Cango Lyec (Healing the Elephant): HIV Prevalence and Vulnerabilities Among Adolescent Girls and Young Women in Postconflict Northern Uganda

OBJECTIVES

Adolescent girls and young women younger than 25 years (AGYW) account for disproportionate HIV infections in sub-Saharan Africa. Impacts of war in Northern Uganda continue to affect HIV-related health and wellbeing of young people postconflict. Prevalence and incidence of HIV infection were estimated, and factors associated with HIV prevalence among sexually active AGYW in Northern Uganda were investigated.

METHODS

Cango Lyec is a cohort involving conflict-affected populations in Northern Uganda. Nine randomly selected communities in Gulu, Nwoya, and Amuru districts were mapped. House-to-house census was conducted. Consenting participants aged 13-49 years were enrolled over 3 study rounds (2011-2015), of whom 533 were AGYW and had ever had sex. Data were collected on trauma, depression, and sociodemographic-behavioral characteristics. Venous blood was taken for HIV and syphilis serology. Multivariable logistic regression determined baseline factors associated with HIV prevalence.

RESULTS

HIV prevalence among AGYW was 9.7% (95% CI: 7.3 to 12.6). AGYW living in Gulu (adjusted risk ratio, aRR: 2.48; 95% CI: 1.12 to 5.51) or Nwoya (aRR: 2.65; 95% CI: 1.03 to 6.83) were more likely than in Amuru to be living with HIV. Having self-reported genital ulcers (aRR: 1.93; 95% CI: 0.97 to 3.85) or active syphilis (aRR: 3.79; 95% CI: 2.35 to 6.12) was associated with increased risk of HIV infection. The likelihood of HIV was higher for those who experienced sexual violence in the context of war (aRR: 2.37; 95% CI: 1.21 to 4.62) and/or probable depression (aRR: 1.95; 95% CI: 1.08 to 3.54). HIV incidence was 8.9 per 1000 person-years.

CONCLUSION

Ongoing legacies of war, especially gender violence and trauma, contribute to HIV vulnerability among sexually active AGYW. Wholistic approaches integrating HIV prevention with culturally safe initiatives promoting sexual and mental health in Northern Uganda are essential.

HIV in the Russian Federation: mortality, prevalence, risk factors, and current understanding of sexual transmission

BACKGROUND

Although HIV infection in the Russian Federation was historically concentrated among marginalized populations (people who inject drugs, sex workers, MSM, and the prison population), recent evidence suggests that it has become a more generalized epidemic. The objective of our research was to explore how these trends in HIV prevalence and HIV-related mortality compare across Russia.

METHODS

We calculated HIV-associated mortality for both male and female individuals in each region (oblast) of the Russian Federation using data from the Russian Fertility and Mortality Database (RusFMD). Using current data on HIV prevalence, we computed the correlation between HIV prevalence and HIV-associated mortality. We also used oblast-level data to examine the associations between HIV prevalence and the risk factors most commonly associated with HIV infection.

RESULTS

Over the past 20 years, the Russian Federation has experienced a rapid increase in HIV-associated mortality in both male and female individuals. Our findings revealed significant heterogeneity, with higher rates of HIV-associated mortality reported in oblasts in the Siberian and Ural Federal Districts. There is a strong correlation (0.8) between HIV-associated mortality and virus prevalence. These findings confirm that there are regional disparities in access and adherence to antiretroviral therapy (ART), as indicated by the low correlation (-0.4) between virus prevalence and access to ART coverage. The results from our modeling analysis revealed that, in addition to the factors most commonly associated with this disease (e.g. intravenous drug use), knowledge about sexual transmission of HIV in the general population has a broad impact on its prevalence at the oblast level.

CONCLUSION

Interventions that reduce HIV prevalence, for example, opioid substitution therapy and needle-sharing programs for people who inject drugs, as well as the increased availability of educational and preventive programs may halt the spread of HIV across the Russian Federation. Similarly, increased access to treatment could help in reducing HIV-related mortality.

