“When I Was Circumcised I Was Taught Certain Things”: Risk Compensation and Protective Sexual Behavior among Circumcised Men in Kisumu,Kenya

Background

Male circumcision has been shown to reduce the transmission of HIV from women to men through vaginal sex by approximately 60%. There is concern that men may engage in risk compensation after becoming circumcised, diminishing the benefits of male circumcision.

Methods and Findings

We conducted qualitative interviews with 30 sexually active circumcised men in Kisumu, Kenya from March to November 2008. Most respondents reported no behavior change or increasing protective sexual behaviors including increasing condom use and reducing the number of sexual partners. A minority of men reported engaging in higher risk behaviors either not using condoms or increasing the number of sex partners. Circumcised respondents described being able to perform more rounds of sex, easier condom use, and fewer cuts on the penis during sex.

Conclusions

Results illustrate that information about MC''s protection against HIV has disseminated into the larger community and MC accompanied by counseling and HIV testing can foster positive behavior change and maintain sexual behavior.     

Preparing for the Rollout of Pre-Exposure Prophylaxis (PrEP): A Vignette Survey to Identify Intended Sexual Behaviors among Women in Kenya and South Africa if Using PrEP

Introduction

Several clinical trials have demonstrated the efficacy of pre-exposure prophylaxis (PrEP) in reducing HIV risk. One concern with introducing PrEP is whether users will engage in riskier sexual behaviors.

Methods

We assessed the effect that PrEP may have on sexual risk behaviors by administering a survey to 799 women in Bondo, Kenya, and Pretoria, South Africa. Participants were asked about their sexual behavior intentions twice — once as if they were taking PrEP and once as if they were not taking PrEP — within four risk situations (vignettes). They responded using a 5-point ordinal scale. We used a series of linear mixed effects models with an unstructured residual covariance matrix to estimate the between- and within-subject differences in the mean likelihood of engaging in risky sexual behavior across the PrEP and non-PrEP contexts. We also calculated the total percentage of participants who reported a greater likelihood of engaging in risky sexual behavior if taking PrEP than if not taking PrEP, by vignette.

Results

We found statistically significant differences in the mean likelihood of engaging in risky sexual behavior with the between-subject comparison (-0.17, p < 0.01) and with the within-subject comparison (-0.31, p < 0.001). Depending on the vignette, 27% to 40% of participants reported a greater likelihood of engaging in risky sexual behavior if taking PrEP than if not taking PrEP.

Conclusions

Our findings indicate that modest increases in risky sexual behavior could occur with PrEP. Although responses from the majority of participants suggest they would not be more likely to engage in risky sexual behavior if they took PrEP, a substantial proportion might. Programs rolling out PrEP should be prepared to assist similar women in making informed choices about reducing their risk of HIV and about their sexual health beyond HIV prevention.     

The Sexual Risk Context among the FEM-PrEP Study Population in Bondo,Kenya and Pretoria,South Africa

Background

Incidence rates in the FEM-PrEP and VOICE trials demonstrate that women from diverse sub-Saharan African communities continue to be at substantial HIV risk.

Objective

To describe and compare the sexual risk context of the study population from two FEM-PrEP trial sites–Bondo, Kenya, and Pretoria, South Africa.

Methods

At baseline we collected information about demographics, sexual behaviors, and partnership beliefs through quantitative questionnaires with all participants (Bondo, n = 720; Pretoria, n = 750). To explore the sexual risk context, we also conducted qualitative, semi-structured interviews with HIV-negative participants randomly selected at several time points (Bondo, n = 111; Pretoria, n = 69).

Results

Demographics, sexual behavior, and partnership beliefs varied significantly between the sites. Bondo participants were generally older, had fewer years of schooling, and were more likely to be employed and married compared to Pretoria participants. Bondo participants were more likely to report multiple partners and not knowing whether their partner had HIV than Pretoria participants. A significantly higher percentage of Bondo participants reported engaging in sex without a condom with their primary and other partners compared to Pretoria participants. We found a borderline association between participants who reported not using condoms in the 4 weeks prior to baseline and lower risk of HIV infection, and no association between having more than one sexual partner at baseline and HIV infection.

Discussion

Despite significantly different demographics, sexual behaviors, and partnership beliefs, many women in the FEM-PrEP trial were at risk of acquiring HIV as demonstrated by the sites’ high HIV incidence. Though gender dynamics differed between the populations, they appear to play a critical role in women’s sexual practices. The findings highlight different ways women from diverse contexts may be at-risk for HIV and the importance of providing HIV prevention options that are both effective and feasible given personal and social circumstances.     

