Kristen L. Hess

Anal intercourse among young heterosexuals in three sexually transmitted disease clinics in the United States.

Objective: To examine factors associated with heterosexual anal intercourse (AI). Methods: Between 2001 and 2004, 1084 heterosexual adults aged 18 to 26 attending public sexually transmitted disease clinics in Seattle, New Orleans, and St Louis were interviewed using computer-assisted self interview and tested for STIs; Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, Trichomonas vaginalis, and genital herpes (HSV-2). Characteristics associated with AI were identified using logistic regression. Results: Overall 400 (37%) reported ever having had AI, 266 (28.9%) reported AI with at least 1 of their last 3 partners, and 19% reported AI with their last partner. Fewer women than men reported condom use at last AI (26% vs. 45%, P <0.001). Ever having AI was associated with sex on the same day as meeting a partner [AOR 3.9 (95% CI, 2.46–6.21)], receiving money for sex [AOR 2.8 (1.40–5.45)], and >3 lifetime sex partners [AOR 2.8 (1.56–5.07)] among women, and sex on the same day as meeting a partner [AOR 2.0 (1.33–3.06]) among men. AI with the last partner was associated with sex toy use [AOR 5.6 (2.63–12.0)] and having concurrent partners [AOR 2.2 (1.21–4.11)] among men, and with sex within a week of meeting [AOR 2.4 (1.28–4.37)], believing the partner was concurrent (AOR 1.9 [1.12–3.22]), and sex toy use [AOR 5.7 (2.31–14.0)] among women. Prevalent vaginal and urethral sexually transmitted infections were not associated with AI. Conclusions: Many young heterosexuals attending sexually transmitted disease clinics reported AI, which was associated with other sexual risk behaviors, suggesting a confluence of risks for HIV infection.

Intimate partner violence and sexually transmitted infections among young adult women

Background: Intimate partner violence (IPV) is common among young adult relationships, and is associated with significant morbidity, including sexually transmitted infections (STI). This study measured the association between IPV victimization and perpetration and prevalent STIs and STI-risk behaviors among a sample of young women. Methods: This analysis uses wave 3 of the National Longitudinal Study of Adolescent Health and was restricted to the 3548 women who reported on a sexual relationship that occurred in the previous 3 months and agreed to STI testing. A multivariate random effects model was used to determine associations between STI and STI-risk behaviors and IPV. Results: The IPV prevalence over the past year was 32%—3% victim-only, 12% perpetrator-only, and 17% reciprocal. The STI prevalence was 7.1%. Overall, 17% of participants reported partner concurrency and 32% reported condom use at last vaginal intercourse. In multivariate analysis, victim-only and reciprocal IPV were associated with not reporting condom use at last vaginal intercourse. Perpetrator-only, victim-only, and reciprocal IPV were associated with partner concurrency. Victim-only IPV was associated with a higher likelihood of having a prevalent STI (odds ratio: 2.1; 95% confidence interval: 1.0–4.2). Conclusions: This analysis adds to the growing body of literature that suggests that female IPV victims have a higher STI prevalence, as well as a higher prevalence of STI-risk behaviors, compared with women in nonviolent relationships. Women in violent relationships should be considered for STI screening in clinics, and IPV issues should be addressed in STI prevention messages, given its impact on risk for STI acquisition.

Intravaginal practices and risk of bacterial vaginosis and candidiasis infection among a cohort of women in the United States.

OBJECTIVE: To measure intravaginal practices among women of differing ages, ethnicities, and human immunodeficiency virus status and the association between intravaginal practices and bacterial vaginosis and candidiasis infection. METHODS: Between 2008 and 2010, we recruited and followed sexually active women aged 18–65 years living in Los Angeles. At the enrollment and month 12 visit, participants completed a self-administered, computer-assisted questionnaire covering demographics, sexual behaviors, vaginal symptoms, and intravaginal practices over the past month. At each visit, bacterial vaginosis and candidiasis infection were diagnosed by Nugent criteria and DNA probe, respectively. RESULTS: We enrolled 141 women. Two thirds (66%) reported an intravaginal practice over the past month; 49% reported insertion of an intravaginal product (other than tampons) and 45% reported intravaginal washing. The most commonly reported practices included insertion of commercial sexual lubricants (70%), petroleum jelly (17%), and oils (13%). In univariable analysis, intravaginal use of oils was associated with Candida species colonization (44.4% compared with 5%, P<.01). In multivariable analysis, women reporting intravaginal use of petroleum jelly over the past month were 2.2 times more likely to test positive for bacterial vaginosis (adjusted relative risk 2.2, 95% confidence interval 1.3–3.9). CONCLUSION: Intravaginal insertion of over-the-counter products is common among women in the United States and is associated with increased risk of bacterial vaginosis. The context, motivations for, and effects of intravaginal products and practices on vaginal health are of concern and warrant further study. LEVEL OF EVIDENCE: III

