G Hart

Limits to modern contraceptive use among young women in developing countries: a systematic review of qualitative research

BackgroundImproving the reproductive health of young women in developing countries requires access to safe and effective methods of fertility control, but most rely on traditional rather than modern contraceptives such as condoms or oral/injectable hormonal methods. We conducted a systematic review of qualitative research to examine the limits to modern contraceptive use identified by young women in developing countries. Focusing on qualitative research allows the assessment of complex processes often missed in quantitative analyses.MethodsLiterature searches of 23 databases, including Medline, Embase and POPLINE®, were conducted. Literature from 1970–2006 concerning the 11–24 years age group was included. Studies were critically appraised and meta-ethnography was used to synthesise the data.ResultsOf the 12 studies which met the inclusion criteria, seven met the quality criteria and are included in the synthesis (six from sub-Saharan Africa; one from South-East Asia). Sample sizes ranged from 16 to 149 young women (age range 13–19 years). Four of the studies were urban based, one was rural, one semi-rural, and one mixed (predominantly rural). Use of hormonal methods was limited by lack of knowledge, obstacles to access and concern over side effects, especially fear of infertility. Although often more accessible, and sometimes more attractive than hormonal methods, condom use was limited by association with disease and promiscuity, together with greater male control. As a result young women often relied on traditional methods or abortion. Although the review was limited to five countries and conditions are not homogenous for all young women in all developing countries, the overarching themes were common across different settings and contexts, supporting the potential transferability of interventions to improve reproductive health.ConclusionIncreasing modern contraceptive method use requires community-wide, multifaceted interventions and the combined provision of information, life skills, support and access to youth-friendly services. Interventions should aim to counter negative perceptions of modern contraceptive methods and the dual role of condoms for contraception and STI prevention should be exploited, despite the challenges involved.

Development of a quality assessment tool for systematic reviews of observational studies (QATSO) of HIV prevalence in men having sex with men and associated risk behaviours

BackgroundSystematic reviews based on the critical appraisal of observational and analytic studies on HIV prevalence and risk factors for HIV transmission among men having sex with men are very useful for health care decisions and planning. Such appraisal is particularly difficult, however, as the quality assessment tools available for use with observational and analytic studies are poorly established.MethodsWe reviewed the existing quality assessment tools for systematic reviews of observational studies and developed a concise quality assessment checklist to help standardise decisions regarding the quality of studies, with careful consideration of issues such as external and internal validity.ResultsA pilot version of the checklist was developed based on epidemiological principles, reviews of study designs, and existing checklists for the assessment of observational studies. The Quality Assessment Tool for Systematic Reviews of Observational Studies (QATSO) Score consists of five items: External validity (1 item), reporting (2 items), bias (1 item) and confounding factors (1 item). Expert opinions were sought and it was tested on manuscripts that fulfil the inclusion criteria of a systematic review. Like all assessment scales, QATSO may oversimplify and generalise information yet it is inclusive, simple and practical to use, and allows comparability between papers.ConclusionA specific tool that allows researchers to appraise and guide study quality of observational studies is developed and can be modified for similar studies in the future.

Recreational drug use, polydrug use, and sexual behaviour in HIV-diagnosed men who have sex with men in the UK: results from the cross-sectional ASTRA study

