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1.  Correlates of Condom Use Intentions and Behaviors Among a Community-Based Sample of Latino Men in Los Angeles 
HIV/AIDS has disproportionately affected Latino communities. The majority of research addressing HIV risk behaviors within this population has focused on women. However, men who have sex with women (MSW) are a population increasingly becoming infected with HIV and heterosexual contact is the primary source of HIV transmission among Latinos diagnosed with AIDS. It has been assumed that because men are likely to control condom use, relationship factors are less likely to influence safer sex behavior among men. However, because condom use is an interdependent behavior, understanding factors that predict safer sex behavior among MSW is critical. This study examined the influence of multiple factors on condom use behavior in a community-based sample of young Latino men. Data from 191 Latino men who completed baseline interviews for an intervention were analyzed to examine the association of background, intrapersonal and relationship factors with intentions to use condoms and condom use in the past three months. Findings from multivariate analyses indicated that more positive attitudes toward condoms, stronger partner condom norms and greater participation in decision-making about condom use were significantly associated with both condom use and condom use intentions. Additionally, men reporting lower expectations of negative partner reactions to condom requests were more likely to use condoms, and condom use intentions were higher among men reporting more health protective communication in the relationship. Findings suggest that interventions to prevent HIV need to include men as well as women and address the role of relationship factors and dynamics in safer sex practices.
PMCID: PMC2430480  PMID: 16845495
Condom use; Condom use intentions; HIV/STI prevention; Intrapersonal factors; Latino men; Relationships characteristics
2.  Anger as a Moderator of Safer Sex Motivation among Low Income Urban Women 
Journal of behavioral medicine  2005;28(5):493-506.
Theoretical models suggest that both HIV knowledge and HIV risk perception inform rational decision-making and, thus, predict safer sex motivation and behavior. However, the amount of variance explained by knowledge and risk perception is typically small. In this cross-sectional study, we investigated whether the predictive power of HIV knowledge and HIV risk perception on safer sex motivation is affected by trait anger. We hypothesized that anger may disrupt rational-decision making, distorting the effects of both HIV knowledge and risk perception on safer sex intentions. Data from 232 low-income, urban women at risk for HIV infection were used to test a path model with past sexual risk behavior, HIV knowledge, and HIV risk perception as predictors of safer sex intentions. Moderator effects of anger on safer sex intentions were tested by simultaneous group comparisons between high-anger and low-anger women (median-split). The theoretically expected “rational pattern” was found among low-anger women only, including (a) a positive effect of knowledge on safer sex intentions, and (b) buffer (inhibitor) effects of HIV knowledge and HIV risk perception on the negative path leading from past risk behavior to safer sex intentions. Among high-anger women, an “irrational pattern” emerged, with no effects of HIV knowledge and negative effects of both past risk behavior and HIV risk perception on safer sex intentions. In sum, the results suggest that rational knowledge and risk-based decisions regarding safer sex may be limited to low-anger women.
PMCID: PMC1383506  PMID: 16247592
HIV; knowledge; anger; safer sex; intention; risk perception
3.  HIV Risk Profiles Among HIV-Positive, Methamphetamine-Using Men Who Have Sex with Both Men and Women 
Archives of Sexual Behavior  2011;40(4):793-801.
This study examined demographic characteristics, sexual risk behaviors, sexual beliefs, and substance use patterns in HIV-positive, methamphetamine-using men who have sex with both men and women (MSMW) (n = 50) as compared to men who have sex with men only (MSM) (n = 150). Separate logistic regressions were conducted to predict group membership. In the final model, of 12 variables, eight were independently associated with group membership. Factors independently associated with MSMW were acquiring HIV through injection drug use, being an injection drug user, using hallucinogens, using crack, being less likely to have sex at a bathhouse, being less likely to be the receptive partner when high on methamphetamine, having greater intentions to use condoms for oral sex, and having more negative attitudes about HIV disclosure. These results suggest that, among HIV-positive methamphetamine users, MSMW differ significantly from MSM in terms of their HIV risk behaviors. Studies of gay men and HIV often also include bisexual men, grouping them all together as MSM, which may obscure important differences between MSMW and MSM. It is important that future studies consider MSM and MSMW separately in order to expand our knowledge about differential HIV prevention needs for both groups. This study showed that there were important differences in primary and secondary prevention needs of MSM and MSMW. These findings have implications for both primary and secondary HIV prevention among these high-risk populations.
PMCID: PMC3114110  PMID: 21203813
Men who have sex with men and women; Men who have sex with men; Bisexual; HIV; Methamphetamine; Injection drug use
4.  Formative Assessment of ARM-U: A Modular Intervention for Decreasing Risk Behaviors Among HIV-Positive and HIV-Negative Methamphetamine-Using MSM 
The Open AIDS Journal  2010;4:105-115.
Methamphetamine is a major contributor to HIV transmission among men who have sex with men (MSM). Recent studies show that up to one-third of methamphetamine-using MSM (MUMSM) inject the drug. We developed a behavioral intervention for MUMSM to decrease unprotected anal intercourse and increase awareness of parenteral HIV transmission risk. This 6-session (3 in-person, 3 by telephone) modular intervention was designed to be tailored to participants’ HIV (+/-) and injection drug user ([IDU] yes/no) status. We present results of formative research used to evaluate the content and to assess feasibility and acceptability of this individual-level HIV risk-reduction intervention.
HIV research clinic in a high MSM and methamphetamine prevalence neighborhood.
Avoiding Risks from Methamphetamine-Use (ARM-U) is a brief toolbox intervention that allows counselors to select modules that suit a client’s individual risk profile and intervention needs employing motivational interviewing and cognitive behavioral theory. We evaluated the format and content of the intervention through focus groups and pre-testing of the entire intervention using volunteers from the target population stratified into four groups (HIV+/IDU, HIV-/IDU, HIV+/non-IDU, HIV-/non-IDU). Four individuals in each stratum were recruited to undergo the intervention and complete a satisfaction survey at the end of each in-person session.
In total, 25 MUMSM attended one of five focus groups. Participants thought all proposed intervention topics were important and could aid in reducing sexual risk behaviors among MUMSM. However, the neurocognitive effects of methamphetamine were reported to be a barrier to practicing safer sex, condom use negotiation or HIV status disclosure. Fifteen (94%) of 16 participants completed all 6 sessions and the satisfaction survey. On average, participants felt the intervention was useful for MUMSM, made them contemplate and move toward behavior change, and would recommend the program to their peers.
Lessons Learned:
Based on our formative research, we revised the ARM-U intervention to emphasize pre-planning to avoid combining methamphetamine use and sex or develop strategies to avoid sex risk following methamphetamine use. We also increased emphasis on referrals for care and other requested services. Future efficacy trials are needed to evaluate the intervention’s ability to reduce HIV-associated risk behaviors.
PMCID: PMC2905777  PMID: 20657829
HIV; injection drug use; MSM; methamphetamine; formative research; behavioral intervention.
5.  Association of methamphetamine use during sex with risky sexual behaviors and HIV infection among non-injection drug users. 
Western Journal of Medicine  1998;168(2):93-97.