The Prevalence, Incidence, and Risk Factors for HIV Among Female Sex Workers-A Cohort Being Prepared for a Phase IIb HIV Vaccine Trial in Dar es Salaam, Tanzania

BACKGROUND

A cohort of female sex workers (FSWs) was established to determine HIV prevalence and incidence, and associated factors in preparation for a phase IIb HIV vaccine and pre-exposure prophylaxis trial (PrEPVacc).

SETTING

A cohort of FSWs in Dar es Salaam, Tanzania.

METHODS

FSWs aged 18-45 years were recruited using a respondent-driven sampling method. Social demographic data, HIV risk behavioral assessments, and blood samples for testing of HIV, syphilis, hepatitis B (HBV), and hepatitis C (HCV) infections were collected at baseline and then at 3, 6, 9, and 12 months. Poisson regressions were used to estimate the prevalence ratios for factors associated with HIV prevalence and to estimate the 12-month HIV incidence rate.

RESULTS

Between October and December 2018, a total of 773 FSWs were screened for eligibility and 700 were enrolled. The baseline prevalence of HIV, syphilis, HBV, and HCV was 7.6%, 1.2%, 1.7%, and 1.0%, respectively. HIV prevalence was associated with older age, using illicit drugs, and being infected with syphilis, HBV, or HCV. Attendance at 12 months was 80% (562/700). Twenty-one FSWs seroconverted during follow-up, giving a 12-month HIV incidence rate of 3.45 per 100 person-years at risk (95% CI; 2.25-5.28/100 person-years at risk). The HIV incidence rate was higher among FSWs aged 18-24 years, FSWs who used drugs, and those diagnosed with syphilis, HBV, or HCV.

CONCLUSION

The high HIV incidence rate and retention rate among FSWs enrolled into the cohort demonstrate that this population is suitable for participation in HIV prevention trials.

Spatial heterogeneity of risk factors associated with HIV prevalence among men who inject drugs in India: An analysis of the data from the integrated bio-behavioral surveillance, India

People who inject drugs (PWID) are India's third-largest vulnerable population to human immunodeficiency virus (HIV) infection. PWID in India are confined to certain geographic locations and exhibit varying injecting and sexual risk behaviors, contributing considerably to increasing HIV trends in specific regions. Spatial heterogeneity in risk factors among vulnerable PWID influences HIV prevalence, transmission dynamics, and disease management. Stratified analysis of HIV prevalence based on risk behaviors and geographic locations of PWID will be instrumental in strategic interventions. To stratify the male PWID based on their risk behaviors in each state and determine the HIV prevalence for each stratum. The behavioral data and HIV prevalence of the national integrated biological and behavioural surveillance (IBBS), a nationwide cross-sectional community-based study conducted in 2014 to 2015, was analyzed. Data from 19,902 men who inject drugs across 53 domains in 29 states of India were included. Women who inject drugs were excluded at the time of IBBS, and hence PWID in this study refers to only men who inject drugs. PWID were categorized based on their risk profile, and the corresponding HIV prevalence for each state was determined. HIV prevalence was the highest (29.6%) in Uttar Pradesh, with a high prevalence of risk behaviors among PWID. High HIV prevalence ranging between 12.1% and 22.4% was observed in a few states in East and North-East India and most states in central and North India. Unsafe injecting and sexual practices were significantly (P < .05) associated with higher HIV prevalence and more significantly in National Capital Territory of Delhi (P < .001). Unsafe injecting practices among PWID were proportionally higher in Western and Central India, whereas unsafe sexual behaviors were widespread among most states. Unsafe sexual practices among male PWID were common. The high prevalence of unsafe injecting had significant HIV infection and transmission risks in Western and Central India. The results emphasize the need for stratified, region-specific interventions and combination approaches for harm reduction among PWID. Strengthening the measures that facilitate the reduction of high-risk behaviors, adoption of safe practices, and utilization of HIV services will positively impact HIV prevention measures among PWID.