BACKGROUND Recreational drug use in men who have sex with men (MSM) is of concern because it might be linked to the transmission of HIV and other sexually transmitted infections. Evidence about drug use in HIV-diagnosed MSM in the UK is limited by representativeness of the study populations. We describe patterns of drug use and associations with sexual behaviours in HIV-diagnosed MSM in the UK. METHODS We used data from the cross-sectional ASTRA study, which recruited participants aged 18 years or older with HIV from eight HIV outpatient clinics in the UK between Feb 1, 2011, and Dec 31, 2012. We examined data for MSM, assessing the prevalence of recreational drug use and polydrug use in the previous 3 months and associations with sociodemographic and HIV-related factors. We examined the association of polydrug use with measures of condomless sex in the previous 3 months and with other sexual behaviours. FINDINGS Our analysis included data for 2248 MSM: 2136 (95%) were gay, 1973 (89%) were white, 1904 (85%) were on antiretroviral treatment (ART), and 1682 (76%) had a viral load of 50 copies per mL or lower. 1138 (51%) used recreational drugs in the previous 3 months; 608 (27%) used nitrites, 477 (21%) used cannabis, 460 (21%) used erectile dysfunction drugs, 453 (20%) used cocaine, 280 (13%) used ketamine, 258 (12%) used 3,4-methylenedioxy-N-methylamphetamine (MDMA), 221 (10%) used gamma-hydroxybutyrate or gamma-butyrolactone, 175 (8%) used methamphetamine, and 162 (7%) used mephedrone. In the 1138 individuals who used drugs, 529 (47%) used three or more drugs and 241 (21%) used five or more. Prevalence of injection drug use was 3% (n = 68). Drug use was independently associated with younger age (p < 0·0001), not being religious (p = 0·001), having an HIV-positive stable partner (p = 0·0008), HIV-serostatus disclosure (p = 0·009), smoking (p < 0·0001), evidence of harmful alcohol drinking (p = 0·0001), and ART non-adherence (p < 0·0001). Increasing polydrug use was associated with increasing prevalence of condomless sex (prevalence range from no drug use to use of five or more drugs was 24% to 78%), condomless sex with HIV-seroconcordant partners (17% to 69%), condomless sex with HIV-serodiscordant partners (10% to 25%), and higher-HIV-risk condomless sex after taking viral load into account (4% to 16%; p ≤ 0·005 for all). Associations were similar after adjustment for sociodemographic and HIV-related factors. Methamphetamine was more strongly associated with higher-HIV-risk condomless sex than were other commonly used drugs. INTERPRETATION Polydrug use is prevalent in HIV-diagnosed MSM and is strongly associated with condomless sex. Specialist support services for MSM with HIV who use recreational drugs might be beneficial in the reduction of harm and prevention of ongoing transmission of HIV and other sexually transmitted infections. FUNDING National Institute for Health Research.

Trends in sexual behaviour among London homosexual men 1998–2003: implications for HIV prevention and sexual health promotion

Objectives: To examine changes in sexual behaviour among London homosexual men between 1998 and 2003 by type and HIV status of partner. Methods: Homosexual men (n = 4264) using London gyms were surveyed annually between 1998 and 2003 (range 498–834 per year). Information was collected on HIV status, unprotected anal intercourse (UAI) in the previous 3 months, and type of partner for UAI. High risk sexual behaviour was defined as UAI with a partner of unknown or discordant HIV status. Results: Between 1998 and 2003, the percentage of men reporting high risk sexual behaviour with a casual partner increased from 6.7% to 16.1% (adjusted odds ratio (AOR) 1.36 per year, 95% confidence interval (CI) 1.26 to 1.46, p <0.001). There was no significant change in the percentage of men reporting high risk sexual behaviour with a main partner alone (7.8%, 5.6%, p = 0.7). These patterns were seen for HIV positive, negative and never tested men alike regardless of age. The percentage of HIV positive men reporting UAI with a casual partner who was also HIV positive increased from 6.8% to 10.3% (AOR 1.27, 95% CI 1.01 to 1.58, p <0.05). Conclusion: The increase in high risk sexual behaviour among London homosexual men between 1998 and 2003 was seen only with casual and not with main partners. STI/HIV prevention campaigns among London homosexual men should target high risk practices with casual partners since these appear to account entirely for the recent increase in high risk behaviour.

Regular partners and risky behaviour: Why do gay men have unprotected intercourse?

Studies in both the UK and the USA continue to show that gay and bisexual men put themselves at risk of exposure to HIV through unprotected intercourse, most often with regular partners. As part of a larger study of homosexually active men, 310 men who had had unprotected anal intercourse with a man in the previous year were asked to describe the last occasion on which this had happened. The majority of men had had unprotected intercourse with a regular partner and did not perceived it as risky, although most did not know the HIV status of their partner. Regular and non-regular partners were perceived differently. Men were more likely to be emotionally involved in regular partners and to perceive unprotected penetrative sex with a regular partner as not risky. Future health education initiatives must take into account mens emotional involvement in regular partners and their perception of unprotected intercourse with such partners as not risky.