Morbidity, mortality, and drug treatment data suggest that methamphetamine use is on the rise. Based on research findings of the sexual behaviors of methamphetamine-using injection drug users, we chose to examine the relationship between methamphetamine use during sex and risky sexual behaviors and human immunodeficiency virus (HIV) seropositivity among clients of publicly funded HIV testing sites in California who reported never injecting drugs. We found that among gay, bisexual, and heterosexual men and heterosexual women, users of methamphetamines reported more sexual partners than non-methamphetamine users. Among heterosexuals, a greater percentage of methamphetamine users than nonusers participated in anal intercourse. Methamphetamine use was independently related to decreased condom use during vaginal and anal intercourse, prostitution, and sex with known injection drug users. In addition, methamphetamine users were more likely to have had a sexually transmitted disease. When controlling for race or ethnicity; age; exposure to possibly infected blood or blood products; and the use of cocaine, alcohol, or marijuana during sex, methamphetamine-using bisexual men were more likely to test positive for HIV than those reporting no history of methamphetamine use. Our data suggest that noninjection methamphetamine use is related to increased, unprotected sexual activity and the risk of contracting sexually transmitted diseases, including HIV.
PMCID: PMC1304836  PMID: 9499742
6.  Systematic Review of Abstinence-Plus HIV Prevention Programs in High-Income Countries 
PLoS Medicine  2007;4(9):e275.
Abstinence-plus (comprehensive) interventions promote sexual abstinence as the best means of preventing HIV, but also encourage condom use and other safer-sex practices. Some critics of abstinence-plus programs have suggested that promoting safer sex along with abstinence may undermine abstinence messages or confuse program participants; conversely, others have suggested that promoting abstinence might undermine safer-sex messages. We conducted a systematic review to investigate the effectiveness of abstinence-plus interventions for HIV prevention among any participants in high-income countries as defined by the World Bank.
Methods and Findings
Cochrane Collaboration systematic review methods were used. We included randomized and quasi-randomized controlled trials of abstinence-plus programs for HIV prevention among any participants in any high-income country; trials were included if they reported behavioural or biological outcomes. We searched 30 electronic databases without linguistic or geographical restrictions to February 2007, in addition to contacting experts, hand-searching conference abstracts, and cross-referencing papers. After screening 20,070 abstracts and 325 full published and unpublished papers, we included 39 trials that included approximately 37,724 North American youth. Programs were based in schools (10), community facilities (24), both schools and community facilities (2), health care facilities (2), and family homes (1). Control groups varied. All outcomes were self-reported. Quantitative synthesis was not possible because of heterogeneity across trials in programs and evaluation designs. Results suggested that many abstinence-plus programs can reduce HIV risk as indicated by self-reported sexual behaviours. Of 39 trials, 23 found a protective program effect on at least one sexual behaviour, including abstinence, condom use, and unprotected sex (baseline n = 19,819). No trial found adverse program effects on any behavioural outcome, including incidence of sex, frequency of sex, sexual initiation, or condom use. This suggests that abstinence-plus approaches do not undermine program messages encouraging abstinence, nor do they undermine program messages encouraging safer sex. Findings consistently favoured abstinence-plus programs over controls for HIV knowledge outcomes, suggesting that abstinence-plus programs do not confuse participants. Results for biological outcomes were limited by floor effects. Three trials assessed self-reported diagnosis or treatment of sexually transmitted infection; none found significant effects. Limited evidence from seven evaluations suggested that some abstinence-plus programs can reduce pregnancy incidence. No trial observed an adverse biological program effect.
Many abstinence-plus programs appear to reduce short-term and long-term HIV risk behaviour among youth in high-income countries. Programs did not cause harm. Although generalisability may be somewhat limited to North American adolescents, these findings have critical implications for abstinence-based HIV prevention policies. Suggestions are provided for improving the conduct and reporting of trials of abstinence-plus and other behavioural interventions to prevent HIV.
In their systematic review, Underhill and colleagues found that abstinence-plus programs appear to reduce short-term and long-term HIV risk behavior among youth in high-income countries.
Editors' Summary
Human immunodeficiency virus (HIV), which causes AIDS, is most often spread through unprotected sex (vaginal, oral, or anal) with an infected partner. Individuals can reduce their risk of becoming infected with HIV by abstaining from sex or delaying first sex, by being faithful to one partner or having few partners, and by always using a male or female condom. Various HIV prevention programs targeted at young people encourage these protective sexual behaviors. Abstinence-only programs (for example, Project Reality in the US) present no sex before marriage as the only means of reducing the risk of catching HIV. Abstinence-plus programs (for example, the UK Apause program) also promote sexual abstinence as the safest behavior choice to prevent HIV infection. However, recognizing that not everyone will remain abstinent, and that in many locations same-sex couples are not permitted to marry, abstinence-plus programs also encourage young people who do become sexually active to use condoms and other safer-sex strategies. Safer-sex programs, a third approach, teach people how to protect themselves from pregnancy and infections and might recommend delaying first sex until they are physically and emotionally ready, but do not promote sexual abstinence over safer-sex strategies such as condom use.
Why Was This Study Done?
There is considerable controversy, particularly in the US, about the relative merits of abstinence-based programs for HIV prevention. Abstinence-only programs, which the US government supports, have been criticized because they provide no information to protect participants who do become sexually active. Critics of abstinence-plus programs contend that teaching young people about safer sex undermines the abstinence message, confuses participants, and may encourage them to become sexually active. Conversely, some people worry that the promotion of abstinence might undermine the safer-sex messages of abstinence-plus programs. Little has been done, however, to look methodically at how these programs change sexual behavior. In this study, the researchers have systematically reviewed studies of abstinence-plus interventions for HIV prevention in high-income countries to get an idea of their effect on sexual behavior.
What Did the Researchers Do and Find?
In an extensive search for existing abstinence-plus studies, the researchers identified 39 trials done in high-income countries that compared the effects on sexual behavior of various abstinence-plus programs with the effects of no intervention or of other interventions designed to prevent HIV infection. All the trials met strict preset criteria (for example, trial participants had to have an unknown or negative HIV status), and all studies meeting the criteria turned out to involve young people in the US, Canada, or the Bahamas, nearly 40,000 participants in total. In 23 of the trials, the abstinence-plus program studied was found to improve at least one self-reported protective sexual behavior (for example, it increased abstinence or condom use) when compared to the other interventions in the trial; none of the trials reported a significant negative effect on any behavioral outcome. Limited evidence from a few trials indicated that some abstinence-plus programs reduced pregnancy rates, providing a biological indicator of program effectiveness. Conversely, there were no indications of adverse biological outcomes such as an increased occurrence of sexually transmitted diseases in any of the trials.
What Do These Findings Mean?
These findings indicate that some abstinence-plus programs reduce HIV risk behavior among young people in North America. Importantly, the findings do not uncover evidence of any abstinence-plus program causing harm. That is, fears that these programs might encourage young people to become sexually active earlier or confuse them about the use of condoms for HIV prevention seem unfounded. These findings may not apply to all abstinence-plus programs in high-income countries, do not include low-income countries, do not specifically address nonheterosexual risk behavior, and are subject to limited reliability in self-reporting of sexual activity by young people. Nonetheless, this analysis provides support for the use of abstinence-plus programs, particularly in light of another systematic review by the same authors (A systematic review of abstinence-only programs for prevention of HIV infection, published in the British Medical Journal), which found that abstinence-only programs did not reduce pregnancy, sexually transmitted diseases, or sexual behaviors that increase HIV risk. Abstinence-plus programs, these findings suggest, represent a reasonable strategy for HIV prevention among young people in high-income countries.
Additional Information.
Please access these Web sites via the online version of this summary at
• US National Institute of Allergy and Infectious Diseases fact sheet on HIV infection and AIDS
• Information from the UK charity AVERT on all aspects of HIV and AIDS, including HIV and AIDS prevention
• US Centers for Disease Control and Prevention fact sheet on HIV/AIDS among young people (in English and Spanish)
• Information on Project Reality, a US abstinence-only program
• Information on Reducing the Risk and on Apause, US and UK abstinence-plus programs, respectively
PMCID: PMC1976624  PMID: 17880259
7.  Effectiveness of a Behavioral Intervention for Increasing Safer Sex Behaviors in HIV-positive MSM Methamphetamine Users: Results from the EDGE Study 
Drug and alcohol dependence  2006;87(2-3):249-257.
