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1.  An integrated model of care to counter high incidence of HIV and sexually transmitted diseases in men who have sex with men – initial analysis of service utilizers in Zurich 
BMC Public Health  2008;8:180.
Background
As other countries, Switzerland experiences a high or even rising incidence of HIV and sexually transmitted infections (STI) among men who have sex with men (MSM). An outpatient clinic for gay men ("Checkpoint") was opened in 2006 in Zurich (Switzerland) in order to provide sexual health services. The clinic provides counselling, testing, medical treatment and follow-up at one location under an "open-door-policy" and with a high level of personal continuity. We describe first experiences with the new service and report the characteristics of the population that utilized it.
Methods
During the 6-month evaluation period, individuals who requested counselling, testing or treatment were asked to participate in a survey at their first visit prior to the consultation. The instrument includes questions regarding personal data, reasons for presenting, sexual behaviour, and risk situations. Number and results of HIV/STI tests and treatments for STI were also recorded.
Results
During the evaluation period, 632 consultations were conducted and 247 patients were seen by the physician. 406 HIV tests were performed (3.4% positive). 402 men completed the entry survey (64% of all consultations). The majority of respondents had 4 and more partners during the last 12 months and engaged in either receptive, insertive or both forms of anal intercourse. More than half of the responders used drugs or alcohol to get to know other men or in conjunction with sexual activity (42% infrequently, 10% frequently and 0.5% used drugs always). The main reasons for requesting testing were a prior risk situation (46.3%), followed by routine screening without a prior risk situation (24.1%) and clarification of HIV/STI status due to a new relationship (29.6%). A fifth of men that consulted the service had no history of prior tests for HIV or other STIs.
Conclusion
Since its first months of activity, the service achieved high levels of recognition, acceptance and demand in the MSM community. Contrary to common concepts of "testing clinics", the Checkpoint service provides post-exposure prophylaxis, HIV and STI treatment, psychological support and counselling and general medical care. It thus follows a holistic approach to health in the MSM community with the particular aim to serve as a "door opener" between the established system of care and those men that have no access to, or for any reason hesitate to utilize traditional health care.
doi:10.1186/1471-2458-8-180
PMCID: PMC2412874  PMID: 18505556
2.  Motivational brief intervention for the prevention of sexually transmitted infections in travelers: a randomized controlled trial 
BMC Infectious Diseases  2011;11:300.
Background
Sexually transmitted infections (STIs) are among the frequent risks encountered by travelers. Efficient interventions are needed to improve the understanding of the risks of STIs. We investigated the potential benefits of a motivational brief intervention (BI) and the provision of condoms on the engagement in unprotected casual sex.
Methods
3-arm randomized controlled trial performed among single travelers aged 18-44 years visiting a travel clinic in Switzerland. The main outcomes were the prevalence of casual unprotected sexual intercourse and their predictors.
Results
5148 eligible travelers were seen from 2006 to 2008. 1681 agreed to participate and 1115 subjects (66%) completed the study. 184/1115 (17%) had a casual sexual relationship abroad and overall 46/1115 (4.1%) had inconsistently protected sexual relations. Women (adjusted OR 2.7 [95%CI 1.4-5.6]) and travelers with a history of past STI (adjusted OR 2.8 [95%CI 1.1-7.4]) had more frequent casual sexual relationships without consistent protection. Regarding the effect of our intervention, the prevalence of subjects using condoms inconsistently was 28% (95%CI16-40) in the motivational BI group, 24% (95%CI10-37) in the condoms group and 24% (95%CI14-33) in the control group (p = 0.7).
Conclusion
This study showed that a motivational brief intervention and/or the provision of free condoms did not modify risky sexual behavior of young travelers. The rate of inconsistently protected sexual relationships during travel was however lower than expected
Trial Registration Number
ClinicalTrials.gov: NCT01056536
doi:10.1186/1471-2334-11-300
PMCID: PMC3214884  PMID: 22044609
3.  Interventions among male clients of female sex workers in Benin, West Africa: an essential component of targeted HIV preventive interventions 
Sexually Transmitted Infections  2007;83(7):577-581.
Objectives
To assess the impact of interventions targeted towards female sex workers (FSWs) and their male clients on client HIV/STI prevalence and sexual behaviour.
Methods
From 1993 to 2006, an HIV/STI preventive intervention focusing on condom promotion and STI care was implemented among FSWs in Cotonou, Benin, and then expanded to cover their male sexual partners in 2000. The interventions were scaled up to five other cities of Benin in 2001–2002. Serial cross‐sectional surveys of HIV/STI prevalence and sexual behaviour were carried out among clients in Cotonou in 1998, 2002 and 2005; and in the five other cities (O/Cotonou) in 2002 and 2005.