Social, Behavioural, and Intervention Research among People of Sub-Saharan African Origin Living with HIV in the UK and Europe: Literature Review and Recommendations for Intervention

Africans are the second largest group affected by HIV in Western Europe after men who have sex with men (MSM). This review describes and summarises the literature on social, behavioural, and intervention research among African communities affected by HIV in the UK and other European countries in order to make recommendations for future interventions. We conducted a keyword search using Embase, Medline and PsychInfo, existing reviews, ‘grey literature’, as well as expert working group reports. A total of 138 studies met our inclusion criteria; 31 were published in peer-reviewed journals, 107 in the grey literature. All peer-reviewed studies were observational or “descriptive,” and none of them described HIV interventions with African communities. However, details of 36 interventions were obtained from the grey literature. The review explores six prominent themes in the descriptive literature: (1) HIV testing; (2) sexual lifestyles and attitudes; (3) gender; (4) use of HIV services; (5) stigma and disclosure (6) immigration status, unemployment and poverty. Although some UK and European interventions are addressing the needs of African communities affected by HIV, more resources need to be mobilised to ensure current and future interventions are targeted, sustainable, and rigorously evaluated.

Health-related quality-of-life of people with HIV in the era of combination antiretroviral treatment: a cross-sectional comparison with the general population

BACKGROUND Combination antiretroviral therapy has substantially increased life-expectancy in people living with HIV, but the effects of chronic infection on health-related quality of life (HRQoL) are unclear. We aimed to compare HRQoL in people with HIV and the general population. METHODS We merged two UK cross-sectional surveys: the ASTRA study, which recruited participants aged 18 years or older with HIV from eight outpatient clinics in the UK between Feb 1, 2011, and Dec 31, 2012; and the Health Survey for England (HSE) 2011, which measures health and health-related behaviours in individuals living in a random sample of private households in England. The ASTRA study has data for 3258 people (response rate 64%) and HSE for 8503 people aged 18 years or older (response rate 66%). HRQoL was assessed with the Euroqol 5D questionnaire 3 level (EQ-5D-3L) instrument that measures health on five domains, each with three levels. The responses are scored on a scale where a value of 1 represents perfect health and a value of 0 represents death, known as the utility score. We used multivariable models to compare utility scores between the HIV and general population samples with adjustment for several sociodemographic factors. FINDINGS 3151 (97%) of 3258 of participants in ASTRA and 7424 (87%) of 8503 participants in HSE had complete EQ-5D-3L data. The EQ-5D-3L utility score was lower for people with HIV compared with that in the general population (marginal effect in utility score adjusted for age, and sex/sexuality -0·11; 95% CI -0·13 to -0·10; p < 0·0001). HRQoL was lower for people with HIV for all EQ-5D-3L domains, particularly for anxiety/depression. The difference in utility score was significant after adjustment for several additional sociodemographic variables (ethnic origin, education, having children, and smoking status) and was apparent across all CD4 cell count, antiretroviral therapy, and viral load strata, but was greatest for those people diagnosed with HIV in earlier calendar periods. Reduction in HRQoL with age was not greater in people with HIV than in the general population (pinteraction > 0·05). INTERPRETATION People living with HIV have significantly lower HRQoL than do the general population, despite most HIV positive individuals in this study being virologically and immunologically stable. Although this difference could in part be due to factors other than HIV, this study provides additional evidence of the loss of health that can be avoided through prevention of further HIV infections. FUNDING UK National Institute for Health Research.

