Prevalence and Correlates of HIV and Hepatitis C Virus Infections and Risk Behaviors among Malaysian Fishermen

Fishermen in Southeast Asia have been found to be highly vulnerable to HIV, with research evidence highlighting the role of sexual risk behaviors. This study aims to estimate the rate of HIV as well as hepatitis C virus (HCV) infections among Malaysian fishermen, and the risky sexual and injection drug use behaviors that may contribute to these infections. The study also includes an assessment of socio-demographic, occupational and behavioral correlates of testing positive for HIV or HCV, and socio-demographic and occupational correlates of risk behaviors. The study had a cross-sectional design and recruited 406 fishermen through respondent-driven sampling (RDS). Participants self-completed a questionnaire and provided biological specimens for HIV and HCV testing. We conducted and compared results of analyses of both unweighted data and data weighted with the Respondent-Driven Sampling Analysis Tool (RDSAT). Of the participating fishermen, 12.4% were HIV positive and 48.6% had HCV infection. Contrary to expectations and findings from previous research, most fishermen (77.1%) were not sexually active. More than a third had a history of injection drug use, which often occurred during fishing trips on commercial vessels and during longer stays at sea. Of the fishermen who injected drugs, 42.5% reported unsafe injection practices in the past month. Reporting a history of injection drug use increased the odds of testing HIV positive by more than 6 times (AOR = 6.22, 95% CIs [2.74, 14.13]). Most fishermen who injected drugs tested positive for HCV. HCV infection was significantly associated with injection drug use, being older than 25 years, working on a commercial vessel and spending four or more days at sea per fishing trip. There is an urgent need to strengthen current harm reduction and drug treatment programs for Malaysian fishermen who inject drugs, especially among fishermen who work on commercial vessels and engage in deep-sea fishing.     

Risk for AIDS in multiethnic neighborhoods in San Francisco,California. The population-based AMEN Study.

To examine the actual and potential spread of human immunodeficiency virus (HIV) from an acquired immunodeficiency syndrome (AIDS) epicenter to surrounding neighborhoods, we studied the prevalence of the viral infection and AIDS risk behaviors from 1988 to 1989 in a representative sample of unmarried whites, African Americans, and Hispanics living in San Francisco. We surveyed 1,770 single men and women aged 20 to 44 years (a 64% response rate) in a random household sample drawn from 3 neighborhoods of varying geographic and cultural proximity to the Castro District where the San Francisco epidemic began. Of 1,369 with blood tests, 69 (5%) had HIV antibodies; all but 5 of these reported either homosexual activity (32% HIV-positive; 95% confidence interval [CI] = 23%, 41%), injection drug use (5% HIV-positive; CI = 1%, 14%), or both (59% HIV-positive; CI 42%, 74%). Homosexual activity was more common among white men than among African-American or Hispanic men, but the proportion of those infected was similar in the 3 races. Both the prevalence of homosexually active men and the proportion infected were much lower in the 2 more outlying neighborhoods. Risk behaviors in the past year for acquiring HIV heterosexually--sex with an HIV-infected person or homosexually active man or injection drug user, unprotected sexual intercourse with more than 4 partners, and (as a proxy) having a sexually transmitted disease--were assessed in 1,573 neighborhood residents who were themselves neither homosexually active men nor injection drug users. The prevalence of reporting at least 1 of these risk behaviors was 12% overall, and race-gender estimates ranged from 5% among Hispanic women to 21% among white women. We conclude that in San Francisco, infection with HIV is rare among people who are neither homosexually active nor injection drug users, but the potential for the use spread of infection is substantial, as 12% of this group reported important risk behaviors for acquiring the virus heterosexually.     

HIV prevention for indigenous people of the Amazon basin.

This study identifies theoretically-based predictors of condom use in a sample of 251 sexually active adults recruited from Sao Gabriel da Cachoeira and six indigneous communities of the Upper Rio Negro region of Amazonas Brazil. The information-motivation-behavioral skills (IMB) model of AIDS-preventive behavior was used to describe the roles of HIV/AIDS knowledge, experiences with and attitudes toward condom use, peer influences, perceived vulnerability, monogamy and behavioral skills. A predictive path analytic model revealed significant predictors of more condom use including male gender, greater sexual HIV knowledge, positive experiences and attitudes about condom use, multiple partners, and greater behavioral skills. Results suggest that attention to behavioral skills for negotiating safer sex and instruction in the correct use of condoms are important elements in reducing high risk behaviors. Increasing the specific knowledge level of indigenous people regarding the complexities of sexual transmission of HIV is crucial and should be addressed. Heightening individuals' understanding of the limited protection of serial monogamy, and the need to conduct gender-specific training for behavior change to reduce transmission of HIV should be an additional goal of Brazilian health professionals. Obstacles to the implementation of the IMB HIV prevention program in Amazonas are noted and an alternative Brazilian HIV/AIDS prevention program is discussed.     