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.     

Delay and Probability Discounting of Sexual and Monetary Outcomes in Individuals with Cocaine Use Disorders and Matched Controls

Individuals with cocaine use disorders are disproportionately affected by HIV/AIDS, partly due to higher rates of unprotected sex. Recent research suggests delay discounting of condom use is a factor in sexual HIV risk. Delay discounting is a behavioral economic concept describing how delaying an event reduces that event’s value or impact on behavior. Probability discounting is a related concept describing how the uncertainty of an event decreases its impact on behavior. Individuals with cocaine use disorders (n = 23) and matched non-cocaine-using controls (n = 24) were compared in decision-making tasks involving hypothetical outcomes: delay discounting of condom-protected sex (Sexual Delay Discounting Task), delay discounting of money, the effect of sexually transmitted infection (STI) risk on likelihood of condom use (Sexual Probability Discounting Task), and probability discounting of money. The Cocaine group discounted delayed condom-protected sex (i.e., were more likely to have unprotected sex vs. wait for a condom) significantly more than controls in two of four Sexual Delay Discounting Task partner conditions. The Cocaine group also discounted delayed money (i.e., preferred smaller immediate amounts over larger delayed amounts) significantly more than controls. In the Sexual Probability Discounting Task, both groups showed sensitivity to STI risk, however the groups did not differ. The Cocaine group did not consistently discount probabilistic money more or less than controls. Steeper discounting of delayed, but not probabilistic, sexual outcomes may contribute to greater rates of sexual HIV risk among individuals with cocaine use disorders. Probability discounting of sexual outcomes may contribute to risk of unprotected sex in both groups. Correlations showed sexual and monetary results were unrelated, for both delay and probability discounting. The results highlight the importance of studying specific behavioral processes (e.g., delay and probability discounting) with respect to specific outcomes (e.g., monetary and sexual) to understand decision making in problematic behavior.     

Evolving Strategies, Opportunistic Implementation: HIV Risk Reduction in Tanzania in the Context of an Incentive-Based HIV Prevention Intervention

Background

Behavior change communication (BCC) interventions, while still a necessary component of HIV prevention, have not on their own been shown to be sufficient to stem the tide of the epidemic. The shortcomings of BCC interventions are partly due to barriers arising from structural or economic constraints. Arguments are being made for combination prevention packages that include behavior change, biomedical, and structural interventions to address the complex set of risk factors that may lead to HIV infection.

Methods

In 2009/2010 we conducted 216 in-depth interviews with a subset of study participants enrolled in the RESPECT study - an HIV prevention trial in Tanzania that used cash awards to incentivize safer sexual behaviors. We analyzed community diaries to understand how the study was perceived in the community. We drew on these data to enhance our understanding of how the intervention influenced strategies for risk reduction.

Results

We found that certain situations provide increased leverage for sexual negotiation, and these situations facilitated opportunistic implementation of risk reduction strategies. Opportunities enabled by the RESPECT intervention included leveraging conditional cash awards, but participants also emphasized the importance of exploiting new health status knowledge from regular STI testing. Risk reduction strategies included condom use within partnerships and/or with other partners, and an unexpected emphasis on temporary abstinence.

Conclusions

Our results highlight the importance of increasing opportunities for implementing risk reduction strategies. We found that an incentive-based intervention could be effective in part by creating such opportunities, particularly among groups such as women with limited sexual agency. The results provide new evidence that expanding regular testing of STIs is another important mechanism for providing opportunities for negotiating behavior change, beyond the direct benefits of testing. Exploiting the latent demand for STI testing should receive renewed attention as part of innovative new combination interventions for HIV prevention.     