HIV Risk Factors and Risk Perception Among Adolescent Girls and Young Women: Results From a Population-Based Survey in Western Kenya, 2018

BACKGROUND

In sub-Saharan Africa, HIV prevalence in adolescent girls and young women (AGYW) is 2-fold to 3-fold higher than that in adolescent boys and young men. Understanding AGYW's perception of HIV risk is essential for HIV prevention efforts.

METHODS

We analyzed data from a HIV biobehavioral survey conducted in western Kenya in 2018. Data from AGYW aged 15-24 years who had a documented HIV status were included. We calculated weighted prevalence and evaluated factors associated with outcomes of interest (HIV infection and high risk perception) using generalized linear models to calculate prevalence ratios.

RESULTS

A total of 3828 AGYW were included; 63% were aged 15-19 years. HIV prevalence was 4.5% and 14.5% of sexually active AGYW had high risk perception. Over 70% of participants had accessed HIV testing and counseling in the past 12 months. Factors associated with both HIV infection and high risk perception included having an HIV-positive partner or partner with unknown status and having a sexually transmitted infection in the past 12 months. Having an older (by ≥10 years) partner was associated with HIV infection, but not high risk perception. Less than 30% of sexually active AGYW with 3 or more HIV risk factors had high perception of HIV risk.

CONCLUSION

Gaps in perceived HIV risk persist among AGYW in Kenya. High access to HIV testing and prevention services in this population highlights platforms through which AGYW may be reached with improved risk counseling, and to increase uptake of HIV prevention strategies.

Trends in HIV prevalence by self-report among MSM diagnosed and reported with gonorrhea in six United States jurisdictions from 2010 to 2019

BACKGROUND

HIV co-infection among persons diagnosed with gonorrhea is not well characterized. Trends in HIV prevalence among persons diagnosed with gonorrhea may have significant implications for HIV prevention interventions, especially for MSM. MSM are increasingly and disproportionately represented among incident gonorrhea cases reported in a multistate sentinel surveillance network. Using data from this network, we estimated HIV prevalence among MSM by self-report and explored trends in co-infection by key demographics.

DESIGN

Observational study using enhanced surveillance data.

METHODS

Six geographically diverse jurisdictions in the STD Surveillance Network (SSuN) 2010-2019 randomly sampled laboratory-confirmed gonorrhea cases. Enhanced investigations on sampled cases included patient interviews eliciting demographic, behavioral and HIV testing history. These data were weighted to adjust for study design and nonresponse to estimate trends in HIV prevalence.

RESULTS

Of 653 522 reported cases, 28 979 were sampled and investigated. The proportion of cases reporting living with diagnosed HIV at the time of their gonorrhea diagnosis increased 61% across the study period from 6.6% in 2010 to 10.8% in 2019. The observed increase in HIV prevalence is concurrent with an increase in the proportion of gonorrhea cases attributable to MSM. HIV prevalence among MSM decreased in two jurisdictions and increasing trends were observed among non-Hispanic Black and Hispanic MSM. HIV prevalence decreased among non-Hispanic white MSM, MSM under 20 and those 40 years of age or older.

CONCLUSION

Diagnosis with gonorrhea, especially among MSM, should be a sentinel event triggering screening for HIV, referral to high-impact HIV prevention interventions or to HIV primary care.

HIV prevalence among men who have sex with men in Brazil: results of the 2nd national survey using respondent-driven sampling

This paper reports human immuno-deficiency virus (HIV) prevalence in the 2nd National Biological and Behavioral Surveillance Survey (BBSS) among men who have sex with men (MSM) in 12 cities in Brazil using respondent-driven sampling (RDS).Following formative research, RDS was applied in 12 cities in the 5 macroregions of Brazil between June and December 2016 to recruit MSM for BBSS. The target sample size was 350 per city. Five to 6 seeds were initially selected to initiate recruitment and coupons and interviews were managed online. On-site rapid testing was used for HIV screening, and confirmed by a 2nd test. Participants were weighted using Gile estimator. Data from all 12 cities were merged and analyzed with Stata 14.0 complex survey data analysis tools in which each city was treated as its own strata. Missing data for those who did not test were imputed HIV+ if they reported testing positive before and were taking antiretroviral therapy.A total of 4176 men were recruited in the 12 cities. The average time to completion was 10.2 weeks. The longest chain length varied from 8 to 21 waves. The sample size was achieved in all but 2 cities.A total of 3958 of the 4176 respondents agreed to test for HIV (90.2%). For results without imputation, 17.5% (95%CI: 14.7-20.7) of our sample was HIV positive. With imputation, 18.4% (95%CI: 15.4-21.7) were seropositive.HIV prevalence increased beyond expectations from the results of the 2009 survey (12.1%; 95%CI: 10.0-14.5) to 18.4%; CI95%: 15.4 to 21.7 in 2016. This increase accompanies Brazil's focus on the treatment to prevention strategy, and a decrease in support for community-based organizations and community prevention programs.