A Descriptive Analysis of HIV Prevalence,HIV Service Uptake,and HIV-Related Risk Behaviour among Patients Attending a Mental Health Clinic in Rural Malawi

Background

Human immunodeficiency virus (HIV) and mental illness are interlinked health problems; mental illness may pose a risk for contracting HIV and HIV-positive individuals are at higher risk of mental illness. However, in countries with high HIV prevalence, the main focus of HIV-related health programmes is usually on prevention and treatment of somatic complications of HIV, and mental illness is not given high priority. We examined HIV prevalence, uptake of HIV services, and HIV-related risk behaviour among people attending a mental health clinic in rural Malawi.

Methodology

Semi-structured interviews were performed with patients capable to consent (94%), and with those accompanied by a capable caregiver who consented. HIV counselling and testing was offered to participants.

Findings

Among 174 participants, we collected 162 HIV test results (91%). HIV prevalence was 14.8%. Women were three times as likely to be HIV-positive compared to men. Two-thirds of participants reported having been tested for HIV prior to this study. The uptake of HIV-services among HIV-positive patients was low: 35% did not use recommended prophylactic therapy and 44% of patients not receiving antiretroviral treatment (ART) had never been assessed for ART eligibility. The reported rate of sexual activity was 61%, and 9% of sexually active participants had multiple partners. Inconsistent condom use with stable (89%) and occasional (79%) sexual partners, and absence of knowledge of the HIV status of those partners (53%, 63%) indicate high levels of sexual risk behaviour.

Conclusions

HIV-prevalence among persons attending the clinic, particularly men, was lower than among the general population in a population survey. The rate of HIV testing was high, but there was low uptake of preventive measures and ART. This illustrates that HIV-positive individuals with mental illness or epilepsy constitute a vulnerable population. HIV programmes should include those with neuropsychiatric illness.     

The British Columbia Positive Women's Survey: a detailed profile of 110 HIV-infected women

OBJECTIVE: To describe the health, social environment, medical care received and satisfaction with medical care of HIV-infected women in British Columbia. DESIGN: Self-administered 75-item questionnaire distributed by mail or in person between March 1994 and February 1996 through community AIDS organizations and physicians'' offices. SETTING: British Columbia. PARTICIPANTS: A total of 110 HIV-positive women. OUTCOME MEASURES: Sociodemographic data, risk factors for HIV infection, details about HIV testing, health status and medical treatment, use of health care services, degree of satisfaction with medical care and psychosocial stressors. RESULTS: Most of the women surveyed were aged 25 to 39 years (70.0%), were Canadian born (76.4%) and were white (80.9%). Over one-third did not complete high school, and half had an annual household income of less than $20,000. Of the 110 women 51.8% had children, who were HIV-positive in 12.3% of cases. The most frequently reported risk factor for HIV infection was sex with a man (49.1%); 19.1% reported both sex with a man and injection drug use, and 12.7% reported injection drug use only. Seventy-five women indicated that they had become infected through sex with a man, with or without injection drug use. Of these, 65 indicated whether or not this was the result of sexual assault or rape; 8 (12.3%) answered affirmatively. Of the 81 women who responded to the question regarding prior sexual assault or abuse, 43 (53.1%) reported being sexually assaulted as an adult, 35 (43.2%) reported being sexually abused as a child, and 22 (27.2%) reported being sexually abused or assaulted both as a child and as an adult. Women who were sexually abused as a child were more likely than those who were not abused as a child to have injection drug use as a risk factor (54.3% v. 7.5%). Menstrual cycle changes were reported by 70.1% of the respondents. Most women stated that they had not received adequate pre- or post-test counselling, and 47.0% were not satisfied with their doctor''s care. Psychosocial concerns identified to be of greatest importance were financial problems, lack of intimacy or satisfying sexual relationship, and fear of rejection or discrimination. CONCLUSION: Several important concerns for HIV-positive women were identified, including dissatisfaction with medical care, fear of discrimination, violence and abuse, and poverty.     

