of infection. Different approaches may be appropriate for M-IDUs and SI-IDUs to prevent HIV.