Epidemiology of HIV among US Air Force Military Personnel, 1996–2011

ObjectiveThe objectives of this study were to describe the epidemiology of HIV in the United States Air Force (USAF) from 1996 through 2011 and to assess whether socio-demographic characteristics and service-related mobility, including military deployments, were associated with HIV infection.MethodsWe conducted a retrospective cohort analysis of USAF personnel who were HIV-infected during the study period January 1, 1996 through December 31, 2011 and a matched case-control study. Cases were USAF personnel newly-diagnosed with HIV during the study period. Five randomly-selected HIV-uninfected controls were matched to each case by age, length of service, sex, race, service, component, and HIV test collection date. Socio-demographic and service-related mobility factors and HIV diagnosis were assessed using conditional logistic regression.ResultsDuring the study period, the USAF had 541 newly diagnosed HIV-infected cases. HIV incidence rate (per 100,000 person-years) among 473 active duty members was highest in 2007 (16.78), among black/ African-American USAF members (26.60) and those aged 25 to 29 years (10.84). In unadjusted analysis restricted to personnel on active duty, 10 characteristics were identified and considered for final multivariate analysis. Of these single (adjusted odds ratio [aOR], 8.15, 95% confidence interval [CI] 5.71–11.6) or other marital status (aOR 4.60, 95% CI 2.72–7.75), communications/ intelligence (aOR 2.57, 95% CI 1.84–3.60) or healthcare (aOR 2.07, 95% CI 1.28–3.35) occupations, and having no deployment in the past 2 years before diagnosis (aOR 2.02, 95% CI 1.47–2.78) conferred higher odds of HIV infection in adjusted analysis.ConclusionThe highest risk of HIV infection in the USAF was among young unmarried deployment-naïve males, especially those in higher risk occupation groups. In an era when worldwide military operations have increased, these analyses identified potential areas where targeted HIV prevention efforts may be beneficial in reducing HIV incidence in the USAF military population.     

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.     

Self-deception does not explain high-risk sexual behavior in the face of HIV/AIDS: A test from northern Kenya

Throughout sub-Saharan Africa, there is resistance to changing sexual behavior despite survey data indicating high levels of knowledge about HIV transmission patterns and high-risk behavior. Previous explanations for this paradox emphasize indigenous cultural models. An alternative explanation is that, due to a strong natural selection for sexual gratification, individuals evoke the evolved trait of self-deception to continue practicing high-risk sexual behavior. This alternative is tested using survey data from an Ariaal community in Marsabit District, northern Kenya. Results indicate that respondents make highly accurate self-assessments of HIV risk, negating the concept of self-deception in this study. These results are discussed within the larger context of the applicability of evolutionary theory to the AIDS pandemic.     

Changes in Sexual Risk Behavior in the Mombasa Cohort: 1993–2007

The Mombasa Cohort is an open cohort study following HIV-seronegative women reporting transactional sex. Established in 1993, the cohort provides regular HIV counseling and testing at monthly visits. Over time, HIV acquisition risk has declined steadily in this cohort. To evaluate whether this decline may reflect changes in sexual risk behavior, we investigated trends in condom use and partner numbers among women who participated in the Mombasa Cohort between 1993 and 2007. Multinomial logistic regression and generalized estimating equations were used to evaluate the association of calendar time and follow-up time with key risk behaviors, after adjustment for potential confounding factors. At enrollment visits by 1,844 women, the adjusted probability of never using condoms decreased over time, from 34.2% to 18.9%. Over 23,911 follow-up visits, the adjusted probabilities of reporting >2 partners decreased from 9.9% to 4.9% and inconsistent condom use decreased from 7.9% to 5.3% after ≥12 cohort visits. Important predictors of risk behavior were work venue, charging low fees for sex, and substance abuse. Women with a later sexual debut had less risky behavior. Although sexual risk has declined among women participating in the Mombasa Cohort, HIV acquisition continues to occur and interventions to promote and reinforce safer sex are clearly needed.     

HIV risk behaviors among outpatients with severe mental illness in Rio de Janeiro,Brazil

We conducted the first study to examine rates of sexual activity, sexual risk behaviors, sexual protective behaviors, injection drug use (IDU), needle sharing, and knowledge about HIV/AIDS among outpatients with severe mental illness (SMI) in Rio de Janeiro, Brazil. Using a measure with demonstrated reliability, we found that 42% of 98 patients engaged in vaginal or anal sex within the past three months. Comorbid substance use disorder was significantly associated with sexual activity. Only 22% of sexually active patients used condoms consistently, despite having better HIV knowledge than those who were sexually abstinent. Overall, 45% of patients reported not engaging in any HIV protective behaviors. There were no reports of drug injection. Adults with SMI in Brazil are in need of efficacious HIV prevention programs and policies that can sustain these programs within mental health treatment settings.     

Predictors of Inconsistent Condom Use among a Hard to Reach Population of Young Women with Multiple Sexual Partners in Peri-Urban South Africa

Background

Evidence suggests that multiple concurrent sexual partnering may be a key driver of the high HIV prevalence among young women in South Africa. However, little is known about whether and to what extent women who have multiple sexual partners also engage in other high risk sexual behaviors such as inconsistent condom use. And yet, multiple concurrent sexual partnering is of little epidemiological relevance if all partners in these sexual networks use condoms consistently. This study assesses the prevalence of sexual risk behaviors and HIV, and predictors of inconsistent condom use among women aged 16–24 with multiple sexual partners in a peri-urban setting in South Africa.