HIV/AIDS and Croatian migrant workers

Due to their geographical mobility and long periods of separation from intimate partners, migrant workers are at increased risk for a variety of sexually transmitted infections (STIs) including HIV/AIDS. This study sought to investigate patterns in HIV/AIDS related knowledge, attitudes and sexual behaviour in migrant workers in Croatia. In 2003, 566 male migrant workers were recruited during regular required medical examinations and surveyed at seven locations throughout the country. Each participant was asked to complete a self-administered KABP (sexual knowledge, attitudes, beliefs and practices) questionnaire. The average age of respondents was 38.2 years and the majority worked as seafarers (77.3%) and construction workers (20.5%). Only 18.5% of respondents were able to correctly answer all 13 questions assessing knowledge of HIV/AIDS. Seafarers reported higher levels of knowledge than did construction workers. The average respondent reported having had two sexual partners in the last 12 months, with slightly over half of the respondents (55.3%) reporting condom use at their last intercourse with a casual partner. One fifth of the respondents (20.3%) who reported having had intercourse with a sex worker during the last year reported not using condoms at last intercourse. The number of sexual partners was correlated with age, marital status, faith in God, and personal HIV risk assessment. Attitudes toward condom use, co-workers' HIV/AIDS concerns and the duration of migrant status (within the last two years) were shown to be significant correlates of condom use at last intercourse with a casual partner. The effect of HIV/AIDS related knowledge on analyzed behaviors did not reach statistical significance. Inadequate patterns of migrant workers' condom use, gaps in knowledge about HIV transmission and modes of protection, as well as widespread ignorance regarding available anonymous HIV testing found by this study suggest a critical need for expert intervention to avert the potential for an increase in new HIV/AIDS cases. A coordinated, systematic campaign for HIV/AIDS prevention among Croatian migrant workers should focus on increasing peer communication about HIV/AIDS, especially among younger migrant workers, and on reducing the frequency of sexual risk taking.     

Efficient Identification of HIV Serodiscordant Couples by Existing HIV Testing Programs in South Brazil

Objective

To examine the feasibility of identifying HIV negative at risk individuals in HIV serodiscordant couples, during voluntary HIV testing in South Brazil.

Methods

We surveyed HIV testers at 4 public testing sites in Rio Grande do Sul. We obtained information on risk behaviors and sexual partnerships. HIV testing and testing for recent infection were performed; HIV prevalence and risk behaviors were assessed among subjects who reported having a steady partner who was HIV positive (serodiscordant group) and compared with the general testing population.

Results

Among 3100 patients, 490 (15.8%) reported being in a steady relationship with an HIV positive partner. New HIV infections were diagnosed in 23% of the serodiscordant group (vs. 13% in the general population, p = 0.01); among newly positive subjects, recent HIV infections were more frequent (23/86, 26.7%) among testers with positive partners than among the general testing group (52/334; 15.6%; p = 0.016). Less than half of the serodiscordant testers reported having used a condom during the last sexual intercourse with their HIV-positive partner. Participants with inconsistent condom use with steady partner were four times more likely to test positive for HIV compared to those who reported always using condoms with the steady partner (OR: 4.2; 95% CI: 2.3 to 7.5).

Conclusion

It is highly feasible to identify large numbers of HIV susceptible individuals who are in HIV serodiscordant relationships in South Brazil testing sites. Condom use within HIV serodiscordant couples is low in this setting, suggesting urgent need for biomedical prevention strategies to reduce HIV transmission.     

