Marguerite A. Urban

Childhood sexual abuse and sexual risk behavior among men and women attending a sexually transmitted disease clinic.

Childhood sexual abuse (CSA) is associated with a wide range of negative outcomes. The authors investigated the relation between CSA and sexual risk behavior in 827 patients recruited from a sexually transmitted disease (STD) clinic. Overall, CSA was reported by 53% of women and 49% of men and was associated with greater sexual risk behavior, including more sexual partners, unprotected sex, and sex trading. Alcohol use for men and drug use for women mediated the relation between CSA and the number of sexual partners in the past 3 months; intimate partner violence mediated the relation between CSA and the number of episodes of unprotected sex in the past 3 months for women. These results document the prevalence of CSA among patients seeking care for an STD and can be used to tailor sexual risk reduction programs for individuals who were sexually abused.

Characteristics of sexual abuse in childhood and adolescence influence sexual risk behavior in adulthood.

Childhood and adolescent sexual abuse has been associated with subsequent (adult) sexual risk behavior, but the effects of force and type of sexual abuse on sexual behavior outcomes have been less well-studied. The present study investigated the associations between sexual abuse characteristics and later sexual risk behavior, and explored whether gender of the child/adolescent moderated these relations. Patients attending an STD clinic completed a computerized survey that assessed history of sexual abuse as well as lifetime and current sexual behavior. Participants were considered sexually abused if they reported a sexual experience (1) before age 13 with someone 5 or more years older, (2) between the ages of 13 and 16 with someone 10 or more years older, or (3) before the age of 17 involving force or coercion. Participants who were sexually abused were further categorized based on two abuse characteristics, namely, use of penetration and force. Analyses included 1177 participants (n=534 women; n=643 men). Those who reported sexual abuse involving penetration and/or force reported more adult sexual risk behavior, including the number of lifetime partners and number of previous STD diagnoses, than those who were not sexually abused and those who were abused without force or penetration. There were no significant differences in sexual risk behavior between nonabused participants and those who reported sexual abuse without force and without penetration. Gender of the child/adolescent moderated the association between sexual abuse characteristics and adult sexual risk behavior; for men, sexual abuse with force and penetration was associated with the greatest number of episodes of sex trading, whereas for women, those who were abused with penetration, regardless of whether the abuse involved force, reported the most episodes of sex trading. These findings indicate that more severe sexual abuse is associated with riskier adult sexual behavior.

Brief and Intensive Behavioral Interventions to Promote Sexual Risk Reduction among STD Clinic Patients: Results from a Randomized Controlled Trial

The purpose of this study was to evaluate the separate and combined effectiveness of brief and intensive interventions for sexual risk reduction among patients at a sexually transmitted disease (STD) clinic. Patients (N =1483; 54% men; 64% African-American; M = 29.2 years old) were recruited from a publicly funded, walk-in STD clinic. Patients completed a baseline assessment, and then were randomized to one of six intervention arms; each arm combined a brief intervention with an intensive intervention. The interventions provided different levels of information, motivational counseling, and behavioral skills training, guided by theory, formative research, and empiric precedent. Follow-up assessments, including STD screening, occurred at 3, 6, and 12 months post-intervention. The results showed that infection rates declined from 18.1% at baseline to 4.5% at 12 months. At a 3-month follow-up, patients reported fewer sexual partners, fewer episodes of unprotected sex, and a lower percentage of unprotected sexual events; they strengthened sexual health knowledge, safer sex attitudes and intentions, and self-efficacy beliefs. No consistent pattern of differential risk reduction was observed among the six intervention conditions, nor was any evidence of decay from 3 to 12-month follow-ups obtained. We conclude that implementing behavioral interventions in a STD clinic was associated with significant reduction of sexual risk behavior and risk antecedents.

Sexual partner concurrency among STI clinic patients with a steady partner: correlates and associations with condom use

Objectives: Partner concurrency facilitates the transmission of HIV and other sexually transmitted infections (STIs). In this study, we sought to (1) determine the correlates of concurrency among patients with a steady partner, and (2) identify correlates of condom use among patients reporting concurrent steady and non-steady partners. Methods: Patients recruited from an STI clinic (n = 973; 48% female; 68% African-American) completed a survey that assessed demographic characteristics, substance use, sexual partnerships and sexual behaviour, including condom use. Patients reporting a steady sexual partner for 3 months or longer were included in the analyses. Those who also reported a non-steady partner in the past 3 months, in addition to a steady partner, were considered to have engaged in concurrency. Results: Nearly two-thirds (64%) of patients reported both steady and non-steady partners in the past 3 months. Steady/non-steady concurrency was associated with being male, not cohabitating with a partner, use of alcohol and other drugs, and thinking their steady partner was monogamous. Patients with steady and non-steady partners reported that they seldom used condoms consistently with steady (5%) or non-steady (24%) partners. Compared to patients who did not report concurrency, patients who reported steady/non-steady concurrency reported more episodes of unprotected sex in the past 3 months. Among patients reporting concurrency, consistent condom use with non-steady partners was more likely among individuals who (a) used less alcohol and (b) thought that their steady partner was non-monogamous. Conclusions: To reduce risk for HIV and other STIs, behavioural interventions need to address partner concurrency and its correlates, including alcohol and other drug use.