Methamphetamine use has been associated with rising STI/HIV transmission rates, particularly among men who have sex with men (MSM). Interventions which successfully reduce risk for HIV transmission among this population are a public health priority. This study examined the efficacy of a behavioral intervention for increasing safer sex behaviors in the context of ongoing methamphetamine use in a sample of HIV-positive, methamphetamine-using MSM.
Three-hundred forty one participants from San Diego, CA were randomly assigned to receive either a safer sex behavioral intervention (EDGE) or a time-equivalent diet-and-exercise attention-control condition. Random effects regression analyses were used to evaluate change in safer sex behaviors over a 12-month period.
Participants in the EDGE intervention engaged in significantly more protected sex acts at the 8-month (p = .034) and 12-month assessment (p = 0.007). By 12-months post-baseline, a greater percentage of protected sex acts that was observed for EDGE (25.8%) vs. control participants (18.7%) (p = 0.038). There was a significant time-by-intervention interaction (p = .018) for self-efficacy for condom use, suggesting that EDGE participants’ self-efficacy demonstrated a greater increase over time compared to control participants.
These results suggest that it is possible to reduce high risk sexual behaviors in the context of ongoing methamphetamine use among HIV-infected MSM.
PMCID: PMC1904343  PMID: 17182196
HIV; AIDS; MSM; Safer Sex; Intervention; Methamphetamine
8.  Sexual Decision-Making in HIV-Positive Men Who Have Sex with Men: How Moral Concerns and Sexual Motives Guide Intended Condom Use with Steady and Casual Sex Partners 
Archives of Sexual Behavior  2007;36(3):437-449.
Determinants of intended condom use with steady and casual sex partners were examined among Dutch HIV-positive men who have sex with men (MSM) (N = 296). Given the proposition that safer sex behavior among HIV-positive people is a form of prosocial behavior, the present study extended the general framework of the Theory of Planned Behavior with Schwartz’s norm-activation theory and tested the assumption that personal norms would mediate the effects of other psychosocial factors on intended condom use for anal sex. In addition, it was hypothesized that, depending on the context in which sex occurs, specific motives for unprotected anal sex may have a negative influence on intended condom use and, as such, undermine a prosocial tendency to practice safer sex. Therefore, we also investigated the influence of sexual motives for unprotected anal sex on intended condom use with steady and casual sex partners. Results indicated that the Theory of Planned Behavior adequately predicted condom use intentions (for casual sex partners and steady sex partners, the explained variance was 52% and 53%, respectively). However, our proposed model of sexual decision-making significantly improved the prediction of behavioral intentions. For steady and casual sex partners, the assumption of the mediating role of personal norms on condom use intention was confirmed empirically. Additionally, sexual motives for unprotected anal sex exerted, as expected, a direct, negative effect on condom use intention with casual sex partners. The implications of the findings for future research and the development of HIV-prevention programs for HIV-positive MSM are discussed.
PMCID: PMC1914258  PMID: 17333328
HIV-positive; Men who have Sex with Men; Sexual risk behavior; Personal norms; Sexual motives
9.  Which outcome expectancies are important in determining young adults’ intentions to use condoms with casual sexual partners?: a cross-sectional study 
BMC Public Health  2013;13:133.
The prevalence of unwanted pregnancy and sexually transmitted infection amongst young adults represents an important public health problem in the UK. Individuals’ attitude towards the use of condoms has been identified as an important determinant of behavioural intentions and action. The Theory of Planned Behaviour has been widely used to explain and predict health behaviour. This posits that the degree to which an individual positively or negatively values a behaviour (termed ‘direct attitude’) is based upon consideration of the likelihood of a number of outcomes occurring (outcome expectancy) weighted by the perceived desirability of those outcomes (outcome evaluation). Outcome expectancy and outcome evaluation when multiplied form ‘indirect attitude’. The study aimed to assess whether positive outcome expectancies of unprotected sex were more important for young adults with lower safe sex intentions, than those with safer sex intentions, and to isolate optimal outcomes for targeting through health promotion campaigns.
A cross-sectional survey design was used. Data was collected from 1051 school and university students aged 16–24 years. Measures of intention, direct attitude and indirect attitude were taken. Participants were asked to select outcome expectancies which were most important in determining whether they would use condoms with casual sexual partners.
People with lower safe sex intentions were more likely than those with safer sex intentions to select all positive outcome expectancies for unprotected sex as salient, and less likely to select all negative outcome expectancies as salient. Outcome expectancies for which the greatest proportion of participants in the less safe sex group held an unfavourable position were: showing that I am a caring person, making sexual experiences less enjoyable, and protecting against pregnancy.
The findings point to ways in which the attitudes of those with less safe sex intentions could be altered in order to motivate positive behavioural change. They suggest that it would be advantageous to highlight the potential for condom use to demonstrate a caring attitude, to challenge the potential for protected sex to reduce sexual pleasure, and to target young adults’ risk appraisals for pregnancy as a consequence of unprotected sex with casual sexual partners.
PMCID: PMC3599836  PMID: 23406327
Outcome expectancies; Condom use; Theory of planned behaviour; Attitude; Expectancy-value muddle; Dimensional salience
10.  Mirtazapine to Reduce Methamphetamine Use 
Archives of general psychiatry  2011;68(11):1168-1175.
No approved pharmacologic treatments for methamphetamine dependence exist. Methamphetamine use is associated with high morbidity and is a major cofactor in the human immunodeficiency virus epidemic among men who have sex with men (MSM).
To determine whether mirtazapine would reduce methamphetamine use among MSM who are actively using methamphetamine.
Double-blind, randomized, controlled, 12-week trial of mirtazapine vs placebo conducted from September 5, 2007, to March 4, 2010.
San Francisco Department of Public Health.
Participants were actively using, methamphetamine-dependent, sexually active MSM seen weekly for urine sample collection and substance use counseling.
Random assignment to daily oral mirtazapine (30 mg) or placebo; both arms included 30-minute weekly substance use counseling.
Main Outcome Measures
The primary study outcome was reduction in methamphetamine-positive urine test results. Secondary outcomes were study medication adherence (by self-report and medication event monitoring systems) and sexual risk behavior.
Sixty MSM were randomized, 85% of follow-up visits were completed, and 56 participants (93%) completed the final visit. In the primary intent-to-treat analysis, participants assigned to the mirtazapine group had fewer methamphetamine-positive urine test results compared with participants assigned to the placebo group (relative risk, 0.57; 95% CI, 0.35–0.93, P = .02). Urine positivity decreased from 67% (20 of 30 participants) to 63% (17 of 27) in the placebo arm and from 73% (22 of 30) to 44% (12 of 27) in the mirtazapine arm. The number needed to treat to achieve a negative weekly urine test result was 3.1. Adherence was 48.5% by medication event monitoring systems and 74.7% by self-report; adherence measures were not significantly different between arms (medication event monitoring systems, P = .82; self-report, P = .92). Most sexual risk behaviors decreased significantly more among participants taking mirtazapine compared with those taking placebo (number of male partners with whom methamphetamine was used, P = .009; number of male partners, P = .04; episodes of anal sex with serodiscordant partners, P = .003; episodes of unprotected anal sex with serodiscordant partners, P = .003; episodes of insertive anal sex with serodiscordant partners, P = .001). There were no serious adverse events related to study drug or significant differences in adverse events by arm (P ≥ .99).