Syphilis Trends among Men Who Have Sex with Men in the United States and Western Europe: A Systematic Review of Trend Studies Published between 2004 and 2015

Globally, men who have sex with men (MSM) are disproportionately burdened with syphilis. This review describes the published literature on trends in syphilis infections among MSM in the US and Western Europe from 1998, the period with the fewest syphilis infections in both geographical areas, onwards. We also describe disparities in syphilis trends among various sub-populations of MSM. We searched electronic databases (Medline, Embase, Global Health, PsychInfo, CAB Abstracts, CINAHL, Sociological Abstracts, Web of Science, Cochrane Library, and LILACS) for peer-reviewed journal articles that were published between January 2004 and June 2015 and reported on syphilis cases among MSM at multiple time points from 1998 onwards. Ten articles (12 syphilis trend studies/reports) from the US and eight articles (12 syphilis trend studies/reports) from Western Europe were identified and included in this review. Taken together, our findings indicate an increase in the numbers and rates (per 100,000) of syphilis infections among MSM in the US and Western Europe since 1998. Disparities in the syphilis trends among MSM were also noted, with greater increases observed among HIV-positive MSM than HIV-negative MSM in both the US and Western Europe. In the US, racial minority MSM and MSM between 20 and 29 years accounted for the greatest increases in syphilis infections over time whereas White MSM accounted for most syphilis infections over time in Western Europe. Multiple strategies, including strengthening and targeting current syphilis screening and testing programs, and the prompt treatment of syphilis cases are warranted to address the increase in syphilis infections among all MSM in the US and Western Europe, but particularly among HIV-infected MSM, racial minority MSM, and young MSM in the US.

Intimate partner violence and anal intercourse in young adult heterosexual relationships.

CONTEXT Although intimate partner violence and anal intercourse are common in young adult relationships, few studies have examined whether these behaviors are associated with each other. METHODS Data from 6,280 women aged 18-28 who took part in Wave 3 of the National Longitudinal Study of Adolescent Health were used to examine the association between physical and sexual intimate partner violence and anal intercourse in 10,462 relationships. Multivariate hierarchical random effects models were used to adjust for the clustered survey design and for the multiple relationships reported per participant. RESULTS Physical violence occurred in 29% of relationships, sexual violence in 11% and anal intercourse in 14%. The odds that a couple had had anal intercourse were greater among relationships that included physical violence perpetrated by both partners or only by the woman than among nonviolent relationships (odds ratios, 1.7 and 1.9, respectively). The odds of anal intercourse were also elevated among sexually abusive relationships, although only if the woman was the sole victim or the sole perpetrator (1.3 and 2.0, respectively). In relationships that included anal intercourse, the odds of condom use were lower if the woman was a victim of physical violence than if no violence occurred (0.2). Sexual violence was not associated with condom use. CONCLUSION Women in physically violent relationships may be at increased risk for STDs because of their elevated exposure to unprotected anal intercourse. More information on the context surrounding anal intercourse and intimate partner violence is needed to understand the nuances of this association.

Risk behaviours by type of concurrency among young people in three STI clinics in the United States

BACKGROUND Concurrent sexual partnerships can increase sexually transmissible infections (STI) transmission on a population level. However, different concurrency types may be associated with differential risks for transmission. To investigate this, we describe the prevalence and correlates of four specific concurrency types. METHODS Between 2001 and 2004, 1098 young adults attending three STI clinics were interviewed and tested for STIs. Characteristics associated with concurrency types were identified using logistic regression. RESULTS Approximately one-third of respondents reported reactive (34%), transitional (36%), compensatory (32%) and experimental (26%) concurrency. Among men, reactive concurrency was associated with not identifying as heterosexual, drug use and having sex the same day as meeting a partner. Among women, reactive concurrency was associated with African-American race and having >3 lifetime partners. Transitional concurrency was associated with >3 lifetime partners for men and women. Among men, compensatory concurrency was associated with African-American race; among women, there were no associations with compensatory concurrency. Among men, experimental concurrency was associated with >3 lifetime partners and having sex the same day as meeting a partner. Among women, experimental concurrency was associated with not identifying as heterosexual, drug use and having sex the same day as meeting a partner. CONCLUSIONS All concurrency types were common in this population and each was associated with a set of demographic and risk factors. Reactive and experimental concurrency types were associated with other high-risk behaviours, such as drug use.

