Lisa M Williamson

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.

Sexual risk behaviour and knowledge of HIV status among community samples of gay men in the UK

Objectives:Undiagnosed infection presents a potential risk for the onward transmission of HIV and denies men early interventions for their health. Little is known about the differences between men who are, and are not, aware of their HIV status in the UK. Methods:Cross-sectional surveys of men in commercial gay venues in London, Brighton, Manchester, Glasgow, and Edinburgh (2003–2005). Anonymous, self-completion questionnaires, and oral fluid samples (tested for HIV antibodies) were obtained from 3672 men (61% response rate). Results:Of 3501 men with a confirmed positive or negative oral fluid result, 318 were HIV positive (9.1%). Of these, 131 (41.2%) were undiagnosed; 81.1% of men with undiagnosed HIV had previously tested (92.2% tested negative; the remainder did not know the result); 62.3% still thought that they were negative. Undiagnosed and diagnosed men reported greater sexual risk and sexually transmitted infections than HIV-negative men. Compared with HIV-negative men, the adjusted odds ratio of unprotected anal intercourse with two or more partners was higher among undiagnosed men (odds ratio 2.21, 95% confidence interval 1.17–4.20), but highest among diagnosed men (odds ratio 6.80, 95% confidence interval 4.39–10.52). Conclusion:A high proportion of the HIV-positive men were undiagnosed and not receiving benefits of clinical care, but sexual risk and sexually transmitted infections were highest among men who were aware of their HIV-positive status. Clinics should proactively offer testing to reduce undiagnosed HIV, target repeat testing at high-risk men who have previously tested negative, and initiate evidence-based behavioural interventions to reduce sexual risk among men living with diagnosed HIV as well as those testing negative.

The Gay Men's Task Force: the impact of peer education on the sexual health behaviour of homosexual men in Glasgow.

Objective: To assess the impact of a peer education intervention, based in the “gay” bars of Glasgow, which sought to reduce sexual risk behaviours for HIV infection and increase use of a dedicated homosexual mens sexual health service, and in particular increase the uptake of hepatitis B vaccination. Design: Self completed questionnaires administered to men who have sex with men (MSM) in Glasgows gay bars. Subjects: 1442 men completed questionnaires in January 1999, 7 months after the end of the 9 month sexual health intervention. Main outcome measures: Self reported contact with the peer education intervention, reported behaviour change, and reported sexual health service use. Results: The Gay Mens Task Force (GMTF) symbol was recognised by 42% of the men surveyed. Among men who reported speaking with peer educators 49% reported thinking about their sexual behaviour and 26% reported changing their sexual behaviour. Logistic regressions demonstrated higher levels of HIV testing, hepatitis B vaccination, and use of sexual health services among men who reported contact with the intervention. These men were more likely to have used the homosexual specific sexual health service. Peer education dose effects were suggested, with the likelihood of HIV testing, hepatitis B vaccination, and use of sexual health services being greater among men who reported talking to peer educators more than once. Conclusion: The intervention had a direct impact on Glasgows homosexual men and reached men of all ages and social classes. Higher levels of sexual health service use and uptake of specific services among men who had contact with the intervention are suggestive of an intervention effect. Peer education, as a form of health outreach, appears to be an effective intervention tool in terms of the uptake of sexual health services, but is less effective in achieving actual sexual behaviour change among homosexual men.

Young women and limits to the normalisation of condom use: a qualitative study

Abstract Encouraging condom use among young women is a major focus of HIV/STI prevention efforts but the degree to which they see themselves as being at risk limits their use of the method. In this paper, we examine the extent to which condom use has become normalised among young women. In-depth interviews were conducted with 20 year old women from eastern Scotland (N=20). Purposive sampling was used to select a heterogeneous group with different levels of sexual experience and from different social backgrounds. All of the interviewees had used (male) condoms but only three reported consistent use. The rest had changed to other methods, most often the pill, though they typically went back to using condoms occasionally. Condoms were talked about as the most readily available contraceptive method, and were most often the first contraceptive method used. The young women had ingrained expectations of use, but for most, these norms centred only on their new or casual partners, with whom not using condoms was thought to be irresponsible. Many reported negative experiences with condoms, and condom dislike and failure were common, lessening trust in the method. Although the sexually transmitted infection (STI) prevention provided by condoms was important, this was seen as additional, and secondary, to pregnancy prevention. As the perceived risks of STIs lessened in relationships with boyfriends, so did condom use. The promotion of condoms for STI prevention alone fails to consider the wider influences of partners and young womens negative experiences of the method. Focusing on the development of condom negotiation skills alone will not address these issues. Interventions to counter dislike, method failure, and the limits of the normalisation of condom use should be included in STI prevention efforts.