HIV behind Bars: Human Immunodeficiency Virus Cluster Analysis and Drug Resistance in a Reference Correctional Unit from Southern Brazil

People deprived of liberty in prisons are at higher risk of infection by the human immunodeficiency virus (HIV) due to their increased exposure through intravenous drug use, unprotected sexual activity, tattooing in prison and blood exposure in fights and rebellions. Yet, the contribution of intramural HIV transmission to the epidemic is scarcely known, especially in low- and middle-income settings. In this study, we surveyed 1,667 inmates incarcerated at Presídio Central de Porto Alegre, located in southern Brazil, for HIV infection and molecular characterization. The HIV seroprevalence was 6.6% (110/1,667). Further analyses were carried out on 40 HIV-seropositive inmates to assess HIV transmission clusters and drug resistance within the facility with the use of molecular and phylogenetic techniques. The molecular epidemiology of HIV-1 subtypes observed was similar to the one reported for the general population in southern Brazil, with the predominance of HIV-1 subtypes C, B, CRF31_BC and unique BC recombinants. In particular, the high rate (24%) of URF_BC found here may reflect multiple exposures of the population investigated to HIV infection. We failed to find HIV-infected inmates sharing transmission clusters with each other. Importantly, the analysis of HIV-1 pol genomic fragments evidenced high rates of HIV primary and secondary (acquired) drug resistance and an alarming proportion of virologic failure among patients under treatment, unveiling suboptimal access to antiretroviral therapy (ARV), low ARV adherence and dissemination of drug resistant HIV strains in primary infections. Our results call for immediate actions of public authority to implement preventive measures, serological screening and, for HIV-seropositive subjects, clinical and treatment follow-up in order to control HIV infection and limit the spread of drug resistance strains in Brazilian prisons.     

On the road: Croatian truck drivers, commercial sex and HIV/AIDS

The primary aims of this study were to examine Croatian truck drivers' sexual contact with sex workers, estimate the frequency of condom use, and assess knowledge of HIV/AIDS within this population. The research was conducted from June 14 to September 16, 2005 at customs offices and accompanying parking lots in four Croatian cities. The sample consists of 69 truck drivers. Information about sexual behavior and condom use were gathered by using a semi-structured interview. Knowledge of HIV/AIDS, measured with a self-administered questionnaire, was found to be low. Six respondents (8.7%) had correctly answered all 13 questions. By contrast, 73% of drivers considered themselves well informed about HIV/AIDS, indicating that most drivers overestimate their knowledge. The majority of respondents (n=62) assumed that most of their colleagues engage in sexual contact with sex workers while on the road, although only one third of respondents reported that they personally have paid for sex. All of the respondents who reported engaging in sexual contact with sex workers stated that they always use condoms. Fear of being infected with a sexually transmitted infection was reported as the main reason for condom use.     

Should Associations between HIV-Related Risk Perceptions and Behaviors or Intentions Be Positive or Negative?

Risk perceptions are important in HIV research and interventions; mixed results were found between HIV-related perceptions and behaviors. We interviewed 377 sexually active injecting drug users in China, finding mixed associations between HIV-related risk perception assessed by two general measures and two previous risk behaviors (syringe sharing: p<.05; unprotected sex: p>.05) – partially supporting the ‘reflective hypothesis’ that reflection on previous behaviors increases risk perceptions. When we use specific measures for risk perceptions (HIV transmission via unprotected sex with specific types of sex partner and via syringe sharing) and use behavioral intention to adopt protective risk behaviors (condom use and avoid syringe sharing totally) as dependent variables, positive significant associations were observed – supporting the motivational hypothesis that risk perceptions motivate one to adopt protective behaviors. The direction and significance of the associations of concern depends on types of measures used. It has important implications on research design, data interpretation and services.     

Epidemiology of Drug Use and HIV-Related Risk Behaviors among People Who Inject Drugs in Mwanza,Tanzania

Heroin trafficking and consumption has increased steadily over the past decade in Tanzania, but limited information regarding HIV and drug use exists for the city of Mwanza. Our study investigates the epidemiology of drug use, and HIV risk behaviors among drug users in the northwestern city of Mwanza. Using a combination of targeted sampling and participant referral, we recruited 480 participants in Mwanza between June and August 2014. The sample was 92% male. Seventy-nine (16.4%) participants reported injecting heroin, while 434 (90.4%) reported smoking heroin. Unstable housing and cohabitation status were the only socioeconomic characteristics significantly associated with heroin injection. More than half of heroin injectors left syringes in common locations, and half reported sharing needles and syringes. Other risk behaviors such as lack of condom use during sex, and the use of illicit drugs during sex was widely reported as well. Among the study sample, there was poor awareness of health risks posed by needle/syringe sharing and drug use. Our results show that heroin use and HIV risk related behaviors are pressing problems that should not be ignored in Mwanza. Harm reduction programs are urgently needed in this population.     

