Devon D. Brewer

Unsafe sexual behavior and correlates of risk in a probability sample of men who have sex with men in the era of highly active antiretroviral therapy.

Objective: To assess the levels and correlates of potential exposure to and transmission of HIV in a contemporary, community-based probability sample of men who have sex with men (MSM). Methods: In 2003, 311 sexually active MSM participated in a random-digit dial telephone survey in Seattle neighborhoods with a high prevalence of MSM. The primary outcomes were potential exposure to and transmission of HIV, defined as unprotected anal intercourse with a man of opposite or unknown HIV status in the preceding 12 months. Results: Fourteen percent of respondents reported being HIV-positive, 77% reported being HIV-negative, and 8% had not been tested. Of 241 HIV-negative MSM, 25 (10%; 95% confidence interval [CI], 7–15%) were potentially exposed to HIV; among 45 HIV-positive MSM, 14 (31%; 95% CI, 20–46%) were potential HIV-transmitters. Among HIV-negative men, the strongest bivariate correlates of potential exposure to HIV were recent bacterial sexually transmitted disease (odds ratio [OR], 5.8), number of recent male sexual partners (OR, 1.01 per partner), recent sex at a bathhouse (OR, 9.1), and recent use of sildenafil (OR, 4.4), amyl nitrite (OR, 6.2), and methamphetamine (OR, 8.0). Among HIV-infected men, the strongest correlates of potential HIV transmission were recent use of amyl nitrite (OR, 3.1), number of recent male sex partners (OR, 1.07 per partner), and having a male spouse or domestic partner (OR, 0.3). Conclusions: Most MSM knew their HIV status and adopted safer sexual behaviors to reduce their risk of HIV acquisition or transmission. However, 10% of HIV-negative MSM and 31% of HIV-positive MSM recently engaged in behaviors that placed them at high risk for acquiring or transmitting HIV.

Mounting anomalies in the epidemiology of HIV in Africa: cry the beloved paradigm

In North America Europe and many parts of Asia the ignition of regional epidemics and rapid HIV transmission has been associated principally with the sharing of contaminated injecting equipment and with anal intercourse. Though heterosexual intercourse has been virtually the sole explanation offered for the AIDS epidemic in sub-Saharan Africa to our knowledge in no other part of the world has penile-vaginal exposure (as opposed to “heterosexual sex”) been demonstrated to initiate or sustain rapid HIV propagation. HIV is not transmitted by “sex” but only by specific risky practices. It is not transmitted by “injections” but only by contaminated implements which need to be clearly differentiated as to type and frequency of injection and by the conditions of the exposure setting. In virtually all societies affected by HIV to date both routes seem to play important roles. If we are to understand and intervene in each of these epidemics well-designed studies at both the population and individual levels are urgently needed. It is vital that these be properly controlled for parenteral exposure specific sexual practices and other co-factors and the complex and specific social patterns and networks that accompany them. (excerpt)

Supplementary Interviewing Techniques to Maximize Output in Free Listing Tasks

Free listing is an important ethnographic tool for defining semantic domains. However, when informants free list items from a particular domain, they often do not mention all items they know because they forget items and/or do not understand that they should list exhaustively. In this article, the author reviews results from research on three supplementary interviewing techniques to encourage full responding and enhance recall in such tasks (nonspecific prompting, reading back to the informant the items he or she free listed, and using free-listed items as semantic cues). These methods increase substantially the number of items elicited from individual informants and the number of items in a domain identified from informants in the aggregate. Moreover, these techniques do not require the interviewer to have any prior domain knowledge to be effective.

Drug use predictors of partner violence in opiate-dependent women

This paper examines the use of specific drugs as longitudinal predictors of violence between domestic partners in a sample of women in methadone treatment for opiate addiction. Crack cocaine use, use of other forms of cocaine, and tranquilizer use are each modestly to moderately positively associated with partner violence victimization. Women who were heavy users of these drugs were more likely to be hit, slapped, or shoved by their partners than light users or nonusers of these drugs. Three possible explanations of these associations are considered.

Forgetting as a cause of incomplete reporting of sexual and drug injection partners.

BACKGROUND AND OBJECTIVES Partner notification and social network studies of infectious disease often involve interviewing people to elicit their sexual and/or drug injection partners. Incomplete reporting of partners in these contexts would significantly hamper efforts to understand and control the spread of sexually transmitted diseases, HIV, and other infections. There are many reasons why individuals might not name their partners in interviews. This study provides a comprehensive assessment of forgetting as a cause of incomplete reporting of sexual and injection partners. STUDY DESIGN One hundred fifty-six persons in Seattle, Washington, at presumed high risk for HIV recalled their sexual and/or injection partners in two interviews separated by 1 week or 3 months. RESULTS Repeated, nonspecific prompting elicited, on average, 10% of all partners recalled in an interview. Subjects displayed substantial forgetting of partners across partner types, recall periods, and four independent measurement approaches, with up to 72% of partners forgotten. The number of partners recalled and subjective assessment of forgetting are moderate to good predictors of the number of partners forgotten. Recalled and forgotten partners do not differ dramatically on any of several partner variables. CONCLUSIONS Forgetting is a primary factor in the incomplete reporting of sexual and injection partners. Interviewers should prompt repeatedly to maximize recall of partners. Reinterviewing is currently the best method available for identifying partners as completely as possible and should be focused on individuals who report many partners and/or sense they have other partners they cannot recall.