Results
Significant declines in gonorrhoea prevalence among clients of FSWs: Cotonou, from 5.4% in 1998 to 1.6% in 2005; O/Cotonou: from 3.5% in 2002 to 0.59% in 2005. Chlamydia prevalence also declined O/Cotonou, from 4.8% to 1.8%, while HIV prevalence remained stable. Reported condom use by clients with both FSWs and casual non‐FSW partners, but not regular partners, increased significantly. While condom use at last sex with an FSW was similar in Cotonou to O/Cotonou around the time of implementation of the interventions (56% in 1998 vs 49% in 2002, respectively), it had risen to similar levels by 2005 (95% and 96%, respectively).
Conclusions
These results demonstrate that it is possible to implement preventive and clinical services for clients of FSWs, and suggest that such interventions, integrated with those targeted towards FSWs, can have a significant effect on sexual behaviour and STI prevalence (particularly gonorrhoea) among this population.
doi:10.1136/sti.2007.027441
PMCID: PMC2598661  PMID: 17942573
4.  Is use of antiretroviral therapy among homosexual men associated with increased risk of transmission of HIV infection? 
Background/objective: There is concern that use of highly active antiretroviral therapy (HAART) may be linked to increased sexual risk behaviour among homosexual men. We investigated sexual risk behaviour in HIV positive homosexual men and the relation between use of HAART and risk of HIV transmission.
Methods: A cross sectional study of 420 HIV positive homosexual men attending a London outpatient clinic. Individual data were collected from computer assisted self interview, STI screening, and clinical and laboratory databases.
Results: Among all men, sexual behaviour associated with a high risk of HIV transmission was commonly reported. The most frequently reported type of partnership was casual partners only, and 22% reported unprotected anal intercourse with one or more new partners in the past month. Analysis of crude data showed that men on HAART had fewer sexual partners (median 9 versus 20, p=0.28), less unprotected anal intercourse (for example, 36% versus 27% had insertive unprotected anal intercourse with a new partner in the past year, p=0.03) and fewer acute sexually transmitted infections (33% versus 19%, p=0.004 in the past 12 months) than men not on HAART. Self assessed health status was similar between the two groups: 72% on HAART and 75% not on HAART rated their health as very or fairly good, (p=0.55). In multivariate analysis, differences in sexual risk behaviour between men on HAART and men not on HAART were attenuated by adjustment for age, time since HIV infection. CD4 count and self assessed health status.
Conclusion: HIV positive homosexual men attending a London outpatient clinic commonly reported sexual behaviour with a high risk of HIV transmission. However, behavioural and clinical risk factors for HIV transmission were consistently lower in men on HAART than men not on HAART. Although use of HAART by homosexual men with generally good health is not associated with higher risk behaviours, effective risk reduction interventions targeting known HIV positive homosexual men are still urgently needed.
doi:10.1136/sti.79.1.7
PMCID: PMC1744584  PMID: 12576605
5.  Sexual and treatment‐seeking behaviour for sexually transmitted infection in long‐distance transport workers of East Africa 
Sexually Transmitted Infections  2007;83(3):242-245.
Objective
To investigate the sexual and treatment‐seeking behaviour for sexually transmitted infection (STI) in long‐distance transport workers of East Africa.
Methods
A health‐seeking behaviour survey was carried out at four sites on the Mombasa–Kampala trans‐Africa highway (n = 381). The questionnaires probed details of STI knowledge, symptoms and care‐seeking behaviour. In one site at the Kenya–Uganda border, a sexual patterning matrix was used (n = 202) to measure sexual behaviour in truck drivers and their assistants over the 12‐month period before the interview.
Results
Over half of the sexual acts of long‐distance transport workers over 12 months were with female sex workers, with an annual average of 2.8 sexual partners. Condom use was reported at 70% for liaisons with casual partners. 15% of truckers had had a self‐reported STI and one‐third exhibited high‐risk sexual behaviour in the previous year. Of those with an STI, 85% had symptoms when on the road and 77.2% sought treatment within 1 week of onset of symptoms. 94% of drivers and 56% of assistants sought treatment for STI in a private health facility or pharmacy. The cost of private facilities and pharmacies was not significantly higher than in the public sector. Waiting times were three times longer in the public sector. Only 28.9% of patients completed their medication courses as prescribed.