HIV among People Who Inject Drugs in the Middle East and North Africa: Systematic Review and Data Synthesis

Background

It is perceived that little is known about the epidemiology of HIV infection among people who inject drugs (PWID) in the Middle East and North Africa (MENA). The primary objective of this study was to assess the status of the HIV epidemic among PWID in MENA by describing HIV prevalence and incidence. Secondary objectives were to describe the risk behavior environment and the HIV epidemic potential among PWID, and to estimate the prevalence of injecting drug use in MENA.

Methods and Findings

This was a systematic review following the PRISMA guidelines and covering 23 MENA countries. PubMed, Embase, regional and international databases, as well as country-level reports were searched up to December 16, 2013. Primary studies reporting (1) the prevalence/incidence of HIV, other sexually transmitted infections, or hepatitis C virus (HCV) among PWIDs; or (2) the prevalence of injecting or sexual risk behaviors, or HIV knowledge among PWID; or (3) the number/proportion of PWID in MENA countries, were eligible for inclusion. The quality, quantity, and geographic coverage of the data were assessed at country level. Risk of bias in predefined quality domains was described to assess the quality of available HIV prevalence measures. After multiple level screening, 192 eligible reports were included in the review. There were 197 HIV prevalence measures on a total of 58,241 PWID extracted from reports, and an additional 226 HIV prevalence measures extracted from the databases.We estimated that there are 626,000 PWID in MENA (range: 335,000–1,635,000, prevalence of 0.24 per 100 adults). We found evidence of HIV epidemics among PWID in at least one-third of MENA countries, most of which are emerging concentrated epidemics and with HIV prevalence overall in the range of 10%–15%. Some of the epidemics have however already reached considerable levels including some of the highest HIV prevalence among PWID globally (87.1% in Tripoli, Libya). The relatively high prevalence of sharing needles/syringes (18%–28% in the last injection), the low levels of condom use (20%–54% ever condom use), the high levels of having sex with sex workers and of men having sex with men (15%–30% and 2%–10% in the last year, respectively), and of selling sex (5%–29% in the last year), indicate a high injecting and sexual risk environment. The prevalence of HCV (31%–64%) and of sexually transmitted infections suggest high levels of risk behavior indicative of the potential for more and larger HIV epidemics.

Conclusions

Our study identified a large volume of HIV-related biological and behavioral data among PWID in the MENA region. The coverage and quality of the data varied between countries. There is robust evidence for HIV epidemics among PWID in multiple countries, most of which have emerged within the last decade and continue to grow. The lack of sufficient evidence in some MENA countries does not preclude the possibility of hidden epidemics among PWID in these settings. With the HIV epidemic among PWID in overall a relatively early phase, there is a window of opportunity for prevention that should not be missed through the provision of comprehensive programs, including scale-up of harm reduction services and expansion of surveillance systems. Please see later in the article for the Editors'' Summary     

Patterns of sexual behaviour and reported symptoms of STI/RTIs among young people in Croatia--implications for interventions' planning

This paper describes some of the results of the first national-level survey on sexual behaviour and the distribution of risks to sexually transmitted infections (STIs), including human immunodeficiency virus infection (HIV), among youth in Croatia, and the nature and the extent of their vulnerability to these adverse health outcomes. The study was a cross-sectional, probability-based household survey conducted in 2005, and included 1093 respondents aged 18-24. This paper aims to describe the findings related to the knowledge of HIV transmission, key behavioural outcomes relevant for potential transmission of HIV and STIs, and correlates of genital discharge in young men and young women. More than 80% of young people know that the correct use of condoms protects against HIV and that HIV can be transmitted by someone who looks healthy. Fifty-nine percent of young men and 52.4% of young women reported using condoms during the first sexual intercourse, and 59.3% of men and 46.1% of women used condoms during the last sexual intercourse with a casual partner. This points to the gap between knowledge of condom use and the actual use of condoms as a high proportion of risky sexual contact remain unprotected. Having sexual intercourse frequently or regularly while consuming alcohol was reported by 19.2% of men and 7.6% of women. Much lower proportion are using drugs frequently or regularly during sexual intercourse (3.7% of men and 2.1% of women). Among those sexually experienced, 11.8% of men and 44.1% of women reported ever having a genital discharge. Higher presence of genital discharge in women is suggestive of reproductive tract infections that are not necessarily sexually transmitted. In the multivariate analysis, the lack of knowledge of whether chlamydial infections is an STI and having more than five partners in life were correlates of genital discharge in men, while in women the correlates included having more than five partners in life and not using condoms during the first sexual intercourse. Higher burden of STI-related symptoms was found among men who have men as sexual partners, those who paid for sex, and those with concurrent partnerships. These findings point out to the immediate need to strengthen sexual health education among young people and to the necessity for further development of other broad-based interventions to prevent adverse sexual health outcomes among both men and women, as well as those targeted towards more vulnerable subgroups.     

