Behavioral factors in the spread of HIV infection

What does PrEP mean for 'safe sex' norms? A qualitative study

While HIV pre-exposure prophylaxis (PrEP) is highly effective, it has arguably disrupted norms of ‘safe sex’ that for many years were synonymous with condom use. This qualitative study explored the culture of PrEP adoption and evolving concepts of ‘safe sex’ in Sydney, Australia, during a period of rapidly escalating access from 2015–2018, drawing on interviews with sexually active gay men (n = 31) and interviews and focus groups with key stakeholders (n = 10). Data were analysed thematically. Our results explored the decreasing centrality of condoms in risk reduction and new patterns of sexual negotiation. With regards to stigma, we found that there was arguably more stigma related to not taking PrEP than to taking PrEP in this sample. We also found that participants remained highly engaged with promoting the wellbeing of their communities through activities as seemingly disparate as regular STI testing, promotion of PrEP in their social circles, and contribution to research. This study has important implications for health promotion. It demonstrates how constructing PrEP as a rigid new standard to which gay men ‘should’ adhere can alienate some men and potentially create community divisions. Instead, we recommend promoting choice from a range of HIV prevention options that have both high efficacy and high acceptability.

AIDS-Related Items for Developing an AIDS Questionnaire for Children and Adolescents

This study presents a pool of AIDS-related items that researchers and clinicians could use to develop self-report AIDS questionnaires for children and adolescents. A total of 352AIDS-related itemsfrom 18AIDSsurvey studies involving children and adolescents, ranging in age from 10 to 21 years, were submitted to content analysis. Unique items with 85% agreement among raters, and items with the higher percentage of agreement (85% or above) among repeated items, were selected. On the basis of these criteria, 164 AIDS-related items were identified AIDS-related items were integrated intofwve mutually exclusive, theoretically defined groups: (a)factual knowledge, (b) misconceptions, (c) attitudes, (d) perceived susceptibility, and (e) perceived self-efficacy. Selection of itemsfrom these groups could lead to the development of a comprehensive and uniform self-report AIDS questionnaire for children and adolescents, and to meaningful comparisons of AIDS surveys by researchers and clinicians using similar items.

Casual sexual encounters among gay men: familiarity, trust and unprotected anal intercourse

Familiarity with and a history of prior sex with casual partners is associated with unprotected anal intercourse and may increase the risk of HIV transmission among gay men. Using data from the Sydney Gay Community Periodic Survey 2007, we explored the relationship between familiarity and unprotected anal intercourse with the last casual partner (UAI-LC). 51% of the men knew their last casual partner and 49% had previously had sex with him. Men were more inclined to engage in UAI-LC if they had previously had sex with this partner. HIV-negative men were more likely to have UAI-LC with a more familiar partner independent of his serostatus. Familiarity with and a previous history of sex between casual partners may result in a false sense of trust and may increase the risk of HIV transmission. HIV prevention services should address this issue and develop programs to improve men's skills in negotiating safer sex.

The four Cs of HIV prevention with African Americans: crisis, condoms, culture, and community

HIV/AIDS continues to be a devastating epidemic with African American communities carrying the brunt of the impact. Despite extensive biobehavioral research, current strategies have not resulted in significantly decreasing HIV/AIDS cases among African Americans. The next generation of HIV prevention and risk reduction interventions must move beyond basic sex education and condom use and availability. Successful interventions targeting African Americans must optimize strategies that integrate socio-cultural factors and address institutional and historical barriers that hinder or support HIV risk reduction behaviors. Community-based participatory research to decrease the HIV/AIDS disparity by building community capacity and infrastructure and advocating for and distributing equitably, power and resources, must be promoted. Recommendations for paradigm shifts in using innovative theories and conceptual frameworks and for training researchers, clinicians, grant and journal reviewers, and community members are made so that culturally congruent interventions may be tested and implemented at the community level.