Evaluating a two-step approach to sexual risk reduction in a publicly-funded STI clinic: Rationale, design, and baseline data from the Health Improvement Project-Rochester (HIP-R)

BACKGROUND Sexually transmitted infection (STI) clinics provide an opportune setting for HIV prevention efforts. This randomized controlled trial evaluated a unique, two-step approach to sexual risk reduction at a publicly-funded STI clinic. METHODS During an initial visit, patients completed an audio-computer assisted self-interview (ACASI), were randomized to and received one of two brief interventions, obtained medical care, and completed a post-assessment. Next, two-thirds of the patients were assigned to attend an intensive sexual risk reduction workshop. At 3, 6, and 12 months, patients completed additional ACASIs and provided urine specimens to assess behavior change and incident STIs. RESULTS During a 28-month interval, 5613 patients were screened, 2691 were eligible, and 1483 consented to participate and were randomized; the modal reason for declining was lack of time (82%). Consenting patients included 688 women and 795 men; 64% of participants were African-American. The sample was low-income, with 57% reporting an annual income of less than

Predicting Condom Use among STD Clinic Patients Using the Information-Motivation-Behavioral Skills (IMB) Model

15,000; most participants (62%) had a high school education or less, and 51% were unemployed. Sexual risk behavior was common, as indicated by multiple sexual partners (mean=32.8, lifetime; mean=2.8, past 3 months), unprotected sex (mean=17.3 episodes, past 3 months), and prior STIs (mean=3.3, lifetime; 23% at baseline). Bivariate analyses confirmed our prediction that HIV-related motivation and behavioral skills would be related to current sexual risk behavior. All patients received a brief intervention; patient satisfaction ratings were uniformly high for both interventions (all means >or=3.7 on 4-point scales). Fifty-six percent of invited patients attended the intensive workshop, and attendance did not differ as a function of brief intervention. Patient satisfaction ratings were also uniformly positive for the workshop interventions (all means >or=3.6). Return to follow-up assessments exceeded 70%. CONCLUSIONS Results demonstrate that implementing an HIV preventive program in a busy, public clinic is feasible and well-accepted by patients. Ongoing evaluation will determine if the interventions reduce sexual risk behavior and lower incident STIs.

Improving HIV rapid testing rates among STD clinic patients: A randomized controlled trial.

We assessed determinants of condom use postulated by the IMB model among STD patients (N = 1474). The model provided acceptable fit to the data (CFI = 0.99, RMSEA = .04). Information was unrelated to condom use but had a negative effect on behavioral skills. Motivation had a positive effect on behavioral skills and condom use. Behavioral skills had a positive effect on condom use. In multiple-groups analyses, stronger associations between motivation and condom use were found among participants reporting no prior STD treatment. Interventions among STD patients should include activities addressing condom use motivation and directly enhancing condom skills.

Recruiting patients from a sexually transmitted disease clinic to sexual risk reduction workshops: are monetary incentives necessary?

OBJECTIVE The Centers for Disease Control and Prevention recommends that HIV testing be a standard part of medical care; however, testing is voluntary and some patients decline. We evaluated 2 brief interventions to promote rapid HIV testing among STD clinic patients who initially declined testing. METHOD Using a randomized controlled trial, patients either viewed an educational digital video disc (DVD) or participated in stage-based behavioral counseling (SBC) provided by a nurse. Sixty clients presenting for care at a STD clinic who initially declined HIV testing at registration and during risk behavior screening participated in the study. RESULTS The primary outcome was whether patients agreed to be tested for HIV. The secondary outcomes included attitudes, knowledge, and stage-of-change regarding HIV testing. Patients receiving both interventions improved their attitudes and knowledge about testing (ps < .01). Patients receiving SBC agreed to testing more often (45%) than did patients who viewed the DVD (19%; p < .05). CONCLUSIONS Brief interventions can increase rapid HIV testing acceptance among patients who are reluctant to be tested; counseling guided by behavioral science theory is more effective than a well-designed information-based intervention.

Do STD Clinic Patients Who Consent to Sexual Health Research Differ from Those Who Decline? Findings from a Randomized Controlled Trial with Implications for the Generalization of Research Results

Most patients attending urban STD clinics can benefit from workshops designed to promote sexual health and reduce sexual risk behaviors. However, many patients do not attend such workshops when invited. The purpose of this study was to evaluate the effects of providing a financial incentive on attendance at a sexual risk reduction workshop tailored to patients at an urban STD clinic. A quasi-experimental design with two conditions (incentive vs no incentive) was implemented sequentially with 107 STD clinic patients (58 men, 49 women; 69% African American; mean age = 27 years) reporting risky sexual behavior. Attendance at a subsequent sexual risk reduction workshop served as the key outcome. Results indicated that participants who were provided with a

Persistent Culture-Positive Legionella Infection in an Immunocompromised Host

30 cash incentive were more likely to attend the risk reduction workshop (38%) than participants who were not offered an incentive (9%), chi (1, N = 107) = 12.88, p < .001. Additional analyses confirmed that incentive (AOR = 7.59, p < .001) predicted attendance even after controlling for other significant predictors, namely, employment status (AOR = 3.04, p < .05) and age (AOR = 1.07, p < .05). We conclude that financial incentives are an effective way to increase attendance at sexual risk reduction workshops for at-risk urban populations.