Young women under 16 years with experience of sexual intercourse: who becomes pregnant?

Background: The UK has the highest rate of teenage pregnancies in western Europe. Although there is a large body of literature focusing on predictors of conception among this age group, almost all the work compares those young women who have become pregnant with their peers, regardless of whether or not their peers have experienced sexual intercourse. Objective: To compare 16-year-old young women who have become pregnant with their peers who also have experience of sexual intercourse, but who have not conceived. Design: Analysis of data from the baseline and follow-up surveys conducted as part of a trial of sex education. Setting and participants: Female school students aged 14–16 years from the East of Scotland. Main results: Young age of self and partner, and non-use of contraception, all at first intercourse, are most strongly associated with pregnancy. Conclusions: Those who engage in sexual intercourse at a relatively young age will often have had more opportunity to become pregnant than those whose sexual debut comes later. Similarly, the fact that those who use contraception at first intercourse have been less likely to conceive than those who do not could reflect the overall patterns of contraceptive use: young women who have used contraception at each occasion of intercourse will have had less chance to conceive than those who have not. Having a young partner at first intercourse suggests that, if this pattern continues, the couple may lack the resources needed to prevent a pregnancy due to the immaturity of both partners.

HIV prevalence and undiagnosed infection among a community sample of gay men in Scotland.

Objective:To examine HIV prevalence among men in gay bars in Glasgow and Edinburgh, Scotland. Methods:Self-complete questionnaires and Orasure oral fluid collection kits (OraSure Technologies, Inc., Bethlehem, PA), to collect samples to be tested anonymously for HIV antibodies, were distributed. A total of 1744 men completed questionnaires (66.1% response rate), and 1350 provided samples (51.6% response rate). Results:HIV prevalence was 4.4% (95% confidence interval: 3.5% to 5.7%). Positivity was associated with older age (mean of 36 years for positive men vs. 32 years for negative men), having 10 or more anal intercourse (AI) partners (12.8% positive vs. 3.4% of men with <10 AI partners, P < 0.05), and self-reported sexually transmitted infections (STIs) in the previous year (12.3% positive vs. 3.5% of men without STIs in the previous year; P < 0.05). Of the HIV-positive men, 41.7% were undiagnosed. More than half had had a negative HIV test result and perceived themselves to be HIV-negative. Men who had not used a genitourinary medicine clinic or had an STI in the previous year were more likely to be undiagnosed (65.0% and 52.5%, respectively). Conclusions:This is the first study to assess HIV prevalence among a community sample of gay men in Scotland. There is an urgent need for HIV prevention efforts to address the high level of undiagnosed infection and incorrect assumptions of status.

Increases in HIV-related sexual risk behavior among community samples of gay men in London and Glasgow: How do they compare?

Objective: In this paper, we compare trends in sexual risk among gay men in the largest city in England (London) and the largest city in Scotland (Glasgow). Methods: Self-complete questionnaires administered to representative samples of men visiting the commercial gay scenes in London and Glasgow in 1996, 1999, and 2002 (N = 8247). Results: Multivariate logistic regression was used to assess the trends in unprotected anal intercourse (UAI), UAI with partners of unknown/discordant HIV status, and UAI with more than 1 partner. Each increased significantly in 1999 and 2002 in London, but only in 2002 in Glasgow. Testing for HIV also increased significantly in London, but not in Glasgow. Overall, HIV testing levels were considerably lower in Glasgow (in 2002, 49.1% vs. 74.6% in London). Overall, sexual risk was higher in London, but UAI with partners of unknown/discordant HIV status was higher in Glasgow (in 2002, 27.4% vs. 21.3%). Conclusions: Although the same pattern of increase in HIV-related sexual risk behavior was apparent in the cities, differences in HIV testing and nonconcordant UAI suggest different HIV prevention needs and that targeted health promotion interventions are required in London and Glasgow. City-specific factors should be considered in the development of appropriate sexual health interventions.