Drug Use and Sex Work: Competing Risk Factors for Newly Acquired HIV in Yunnan,China

Objective

To investigate the HIV incidence and its related factors among female sex workers (FSWs) in a high prevalence area where injection drug use is also widely documented.

Method

A cross-sectional study of 1642 female sex workers (FSWs) was conducted in Honghe Prefecture of Yunnan Province. Interviewed-questionnaires were administrated to collect information on sexual partnerships, condom use and illicit drug using behaviors etc. Blood samples were collected to test for HIV antibodies, and all HIV seropositive specimens were tested with the BED IgG capture-based enzyme immunosorbent assay (BED-CEIA) to distinguish between new and established HIV infection (<153 days).

Results

15.9% (261/1642) of participants reported ever having used drugs, and 7.4% had injected in recent 3 months. The overall HIV prevalence was 10.2% (168/1642), among which 16.7% (28/168) were identified as recent infections using BED-CEIA. The crude HIV incidence estimated from BED-CEIA results was 4.4 (95%CI 2.8–6.0) /100 person years (PY). Multivariate logistic analysis showed that an illicit drug using history (by either self-reporting or urine opiates testing) was both significant risk factors both for HIV established and recent infection (each p<0.05). Drug using FSWs (DU-FSW) reported more male clients in the previous week, and had significantly higher prevalence of HIV, chlamydia trachomatis and HSV-2 as compared to non DU-FSW (each p<0.05).

Conclusion

Our results show that a history of drug use poses significant risks for both new and established HIV infection among FSWs, and that HIV-incidence among Honghe FSWs is relatively high compared to similar populations. Comprehensive interventions targeted at DU-FSWs'' injection drug using and high risk sexual behaviors are urgently needed to reduce the rapid spread of HIV epidemic.     

Factors Associated with Inconsistent Condom Use among Men Who Have Sex with Men in Cambodia

Background

Compared to the general population, men who have sex with men (MSM) are at greater risk for HIV and less understood due to their more hidden and stigmatized nature. Moreover, the discrepancy in findings in the literature merits further investigations in MSM populations from different cultures and settings. We therefore conducted this study to explore factors associated with inconsistent condom use among high-risk MSM in Cambodia.

Methods

This cross-sectional study was conducted in 2014 among 367 MSM randomly selected from Battembang and Siem Reap using a two-stage cluster sampling method. A structured questionnaire was used for face-to-face interviews to collect information on characteristics of respondents, HIV testing history, self-perception of HIV risk, substance use, sexual behaviors, mental disorders, and HIV knowledge. Multivariable logistic regression analysis was performed to identify factors independently associated with inconsistent condom use.

Results

On average, 62.3% of respondents reported that they always used condoms over the past three months. The rates varied with types of sexual partners; the proportion of respondents who reported always using condoms was 55.1%, 64.2%, 75.9%, 73.0%, 78.1%, and 70.3%, for sexual partners who were girlfriends, boyfriends, female sex workers, male sex workers, female clients, or male clients, respectively. After adjustment, inconsistent condom use was significantly associated with age of ≥25 (AOR = 1.77, 95% CI = 1.09–2.86), self-rated quality of life as good or very good (AOR = 4.37, 95% CI = 1.79–5.67), self-perception of higher HIV risk compared to the general population (AOR = 2.37, 95% CI = 1.35–4.17), illicit drug use in the past three months (AOR = 5.76, 95% CI = 1.65–10.09), and reported consistent lubricant use when selling anal sex to men in the past three months (AOR = 2.85, 95% CI = 1.07–8.12).

Conclusions

We found risky sexual behaviors to be considerably high among MSM in this study, especially among those who used illicit drugs or were older than 25. HIV education and social marketing should be expanded and specifically designed for MSM to better educate on the increased risk of HIV with unprotected anal sex and illicit drug use as risk factors, and the importance of the use of both condoms and lubricant during anal intercourse.     