An action agenda for HIV and sex workers

The women, men, and transgender people who sell sex globally have disproportionate risks and burdens of HIV in countries of low, middle, and high income, and in concentrated and generalised epidemic contexts. The greatest HIV burdens continue to be in African female sex workers. Worldwide, sex workers still face reduced access to needed HIV prevention, treatment, and care services. Legal environments, policies, police practices, absence of funding for research and HIV programmes, human rights violations, and stigma and discrimination continue to challenge sex workers' abilities to protect themselves, their families, and their sexual partners from HIV. These realities must change to realise the benefits of advances in HIV prevention and treatment and to achieve global control of the HIV pandemic. Effective combination prevention and treatment approaches are feasible, can be tailored for cultural competence, can be cost-saving, and can help to address the unmet needs of sex workers and their communities in ways that uphold their human rights. To address HIV in sex workers will need sustained community engagement and empowerment, continued research, political will, structural and policy reform, and innovative programmes. But such actions can and must be achieved for sex worker communities everywhere.

HIV testing practices among men who have sex with men in Buenos Aires, Argentina

The objective of the study was to explore HIV-testing practices among men who have sex with men (MSM) in Buenos Aires, Argentina, in light of current international health guidelines that recommend frequent HIV testing for MSM who engage in high-risk behavior. Participants, who were recruited using respondent-driven sampling (RDS), were 500 mostly young, nongay-identified MSM of low socioeconomic status, high levels of unemployment, living mainly in the less-affluent areas surrounding Buenos Aires, and lacking health insurance. They provided blood samples for HIV testing and responded to a Computer Assisted Self Interview. Fifty-two percent had never been tested for HIV, and 20% had been tested only once; 17% were found to be HIV infected, of whom almost half were unaware of their status. Main reasons for never having tested previously were: not feeling at risk, fear of finding out results, and not knowing where to get tested. Among those previously tested, men had been tested a median of 2 times with their most recent test having occurred a median of 2.7 years prior to study enrollment. Of those who had not tested positive before entering the study, only 41% returned for their results. HIV testing was infrequent and insufficient for early detection of infection, entry into treatment, and protection of sexual partners. This was particularly the case among nongay-identified MSM. Testing campaigns should aim to help MSM become aware of their risk behavior, decrease fear of testing by explaining available treatment resources and decreasing the stigma associated with HIV, and by publicizing information about free and confidential testing locations. Rapid HIV testing should be made available to eliminate the need for a return visit and make results immediately available to individuals who are tested.

HIV status disclosure among infected men who have sex with men (MSM) in Buenos Aires, Argentina

Five hundred men who have sex with men were recruited in Buenos Aires using respondent driven sampling. Of them, 46 respondents (24 of them not gay identified) who were HIV infected were asked questions on serodisclosure. The sample was characterized by indicators of low socioeconomic status. Most of the respondents reported being in good to excellent health despite 42% of them having been diagnosed with AIDS. Only 10% of respondents had not disclosed their serostatus to at least one person. Coworkers and lovers or main sexual partners were those most likely to know the respondents' serostatus. Reactions to disclosure were for the most part supportive. Those who had not disclosed anticipated less favorable reactions than those who had disclosed. No significant differences were observed between gay and non-gay identified respondents. The progressive social environment of Argentina that includes federal laws recognizing gay marriage may contribute to create a climate favorable for serostatus disclosure.

