Vivian F. Go

Decreasing incidence of HIV and sexually transmitted diseases in young Thai men: Evidence for success of the HIV/AIDS control and prevention program

Objective:To determine whether HIV and sexually transmitted disease (STD) incidence rates among young men in northern Thailand have declined since the establishment of the ‘100% Condom Program’, and to prospectively document changes in the association between behavioral risk factors and incident HIV and STD infections. Setting:Thirteen military bases in northern Thailand. Methods:Serial prospective cohorts of 19–23-year-old male conscripts (n = 4086) inducted into military service from six northern Thai provinces between 1991 and 1993 were followed at 6-month intervals for incident HIV and STD through May 1995. HIV incidence was determined by serology, and incident STD were reported by conscripts as diagnosed by health-care providers. Results:HIV incidence declined from a rate of 2.48 per 100 person-years during 1991–1993 to 0.55 per 100 person-years during 1993–1995. STD incidence showed an even greater decline, with a 10-fold decrease from 1991–1993 to 1993–1995. Behavioral risk factors for incident STD infections included a history of prior STD and sex with girlfriends and sex workers. Inconsistent condom use remained a strong predictor of incident STD among brothel visitors. Other previously-reported risk factors in 1991–1993 such as illicit drug use, frequency and cost of brothel visits, and low socioeconomic status were not associated with incident STD or HIV in 1993–1995. Conclusions:Although several studies have recently reported decreased prevalence of HIV and STD infections in Thailand, these data demonstrate that a dramatic decrease in the incidence rates of STD, including HIV infection, has occurred among young men in military service in northern Thailand. The Thai AIDS prevention and control program might be implemented by other countries experiencing major epidemics of heterosexually transmitted HIV infections. Similar prevention programs targeted at other populations in Thailand and elsewhere in Asia are needed to decrease the spread of the HIV epidemic.

When HIV-Prevention Messages and Gender Norms Clash: The Impact of Domestic Violence on Women's HIV Risk in Slums of Chennai, India

This paper examines how marital violence affects womens ability to protect themselves from HIV/AIDS. In-depth interviews (n = 48) and focus groups (n = 84, 3–7 per group) were conducted among men and women in two randomly selected slums of Chennai, India. The study showed that community gender norms tacitly sanction domestic violence that interferes with adopting HIV-preventive behaviors. Given the choice between the immediate threat of violence and the relatively hypothetical specter of HIV, women often resign themselves to sexual demands and indiscretions that may increase their risk of HIV acquisition. In conclusion, AIDS-prevention interventions must incorporate gender-related social contexts in settings where husbands strictly enforce their locus of control. HIV-prevention messages targeting men may effectively reduce womens exposure to HIV/AIDS.

High HIV Prevalence and Risk Behaviors in Men Who Have Sex with Men in Chennai, India

ObjectiveTo estimate HIV and sexually transmitted disease (STD) prevalence and behavioral risk characteristics of men who have sex with men (MSM) in Chennai, India. MethodsA cross-sectional population-based random sample survey was conducted in 2001. Randomly selected residents of 30 slums in Chennai were interviewed for behavioral risk factors through face-to-face interviews. Sera and urine were examined for syphilis, HIV-1, gonorrhea, and chlamydia. Logistic regression analyses were used to assess associations between MSM status and HIV infection and to identify risk characteristics of MSM. ResultsOf 774 men, 46 reported (5.9%) sex with other men. MSM were more likely to be seropositive for HIV (odds ratio [OR] = 8.57; 95% confidence interval [CI]: 1.83, 40.23) and were more likely to have a history of STD (OR = 2.66; 95% CI: 1.18, 6.02) than non-MSM. Men who used illicit drugs in past 3 months (adjusted odds ratio [AOR] = 4.01; 95% CI: 1.92, 8.41), ever exchanged money for sex (AOR = 3.93; 95% CI: 1.97, 7.84), or were ever tested for HIV (AOR = 3.72; 95% CI: 1.34, 10.34) were significantly more likely to report sex with men. ConclusionsMSM in Chennai slums are at high risk for HIV. HIV prevention strategies aimed at changing unsafe drug and sexual practices should target the general population of men, with specific attention to areas with high rates of MSM.

Injection drug use, sexual risk, violence and STI/HIV among Moscow female sex workers

Background/objectives The HIV prevalence in Eastern Europe and Central Asia continues to increase. While injection drug use (IDU) is leading factor, heterosexual transmission is on the rise. Little is known about female sex workers (FSWs) in the region despite the central role of commercial sex in heterosexual sexually transmitted infection (STI)/HIV transmission globally. The authors evaluated the prevalence of STI/HIV among Moscow-based FSWs and potential risk factors including IDU, sexual risks and violence victimisation. Methods Moscow-based FSWs (n=147) completed a clinic-based survey and STI/HIV testing over an 8-month period in 2005. Results HIV prevalence was 4.8%, and 31.3% were infected with at least one STI including HIV. Sexual behaviours significantly associated with STI/HIV included anal sex (adjusted odds ratio (AOR) 3.48), high client volume (three or more clients daily, AOR 2.71), recent subbotnik (sex demanded by police; AOR 2.50) and regularly being presented with more clients than initially agreed to (AOR 2.45). Past year experiences of physical violence from clients and threats of violence from pimps were associated with STI/HIV (AOR 3.14 and AOR 3.65, respectively). IDU was not significantly associated with STI/HIV. Anal sex and high client volume partially mediated the associations of abuse with STI/HIV. Conclusions Findings illustrate substantial potential for heterosexual STI/HIV transmission in a setting better known for IDU-related risk. Many of the STI/HIV risks observed are not modifiable by FSWs alone. STI/HIV prevention efforts for this vulnerable population will benefit from reducing coercion and abuse perpetrated by pimps and clients.