Who would use PrEP? Factors associated with intention to use among MSM in London: a community survey

Objective To assess current and intended future use of pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) and characterise those attending sexual health clinics, the anticipated PrEP delivery setting. Design Cross-sectional study. Methods Self-administered survey of 842 HIV negative MSM recruited from social venues in London in 2011. Results One in 10 (10.2%, 83/814, 95% CI 8.2% to 12.5%) and one in 50 (2.1%, 17/809, 95% CI 1.2% to 3.3%) reported having ever used post-exposure prophylaxis (PEP) and PrEP respectively. Half reported they would be likely to use PrEP if it became available as a daily pill (50.3%, 386/786, 95% CI 46.7% to 53.9%). MSM were more likely to consider future PrEP use if they were <35 years (adjusted OR (AOR) 1.57, 95% CI 1.16 to 2.14), had unprotected anal intercourse with casual partners (AOR 1.70, 95% CI 1.13 to 2.56), and had previously used PEP (AOR 1.94, 95% CI 1.17 to 3.24). Over half of MSM (54.8% 457/834 95% CI 51.3 to 58.2) attended a sexual health clinic the previous year. Independent factors associated with attendance were age <35 (AOR 2.29, 95% CI 1.68 to 3.13), and ≥10 anal sex partners in the last year (AOR 2.49, 95% CI 1.77 to 3.52). Conclusions The concept of PrEP for HIV prevention in the form of a daily pill is acceptable to half of sexually active MSM in London. MSM reporting higher risk behaviours attend sexual health clinics suggesting this is a suitable setting for PrEP delivery.

Sex, drugs and smart phone applications: findings from semistructured interviews with men who have sex with men diagnosed with Shigella flexneri 3a in England and Wales

Objectives To inform control strategies undertaken as part of an outbreak of Shigella flexneri 3a among men who have sex with men (MSM). Methods All men aged ≥18 years diagnosed with S flexneri 3a between October 2012 and May 2013 were invited to participate. Semistructured in-depth quantitative interviews were conducted to explore lifestyle and sexual behaviour factors. Results Of 53 men diagnosed, 42 were interviewed of whom 34 were sexually active MSM. High numbers of sexual partners were reported (median=22) within the previous year; most were casual encounters met through social media networking sites (21/34). 63% (20/32) were HIV-positive and actively sought positive partners for condomless sex. 62% (21/34) of men had used chemsex drugs (mephedrone, crystal methamphetamine and γ-butyrolactone/γ-hydroxybutrate), which facilitate sexually disinhibiting behaviour during sexual encounters. 38% (8/21) reported injecting chemsex drugs. Where reported almost half (12/23) had attended or hosted sex parties. All reported oral–anal contact and fisting was common (16/34). Many had had gonorrhoea (23/34) and chlamydia (17/34). HIV-positive serostatus was associated with both insertive anal intercourse with a casual partner and receptive fisting (adjusted OR=15.0, p=0.01; adjusted OR=18.3, p=0.03) as was the use of web applications that promote and facilitate unprotected sex (adjusted OR=19.8, p=0.02). Conclusions HIV-positive MSM infected with S flexneri 3a used social media to meet sexual partners for unprotected sex mainly at sex parties. The potential for the transmission of S flexneri, HIV and other infections is clear. MSM need to be aware of the effect that chemsex drugs have on their health.

Risk behaviour and STD acquisition in genitourinary clinic attenders who have travelled.

OBJECTIVE--To investigate the travel history of clients presenting at a genitourinary medicine (GUM) clinic in order to assess the contribution made by sexual partnerships abroad to STD transmission in the UK. SUBJECTS--386 old and new clients who attended during a 3-month period and who had travelled abroad in the 3 months preceding their visit. METHODS--All participating clients self-completed a confidential questionnaire, the results of which were then linked to their clinical diagnosis (if any). RESULTS--25% of participants reported a new sexual partner during their most recent trip abroad. In comparison to those not reporting a new partner, they were more likely to be male, travelling alone, to have visited the clinic previously and to have no regular sexual partner. Two-thirds reported never or inconsistently using condoms with these new partners. A total of 11.6% of the STDs diagnosed in the study participants may have been acquired abroad. CONCLUSION--We have found a high rate of new sexual relationships reported by attendees at our GUM clinic, and a low rate of reported condom use. With high HIV incidence rates in many tourist regions, the need for further studies to establish the true extent of imported STDs in the UK is a priority, and primary prevention campaigns to inform travellers are of paramount importance.