Age biases in a large HIV and sexual behaviour-related internet survey among MSM

BACKGROUND

Behavioural data from MSM are usually collected in non-representative convenience samples, increasingly on the internet. Epidemiological data from such samples might be useful for comparisons between countries, but are subject to unknown participation biases.

METHODS

Self-reported HIV diagnoses from participants of the European MSM Internet Survey (EMIS) living in the Czech Republic, Germany, The Netherlands, Portugal, Sweden and the United Kingdom were compared with surveillance data, for both the overall diagnosed prevalence and for new diagnoses made in 2009. Country level prevalence and new diagnoses rates per 100 MSM were calculated based on an assumed MSM population size of 3% of the adult male population. Survey-surveillance discrepancies (SSD) for survey participation, diagnosed HIV prevalence and new HIV diagnoses were determined as ratios of proportions. Results are calculated and presented by 5-year age groups for MSM aged 15-64.

RESULTS

Surveillance derived estimates of diagnosed HIV prevalence among MSM aged 15-64 ranged from 0.63% in the Czech Republic to 4.93% in The Netherlands. New HIV diagnoses rates ranged between 0.10 per 100 MSM in the Czech Republic and 0.48 per 100 in The Netherlands. Self-reported rates from EMIS were consistently higher, with prevalence ranging from 2.68% in the Czech Republic to 12.72% in The Netherlands, and new HIV diagnoses rates from 0.36 per 100 in Sweden to 1.44 per 100 in The Netherlands. Across age groups, the survey surveillance discrepancies (SSD) for new HIV diagnoses were between 1.93 in UK and 5.95 in the Czech Republic, and for diagnosed prevalence between 1.80 in Germany and 4.26 in the Czech Republic.Internet samples of MSM were skewed towards younger age groups when compared to an age distribution of the general adult male population. Survey-surveillance discrepancies (SSD) for EMIS participation were inverse u-shaped across the age range. The two HIV-related SSD were u- or j-shaped with higher values for the very young and for older MSM. The highest discrepancies between survey and surveillance data regarding HIV-prevalence were observed in the oldest age group in Sweden and the youngest age group in Portugal.

CONCLUSION

Internet samples are biased towards a lower median age because younger men are over-represented on MSM dating websites and therefore may be more likely to be recruited into surveys. Men diagnosed with HIV were over-represented in the internet survey, and increasingly so in the older age groups. A similar effect was observed in the age groups younger than 25 years. Self-reported peak prevalence and peak HIV diagnoses rates are often shifted to higher age groups in internet samples compared to surveillance data. Adjustment for age-effects on online accessibility should be considered when linking data from internet surveys with surveillance data.

Overview of the current state of the epidemic

At the end of 2011, about half of the 34.0 million [31.4-35.9 million] people living with HIV infection knew their HIV status. With large regional variations, an estimated 0.8% of all adults aged 15 to 49 years have HIV infection and HIV subtype diversity is increasing. Although HIV incidence has declined in 39 countries, it is stable or increasing in others. HIV prevalence continues to rise as antiretroviral treatment scale-up results in fewer HIV-related deaths while new infections continue to occur. Increased treatment uptake is likely reducing HIV transmission in countries with large mortality declines. Key populations, including sex workers, men who have sex with men, transgender people, people who inject drugs and young women in high prevalence settings require effective prevention programs urgently. Correcting mismatches in resource allocation and reducing community viral load will accelerate incidence declines and affect future epidemic trends, if concerted action is taken now.

Estimate of HIV prevalence and number of people living with HIV in India 2008-2009

OBJECTIVES

To update the estimation of the adult HIV prevalence and number of people living with HIV (PLHIV) in India for the year 2008-2009 with the combination of improved data and methods.

DESIGN

Based on HIV sentinel surveillance (HSS) data and a set of epidemiological assumptions, estimates of HIV prevalence and burden in India have been derived.

SETTING

HSS sites spread over all the States of India.

PARTICIPANTS

Secondary data from HSS sites which include attendees of antenatal clinics and sites under targeted interventions of high-risk groups, namely, female sex workers (FSW), intravenous drug users (IDU) and men having sex with men (MSM).