HIV-related risk behaviors, perceptions of risk, HIV testing, and exposure to prevention messages and methods among urban American Indians and Alaska Natives

The goal of this study was to describe HIV risk behaviors, perceptions, testing, and prevention exposure among urban American Indians and Alaska Natives (AI/AN). Interviewers administered a questionnaire to participants recruited through anonymous peer-referral sampling. Chi-square tests and multiple logistic regression were used to compare HIV testing by perception of risk and risk behavior status. Of 218 respondents with seronegative or unknown HIV status, 156 (72%, 95% confidence interval [CI]: 66-78%) reported some HIV risk behavior: 57 (26%, 95% CI: 20-32%) high-risk behavior, and 99 (45%, 95% CI: 39-52%), potentially high-risk. Among respondents reporting high-risk behavior, 44% rated themselves at no or low risk for HIV infection. Overall, 180 respondents (83%, 95% CI: 78-88%) had ever received an HIV test, 79 (36%, 95% CI: 31-57%) in the past year. HIV risk behaviors and perception of risk were independently associated with recent HIV testing after adjustment for gender, income, and homelessness (odds ratio [OR] = 3.6; 95% CI: 1.5-9.0 for high-risk behavior vs. no reported risk behavior, and OR: 3.2; 95% CI: 1.3-7.6, for high vs. no perceived risk). Addressing inaccurate perception of risk may be a key to improving uptake of HIV testing among high-risk urban AI/AN.

Convergence of behaviour change models for AIDS risk reduction in sub-Saharan Africa

There is increasing programme focus on the impact of HIV and AIDS and the advances in biomedical research that are taking central stage even in sub-Saharan Africa. Perhaps out of frustration, communication and behaviour change efforts are receiving lesser attention. But as long as heterosexual intercourse remains the predominant means of transmission of HIV in sub-Saharan Africa, there is the inherent danger of more people getting infected thus mopping up the gains from other approaches. This paper therefore argues for evidence based behaviour change interventions in sub-Saharan Africa, revisits the behaviour change theories and their relevance to the African situation. It proposes an integration of models based on the convergence of three existing theories of social learning, diffusion of innovation and social networks and the author's understanding of some African culture. The beauty of the model is based on the fact that 'social norms are best understood and influenced at the level of social networks'; existing chains of communication and the naturalness of exchange of information. A case is made for application of the 'model' to precipitate sexual behaviour change and HIV reduction in sub-Saharan Africa.

The Healthy Living Project: an individually tailored, multidimensional intervention for HIV-infected persons

The NIMH Healthy Living Project (HLP), a randomized behavioral intervention trial for people living with HIV, enrolled 943 individuals, including women, heterosexual men, injection drug users, and men who have sex with men from Los Angeles, Milwaukee, New York, and San Francisco. The intervention, which is based on qualitative formative research and Ewart's Social Action Theory, addresses three interrelated aspects of living with HIV: stress and coping, transmission risk behavior, and medication adherence. Fifteen 90-minute structured sessions, divided into 3 modules of five sessions each, are delivered to individuals. Sessions are tailored to individuals within a structure that uses role-plays, problem solving, and goal setting techniques. A 'Life Project'--or overarching goal related to personal striving-provides continuity throughout sessions. Because this is an ongoing project with efficacy yet to be established, we do not report intervention outcomes. However, the intervention was designed to be useful for prevention case management, settings where repeated one-on-one contact is possible, and where a structured but highly individualized intervention approach is desired.

The influence of gender on factors associated with HIV transmission risk among young Russian injection drug users

HIV infection rates are dramatically increasing in the Russian Federation. Epidemiological studies indicate that the greatest rise of HIV incidence has been among injection drug users (IDU). Young adults (N = 188) who reported injecting drug use completed surveys and interviews that assessed injection drug use behavior, sexual behavior, and HIV-related knowledge. The average age of participants was 21.3 years. Multiple linear regression analysis found male gender and younger age at sexual debut was positively and significantly associated with having multiple sexual partners. Gender moderated the effects of sexual debut and number of times injected drugs were used in the past month. Males who initiate sex at a younger age were more likely to report multiple sex partners and females who reported higher frequency of drug use were more likely to report multiple sex partners. Gender is an important factor, as well as moderator of risk behavior among Russian injection drug users. Delaying sexual debut, particularly for males, may be an effective strategy to reduce subsequent risk behavior. Prevention efforts among IDUs need to address sexual risk behavior in conjunction with injection risk behavior.

