Sharon S. Weir

Depression, Sexually Transmitted Infection, and Sexual Risk Behavior Among Young Adults in the United States

OBJECTIVE To measure associations among depression, sexual risk behaviors, and sexually transmitted infection (STI) among white and black youth in the United States. DESIGN Analysis of prospective cohort study data. Wave I of the National Longitudinal Study of Adolescent Health occurred in 1995 when participants were in grades 7 through 12. Six years later, all Wave I participants who could be located were invited to participate in Wave III and to provide a urine specimen for STI testing. SETTING In-home interviews in the continental United States, Alaska, and Hawaii. PARTICIPANTS Population-based sample. A total of 10 783 Wave I (adolescence) and Wave III (adulthood) white and black respondents with sample weight variables. Main Exposures Chronic depression (detected at Waves I and III) and recent depression (detected at Wave III only) vs no adult depression (not detected at Wave III). OUTCOME MEASURES Multiple sexual partners and inconsistent condom use in the past year and a current positive test result for Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis (adulthood). RESULTS Recent or chronic depression in adulthood was more common for blacks (women, 19.3%; men, 11.9%) than for whites (women, 13.0%; men, 8.1%). Among all groups (white men and women, and black men and women), adult depression was associated with multiple partners but not with condom use. Among black men, depression was strongly associated with STI (recent: adjusted prevalence ratio, 2.36; 95% confidence interval, 1.26-4.43; chronic: adjusted prevalence ratio, 3.05; 95% confidence interval, 1.48-6.28); having multiple partners did not mediate associations between depression and STI. CONCLUSIONS Integration of mental health and STI programs for youth is warranted. Further research is needed to elucidate how depression may influence the prevalence of STI among black men.

Fertility and contraceptive use among young adults in Harare, Zimbabwe.

In 1986, a survey of young adults aged 14-24 in Harare, Zimbabwe obtained information about their knowledge, attitudes, and sexual behavior. Most adolescent childbearing took place within marriage, although sexual intercourse was generally initiated before marriage. Knowledge of family planning was high, but contraceptive use lagged behind knowledge. Fewer than half of the respondents had talked to an elder about family planning, sex, or pregnancy. Fourteen percent of young women who were unmarried at the time of first intercourse used contraceptives, compared to 18 percent of young unmarried men. Current contraceptive use among sexually active unmarried youths was 36 percent among women and 29 percent among men. One consequence of low contraceptive use was a high number of unwanted premarital pregnancies. Twenty-nine percent of the women had been pregnant; those not married at the time they got pregnant generally got married soon after. Of the girls who got pregnant while in school, 90 percent had to drop out of school. A second consequence of low contraceptive use is an increased risk of transmission of STDs and AIDS among the youth of Harare.

TIMING AND DURATION OF INCARCERATION AND HIGH-RISK SEXUAL PARTNERSHIPS AMONG AFRICAN AMERICANS IN NORTH CAROLINA

PURPOSE Incarceration may contribute to HIV transmission by disrupting stable partnerships and promoting high-risk partnerships. We investigated incarceration and high-risk partnerships among African Americans in North Carolina. METHODS We conducted a weighted analysis using the North Carolina Rural Health Project (N = 320), a population-based case-control study of HIV among African Americans. We measured associations between timing and duration of incarceration and high-risk partnerships (multiple partnerships or sex trade for money or drugs). RESULTS Duration of incarceration appeared to be more important than how long ago incarceration occurred. After adjustment for sociodemographic indicators, high-risk partnerships were associated with short-term (<1 month) incarceration of the respondent versus no respondent incarceration (men: adjusted prevalence ratio (aPR) 1.9, 95% confidence interval (95% CI) 1.2-2.8; women: aPR 3.1, 95% CI 1.2-8.3). High-risk partnerships also were associated with incarceration of a partner versus no partner incarceration (men: aPR 1.8, 95% CI 1.1-3.0; women: aPR 2.0, 95% CI 1.1-3.8). Among men, associations remained when adjusting for substance use. Among women, adjustment for substance use weakened estimates due to the strong correlation between substance use and incarceration. CONCLUSIONS HIV-prevention programs targeting currently and formerly incarcerated individuals and their partners may decrease HIV in African American communities with high incarceration rates.

The use of nonoxynol-9 for protection against cervical gonorrhea.

OBJECTIVES Although condoms are the best defense against sexually transmitted disease, little is known about the effectiveness of female-controlled methods containing nonoxynol-9 as backup protection when condoms are not being used. METHODS To assess the extent to which nonoxynol-9 protects women against gonorrhea, a cohort of 303 female sex workers (prostitutes) in Yaounde, Cameroon, were asked to use condoms and suppositories containing nonoxynol-9 at every sexual encounter and to record daily sexual activity and use of condoms and suppositories on coital logs that were reviewed monthly. Evidence of gonorrheal infection was based on a positive gonorrhea culture. Stratified analysis and proportional hazards regression were used to estimate rate ratios. RESULTS Forty-one women enrolled in the study were excluded from the current analysis. The estimated incidence of gonorrhea was 6.2 infections per 100 person-months of observation. Incidence rate ratios estimated from proportional hazards regression models controlling for condom use showed that using nonoxynol-9 during acts not protected by condoms reduced the risk of infection. CONCLUSIONS Although the protective effect of condoms against sexually transmitted disease is greater than that afforded by nonoxynol-9, using nonoxynol-9 when condoms are not used is a far better strategy in gonorrhea prevention than using no method at all.