PRIMARY AND SECONDARY OUTCOME MEASURES

Estimates of adult HIV prevalence and PLHIV in India and its states.

RESULTS

The adult HIV prevalence in India has declined to an estimated 0.31% (0.25-0.39%) in 2009 against 0.36% (0.29-0.45%) in 2006. Among the high prevalence states, the HIV prevalence has declined in Tamil Nadu to 0.33% in 2009 and other states show either a plateau or a slightly declining trend over the time period 2006-2009. There are states in the low prevalence states where the adult HIV prevalence has risen over the last 4 years. The estimated number of PLHIV in India is 2.4 million (1.93-3.04 million) in 2009. Of which, 39% are women, children under 15 years of age account for 4.4% of all infections, while people aged 15-49 years account for 82.4% of all infections.

CONCLUSIONS

The estimated adult prevalence has declined in few states, a plateau or a slightly declining trend over the time. In future, efforts may be made to examine the implications of the emerging trend of the HIV prevalence on the recent infections in the study population.

Spatial clustering of HIV prevalence in Atlanta, Georgia and population characteristics associated with case concentrations

We assessed prevalent HIV cases in Atlanta to examine case distribution trends and population characteristics at the census tract level that may be associated with clustering effects. We calculated cluster characteristics (area and internal HIV prevalence) via Kuldorff's spatial scan method. Subsequent logistic regression analyses were performed to analyze sociodemographics associated with inclusion in a cluster. Organizations offering voluntary HIV testing and counseling services were identified and we assessed average travel time to access these services. One large cluster centralized in downtown Atlanta was identified that contains 60% of prevalent HIV cases. The prevalence rate within the cluster was 1.34% compared to 0.32% outside the cluster. Clustered tracts were associated with higher levels of poverty (OR = 1.19), lower density of multi-racial residents (OR = 1.85), injection drug use (OR = 1.99), men having sex with men (OR = 3.01), and men having sex with men and IV drug use (OR = 1.6). Forty-two percent (N = 11) of identified HIV service providers in Atlanta are located in the cluster with an average travel time of 13 minutes via car to access these services (SD = 9.24). The HIV epidemic in Atlanta is concentrated in one large cluster characterized by poverty, men who have sex with men (MSM), and IV drug usage. Prevention efforts targeted to the population living in this area as well as efforts to address the specific needs of these populations may be most beneficial in curtailing the epidemic within the identified cluster.

Estimation of HIV prevalence, risk factors, and testing frequency among sexually active men who have sex with men, aged 18-64 years--New York City, 2002

Population-based estimates of human immunodeficiency virus (HIV) prevalence and risk behaviors among men who have sex with men (MSM) are valuable for HIV prevention planning but not widely available, especially at the local level. We combined two population-based data sources to estimate prevalence of diagnosed HIV infection, HIV-associated risk-behaviors, and HIV testing patterns among sexually active MSM in New York City (NYC). HIV/AIDS surveillance data were used to determine the number of living males reporting a history of sex with men who had been diagnosed in NYC with HIV infection through 2002 (23% of HIV-infected males did not have HIV transmission risk information available). Sexual behavior data from a cross-sectional telephone survey were used to estimate the number of sexually active MSM in NYC in 2002. Prevalence of diagnosed HIV infection was estimated using the ratio of HIV-infected MSM to sexually active MSM. The estimated base prevalence of diagnosed HIV infection was 8.4% overall (95% confidence interval [CI] = 7.5-9.6). Diagnosed HIV prevalence was highest among MSM who were non-Hispanic black (12.6%, 95% CI = 9.8-17.6), aged 35-44 (12.6%, 95% CI = 10.4-15.9), or 45-54 years (13.1%, 95% CI = 10.2-18.3), and residents of Manhattan (17.7%, 95% CI = 14.5-22.8). Overall, 37% (95% CI = 32-43%) of MSM reported using a condom at last sex, and 34% (95% CI = 28-39%) reported being tested for HIV in the past year. Estimates derived through sensitivity analyses (assigning a range of HIV-infected males with no reported risk information as MSM) yielded higher diagnosed HIV prevalence estimates (11.0-13.2%). Accounting for additional undiagnosed HIV-infected MSM yielded even higher prevalence estimates. The high prevalence of diagnosed HIV among sexually active MSM in NYC is likely due to a combination of high incidence over the course of the epidemic and prolonged survival in the era of highly active antiretroviral therapy. Despite high HIV prevalence in this population, condom use and HIV testing are low. Combining complementary population-based data sources can provide critical HIV-related information to guide prevention efforts. Individual counseling and education interventions should focus on increasing condom use and encouraging safer sex practices among all sexually active MSM, particularly those groups with low levels of condom use and multiple sex partners.