HIV testing trends among gay men in Scotland, UK (1996–2005): implications for HIV testing policies and prevention

Objective: To examine trends in the HIV testing behaviour of gay men in Scotland over a 10-year period. Methods: Seven cross-sectional surveys in commercial gay venues in Glasgow and Edinburgh (1996–2005). 9613 men completed anonymous, self-completed questionnaires (70% average response rate). Results: Among 8305 respondents included in these analyses, HIV testing increased between 1996 and 2005, from 49.7% to 57.8% (p<0.001). The proportion of men who had tested recently (in the calendar year of, or immediately before, the survey) increased from 28.4% in 1996 to 33.2% in 2005, when compared with those who have tested but not recently, and those who have never tested (adjusted odds ratio 1.31, 95% CI 1.13 to 1.52). However, among ever testers, there was no increase in rates of recent testing. Recent testing decreased with age: 31.3% of the under 25, 30.3% of the 25–34, 23.2% of the 35–44 and 21.2% of the over 44 years age groups had tested recently. Among men reporting two or more unprotected anal intercourse partners in the previous year, only 41.4% had tested recently. Conclusions: HIV testing among gay men in Scotland increased between 1996 and 2005, and corresponds with the Scottish Government policy change to routine, opt-out testing in genitourinary medicine clinics. Testing rates remain low and compare unfavourably with near-universal testing levels elsewhere. The limited change and decline across age groups in recent HIV testing rates suggest few men test repeatedly or regularly. Additional, innovative efforts are required to increase the uptake of regular HIV testing among gay men.

Chlamydia trachomatis testing among 13–25-year-olds in non-genitourinary medicine settings

Objectives In this paper we examine Chlamydia trachomatis testing in settings other than genitourinary medicine (GUM) clinics, focusing on the factors associated with chlamydial infection and with postal testing. Methods Analysis of tests collected from young people aged 13–25 years (n = 4475) between May 2001 and June 2004 via postal testing kits, at a local sexual health clinic, and at further education colleges in Lothian, Scotland. Results 84.8% of the testers were female and 15.2% were male. 84 men (12.3%, 95% CI 10.1–15.0) and 403 women (10.6%, 95% CI 9.7–11.6) tested positive. The odds of a positive result was nearly doubled for postal and clinic testers, relative to college testers; and increased by 70% for 16–19-year-olds, compared with 13–15-year-olds. Postal testing was the main source for men (80.2%) while 46.1% of women used postal and 48.1% used clinic testing. Postal testing was significantly associated with age, sex and National Health Service (NHS) board area, with odds increasing with age, and lower odds among females than males, and among Lothian residents than those outwith this NHS board area. Conclusions Substantial chlamydial infection was apparent among the young people in this study and positivity rates were highest among postal and clinic testers and those in the 16–19-year age group. While postal kits were the main source for men, and should be used to target them, the combination of this approach with continuing screening programmes in clinic settings would be most effective at targeting those most at risk.

AIDS mortality in African migrants living in Portugal: evidence of large social inequalities

Objective: To examine infectious disease and AIDS mortality among African migrants in Portugal, gender and socio-economic differences in AIDS mortality risk, and differences between African migrants to Portugal and to England and Wales. Methods: Data from death registrations, 1998–2002, and the 2001 Census were used to derive standardised death rates by country of birth, occupational class (men only), and marital status. Results: Compared with people born in Portugal, African migrants had higher mortality for infectious diseases including AIDS. There was considerable heterogeneity among Africans, with those from Cape Verde having the highest mortality. Death rates were more than five times higher among those who were unmarried than those who were. A larger proportion of Africans were unmarried accounting for some excess mortality. Death rates were also higher among men from manual occupational classes than among men from non-manual. A comparison with England and Wales shows that death rates for infectious disease and AIDS in Portugal are much higher and Africans in Portugal also fare worse than Africans in England and Wales. Conclusion: AIDS mortality rates were higher among Africans than those born in Portugal and were associated with socio-environmental factors. Further research is required to interpret the excess mortality among Africans and there is a need to ensure the inclusion of relevant data items on ethnicity in national monitoring and surveillance systems.