The addition of mirtazapine to substance use counseling decreased methamphetamine use among active users and was associated with decreases in sexual risk despite low to moderate medication adherence.
PMCID: PMC3437988  PMID: 22065532
11.  Bridging Sexual Boundaries: Men Who Have Sex with Men and Women in a Street-Based Sample in Los Angeles 
The purpose of the study was to determine the potential contribution of bisexual men to the spread of HIV in Los Angeles. We compare the characteristics and behaviors of men who have sex with men and women (MSMW) to men who have sex with only women (MSW) and men who have sex with only men (MSM) in Los Angeles. Men (N = 1,125) who participated in one of the two waves of data collection from 2005 to 2007 at the Los Angeles site for NIDA’s Sexual Acquisition and Transmission of HIV—Cooperative Agreement Program were recruited using Respondent Driven Sampling. Participants completed Audio Computer Assisted Self Interviews and received oral HIV rapid testing with confirmatory blood test by Western Blot and provided urine specimens for detection of recent powder cocaine, crack cocaine, methamphetamine, or heroin use. MSM, MSW, or MSMW were defined by the gender of whom they reported sex with in the past 6 months. Chi-square tests and ANOVAs were used to test independence between these groups and demographic characteristics, substance use, and sexual behaviors. We fit generalized linear random intercept models to predict sexual risk behaviors at the partner level. Men were mostly of low income, unemployed, and minority, with many being homeless; 66% had been to jail or prison, 29% had ever injected drugs, and 25% had used methamphetamine in the past 30 days. The sample had high HIV prevalence: 12% of MSMW, 65% of MSM, and 4% of MSW. MSMW were behaviorally between MSW and MSM, except that more MSMW practiced sex for trade (both receiving and giving), and more MSMW had partners who are drug users than MSW. Generalized linear random intercept models included a partner-level predictor with four partner groups: MSM, MSMW-male partners, MSMW-female partners, and MSW. The following were significantly associated with unprotected anal intercourse (UAI): MSW (AOR 0.15, 95% CI 0.08, 0.27), MSMW-female partners (AOR 0.4, 95% CI 0.27, 0.61), HIV-positive partners (AOR 2.03, 95% CI 1.31, 3.13), and being homeless (AOR 1.37, 95% CI 1.01, 1.86). The factors associated with giving money or drugs for sex were MSMW-female partners (AOR 1.70, 95% CI 1.09, 2.65), unknown HIV status partners (AOR 1.72, 95% CI 1.29, 2.30), being older (AOR 1.02, 95% CI 1.00, 1.04), history of incarceration (AOR 1.64, 95% CI 1.17, 2.29), and being homeless (AOR 1.73, 95% CI 1.27, 2.36). The following were associated with receiving money or drugs for sex: MSW (AOR 0.53, 95% CI 0.32, 0.89), African American (AOR 2.42, 95% CI 1.56, 3.76), Hispanic (AOR 1.85, 95% CI 1.12, 3.05), history of incarceration (AOR 1.44, 95% CI 1.04, 2.01), history of injecting drugs (AOR 1.57, 95% CI 1.13, 2.19), and had been recently homeless (AOR 2.14, 95% CI 1.57, 2.94). While overall HIV-positive MSM had more UAI with partners of any HIV status than MSMW with either partner gender, among HIV-positive MSMW, more had UAI with HIV-negative and HIV status unknown female partners than male partners. Findings highlight the interconnectedness of sexual and drug networks in this sample of men—as most have partners who use drugs and they use drugs themselves. We find a concentration of risk that occurs particularly among impoverished minorities—where many men use drugs, trade sex, and have sex with either gender. Findings also suggest an embedded core group of drug-using MSMW who may not so much contribute to spreading the HIV epidemic to the general population, but driven by their pressing need for drugs and money, concentrate the epidemic among men and women like themselves who have few resources.
PMCID: PMC2705489  PMID: 19543837
Sexual bridging; MSMW; HIV risk behavior; HIV transmission risks
12.  Concordance of Text Message Ecological Momentary Assessment and Retrospective Survey Data Among Substance-Using Men Who Have Sex With Men: A Secondary Analysis of a Randomized Controlled Trial 
JMIR mHealth and uHealth  2016;4(2):e44.
Alcohol and illicit drug use is more prevalent among men who have sex with men (MSM) compared to the general population and has been linked to HIV transmission in this population. Research assessing individual patterns of substance use often utilizes questionnaires or interviews that rely on retrospective self-reported information, which can be subject to recall bias. Ecological momentary assessment (EMA) is a set of methods developed to mitigate recall bias by collecting data about subjects’ mental states and behaviors on a near real-time basis. EMA remains underutilized in substance use and HIV research.
To assess the concordance between daily reports of substance use collected by EMA text messages (short message service, SMS) and retrospective questionnaires and identify predictors of daily concordance in a sample of MSM.
We conducted a secondary analysis of EMA text responses (regarding behavior on the previous day) and audio computer-assisted self-interview (ACASI) survey data (14-day recall) from June 2013 to September 2014 as part of a randomized controlled trial assessing a pharmacologic intervention to reduce methamphetamine and alcohol use among nondependent MSM in San Francisco, California. Reports of daily methamphetamine use, alcohol use, and binge alcohol use (5 or more drinks on one occasion) were collected via EMA and ACASI and compared using McNemar’s tests. Demographic and behavioral correlates of daily concordance between EMA and ACASI were assessed for each substance, using separate multivariable logistic regression models, fit with generalized estimating equations.
Among 30 MSM, a total of 994 days were included in the analysis for methamphetamine use, 987 for alcohol use, and 981 for binge alcohol use. Methamphetamine (EMA 20%, ACASI 11%, P<.001) and alcohol use (EMA 40%, ACASI 35%, P=.001) were reported significantly more frequently via EMA versus ACASI. In multivariable analysis, text reporting of methamphetamine (adjusted odds ratio 0.06, 95% CI 0.04-0.10), alcohol (0.48, 0.33-0.69), and binge alcohol use (0.27, 0.17-0.42) was negatively associated with daily concordance in the reporting of each respective substance. Compared to white participants, African American participants were less likely to have daily concordance in methamphetamine (0.15, 0.05-0.43) and alcohol (0.2, 0.05-0.54) reporting, and other participants of color (ie, Asian, Hispanic, multi-racial) were less likely to have daily concordance in methamphetamine reporting (0.34, 0.12-1.00). College graduates were more likely to have daily concordance in methamphetamine reporting (6.79, 1.84-25.04) compared to those with no college experience.
We found that methamphetamine and alcohol use were reported more frequently with daily EMA texts compared to retrospective ACASI, concordance varied among different racial/ethnic subgroups and education levels, and reported substance use by EMA text was associated with lower daily concordance with retrospective ACASI. These findings suggest that EMA methods may provide more complete reporting of frequent, discrete behaviors such as substance use.
PMCID: PMC4901189  PMID: 27230545
data collection; cell phones; drug users; drinking behavior; homosexuality, male
13.  Cost-Effectiveness of Combined Sexual and Injection Risk Reduction Interventions among Female Sex Workers Who Inject Drugs in Two Very Distinct Mexican Border Cities. 
PLoS ONE  2016;11(2):e0147719.
We evaluated the cost-effectiveness of combined single session brief behavioral intervention, either didactic or interactive (Mujer Mas Segura, MMS) to promote safer-sex and safer-injection practices among female sex workers who inject drugs (FSW-IDUs) in Tijuana (TJ) and Ciudad-Juarez (CJ) Mexico. Data for this analysis was obtained from a factorial RCT in 2008–2010 coinciding with expansion of needle exchange programs (NEP) in TJ, but not in CJ.