Risks for HIV, HBV, and HCV infections among male injection drug users in northern Vietnam: a case-control study.

Abstract Injection drug use (IDU) and HIV infection are important public health problems in Vietnam. The IDU population increased 70% from 2000 to 2004 and is disproportionately affected by HIV and AIDS – the countrys second leading cause of death. Hepatitis B virus (HBV) and hepatitis C virus (HCV) share transmission routes with HIV and cause serious medical consequences. This study aimed to determine risk factors for acquisition of HIV, HBV, and HCV infections among IDUs in a northern province. We conducted a matched case–control study among active IDUs aged 18–45 who participated in a community-based survey (30-minute interview and serologic testing). Each HIV-infected IDU (case) was matched with one HIV-uninfected IDU (control) by age, sex (males only), and study site (128 pairs). Similar procedures were used for HBV infection (50 pairs) and HCV infection (65 pairs). Conditional logistic regression models were fit to identify risk factors for each infection. Among 309 surveyed IDUs, the HIV, HBV, and HCV prevalence was 42.4%, 80.9%, and 74.1%, respectively. Only 11.0% reported having been vaccinated against hepatitis B. While 13.3% of the IDUs reported sharing needles (past six months), 63.8% engaged in indirect sharing practices (past six months), including sharing drug solutions, containers, rinse water, and frontloading drugs. In multivariable models, sharing drugs through frontloading was significantly associated with HIV infection (odds ratio [OR]=2.8), HBV infection (OR=3.8), and HCV infection (OR=4.6). We report an unrecognized association between sharing drugs through frontloading and higher rates of HIV, HBV and HCV infections among male IDUs in Vietnam. This finding may have important implications for bloodborne viral prevention for IDUs in Vietnam.

HIV Infection, Immune Suppression, and Uncontrolled Viremia Are Associated With Increased Multimorbidity Among Aging Injection Drug Users

BACKGROUND Despite an increasing burden of age-associated non-AIDS outcomes, few studies have investigated the prevalence or correlates of multimorbidity among aging human immunodeficiency virus (HIV)-infected and epidemiologically comparable at-risk populations. METHODS Among 1262 AIDS Linked to the IntraVenous Experience (ALIVE) study participants followed in a community-based observational cohort, we defined the prevalence of 7 non-AIDS-defining chronic conditions (diabetes, obstructive lung disease, liver disease, anemia, obesity, kidney dysfunction, and hypertension) using clinical and laboratory criteria. Ordinal logistic regression was used to model the odds of increased multimorbidity associated with demographic, behavioral, and clinical factors. Self-reported prevalence was compared with clinically defined prevalence. RESULTS Participants were a median of 48.9 years of age; 65.1% were male, 87.5% were African-American, and 28.7% were HIV infected. In multivariable analysis, HIV infection (odds ratio [OR], 1.50; 95% confidence interval [CI], 1.13-1.99) was positively associated with increased multimorbidity. Among HIV-infected participants, multimorbidity was increased with lower nadir CD4 T-cell count (OR, 1.14 per 100-cell decrease; 95% CI, 1.00-1.29) and higher current HIV RNA (OR, 1.32 per log(10) increase; 95% CI, 1.08-1.60). Older age, being female, not using cigarettes or drugs, and having depressive symptoms were also associated with increased multimorbidity. A substantial proportion of multimorbid conditions in HIV-infected and HIV-uninfected participants were unrecognized and untreated. CONCLUSIONS HIV-infected participants experienced increased numbers of multimorbid conditions; risk increased with advanced immunosuppression and higher viremia. These results underscore the heavy burden of multimorbidity associated with HIV and highlight the need for incorporating routine assessment and integrated management of chronic diseases as part of comprehensive healthcare for aging, HIV-infected persons.

Crossing the threshold: engendered definitions of socially acceptable domestic violence in Chennai, India

The objective of this study was to examine the pathways by which gender norms may influence marital violence in low‐income communities of Chennai, India. As part of a multisite international behavioural HIV intervention trial, 48 in‐depth interviews and 14 focus groups with men and women were conducted in two randomly selected low‐income communities within the city. Interviews were taped, transcribed, translated, coded and analysed to identify recurrent themes. A multi‐layered conceptual framework was used to examine individual, relational, community and societal level determinants of marital violence in this setting. Participants noted that husbands hold decision‐making power in economic, social and sexual spheres. Clear patterns of violence were present; respondents reported that husbands regularly beat wives in most marriages. Marital conflicts were intensified by the presence of community level stressors such as poverty and unemployment. Participants perceived violence to be a necessary tool that served to discipline wives and ultimately enforce gender norms. Although many respondents felt wife‐beating was the norm, the acceptable intensity of violence varied by gender. Interventions that reconsider gender‐based roles and empower men and women to lower the threshold of socially acceptable violence should be developed to alleviate the consequences of violence.