A gender-specific HIV/STD risk reduction intervention for women in a health care setting: short- and long-term results of a randomized clinical trial

This study assessed the short- and long-term effect of a gender-specific group intervention for women on unsafe sexual encounters and strategies for protection against HIV/STD infection. Family planning clients (N = 360) from a high HIV seroprevalence area in New York City were randomized to an eight-session, a four-session or a control condition and followed at one, six and 12 months post-intervention. Using an intention-to-treat analysis, women who were assigned to the eight-session group had about twice the odds of reporting decreased or no unprotected vaginal and anal intercourse compared to controls at one month (OR = 1.93, 95% confidence interval [CI] = 1.07, 3.48, p = 0.03) and at 12-month follow-up (OR = 1.65, 95% CI = 0.94, 2.90, p = 0.08). Relative to controls, women assigned to the eight-session condition reported during the previous month approximately three-and-a-half (p = 0.09) and five (p < 0.01) fewer unprotected sex occasions at one- and 12-month follow-up, respectively. Women in the eight-session group also reduced the number of sex occasions at both follow-ups, and had a greater odds of first time use of an alternative protective strategy (refusal, outercourse, mutual testing) at one-month follow-up. Results for the four-session group were in the expected direction but overall were inconclusive. Thus, gender-specific interventions of sufficient intensity can promote short- and long-term sexual risk reduction among women in a family planning setting.

Research on HIV sexual risk: social relations-based approach in a cross-cultural perspective

In opposition to individual-oriented approaches to sexual risk taking, new theoretical approaches have emerged that strive to encompass all of the social relations--that is to say, the connections that structure the components of relations between groups and go beyond simple adaptations to a given interaction--that prevail in a sexual relationship. This paper examines the strengths and weaknesses of such an approach for understanding HIV risk-related behaviour. The analysis is based on data from European surveys of sexual behaviour in the general population, with special attention paid to the data from the Belgian survey, which used a relation-based approach to risk-related behaviour. The analysis shows that sexual behaviour and preventive behaviour patterns of men and women appear to be linked to women's status in a given society. The data also tend to show that the social and preventive contexts also help structure the relations that develop between partners when it comes to negotiating about using a condom. Finally, the same people behave differently depending on the relationship's context. In particular, the balance of power within the couple, which is strongly interconnected with gender relations issues, and even characteristics of the former relationship help explain these behaviour differences.

HIV testing practices of Zimbabwean physicians and their perspectives on the future use of rapid on-site tests

To improve HIV testing procedures, rapid on-site HIV tests have been introduced in Zimbabwe. At present, little is known about physicians' perspectives on the potential use of rapid tests in their clinics or about their current laboratory-based testing practices. In a sample of 63 general practitioners in Harare, this study found physicians were generally testing individuals, not couples, and an important reason for suggesting a patient be tested was medical symptoms; frequent reasons for patients requesting the test were insurance purposes, being about to get married or having suspicions about a partner. A primary deterrent to physicians testing patients, even when patients requested it, was fear of traumatizing them. Fifty-six per cent of the physicians believed rapid tests would increase the number of HIV tests they performed; significant associations were found between this belief and whether physicians ever chose not to test patients they suspected were HIV-positive (a positive association) and whether they chose not to test specifically out of fear that patients would commit suicide (a negative association). Prior to any expansion of testing with rapid tests, training in counselling and confidentiality measures is essential, given that over half the medical personnel providing counselling to these physicians' patients had received no training in pre- and post-test HIV counselling.

Knowledge of HIV infection and the fear of mixing socially with HIV-infected and AIDS-sick patients among STD patients in Bergen, Norway

This is a study of data from 599 STD (sexually transmitted disease) clinic patients in Bergen, Norway who visited the clinic in April-June 1989. We studied the patients' knowledge of modes of HIV transmission and their degree of ignorance of how HIV is not transmitted. Particular interest was focused on how misconceptions influenced the respondents' perception of HIV/AIDS sick persons and the importance of confidence in AIDS information from the health authorities. The objective of the study was to compare the data from this investigation of STD patients with data from similar studies in the general public conducted in Norway between 1986 and 1991. HIV-infected blood (98.3%; 589/599) and unprotected vaginal intercourse (91%; 545/599) were frequently suggested as a mode of HIV transmission, while 22.4% (134/599) did not recognize anal sex as an unsafe sexual practice. There was no statistically significant difference in their knowledge of modes of HIV transmission between the following patient subgroups: homosexuals/bisexuals, intravenous drug users (IVDUs)/prostitutes, sex customers and respondents classified as 'other heterosexuals'. Regarding ways in which HIV is not transmitted, ignorance was first and foremost related to whether the HIV virus could be passed on by oral kissing (wrong: 38.5%). Knowledge of how HIV is not transmitted was positively correlated with education (p < 0.05) and confidence in the HIV/AIDS information from health authorities (p < 0.05), and negatively correlated with age (p < 0.05). Respondents knowing how HIV is not transmitted considered social contact with HIV/AIDS sick persons to be harmless (p < 0.001). The present information campaigns on HIV/AIDS have been less effective than expected. In the future we must find new ways of informing the public by identifying the essential components that are missing from the information campaigns we have today.