A Markov model was developed to estimate the incremental cost per quality adjusted life year gained (QALY) over a lifetime time frame among a hypothetical cohort of 1,000 FSW-IDUs comparing a less intensive didactic vs. a more intensive interactive format of the MMS, separately for safer sex and safer injection combined behavioral interventions. The costs for antiretroviral therapy was not included in the model. We applied a societal perspective, a discount rate of 3% per year and currency adjusted to US$2014. A multivariate sensitivity analysis was performed. The combined and individual components of the MMS interactive behavioral intervention were compared with the didactic formats by calculating the incremental cost-effectiveness ratios (ICER), defined as incremental unit of cost per additional health benefit (e.g., HIV/STI cases averted, QALYs) compared to the next least costly strategy. Following guidelines from the World Health Organization, a combined strategy was considered highly cost-effective if the incremental cost per QALY gained fell below the gross domestic product per capita (GDP) in Mexico (equivalent to US$10,300).
For CJ, the mixed intervention approach of interactive safer sex/didactic safer injection had an incremental cost-effectiveness ratio (ICER) of US$4,360 ($310–$7,200) per QALY gained compared with a dually didactic strategy. Using the dually interactive strategy had an ICER of US$5,874 ($310–$7,200) compared with the mixed approach. For TJ, the combination of interactive safer sex/didactic safer injection had an ICER of US$5,921 ($104–$9,500) per QALY compared with dually didactic. Strategies using the interactive safe injection intervention were dominated due to lack of efficacy advantage. The multivariate sensitivity analysis showed a 95% certainty that in both CJ and TJ the ICER for the mixed approach (interactive safer sex didactic safer injection intervention) was less than the GDP per capita for Mexico. The dual interactive approach met this threshold consistently in CJ, but not in TJ.
In the absence of an expanded NEP in CJ, the combined-interactive formats of the MMS behavioral intervention is highly cost-effective. In contrast, in TJ where NEP expansion suggests that improved access to sterile syringes significantly reduced injection-related risks, the interactive safer-sex combined didactic safer-injection was highly cost-effective compared with the combined didactic versions of the safer-sex and safer-injection formats of the MMS, with no added benefit from the interactive safer-injection component.
PMCID: PMC4758635  PMID: 26890001
14.  The Acetylcholinesterase Inhibitor Rivastigmine Does Not Alter Total Choices for Methamphetamine, but May Reduce Positive Subjective Effects, in a Laboratory Model of Intravenous Self-Administration in Human Volunteers 
A human laboratory model of intravenous methamphetamine self-administration may facilitate study of putative treatments for methamphetamine addiction. We conducted a double-blind, placebo-controlled, between groups investigation of the acetylcholinesterase (AChE) inhibitor rivastigmine in non-treatment-seeking volunteers who met criteria for methamphetamine abuse or dependence. Safety and subjective effects data derived from days 1–10 of this protocol are described in a separate publication. In this report, we describe self-administration outcomes in participants randomized to treatment with rivastigmine (0 mg, N=7; 1.5 mg, N=6; 3 mg, N=9); data that were collected on days 11–15 of the inpatient protocol. On day 11, participants sampled two infusions of methamphetamine (0 and 30 mg, IV). On days 12–15, participants made ten choices each day to receive an infusion of either methamphetamine (3 mg, IV) or saline or a monetary alternative ($0.05 – $16). The study design allowed for evaluation of differences in behavior on days in which infusions were performed by the physician (experimenter-administered) versus by the participant using a PCA pump (self-administered), and when monetary alternatives were presented in either ascending or descending sequence. The data show that rivastigmine (1.5 and 3 mg), as compared to placebo, did not significantly alter total choices for methamphetamine (p=0.150). Importantly, the number of infusion choices was greater when methamphetamine was available then when saline was available (p<0.0001), and the number of money choices was greater when saline was available then when methamphetamine was available (p<0.0001). The total number of choices for methamphetamine was not altered as a function of a participant’s preferred route of methamphetamine use (p=0.57), and did not differ significantly whether they were experimenter-administered or self-administered (p=0.30). In addition, total choices for methamphetamine were similar made when money was available in an ascending versus descending sequence (p=0.49). The participants’ years of methamphetamine use, recent use of methamphetamine (in the past 30 days), or baseline craving (indexed here as “Desire”) on the day of the self-administration task was not predictive of number of choices for methamphetamine. In a subset of participants (N=8) for which data was available, individual does of methamphetamine (3×3 mg, IV) produced significant increases in positive subjective effects, and a preliminary analysis revealed that 3mg rivastigmine was associated with reductions in these responses, as compared to placebo. In summary, the current report indicates that there were no effects of rivastigmine on total choices for methamphetamine, that there were low levels of methamphetamine self-administration but these were 8 times greater than saline, and that choice behavior was insensitive to alternative reinforcers. In addition, we showed that rivastigmine may reduce the positive subjective effects produced by methamphetamine during self-administration.
PMCID: PMC4170947  PMID: 18207225
15.  Adolescent Males and Young Females in Tehran: Differing Perspectives, Behaviors and Needs for Reproductive Health and Implications for Gender Sensitive Interventions 
Despite cultural and religious prohibitions against premarital heterosexual relationships and intimacy, some recent evidence suggests some rise in premarital heterosexual interactions and relationships among young people. On the other hand, although HIV in Iran is a concentrated epidemic and mainly reported among high risk groups such as injecting drug users (IDUs), but there are evidences that the mode of transmission is shifting towards sexual contacts. This trend has caused concern among health policy makers in terms of prevention of STDs and HIV/AIDS particularly, among young people. This paper was prepared with the aim of highlighting how gender contributes to variation in reproductive health needs and conduct of young people in Iran.
This paper is based on a secondary analysis and compares comparable reproductive beliefs and conducts of women and men based on the data of two surveys conducted in Tehran in 2002 and 2005. A survey among 1385 adolescent males and another survey among 1743 female undergraduate students in four multidisciplinary universities in Tehran. Both surveys used anonymous self-administered questionnaires. To make the two samples comparable, the data of unmarried female university undergraduate students who resided in Tehran were merged with the data of adolescent male students who intended to pursue higher education. Common variables of the two surveys were identified, homogenized, merged and analysed.
Reproductive health knowledge among male adolescents was poor compared to that of their female peers. Although premarital friendships were moderately acceptable from view points of both males and females, the majority were against premarital sex, particularly among female participants. There were evidences of gender-based double standards in perceptions of premarital sexuality among both males and females; particularly, it was stronger among males than females. Male adolescents reported earlier and greater experiences of premarital heterosexual intimacy and sexual contact than females. Multiple partners were also more common among males than females. Females had a tendency to regret first sexual contact more than males, which reflects that first sex is more likely to be unplanned and unwanted among females compared to males.
Significant gender–based double standards prevailed current sexual attitudes and conduct of young people in Iran. Gender norms which encourage unmarried men to practice premarital sex lead to an earlier transition of men to sexual relations and multiple sexual partners. Due to poor knowledge and various misconceptions about sexual health and lack of consistent contraceptive and condom use among adolescents and young people in Iran, both young men and women are susceptible to sexual and reproductive health hazards such as sexually transmitted infections (STIs), HIV/AIDS, pregnancy and unsafe abortion. Changing gender norms associated with sexuality may lead to promotion of safer sexual behaviors particularly among young people. Current reproductive health and HIV prevention programs should take into account gender-based double standards among young people and their unmet reproductive health needs.
PMCID: PMC3719336  PMID: 23926532
Adolescents; Attitude; Gender; Reproductive behavior; Sexual behavior; young people
16.  The Safety of Adult Male Circumcision in HIV-Infected and Uninfected Men in Rakai, Uganda 
PLoS Medicine  2008;5(6):e116.