Case-Finding Effectiveness of Partner Notification and Cluster Investigation for Sexually Transmitted Diseases/HIV

Objective: To assess the case-finding effectiveness of partner notification(PN) and cluster investigation for sexually transmitted disease (STD)/human immunodeficiency virus (HIV). Study: Literature review and quantitative summary. Results: Since 1975, the median case-finding yield for syphilis, gonorrhea, and chlamydia PN reported in the literature is about 1 new case found for every 4 or 5 cases interviewed. The yield from HIV PN is approximately half as large, although there is substantial variability in yield across reports for each disease. Published reports underline the central role provider referral plays in effective PN and case-finding. Successful PN is more likely with index cases who are of majority ethnicity and detected through screening or spontaneous presentation for care with symptoms and with partners with whom index cases have had sexual contact that is recent, frequent, and of long duration. The case-finding yield for HIV PN also is much higher when cases are diagnosed through confidential, rather than anonymous, testing. Cluster investigation and related strategies tend to have lower case-finding yields than PN but can play a very useful case-finding role, especially in settings with high disease incidence. Conclusions: STD/HIV PN and cluster investigation can contribute meaningfully to case finding. More research is needed to strengthen the empiric foundation of PN and related strategies, including the impact they have on disease transmission.

Evaluation of interviewing techniques to enhance recall of sexual and drug injection partners

Background People with multiple sex partners forget a significant proportion of their partners, and drug injectors forget a large proportion of the persons with whom they inject drugs. This incomplete reporting poses a problem for partner notification and social network research on infectious disease. Goal To evaluate supplementary interviewing techniques to enhance recall of sex and injection partners. Study Design One hundred thirty-nine persons at high risk for HIV participated in a randomized trial of interviewing techniques. After participants freely recalled their partners, interviewers administered one of five techniques to elicit partners who might have been forgotten. Four experimental techniques involved cues (locations, role relationships, personal timeline, and partners recalled prior to cues) developed from memory research. Alphabetic cues served as a control technique. To assess the cumulative effects of the techniques, all five techniques were administered to another 19 participants. Results In the randomized trial, the techniques varied moderately in effectiveness and time efficiency. When administered as a set, the five techniques increased the number of sex and injection partners elicited by 40% and 123%, respectively, on average. The techniques were most effective with individuals who recalled many partners before the cues and/or sensed they might be forgetting partners. The available evidence indicates cue-elicited partners are as valid as partners recalled before the cues. On epidemiologically significant variables, cue-elicited partners also are similar to partners recalled before the cues. Conclusion The supplementary techniques counteract forgetting appreciably and may promote more effective partner notification and more complete description of risk networks.

Rising rates of syphilis in the era of syphilis elimination.

Objective: The objective of this study was to assess the impact of syphilis control activities in King County, Washington. Study Design: We calculated rates of early syphilis and trends in numbers of persons tested and diagnosed through screening and partner notification from 1998 to 2005. Results: Early syphilis cases increased from 38 in 1998 to 188 in 2005 with 92% occurring among men who have sex with men (MSM). Our health department conducted public awareness campaigns, increased publicly financed syphilis screening among MSM by 179%, and intensified partner notification efforts. Despite these efforts, the prevalence of syphilis among screened populations was only 1.1%, and 71% syphilis cases were diagnosed after seeking care for symptoms. The proportion of cases diagnosed through screening and partner notification did not significantly change during the evaluation period. Early syphilis incidence among MSM more than doubled between 2003 and 2005. Conclusions: New, innovative approaches to syphilis control are needed.

Agreement in Reported Sexual Partnership Dates and Implications for Measuring Concurrency

Objectives: To describe the reliability of reported dates of first and last sexual exposure, as elicited from sexually transmitted disease/human immunodeficiency virus cases during routine contact investigation, and determine their adequacy for assessing concurrency. Methods: We used contact tracing data from 5 studies in which both members of 774 dyads were interviewed and named each other as sex partners. We assessed partners’ agreement on the dates of first and last exposure as related to precision (to the day, month, or year) of reported dates and demographic and behavioral characteristics of the dyad. We performed simulations that introduced reporting error, based on our observed data, to posited “true” temporal configurations of partnerships to assess the impact of unreliability in reporting on the measurement of concurrency. Results: Thirty-two percent of dyads agreed on the exact date of first sexual exposure, and 36% did so for the date of last sexual exposure. Sixty-four percent agreed within 30 days on the date of first sexual exposure, and 81% did so for the date of last sexual exposure. The reliability of reported dates was positively related to the precision of the reports. Agreement on reported exposure dates was not meaningfully associated with any of the sociodemographic and behavioral variables available. Based on simulations, the positive predictive value of reported dates for estimating concurrency is approximately 80% over a wide range of conditions. Conclusions: These data suggest that the reliability of reported exposure dates is reasonably good but that estimating concurrency with reported dates is subject to some error. Data designed for the purpose and analyzed with adequate attention to the statistical and epidemiologic issues of assessing concurrency are needed.

Measures and tests of heaping in discrete quantitative distributions

Heaping is often found in discrete quantitative data based on subject responses to open-ended interview questions or observer assessments. Heaping occurs when subjects or observers prefer some set of numbers as responses (e.g. multiples of 5) simply because of the features of this set. Although heaping represents a common type of measurement error, apparently no prior general measure of heaping exists. We present simple measures and tests of heaping in discrete quantitative data, illustrate them with data from an epidemiologic study, and evaluate the bias of these statistics. These techniques permit formal measurement of heaping and facilitate comparisons of the degree of heaping in data from different samples, substantive domains, and data collection methods.