HIV prevalence and sexual behaviour changes measured in an antenatal clinic setting in northern Tanzania

OBJECTIVES

To assess the feasibility of collecting sexual behaviour data during HIV surveillance in antenatal care (ANC) clinics, and to establish whether these data can provide information about the correlates of HIV infection in this population.

METHODS

Sexual behaviour surveys were conducted in the context of two HIV sentinel surveillance rounds in 11 ANC clinics in north west Tanzania between 2000 and 2002. Responses of individual women were anonymously linked to their HIV status. Three clinic catchment areas overlapped with a community based longitudinal study, which provided independent estimates of HIV prevalence and sexual behaviour. Changes between rounds and differentials between clinics were assessed and a two level logistic regression model used to identify behavioural and contextual correlates of HIV in 3689 women under 25 years of age.

RESULTS

Women attending clinics were willing to participate in the study. The sexual behaviour data obtained were internally consistent and tallied reasonably well with sexual behaviour data collected in the community overlapping the clinic catchment. Clear relations emerged between HIV infection and measures of sexual exposure: OR 1.20 (95% CL 1.12 to 1.28) for each year of premarital exposure and 1.09 (1.04 to 1.16) for each year after first marriage; background prevalence OR 1.15 (1.04 to 1.26) associated with each percentage point increase in background prevalence at the clinic; and certain partnership variables such as partner's age OR 0.58 (0.45 to 0.76) if partner less than 10 years older.

CONCLUSION

Conducting sexual behaviour surveys in the context of ANC clinics surveillance is feasible and yields useful data.

Estimated numbers of men and women infected with HIV/AIDS in Tijuana, Mexico

Tijuana, Mexico, just south of San Diego, California, is located by the busiest land border crossing in the world. Although UNAIDS considers Mexico to be a country of "low prevalence, high risk," recent surveillance data among sentinel populations in Tijuana suggests HIV prevalence is increasing. The aim of this study was to estimate the number of men and women aged 15 to 49 years infected with HIV in Tijuana. Gender and age-specific estimates of the Tijuana population were obtained from the 2000 Mexican census. Population and HIV prevalence estimates for at-risk groups were obtained from published reports, community based studies, and data from the Centro Nacional para la Prevención y Control del VIH/SIDA (CENSIDA). Age-specific fertility rates for Mexico were used to derive the number of low and high-risk pregnant women. Numbers of HIV-positive men and women were estimated for each at-risk group and then aggregated. A high growth scenario based on current HIV prevalence and a conservative, low growth estimate were determined. A total of 686,600 men and women in Tijuana were aged 15 to 49 years at the time of the 2000 census. Considering both scenarios, the number of infected persons ranged from 1,803 to 5,472 (HIV prevalence: 0.26 to 0.80%). The majority of these persons were men (>70%). The largest number of infected persons were MSM (N = 1,146 to 3,300) and IDUs (N = 147 to 650). Our data suggest that up to one in every 125 persons aged 15-49 years in Tijuana is HIV-infected. Interventions to reduce ongoing spread of HIV are urgently needed.