The objective of the study was to compare rates of adverse events (AEs) related to male circumcision (MC) in HIV-positive and HIV-negative men in order to provide guidance for MC programs that may provide services to HIV-infected and uninfected men.
Methods and Findings
A total of 2,326 HIV-negative and 420 HIV-positive men (World Health Organization [WHO] stage I or II and CD4 counts > 350 cells/mm3) were circumcised in two separate but procedurally identical trials of MC for HIV and/or sexually transmitted infection prevention in rural Rakai, Uganda. Participants were followed at 1–2 d and 5–9 d, and at 4–6 wk, to assess surgery-related AEs, wound healing, and resumption of intercourse. AE risks and wound healing were compared in HIV-positive and HIV-negative men. Adjusted odds ratios (AdjORs) were estimated by multiple logistic regression, adjusting for baseline characteristics and postoperative resumption of sex. At enrollment, HIV-positive men were older, more likely to be married, reported more sexual partners, less condom use, and higher rates of sexually transmitted disease symptoms than HIV-negative men. Risks of moderate or severe AEs were 3.1/100 and 3.5/100 in HIV-positive and HIV-negative participants, respectively (AdjOR 0.91, 95% confidence interval [CI] 0.47–1.74). Infections were the most common AEs (2.6/100 in HIV-positive versus 3.0/100 in HIV-negative men). Risks of other complications were similar in the two groups. The proportion with completed healing by 6 wk postsurgery was 92.7% in HIV-positive men and 95.8% in HIV-negative men (p = 0.007). AEs were more common in men who resumed intercourse before wound healing compared to those who waited (AdjOR 1.56, 95% CI 1.05–2.33).
Overall, the safety of MC was comparable in asymptomatic HIV-positive and HIV-negative men, although healing was somewhat slower among the HIV infected. All men should be strongly counseled to refrain from intercourse until full wound healing is achieved.
Trial registration:; for HIV-negative men, #NCT00047073 and for HIV-positive men, #NCT00047073.
Ron Gray and colleagues report on complications of circumcision in HIV-infected and HIV-uninfected men from two related trials in Uganda, finding increased risk with intercourse before wound healing.
Editors' Summary
Worldwide over 33 million people are thought to be living with HIV, and in the absence of a vaccine, preventing its spread is a major health issue. The World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimate that 68% of 2.5 million new infections worldwide in 2007 took place in sub-Saharan Africa, where 76% of 2.1 million AIDS-related deaths also took place.
One of the principal means of person-to-person transmission of HIV is through sex without the protection of a condom. In parts of Africa, male circumcision is performed in infancy or childhood for religious or cultural reasons or is a traditional rite of passage that marks the transition from child to man. Three trials, in South Africa, Kenya, and Uganda, each found that circumcised men were around half as likely as uncircumcised men to contract HIV from HIV-positive female partners. After reviewing the results, WHO and UNAIDS issued joint advice that male circumcision should be promoted for preventing HIV infection in heterosexual men. As male circumcision does not provide complete protection against HIV infection, they advised that it should be promoted in addition to existing strategies of promoting condom use, abstinence, and a reduction in the number of sexual partners.
Why Was This Study Done?
Although earlier studies had shown that adult male circumcision, when performed in Africa under optimal conditions, is a safe procedure for HIV-negative men, it was not known whether it would also be a safe procedure for HIV-positive men. WHO guidelines recommend that HIV-positive men who request the procedure or have a medical need and no contraindications for it should be circumcised. Also, exclusion of HIV-positive men from circumcision programs may result in stigmatization of these men, and discourage participation by men who do not wish to be tested for HIV. Therefore, it is important to know whether the procedure is safe for HIV-positive men.
What Did the Researchers Do and Find?
The authors compared results from two separate clinical trials carried out with identical procedures in rural Rakai, Uganda. The first, which compared the effect of circumcision with no circumcision in HIV-negative men, was one of the three trials that persuaded the WHO and UNAIDS to promote male circumcision as an HIV prevention strategy. The second Rakai trial did the same comparison but in men who were HIV positive and without symptoms. In this present study, the authors used data from both trials to compare the likelihood of surgery-related complications following circumcision for HIV-negative and HIV-positive men.
The trials recruited men aged 15–49, who were randomly assigned to be circumcised either on enrollment or two years later and were followed up to monitor complications related to the procedure, such as infections, as well as wound healing and when the participant first had sex after the operation. Condom use was recorded at enrollment and six months after enrollment.
The researchers found that most complications were infrequent, mild, and comparable in both groups, with moderate-to-severe complications occurring in only 3%–4% of men in each group. However, delayed wound healing was more frequent in HIV-positive men. Complications were more likely among men who had sex before healing was complete; such men were more likely to be HIV-positive and/or married. Similarly, moderate or severe complications were more likely where men had symptoms of sexually transmitted disease at enrollment, although these were treated before surgery, and these men were more likely to be HIV-positive. Six months after enrollment, similar proportions of HIV-positive and HIV-negative men used condoms consistently, but HIV-positive men were more likely to report using condoms inconsistently than HIV-negative men. However, consistent use of a condom increased among the HIV-positive men compared to when they enrolled.
What Do these Findings Mean?
Circumcision in HIV-positive men without symptoms of AIDS has a low rate of complications, although healing is slower than in HIV-negative men. Because of the greater risk of complications if sex is resumed before full healing, both men and their women partners should be advised to have no sex for at least six weeks after the operation. A separately reported analysis from one of these studies found that women partners are more likely to become HIV infected by HIV-positive men who resume sex prior to complete wound healing. Therefore, for protection of both men and their female partners, it is essential to refrain from intercourse after circumcision until the wound has completely healed.
Because the study found no increased risk of surgical complications in HIV-positive men who undergo circumcision, it should not be necessary to screen men with no symptoms of HIV in future circumcision programs. This should reduce the complexity of implementing such programs and reduce any stigma resulting from exclusion, making it likely that more men will be willing to be circumcised. The rise in consistent condom use among HIV-positive men suggests that messages of safe sex are reaching an important target group and changing their behavior, and that circumcision does not make men less likely to use a condom.
The authors also noted that the rates of complications they observed were low compared with those following traditional circumcision procedures. Others have found that circumcision carried out under unsafe conditions has a high rate of complications. The authors of this study comment that the resources and standards of surgery during the trial represented best practice and that to attain similarly low rates of complications—and the confidence of men in the safety of the procedure—there is a need to ensure sufficient resources and high standards of training.
Additional Information.
Please access these Web sites via the online version of this summary at
WHO and the UNAIDS issued a joint report recommending male circumcision for HIV prevention and another on the HIV epidemic worldwide in December 2007
An information pack here on male circumcision and HIV prevention has also been developed jointly by WHO/UNAIDS, the United Nations International Children's Emergency Fund (UNICEF), the United Nations Population Fund (UNFPA), and the World Bank
The University of California San Francisco's HIV InSite provides information on HIV prevention, treatment, and policy
AEGIS is the world's largest searchable database on HIV and AIDS
The National AIDS Trust provides information on HIV prevention
PMCID: PMC2408615  PMID: 18532873
17.  Factors associated with sex in the context of methamphetamine use in different sexual venues among HIV-positive men who have sex with men 
BMC Public Health  2010;10:178.
Harm reduction has focused primarily on reduction of high-risk substance using behaviors rather than reductions in high-risk sexual behaviors. Furthermore, most studies focus on individual behavior change, with less attention paid to the social and environmental context. This paper promotes understanding of the interplay between the individual and the social context by examining the psychosocial and behavioral characteristics of 321 methamphetamine-using HIV-positive men who have sex with men (MSM) in San Diego, CA based on the locations or venues of their sexual activities when "high" on methamphetamine.