Gonorrhea as a risk factor for HIV acquisition.

ObjectiveThe role of gonorrhea in facilitating acquisition of HIV infection has only recently been studied. A previous nested case-control analysis in a cohort of female sex workers in Zaïre found a strong association between HIV seroconversion and prior gonorrheal infection. The objective of this study was to replicate the Zaïre study analysis in a cohort of 273 Cameroonian sex workers to determine whether gonorrhea increased the risk of HIV acquisition, and if the crude association between gonorrheal infection and HIV acquisition was weakened when the level of unprotected coitus was more carefully controlled. MethodsWe conducted a nested case-control study of initially HIV-1-negative women (n = 273) followed prospectively (with monthly sexually transmitted disease check-ups and 3-monthly HIV-1 serology). As in Zaire, cases (seroconverters, n = 17) were compared with controls (women who remained HIV-1-negative, n = 68) for incidence of gonorrhea and sexual exposure during the presumed period of HIV-1 acquisition. ResultsThe association between gonorrheal infection and subsequent HIV acquisition was stronger in Zaire than in Cameroon [crude odds ratios (OR), 6.3 versus 2.2]. In both the Zaïre and Cameroon data the crude OR were reduced (6.3 to 4.8, and 2.2 to 1.7, respectively) by controlling for risk factors including a dichotomous variable indicating irregular or no condom use. When this variable was replaced in the Cameroon data with a more precise continuous variable indicating the percentage of unprotected coital acts, the gonorrhea OR was further reduced to 1.4 (95% confidence interval, 0.4–4.9). ConclusionThese results suggest that in the Cameroon cohort, gonorrheal infection did not facilitate HIV acquisition, but that having gonorrhea was a marker for unprotected coitus that facilitated HIV acquisition. The data demonstrate how OR can be overestimated when imprecise dichotomous measures of unprotected coitus are used. Future studies should plan for better control of self-reported condom use.

Where the action is: monitoring local trends in sexual behaviour

Objectives: To assess the role in an overall monitoring strategy of the PLACE method of estimating local trends in sexual behaviour among individuals at social venues in areas at increased risk of HIV transmission. Methods: Public venues identified by community informants as places where people meet new sexual partners were visited and characterised in Karaganda, Kazakhstan, in 2002 and 2003, and in a township in South Africa in 2000 and 2003. At a subset of venues, a representative sample of individuals socialising at the venue were interviewed about their sexual behaviour. The age distribution and partnerships rates of those socialising at these venues were compared by year and with national data from Kazakhstan and South Africa obtained via household surveys. Results: Women and men socialising at venues were younger and had higher rates of new and concurrent partnerships than men and women interviewed in national household surveys. There was little apparent change in sexual behaviour between 2002 and 2003 in Karaganda. In the South African township, there was a reduction in sexual partnerships and an increase in condom use, possibly due to a local AIDS prevention programme. Conclusion: Findings from the PLACE method supplement national data on sexual behaviours with data from key populations in high transmission areas, inform local targeting of interventions, and, when subsequent rounds of PLACE are implemented, can evaluate change in target populations.

Dissolution of Primary Intimate Relationships During Incarceration and Associations With Post-release Sti/hiv Risk Behavior in a Southeastern City

Background: Incarceration is associated with sexually transmitted infections (STIs) including human immunodeficiency virus (HIV). It may contribute to STI/HIV by disrupting primary intimate relationships that protect against high-risk partnerships. Methods: In an urban sample of men (N = 229) and women (N = 144) in North Carolina, we assessed how often respondents experienced the dissolution of a primary intimate relationship at the time of their own (among men) or their partners (among women) incarceration. We then measured the association between dissolution of relationships during incarceration and STI/HIV-related risk behaviors. Results: Among men who had ever been incarcerated for 1 month or longer (N = 72), 43% (N = 31) had a marital or nonmarital primary partner at the time of the longest prior sentence. Among women, 22% (N = 31) had ever had a primary partner who had been incarcerated for 1 month or longer. Of men and women who were in a relationship at the time of a prior incarceration of 1 month or longer (N = 62), more than 40% of men and 30% of women reported that the relationship ended during the incarceration. In analyses adjusting for sociodemographic characteristics and crack/cocaine use, loss of a partner during incarceration was associated with nearly 3 times the prevalence of having 2 or more new partners in the 4 weeks before the survey (prevalence ratio: 2.80, 95% confidence interval: 1.13–6.96). Conclusions: In this sample, incarceration disrupted substantial proportions of primary relationships and dissolution of those relationships was associated with subsequent STI/HIV risk. The results highlight the need for further research to investigate the effects of incarceration on relationships and health.