Trajectories of Injection Drug Use Over 20 Years (1988–2008) in Baltimore, Maryland

The objective of this study was to identify longitudinal patterns of injection drug use over 20 years in the AIDS Linked to the Intravenous Experience (ALIVE) Study, a community-based cohort of injection drug users (IDUs) in Baltimore, Maryland, with a focus on injection cessation. Starting in 1988, persons over 18 years of age with a history of injection drug use were recruited into the study. Participants provided information on their injection drug use semiannually through 2008. The analysis was restricted to 1,716 IDUs with at least 8 study visits. Finite mixture models were used to identify trajectories and predictors of injection patterns over time. The mean age of participants was 35 years; 75% were male, and 95% were African-American. Five distinct patterns were identified: 2 usage patterns (32% engaged in persistent injection and 16% had frequent relapse) and 3 cessation patterns (early cessation (19%), delayed cessation (16%), and late cessation (18%)). A history of drug treatment, no recent use of multiple substances, and less frequent injection distinguished the early cessation group from the other groups. This study demonstrated multiple trajectories of drug injection behaviors, with a substantial proportion of IDUs stopping injection over extended time frames. For maximum effectiveness, public health programs for IDUs should be long-term, comprehensive, and targeted toward individual patterns of use.

The effect of neighborhood deprivation and residential relocation on long-term injection cessation among injection drug users (IDUs) in Baltimore, Maryland.

AIMS To determine the incidence of long-term injection cessation and its association with residential relocation and neighborhood deprivation. DESIGN ALIVE (AIDS Linked to the Intravenous Experience) is a prospective cohort with semi-annual follow-up since 1988. Multi-level discrete time-to-event models were constructed to investigate individual and neighborhood-level predictors of long-term injection cessation. SETTING Baltimore, USA. PARTICIPANTS A total of 1697 active injectors from ALIVE with at least eight semi-annual study visits. MEASUREMENTS Long-term injection cessation was defined as 3 consecutive years without self-reported injection drug use. FINDINGS A total of 706 (42%) injectors achieved long-term cessation (incidence=7.6 per 100 person-years). After adjusting for individual-level factors, long-term injection cessation was 29% less likely in neighborhoods in the third quartile of deprivation [hazard ratio (HR)=0.71, 95% CI: 0.53, 0.95) and 43% less likely in the highest quartile of deprivation (HR=0.57, 95% CI: 0.43, 0.76) compared to the first quartile. Residential relocation was associated with increased likelihood of long-term injection cessation (HR=1.55, 95% CI: 1.31, 1.82); however, the impact of relocation varied depending on the deprivation in the destination neighborhood. Compared to those who stayed in less deprived neighborhoods, relocation from highly deprived to less deprived neighborhoods had the strongest positive impact on long-term injection cessation (HR=1.96, 95% CI: 1.50, 2.57), while staying in the most deprived neighborhoods was detrimental (HR=0.76, 95% CI: 0.63, 0.93). CONCLUSIONS Long-term cessation of injection of opiates and cocaine occurred frequently following a median of 9 years of injection and contextual factors appear to be important. Our findings suggest that improvements in the socio-economic environment may improve the effectiveness of cessation programs.

Gender gaps, gender traps: sexual identity and vulnerability to sexually transmitted diseases among women in Vietnam

We conducted a qualitative study to explore the pathways by which traditional gender roles may ultimately affect Vietnamese womens interpretation of sexually transmitted disease (STD) symptoms and health-seeking strategies. Data on gender roles, perceptions of types of sexual relationships, perceptions of persons with STDs, and STD patient experiences were gathered through in-depth interviews and focus groups with 18 men and 18 women in the general population of northern Vietnam. A framework integrating Andersens behavioral model of health services use and Zurayks multi-layered model was used to conceptualize womens health-seeking behavior for STD symptoms. Both men and women noted clear gender differences in sexual roles and expectations. According to participants, a womans primary roles in northern Vietnam are socially constructed as that of a wife and mother-and in these roles, she is expected to behave in a faithful and obedient manner vis à vis her husband. It emerged that mens marital and sexual roles are less clearly defined by traditional norms and are more permissive in their tolerance of premarital and extramarital sex. For women, however, these activities are socially condemned. Finally, since STDs are associated with sexual promiscuity, both men and women expressed anxiety about telling their partners about an STD; womens expressions were characterized more by fear of social and physical consequences, whereas men expressed embarrassment. Community level interventions that work towards disassociating STDs from traditional social norms may enable Vietnamese women to report possible STD symptoms and promote diagnosis and care for STDs.