Anthropology and AIDS: the cultural context of sexual risk behavior among urban Baganda women in Kampala, Uganda

One hundred and thirty Baganda women (65 HIV antibody positive and 65 HIV antibody negative), recruited from the Makerere University-Case Western Reserve University Collaborative Pediatric follow-up clinic in Kampala, Uganda were interviewed about cultural rules and norms for sexual behavior and HIV-specific risk behaviors. Interviews were analyzed for themes related to sexual risk, cultural rules regarding sex, and individual sexual practices. Statistical relationships were tested using chi 2 and t-test statistics. The mean age of the women was 21 years (range 15-30). Despite sexual norms prohibiting sex for women outside marriage, subjects reported that there are certain circumstances when a woman may take other partners, including economic need, desire for greater sexual satisfaction, or revenge on a husband with other partners. Cases were more likely to state that women may have outside partners for economic reasons (P < 0.05) and that women have outside partners for sexual satisfaction (P < 0.01). Women interviewed for this study are complying with Ugandan AIDS control messages to 'zerograze' and 'stick to one partner'. Fear of AIDS remains high, however, because women fear that their partners have not responded to risk reduction messages. Of those women stating fear of AIDS, 57% of cases and 62% of controls based their fear on their perceptions of their partners' activities. Therefore, women feel that they remain at risk of infection despite their own behavior change. We find that, while the potential for risk reduction is high for these women, cultural norms permitting males to have multiple partners limit a woman's ability to control her risk reduction. Important conclusions are: (1) a focus on women's behavior alone is not sufficient as both partners must respond to risk reduction messages; (2) knowledge about AIDS is not sufficient to achieve change in sexual behavior because sexual behavior is linked to economics, gender relations, and other complex socio-cultural factors; and (3) a study of Baganda male sexual values and behavior is urgently needed.

Predictors of changes in sexual behavior among women on methadone

This study identified predictors of reported sexual risk reduction among 109 female injection drug users enrolled in methadone clinics. Univariate analyses were used to examine the individual effects of each variable on the outcome of sexual behavior change over the past 6 months. Multiple logistic regression was then used to identify which of these variables were independently associated with such a change. Women with more than one sexual partner were more likely than women with one or no sexual partner to report changing their sexual behavior. African-American women were less likely than White Anglo or Latina women to report changing their sexual behavior. Women who held stronger beliefs that luck plays the largest role in getting AIDS were less likely to report changing their sexual behavior. Change in sexual behavior was associated with feeling comfortable asking partners to use condoms, higher depression scores, and loss of friends or family to AIDS. The observed relationship between personal susceptibility and depression suggests that risk reduction interventions should also address the depressive symptomatology associated with feelings of vulnerability.

Alcohol and risky sex: in search of an elusive connection

Since the publication of the 1986 article by Stall, McKusick, Wiley, Coates and Ostrow, the conclusion that drinking alcohol prior to or during erotic encounters increases the probability of engaging in high-risk sexual behavior has been widely accepted, despite some contradictory findings from research on this hypothesis. This paper presents the results of tests of the alcohol/risky-sex hypothesis in a cohort of gay men in Flanders, Belgium. Failing to find evidence to support the hypothesis of a general effect of alcohol on sexual risk taking, we argue that previous conclusions on this matter must be viewed with extreme caution, especially in light of the implications that this failure to replicate has for AIDS prevention programs. Cultural, social, and methodological factors that could account for this failure to replicate are discussed in the context of a review of the literature on this hypothesis.