Methods

We used Respondent Driven Sampling, a sampling strategy for hard-to-reach populations to recruit 259 women aged 16–24 in a bio-behavioral cross-sectional survey in the Western Cape province. Estimates of population proportions and 95% confidence intervals (CIs) were calculated using the Respondent-Driven Sampling Analysis Tool 5.6 (RDSAT). The primary outcome was inconsistent condom use in the past three months.

Results

Young women reported an average of 7 partners in the past 3 months and a high prevalence of sexual risk behaviors: concurrency (87%), transactional sex (91%) and age mixing (59%). Having >5 sexual partners in the last 3 months doubled the risk of unprotected sex (OR 2.43, CI 1.39–4.25). HIV prevalence was 4% among 16–19 year olds, increasing threefold (12%) at age 20–24.

Discussion

Multiple sexual partnering, where a high number of partners are acquired in a short space of time, is a fertile context for unprotected and risky sexual behavior. The young women featured in this survey present with a constellation of high-risk sexual behaviors that cluster to form a risk syndrome. Carefully tailored repeat bio-behavioral surveillance surveys are recommended for this sub-population.     

Women's lives and sex: Implications for AIDS prevention

Preliminary findings from the Women and AIDS program, a research grants program of the International Center for Research on Women in Washington, D.C. that supports 17 studies in developing countries worldwide, provide a glimpse into the complex interaction between women's social and economic status and risk of HIV infection. In many settings, the cultural norms that demand sexual fidelity and docile and acquiescent sexual behavior among women permit — and sometimes even encourage —early sexual experimentation, multiple partnerships, and aggressive and dominating sexual behavior among men. Drawing upon the findings from the program, the paper analyzes how such cultural norms, together with women's social and economic dependency, can limit a woman's ability to negotiate safer sex with her partner; restrict her access to information and knowledge about her body; force her to sometimes barter sex for survival; increase her vulnerability to physical violence in sexual interaction; and compromise her self-esteem. The findings highlight the limitations of the current HIV/AIDS prevention strategy for reducing women's risk of HIV, and underline the urgency for an approach to prevention that is grounded in the realities of women's lives and sexual experiences — an approach that recognizes the relationship between the dynamics of gender relations, sexual behavior, and HIV risk.     

Kunyenga, "real sex," and survival: assessing the risk of HIV infection among urban street boys in Tanzania

This article examines possible avenues of HIV infection among urban street boys in Tanzania. In doing so, it questions the ways that AIDS researchers have defined and approached the phenomenon of "survival sex" in East and Central Africa. The article specifically examines the boys' sexual networks, sexual practices, and attitudes regarding their own sexual behavior, including their perceived risk of HIV/AIDS infection. Seventy-five street boys aged eight to 20 from the city of Mwanza were interviewed. Results suggest that almost all street boys are involved in a sexual network in which homosexual and heterosexual behavior occurs. Homosexual practices are rooted in a complex set of behaviors and ideologies known as kunyenga, which is a situated aspect of life on the streets and helps maintain the boys' strong dependence on one another. A key aspect of the boys' sexual careers involves a decrease in kunyenga activity as they approach the age of 18 and an increase in heterosexual encounters after the age of 11. There appears to be a critical period between these ages in which heterosexual and kunyenga activities overlap. It is suggested that boys between these ages represent a potential bridge for HIV/AIDS infection between the general population and the relatively enclosed sexual network of street boys.     

Perceptions of Audio Computer-Assisted Self-Interviewing (ACASI) among Women in an HIV-Positive Prevention Program

Background

Audio Computer-Assisted Self Interviewing (ACASI) has improved the reliability and accuracy of self-reported HIV health and risk behavior data, yet few studies account for how participants experience the data collection process.

Methodology/Principal Findings

This exploratory qualitative analysis aimed to better understand the experience and implications of using ACASI among HIV-positive women participating in sexual risk reduction interventions in Chicago (n = 12) and Philadelphia (n = 18). Strategies of Grounded Theory were used to explore participants'' ACASI experiences.

Conclusion/Significance

Key themes we identified included themes that could be attributed to the ACASI and other methods of data collection (e.g., paper-based self-administered questionnaire or face-to-face interviews). The key themes were usability; privacy and honesty; socially desirable responses and avoiding judgment; and unintentional discomfort resulting from recalling risky behavior using the ACASI. Despite both positive and negative findings about the ACASI experience, we conclude that ACASI is in general an appropriate method for collecting sensitive data about HIV/AIDS risk behaviors among HIV-positive women because it seemed to ensure privacy in the study population allowing for more honest responses, minimize socially desirable responses, and help participants avoid actual or perceived judgment.