A comparison of respondent-driven and venue-based sampling of female sex workers in Liuzhou, China

Objectives To compare two methods for sampling female sex workers (FSWs) for bio-behavioural surveillance. We compared the populations of sex workers recruited by the venue-based Priorities for Local AIDS Control Efforts (PLACE) method and a concurrently implemented network-based sampling method, respondent-driven sampling (RDS), in Liuzhou, China. Methods For the PLACE protocol, all female workers at a stratified random sample of venues identified as places where people meet new sexual partners were interviewed and tested for syphilis. Female workers who reported sex work in the past 4 weeks were categorised as FSWs. RDS used peer recruitment and chain referral to obtain a sample of FSWs. Data were collected between October 2009 and January 2010. We compared the socio-demographic characteristics and the percentage with a positive syphilis test of FSWs recruited by PLACE and RDS. Results The prevalence of a positive syphilis test was 24% among FSWs recruited by PLACE and 8.5% among those recruited by RDS and tested (prevalence ratio 3.3; 95% CI 1.5 to 7.2). Socio-demographic characteristics (age, residence and monthly income) also varied by sampling method. PLACE recruited fewer FSWs than RDS (161 vs 583), was more labour-intensive and had difficulty gaining access to some venues. RDS was more likely to recruit from areas near the RDS office and from large low prevalence entertainment venues. Conclusions Surveillance protocols using different sampling methods can obtain different estimates of prevalence and population characteristics. Venue-based and network-based methods each have strengths and limitations reflecting differences in design and assumptions. We recommend that more research be conducted on measuring bias in bio-behavioural surveillance.

Systematic differences in risk behaviors and syphilis prevalence across types of female sex workers: a preliminary study in Liuzhou, China.

Background: Female sex workers (FSWs) have become one of the key populations for HIV/STI control in China. Categorization of FSWs can help prioritize HIV/STI intervention efforts. We examined 2 possible categorizations of FSWs and the relationship with syphilis infection risk in Liuzhou City, China. Methods: From October 2009 to February 2010, a total of 583 FSWs recruited by respondent-driven sampling in a cross-sectional survey were tested for syphilis and interviewed to collect sociodemographic and behavioral information. Respondents were categorized based on transaction price for vaginal sex and type of sex work location. The relationship between the 2 categorizations and syphilis infection risk was assessed using univariate and multivariate logistic regression analysis. Results: The prevalence rates of lifetime and active syphilis infection were 8.6% and 4.1%, respectively. Lifetime and active syphilis prevalence was higher among FSWs in the lowest price category (52.7% and 25.4%, respectively) and those working in streets (69.7% and 39.8%, respectively) or through telephone (46.3% and 17.0%, respectively). Multivariate analysis showed that lifetime syphilis prevalence was significantly higher among street- (adjusted odds ratio [AOR]: 38.7, 95% confidence intervals [CI]: 10.7–139.9) and telephone-based FSWs (AOR: 10.8, 95% CI: 3.3–35.1), and that active syphilis prevalence was significantly higher among street-based FSWs (AOR: 15.2, 95% CI: 3.7–62.1) after adjusting for demographic and behavioral factors. Conclusions: Categorization based on sex work location was more closely related to the risk of syphilis infection than the price classification. Street- and telephone-based FSWs had significantly higher risk of syphilis infection. Focused interventions among these particular high-risk FSWs subgroups are warranted.

Evidence of high-risk sexual behaviors among injection drug users in the Kenya PLACE study

BACKGROUND Injection drug users (IDUs) in resource poor settings are at high risk for HIV transmission through unsafe needle-sharing and sexual practices. We report on the injecting and sexual behavior of a sample of IDUs from Malindi, Kenya. METHODS A Priority for Local AIDS Control Efforts (PLACE) study was conducted from April to May 2010 to identify areas where HIV transmission is most likely to occur and specific venues where people meet new sexual partners. Community informants (n=202) listed 157 unique venues from which 29 were randomly selected using a systematic fixed interval sampling strategy with probability of selection proportional to venue size. Twenty patrons and four workers were interviewed at each venue. Drug use practices were elicited in a staff-administered interview. RESULTS Between 40% and 50% of IDUs reported needle-sharing, taking drugs from a common reservoir, using a ready-made solution without boiling, and not exchanging a used for a new syringe in the past month. Most could inconsistently or never get new syringes. In multivariate logistic regression models controlling for age, education, residence, and poverty status, IDUs were twice as likely as non-IDUs to report multiple partners in the past year (OR 1.94, 95% CI 1.26-3.00, p<.01) and multiple new partners in the past year (OR 2.11, 95% CI 1.30-3.42, p<.01). CONCLUSIONS High prevalence of multiple sexual partnerships and risky injecting behaviors among IDUs and unavailability of new injecting needles are likely facilitating HIV transmission in Malindi, Kenya.