Condom use in multi-ethnic neighborhoods of San Francisco: the population-based AMEN (AIDS in Multi-Ethnic Neighborhoods) Study

We examined the prevalence and correlates of condom use in a community-based sample of unmarried heterosexual and gay/bisexual Whites, Blacks, and Hispanics (aged 20 to 44 years) in San Francisco (n = 1229). Only 9% of heterosexual males reported always using condoms, and fewer of those with multiple sexual partners (6%) reported always using condoms compared with those in monogamous relationships (12%). Much higher proportions of gay/bisexual men reported always using condoms (48%). Racial differences in condom use were observed only among women. Sexual communication and the sexual enjoyment value of condoms were consistent correlates of condom use across gender and sexual orientation, while other condom-related beliefs were significant predictors of condom use only for men. In general, condom promotion programs should build sexual communication skills, teach people how to enhance enjoyment with condoms, and reduce psychological barriers to condom acquisition and use.

Alcohol, drugs, and adolescent sexual behavior

In a 1990 Massachusetts-wide random digit-dial telephone survey of 16-19 year olds, 66% reported sexual intercourse of whom 64% had sex after drinking and 15% after other drug use. Thirty-seven percent always used condoms. Forty-nine percent were more likely to have sex if they and their partner had been drinking, and 17% used condoms less often after drinking. Fewer, 32%, said they would be more likely to have sex if they and their partner had used drugs, with 10% less likely to use condoms after drug use. Since so few adolescents consistently use condoms, the greatest risk for HIV, sexually transmitted diseases, and unwanted pregnancy is the increased likelihood of having sex after drinking or drug use, not the decreased likelihood of condom use after drinking and drug use.

HIV disease: present status and future directions

This review of the human immunodeficiency virus (HIV) epidemic shows that HIV has had and will have a major impact on dentistry, just as it has had on so many other aspects of medical practice and society. These areas include the prevention of HIV transmission in the dental care workplace, the early and safe care and treatment of those who are infected, and the protection of those who are vulnerable or made more vulnerable because of HIV infection. To do this, the dental professional must be educated about HIV and its diseases, their treatment, and what must be done to prevent HIV transmission. Early recognition and treatment of HIV-related oral diseases have become the norms of practice today. Although more and more dentists face potential exposure to HIV, excellent dental care can be provided while minimizing this risk.

Global AIDS: critical issues for prevention in the 1990s

A review of the first decade of global experience with the struggle against HIV/AIDS suggests that prevention will require both full application of existing approaches and fundamental changes in concepts and values. The critical deeper issues can be grouped under three headings: behavior, societal action, and globalism. Behavior, individual and collective, will be increasingly recognized as the major challenge for public health. However, for purposes of HIV prevention (and other issues) a sufficient understanding of behavior has not yet been developed. At the societal level, the activism of community organizations has shifted the balance of initiative in public health toward the community. The long-term implications of this evolution for roles and responsibilities at the community, national, and international levels must be explored. Finally, an understanding of global solidarity, based on respect for human rights and on the objective conditions of the modern world, will be critical for the future capability to deal effectively with HIV/AIDS. In summary, the future of HIV/AIDS prevention and control cannot be separated from the major public health and social issues of our time.

Longitudinal predictors of reductions in unprotected anal intercourse among gay men in San Francisco: the AIDS Behavioral Research Project

Predictors of unprotected anal intercourse were examined among 508 gay men in San Francisco. The cohort was recruited in 1983-84 at which time 49.8 percent of non-monogamous men (N = 435) and 71.2 percent of monogamous men (N = 73) reported practicing unprotected anal intercourse. Only 12 percent of non-monogamous and 27.4 percent of monogamous men reported these practices in 1988. The non-monogamous men who practiced unprotected anal intercourse in 1984 were more likely to be younger, to report that unprotected anal intercourse was their favorite sexual activity, to be low in perceived efficacy to change sexual behavior, to report that friends were more likely to engage in high-risk behaviors, to have less knowledge of health guidelines, and to be less depressed at that time. Non-monogamous individuals who in 1984 reported that unprotected anal intercourse was their favorite sexual activity were more likely to practice that behavior in 1988. Those who knew their serostatus as positive were less likely to report unprotected anal intercourse in 1988. These data infer that in order to modify AIDS-related high-risk behaviors, community risk-reduction programs be differentially aimed at young persons so as to increase personal efficacy about risk reduction, challenge peer norms, promote antibody testing, and eroticize safer sexual activities.