Motivations for Intravaginal Product Use among a Cohort of Women in Los Angeles

Objective Intravaginal practices—including behaviors such as intravaginal cleansing and insertion of products—have been linked to a number of adverse reproductive health outcomes, including increased risk for bacterial vaginosis, sexually transmitted infections, and HIV. Currently, little is known about the motivations for intravaginal practices among women in the United States. The objective of this study was to identify and describe motivations for intravaginal washing and intravaginal insertion of products among women of differing ages and racial/ethnic groups. Methods Between 2008 and 2010, we enrolled a convenience sample of sexually active women aged 18–65 years living in Los Angeles recruited through community education and outreach activities in HIV/AIDS service organizations, women’s health clinics, community-based organizations, and HIV testing sites. At the enrollment visit, women completed a self-administered, computer-assisted questionnaire covering demographics, sexual behaviors, intravaginal practices, and motivations for intravaginal practices over the past month and past year. Results We enrolled 141 women; 34% of participants were Caucasian, 40% African American, and 26% Latina. Peri-sexual intravaginal washing was common in all groups, whether to clean up after sex (70%) or to prepare for sex (54%). African American women were more likely to report learning to wash intravaginally from their mothers compared to Latina or Caucasian women (70% vs. 49%, P = 0.04). Sixty-one percent of African American women reported using a douching device over the past year compared to 41% of Latina and 40% of Caucasian women (p = 0.02). Younger women were more likely to report that their male partners wanted them to wash intravaginally than older women (77% vs. 24%, P<0.01), and more likely to report the removal of odors as a motive than older women (65% vs. 40%, P = 0.04). The most commonly used intravaginal products included sexual lubricants, petroleum jelly, body lotions, oils, and wet wipes. Use of these products varied by race, and motives given included increasing lubrication, preparing for sex, smelling good, and preventing sexually transmitted infections. Conclusion Women’s intravaginal practices and motivations for these practices differ across race and age. Motivations for use also vary by type of intravaginal product used. Given that some intravaginal practices have been shown to be harmful, interventions, programs and counseling messages to encourage less harmful practices are needed, and should consider underlying motivations that influence women’s vaginal practices. Practitioners may use these results to better support women in achieving vaginal health.

Exchange Sex and HIV Infection Among Women Who Inject Drugs—20 US Cities, 2009

Background: Women who inject drugs and who also exchange sex are at increased risk for HIV infection, but data on this population in the United States remain sparse. Methods: This study assessed the prevalence of exchanging sex for money or drugs among women who inject drugs using data from the 2009 US National HIV Behavioral Surveillance (NHBS) system. Prevalence of being HIV-positive (testing positive in NHBS), HIV-positive–unaware (reporting being HIV-negative or unknown status but testing positive in NHBS), and risk behaviors and use of services were compared between women who did and did not exchange sex. The association between exchange sex and being HIV-positive–unaware of the infection was examined using multivariate Poisson models with robust standard errors. Results: Among 2305 women who inject drugs, 39% reported receiving things like money or drugs from ≥1 male partners in exchange for oral, vaginal, or anal sex in the previous 12 months. Women who exchanged sex were more likely to be unemployed, homeless, lack health insurance, have multiple condomless vaginal or anal sex partners, and receptively share syringes. In multivariate analysis, exchange sex was associated with being HIV-positive–unaware (adjusted prevalence ratio 1.97, 95% confidence intervals: 1.31 to 2.97). Conclusions: Prevalence of exchange sex was high in this population. Women who exchange sex were more likely to be socially disadvantaged, report sexual and injection risk, and be HIV-positive–unaware. They represent an important group to reach with HIV prevention, testing, and care services.

P1-S1.27 Intravaginal practices, lubrication, and bacterial vaginosis among women in Los Angeles

Background Bacterial vaginosis (BV) has been associated with HIV acquisition and transmission. Intravaginal practices may affect womens vulnerability to BV and HIV/STIs, and may influence results of trials of microbicides for HIV prevention through effects on the vaginal environment and on adherence to investigational microbicidal products. We measured the prevalence and frequency of intravaginal hygiene and lubricant use and their association with BV among both HIV-positive and HIV-negative women. Methods Between October 2008 and June 2009, we recruited women aged 18 years and older in Los Angeles. At the enrolment visit and 12 months later, participants underwent a self-administered, web-based questionnaire covering demographics, sexual behaviours, intravaginal hygiene, and lubricant use. HIV was diagnosed by rapid ELISA, with confirmation by Western blot. BV was diagnosed by Nugent criteria from a self-collected vaginal swab. Here we report data collected at enrolment. Results We enrolled 141 women (34% identified as White, 40% Black, 26% Hispanic; the median age was 33 years (IQR=25–44)). Overall, 56% of women reported intravaginal cleaning and 45% reported douching over the past month. Overall, nearly three-quarters (73.8%) reported intravaginal insertion of a lubricating product over the past month; commercial lubricant (42.6%), lotion (12.1%), petroleum jelly (10.6%), and oil (7.8%) were the most commonly reported lubricants. The prevalence of BV was 21% and HIV was 27%. In multivariable analysis, intravaginal insertion of oil, lotion, or petroleum jelly (aOR=3.4 (95% CI=1.2 to 9.7)) was associated with BV controlling for douching, age, race, HIV status, and multiple sexual partners. Conclusion Use of intravaginal lubricating products not specifically designed for sexual intercourse is common among women. The use of such lubricants and their association with BV is of particular concern and warrants further study; not only in light of the direct association with BV, but also because of the link between BV and HIV infection.