Participants in a safer-sex intervention study underwent a baseline assessment that queried demographic and psychosocial characteristics as well as drug use and sexual risk behaviors. For purposes of analysis, respondents were classified according to their preference of sexual venue: private (e.g., home), commercial (e.g., bathhouse), or public (e.g., public park or restroom).
The commercial venue group was younger, better educated, more likely to identify as gay, and significantly more likely to have used "club drugs" as compared to the other two groups. Men in the commercial- and public-venue groups reported more high-risk sex compared to the private-venue group. The public-venue group reported heavier drug and alcohol use, had significantly higher Beck depression scores, reported more experiences of stigma, and scored higher on a measure of sexual compulsivity than did the other two groups.
In an effort to reduce HIV/STI risk-behaviors, future studies should investigate the feasibility of modifying personal, psychosocial and structural factors associated with the use of risky sexual venues where HIV-positive methamphetamine users engage in sexual activity when "high" on methamphetamine.
Trial registration NCT00432926
PMCID: PMC2858118  PMID: 20359362
18.  ‘It is not expected for married couples’: a qualitative study on challenges to safer sex communication among polygamous and monogamous partners in southeastern Tanzania 
Global Health Action  2016;9:10.3402/gha.v9.32326.
Behavioral change approaches for human immunodeficiency virus (HIV) prevention in Tanzania encourage married partners to observe safe sex practices (condom use, avoidance of, or safe sex with multiple partners). To implement this advice, partners need to communicate with each other about safer sex, which is often challenging. Although social-structural factors are crucial in understanding sexual behavior, only a few studies focus on understanding safer sex dialogue in a broader social context.
Drawing on the WHO-Commission on the Social Determinants of Health (WHO-CSDH) framework, this study explored key social-structural constructs for studying health in the context of improving safer sex dialogue between polygamous and monogamous partners. Twenty-four in-depth interviews (IDIs) and six focus group discussions (FGDs) with 38 men and women aged 18–60 years were conducted in Ifakara town located in Kilombero district, Tanzania. The study was nested within the community health surveillance project MZIMA (Kiswahili: ‘being healthy’). Partners’ experiences of safer sex dialogue in polygamous and monogamous relations were investigated and the challenges to safer sex dialogue explored.
The study revealed that open safer sex dialogue in marriage is limited and challenged by social norms about marriage (a view that safer sex dialogue imply that partners are ‘not really’ married); marital status (a belief that safer sex dialogue is not practical in polygamous marriages, the elder wife should be exempted from the dialogue since she is at lower risk of engaging in extramarital affairs); relationship quality (marital conflicts, extramarital affairs, trust, and sexual dissatisfaction); and gender power relations (the notion that females’ initiative to discuss condom use and HIV couple counseling and testing may lead to conflict or divorce).
Implementing safer sex practices requires interventions beyond promotion messages. HIV prevention interventions in Tanzania should be carefully adapted to the local context including respective social norms, gender systems, marital context and relationship uncertainties as aspects that facilitate or hinder safer sex dialogue between partners. The WHO-CSDH framework could be strengthened by explicitly integrating relationship quality, marital status, and social norms as additional determinants of health.
PMCID: PMC5025524  PMID: 27633036
safer sex; HIV vulnerability; marriage; marital relationship; social norms; communication; polygamous; Tanzania; qualitative study
19.  Reducing widespread pipe sharing and risky sex among crystal methamphetamine smokers in Toronto: do safer smoking kits have a potential role to play? 
Crystal methamphetamine smoking is associated with many negative health consequences, including the potential for transmission of hepatitis. We examined whether or not a kit for crystal methamphetamine smoking might have some potential to reduce the negative health effects of crystal methamphetamine smoking.
Five focus groups were conducted with crystal methamphetamine smokers recruited by community health agencies and youth shelters in Toronto, Canada. Target groups included homeless/street-involved youth, sex workers, men who have sex with men, and youth in the party scene. Participants (n = 32) were asked questions about motivations for crystal methamphetamine use, the process of smoking, health problems experienced, sharing behaviour, risky sexual practices, and the ideal contents of a harm reduction kit.
Pipe sharing was widespread among participants and was deemed integral to the social experience of smoking crystal methamphetamine. Heated pipes were unlikely to cause direct injuries, but participants mentioned having dry, cracked lips, which may be a vector for disease transmission. Many reported having sex with multiple partners and being less likely to use condoms while on the drug. Demand for harm reduction kits was mixed.
Changing pipe sharing behaviours may be difficult because many participants considered sharing to be integral to the social experience of smoking crystal methamphetamine. Within the context of a broader health promotion and prevention program, pilot testing of safer smoking kits to initiate discussion and education on the risks associated with sharing pipes and unprotected sex for some communities (e.g., homeless/street-involved youth) is worth pursuing.
PMCID: PMC3306827  PMID: 22339847
Crystal methamphetamine; Qualitative; Harm reduction
20.  The Relationship of Alcohol and Other Drug Use Typologies to Sex Risk Behaviors among Vulnerable Women in Cape Town, South Africa 
Journal of AIDS & clinical research  2012;Suppl 1(15):015.
Alcohol and other drug (AOD) use remains an important contributing factor to the spread of HIV in South Africa, mainly because of the strong associations found between AOD use and sex risk behaviors. Specifically, AOD use can lead to disinhibition and impaired judgment that may result in inconsistent condom use and other risky sex behaviors among vulnerable and disempowered women.
Latent Class Analysis was used to identify AOD use typologies among 720 vulnerable women from a randomized trial baseline assessment in Cape Town, South Africa and to examine whether these AOD use classes predict sex risk for HIV.
Three classes emerged with distinct differences in AOD use: the Marijuana and Alcohol class (34.6%) mainly comprised participants who used marijuana and drank alcohol frequently; the High AOD Risk class (26.1%) mainly comprised participants who used methamphetamine and marijuana, reported heavy drinking, and moderate probabilities of Mandrax use; and the Polydrug use class (39.3%) predominately comprised participants who used methamphetamine, marijuana, and Mandrax. Participants in the Marijuana and Alcohol class were less likely to report past-month unprotected sex with their main sex partner compared with participants in the Polydrug Use class. When examining the adjusted model, Black African women were significantly less likely to report past-month unprotected sex with their main sex partner compared with Coloured women. Women who were HIV negative were more likely to report unprotected sex with their main sex partner than women who were HIV positive.
The fewer substances that women used seemed to serve as protective factors against engaging in AOD-impaired sex. This study provides an important contribution to understand the intersection of AOD use and sexual risk for HIV by measuring polydrug use among vulnerable women and its association with sexual risk taking.
PMCID: PMC3568528  PMID: 23403403
Alcohol and other drug use; Women; Sex risk; Latent class analysis; South Africa
21.  Methamphetamine and Young Men who have Sex with Men: Patterns, Correlates and Consequences of Use 
To examine patterns, consequences and correlates of methamphetamine use among adolescent/young adult men who have sex with men (YMSM).
Descriptive, bivariate and hierarchical regression analyses of cross-sectional data.
Howard Brown Health Center, a community-based facility in Chicago, IL from 2004-2005.
310 YMSM age 16-24 completed an anonymous, computer-assisted survey.
Main Outcome Measure
Methamphetamine use in the past year.