Risky sexual behaviors associated with recreational drug use among men who have sex with men in an international resort area: challenges and opportunities

South Florida is home to a highly transient population of approximately 145,000 men who have sex with men (MSM) and annually hosts over 1.8 million gay and bisexual visitors. To develop more effective interventions for HIV/sexually transmitted infections (STI) prevention in this setting, we conducted a cross-sectional study of recreational drug use and risky sexual behaviors among MSM. A standardized, self-administered questionnaire, reviewed and approved by a university Institutional Review Board, was offered to men 18 years of age and older who reported ever having sex with a man. Men were approached on weekends in five diverse locations in Miami-Dade County and five in Broward County in winter 2004. An honorarium of $10 was offered to those who completed and returned a questionnaire. Of 407 participants, 115 men (28%) lived in Miami-Dade, 147 (36%) lived in Broward, 46 (11%) lived in another county in south Florida, and 99 (24%) lived elsewhere. Overall, 32% reported using one or more "club drugs" in the past year. Club drug use was highly associated with unprotected anal intercourse (UAI) (P < .001). MSM residing outside of south Florida were more likely than local residents to report using cocaine and ketamine and engaging in unprotected receptive anal intercourse (URAI) in the past month (P = .03). Tourists may be even more likely than residents to engage in risky sexual behaviors and use certain recreational drugs. Interventions must be developed, implemented, and evaluated that take into account the unique characteristics of international resort areas.

Race/ethnic differences in HIV prevalence and risks among adolescent and young adult men who have sex with men

The prevalence of HIV infection is disproportionately higher in both racial/ethnic minority men who have sex with men (MSM) and in men under the age of 25, where the leading exposure category is homosexual contact. Less is known, however, about patterns of HIV prevalence in young racial/ethnic minority MSM. We analyzed data from the Young Men's Survey (YMS), an anonymous, cross-sectional survey of 351 MSM in Baltimore and 529 MSM in New York City, aged 15-22, to determine whether race/ethnicity differences exist in the prevalence of HIV infection and associated risk factors. Potential participants were selected systematically at MSM-identified public venues. Venues and associated time periods for subject selection were selected randomly on a monthly basis. Eligible and willing subjects provided informed consent and underwent an interview, HIV pretest counseling, and a blood draw for HIV antibody testing. In multivariate analysis, adjusted for city of recruitment and age, HIV seroprevalence was highest for African Americans [adjusted odds ratio (AOR) = 12.5], intermediate for those of "other/mixed" race/ethnicity (AOR = 8.6), and moderately elevated for Hispanics (AOR = 4.6) as compared to whites. Stratified analysis showed different risk factors for HIV prevalence in each ethnic group: for African Americans, these were history of sexually transmitted diseases (STDs) and not being in school; for Hispanics, risk factors were being aged 20-22, greater number of male partners and use of recreational drugs; and for those of "other/mixed" race/ethnicity, risk factors included injection drug use and (marginally) STDs. These findings suggest the need for HIV prevention and testing programs which target young racial/ethnic minority MSM and highlight identified risk factors and behaviors.

An HIV prevalence-based model for estimating urban risk populations of injection drug users and men who have sex with men

Issues of cost and complexity have limited the study of the population sizes of men who have sex with men (MSM) and injection drug users (IDUs), two groups at clearly increased risk for human immunodeficiency virus (HIV) and other acute and chronic diseases. We developed a prototypical, easily applied estimation model for these populations and applied it to Miami, Florida. This model combined HIV prevalence estimates, HIV seroprevalence rates, and census data to make plausible estimates of the number and proportion of MSM and IDUs under a number of assumptions. Sensitivity analyses were conducted to test the robustness of the model. The model suggests that approximately 9.5% (plausible range 7.7%-11.3%) of Miami males aged 18 years or older are MSM (point estimate, N = 76,500), and 1.4% (plausible range 0.9%-1.9%) of the total population aged 18 years or older are IDUs (point estimate, N = 23,700). Males may be about 2.5 times more likely than females to be IDUs. The estimates were reasonably robust to biases. The model was used to develop MSM and IDU population estimates in selected urban areas across Florida and should be replicable in other medium-to-large urban areas. Such estimates could be useful for behavioral surveillance and resource allocation, including enhanced targeting of community-based interventions for primary and secondary HIV prevention.