HIV/AIDS knowledge, women's education, epidemic severity and protective sexual behaviour in low- and middle-income countries

A fundamental public health strategy to reduce the risk of HIV/AIDS is to increase levels of awareness and knowledge about the disease. Although knowledge about HIV/AIDS and protective sexual behaviour are linked theoretically, relatively little is known about their empirical relationship. Using Demographic and Health Survey data from 23 low- and middle-income countries, this study used multilevel logistic regression models: to examine cross-national variability in the relationship between HIV/AIDS knowledge and protective behaviour (condom use and restricted sex); to investigate the moderating influences of women's educational attainment on this relationship; and to test the extent to which severity of the HIV/AIDS epidemic accounts for cross-national variability in the association between HIV/AIDS knowledge and protective behaviour. There was an association between increased knowledge of HIV/AIDS and condom use that varied in strength and form cross-nationally. This cross-national variation was accounted for partially by the socioeconomic characteristics of women resident in the study countries and between-country differences in the severity of the HIV epidemic. While education modified the association between HIV/AIDS knowledge and protective behaviour--stronger associations at lower levels of education--epidemic severity exerted a stronger influence on behaviour than any other characteristic. Finally, this study indicates that protective sexual practices are disturbingly low. In eight of 23 countries, overall levels of condom use to prevent STDs and HIV/AIDS were less than 5.0%. Waiting for the spread of HIV/AIDS infection to change sexual practices in low- and middle-income countries will result in dramatic unnecessary suffering.     

Condom use and its consistency among metropolitan high school students in Croatia, 1997-2001: has anything changed?

Sexually active adolescents face serious health risks associated with unprotected sexual intercourse, such as HIV infection and other sexually transmitted diseases (STDs), as well as unwanted pregnancy. To assess protective behavior among urban adolescents in Croatia we surveyed over 4000 high-school students, 15-19 years of age, in two waves: 2070 in 1997 and 1972 in 2001. The survey was carried out in various types of secondary schools in the capital city. The analyses suggest statistically significant increase in HIVIAIDS related knowledge in the observed period. A slight but significant increase was also observed in the acceptance of condom use. Both changes were more substantial among female students. In regards to protective behavior, we found significant increase in condom use, as well as in its consistency. Still, a large proportion of students did not use condom at last sexual intercourse (40% in 2001). In addition to generational effect, number of sexual partners, sexual victimization and mother's education (only in the case of young women) were identified as correlates of condom use consistency. While mother's education had positive effect, having 4 or more partners and having survived sexual violence decreased the likelihood of consistent condom use. In conclusion, the authors discuss the relevance of systematic school-based prevention of sexual risk taking among Croatian adolescents.     

Sexual risk behaviors for HIV/AIDS in Chuuk State, Micronesia: the case for HIV prevention in vulnerable remote populations

Background

After the first two cases of locally-acquired HIV infection were recognized in Chuuk State, Federated States of Micronesia (FSM), a public health response was initiated. The purpose of the response was to assess the need for HIV education and prevention services, to develop recommendations for controlling further spread of HIV in Chuuk, and to initiate some of the prevention measures.

Methodology/Principal Findings

A public health team conducted a survey and rapid HIV testing among a sample of residents on the outer islands in Chuuk. Local public health officials conducted contact tracing and testing of sex partners of the two locally-acquired cases of HIV infection. A total of 333 persons completed the survey. The majority knew that HIV is transmitted through unprotected sexual contact (81%), injection drug use (61%), or blood transfusion (64%). Sexual activity in the past 12 months was reported among 159 participants, including 90 females and 69 males. Compared to women, men were more likely to have had multiple sex partners, to have been drunk during sex, but less likely to have used a condom in the past 12 months. The two men with locally acquired HIV infection had unprotected anal sex with a third Chuukese man who likely contracted HIV while outside of Chuuk. All 370 persons who received voluntary, confidential HIV counseling and testing had HIV negative test results.

Conclusions/Significance

Despite the low HIV seroprevalence, risky sexual behaviors in this small isolated population raise concerns about the potential for rapid spread of HIV. The lack of knowledge about risks, along with stigmatizing attitudes towards persons infected with HIV and high risk sexual behaviors indicate the need for resources to be directed toward HIV prevention in Chuuk and on other Pacific Islands.