Participants ranged in age from 16-24 years (M=20.3); 70% were of color. Participants reported a number of high-risk sexual and substance use behaviors. Thirteen percent used methamphetamine in the past year. Methamphetamine use was more common among HIV-infected participants, odds ratio (OR) = 2.8; 95% confidence interval (CI) = 1.3-5.3, and varied by age and race/ethnicity; substantially higher prevalence was reported by older and non African-American YMSM (p<0.001). Compared to other illicit substance users, methamphetamine users reported more memory difficulties, impairments in daily activities and unintended risky sex resulting from substance use (all p<0.01). Hierarchical regression identified sexual risk (unprotected intercourse and multiple partners), sexualized social context (e.g. internet sex, sex in a bathhouse/sex club, sex with older partners, and commercial sex), lower self-esteem and psychological distress as correlated with methamphetamine use among participants (p<0.05).
A substantial proportion of YMSM in this sample use methamphetamine. Methamphetamine use is a public health problem with significant implications for the health and well-being of adolescent/young adult MSM. Methamphetamine use was associated with HIV-related risk and patterns of use were predicted by demographics, sexualized social contexts, and psychological variables.
PMCID: PMC3985401  PMID: 17548765
22.  Predicting active school travel: The role of planned behavior and habit strength 
Despite strong support for predictive validity of the theory of planned behavior (TPB) substantial variance in both intention and behavior is unaccounted for by the model’s predictors. The present study tested the extent to which habit strength augments the predictive validity of the TPB in relation to a currently under-researched behavior that has important health implications, namely children’s active school travel.
Participants (N = 126 children aged 8–9 years; 59 % males) were sampled from five elementary schools in the west of Scotland and completed questionnaire measures of all TPB constructs in relation to walking to school and both walking and car/bus use habit. Over the subsequent week, commuting steps on school journeys were measured objectively using an accelerometer. Hierarchical multiple regressions were used to test the predictive utility of the TPB and habit strength in relation to both intention and subsequent behavior.
The TPB accounted for 41 % and 10 % of the variance in intention and objectively measured behavior, respectively. Together, walking habit and car/bus habit significantly increased the proportion of explained variance in both intention and behavior by 6 %. Perceived behavioral control and both walking and car/bus habit independently predicted intention. Intention and car/bus habit independently predicted behavior.
The TPB significantly predicts children’s active school travel. However, habit strength augments the predictive validity of the model. The results indicate that school travel is controlled by both intentional and habitual processes. In practice, interventions could usefully decrease the habitual use of motorized transport for travel to school and increase children’s intention to walk (via increases in perceived behavioral control and walking habit, and decreases in car/bus habit). Further research is needed to identify effective strategies for changing these antecedents of children’s active school travel.
PMCID: PMC3419676  PMID: 22647194
Theory of planned behavior; Habit; Active school travel; Walking; Children
23.  Seriously Mentally Ill Women’s Safer Sex Behaviors and the Theory of Reasoned Action 
Seriously mentally ill women at risk for HIV infection (n = 96) participated in structured interviews assessing sexual and substance use behavior over a 3-month period. The majority of the women (63.5%) did not use condoms. Consistent with the Theory of Reasoned Action, condom use attitudes and perceived social norms about safer sex were associated with safer sex intentions. Supplementing TRA variables with safer sex self-efficacy explained additional variance in safer sex intentions. Greater safer sex intentions were related to both greater condom use and to less frequent unprotected intercourse. In addition, less frequent sex after drug use and a less fatalistic outlook were associated with less frequent unprotected intercourse. Life circumstances specific to this population are particularly important to examine to improve the effectiveness of risk reduction interventions for seriously mentally ill women.
PMCID: PMC4107413  PMID: 19458268
sexual risk behavior; HIV/AIDS; severe mental illness
24.  Better learning in schools to improve attitudes toward abstinence and intentions for safer sex among adolescents in urban Nepal 
BMC Public Health  2013;13:244.
School-based sex education is an effective medium to convey health information and skills about preventing sexually transmitted infections (STIs) and unwanted pregnancies among adolescents. However, research on school-based sex education is limited in many developing countries, including Nepal. This study thus had two main objectives: (1) to assess students’ evaluation of school-based sex education, and (2) to examine the associations between students’ evaluations of school-based sex education and their (a) attitudes toward abstinence and (b) intentions for safer sex.
This cross-sectional study was conducted among 634 students from six schools in the Kathmandu Valley during May–June 2010. We used a self-administered questionnaire to assess students’ evaluations of school-based sex education, attitudes toward abstinence, and intentions for safer sex. The data were then analyzed using multiple linear regression models.
Regarding “information on HIV and sexual health”, many students perceived that they received the least amount of information on HIV counseling and testing centers (mean 2.29, SD 1.00) through their schools. In terms of “support and involvement of teachers and parents” in sex education, parents’ participation ranked as the lowest (mean 1.81, SD 1.01). Audiotapes were reported as the least used among the listed “teaching aids for sexual health education” (mean 1.54, SD 0.82). In multivariate analysis, receiving more “information on HIV and sexual health” was positively associated with more positive “attitudes toward abstinence” (β = 0.11, p = <0.018) and greater “intentions for safer sex” (β = 0.17, p = <0.001) among students. Similarly, increased “support and involvement from teachers and parents” was also positively associated with more positive “attitudes toward abstinence” (β = 0.16, p = <0.001) and greater “intentions for safer sex” (β = 0.15, p = <0.002).
Our results suggest that students’ needs and expectations regarding HIV and sexual health education are not being met through their schools. Moreover, comprehensive information on HIV and sexual health along with increased support and involvement of teachers and parents in sex education might help to improve adolescents’ attitudes toward abstinence and intentions for safer sex. Adapting future school-based interventions to incorporate such elements may thus be an effective strategy to promote adolescent sexual health.
PMCID: PMC3608152  PMID: 23509909
Students; School health services; Sex education; Attitudes; Intentions; Abstinence; Safer sex; Nepal
25.  Intention to voluntary HIV counseling and testing (VCT) among health professionals in Jimma zone, Ethiopia: the theory of planned behavior (TPB) perspective 
BMC Public Health  2013;13:140.
Voluntary HIV Counseling and Testing (VCT) forms one of the cornerstones of HIV prevention strategies. It is imperative to understand HIV testing correlates and their theoretical underpinnings in order to promote VCT uptake. The aim of this study was to predict the intention to VCT and associated factors among health professionals in Jimma zone, Ethiopia using the theory of planned behavior.
An institution based cross-sectional quantitative study among a sample of 336 health professionals in 12 selected districts of Jimma, Ethiopia was conducted in 2012. The constructs and principles of the theory of planned behavior (TPB) were measured. Data were collected using structured questionnaire on self administered basis. A multivariable linear regression model was used to predict the role of independent variables/TPB constructs on the intention to use VCT using SPSS version 16.0.
The components of TPB independently explained the variance in intention to VCT by 30.3%. Both components of TPB and socio-demographic characteristic in the final model explained 32.7% of variance in the intention to use VCT services. Significant proportions (33.0%) of the respondents have never been tested for HIV. The respective indirect components of the TPB predicted the direct components. The strongest predictors of intention to VCT were subjective norm (β=0.39, p<0.001) and attitude (β= 0.19, p<0.001) whereas, none of the socio-demographic variables were significantly predicted the intention to use VCT. Past VCT experience did not have significant statistical association with VCT use intention.
Behavioral intention to use VCT was a function of attitude and perceived social pressure. Demographic related social determinants were not barriers for VCT use intention. Most health workers test their blood by themselves. Strategies to empower health professionals on social pressure resistance and programs targeted at changing negative attitude on VCT use can enhance intention of health professionals to use VCT.
PMCID: PMC3599811  PMID: 23414398
HIV/AIDS; VCT; HCT; Health professionals; Intention; TPB; Jimma zone; Ethiopia

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