Conclusions
Truck drivers and their assistants in East Africa have high rates of reported STIs and many continue to exhibit high‐risk sexual behaviour. The transport workers studied here favoured private health facilities because of convenience and shorter waiting times.
doi:10.1136/sti.2006.024117
PMCID: PMC2659098  PMID: 17314124
6.  Risky Sexual Behaviors among a Sample of Gang-identified Youth in Los Angeles 
Gang youth are at an increased likelihood of participating in unsafe sexual behaviors and at an elevated risk of exposure to sexually transmitted infection (STIs), including HIV. This manuscript presents quantitative and qualitative data on sexual behaviors among a sample of predominately heterosexual, male gang youth aged 16 to 25 years interviewed in Los Angeles between 2006 and 2007 (n = 60). In particular, sexual identity, initiation and frequency of sex, and number of sexual partners; use of condoms, children, and other pregnancies; group sex; and STIs and sex with drug users. We argue that gang youth are a particular public health concern, due to their heightened risky sexual activity, and that behavioral interventions targeting gang youth need to include a component on reducing sexual risks and promoting safe sexual health.
PMCID: PMC3178395  PMID: 21949598
7.  Sexual attitudes and behaviour of university students at a rural South African University: Results of a Pilot Survey 
A cross sectional qualitative and quantitative pilot survey, using self administered questionnaire and focus group discussions, was conducted to assess the need for, and feasibility of, a health promotion programme for university students at a South African University. We examined the gender and cultural effects on sexual attitudes and behaviour, as well as condom use.
A total of 73 students, age’s between 18 and 30 years, participated in the pilot survey. The results suggest that females compared to the males are more likely to abstain until they find a partner with whom they intend to settle. There was a strong belief that unprotected sex can lead to pregnancy and STIs. Overall participants were not sure if condom use had any negative effects, although female respondents felt that condoms affect the pleasure of sexual intercourse.
The results suggest that there is a clear need for health promotion programmes aimed at young adults, who attend university. The programme would need to aim at improving general health knowledge, targeting health promotion and sexual risk behaviour among university students. Such a programme would have to consider gender, socio-economic circumstances as well as national and cultural background of the target population.
doi:10.1080/10911359.2012.720909
PMCID: PMC3954693  PMID: 24634577
South Africa; university students; health promotion; HIV/AIDS intervention; risk behaviour; condom use; abstinence; survey
8.  Mycoplasma genitalium infection among HIV-positive women: prevalence, risk factors and association with vaginal shedding 
Summary:
This study examined the prevalence and factors associated with Mycoplasma genitalium (MG) infection among HIV-positive women and the association between MG and vaginal HIV-1 RNA shedding. HIV-positive women attending an outpatient clinic in New Orleans, Louisiana, USA, from 2002 to 2005 were examined for a battery of sexually transmitted infections (STIs) and underwent a behavioural survey. A selected subset had a measurement of vaginal shedding analysed. Of the 324 HIV-positive women, 32 (9.9%) were infected with MG. HIV-positive women with MG were more likely to be co-infected with Neisseria gonorrhoeae and Chlamydia trachomatis and to have had ≥1 male sexual partners in the last month. In the subset (n = 164), no differences were found in the presence of detectable vaginal HIV-1 RNA between women infected and not infected with MG (30.8% versus 34.8% shedding; P = 0.69). While MG was a common co-STI in this sample of HIV-positive women, it was not associated with vaginal HIV shedding.
doi:10.1258/ijsa.2010.010320
PMCID: PMC3778661  PMID: 21464453
Mycoplasma genitalium; HIV-infected women; vaginal shedding
9.  Condom Use and Duration of Concurrent Partnerships among Men in the United States 
Sexually transmitted diseases  2009;36(5):265-272.
This analysis of male respondents in the 2002 National Survey of Family Growth describes features of concurrent sexual partnerships including duration, patterns, and condom use.
Objectives
Concurrent partnerships accelerate dissemination of STIs. Most investigations of the features of concurrent partnerships have focused on higher risk subpopulations.
Goal
To assess condom use and the duration of concurrent sexual partnerships among men in the United States.
Study Design
Analysis of concurrent sexual partnerships among males in the 2002 National Survey of Family Growth. We classified pairs of concurrent partnerships into three types: transitional, contained, and experimental concurrency, and assessed the duration of overlap. We also report the distribution of condom use at the last sexual intercourse with neither, one, or both concurrent partners of each pair and characteristics of men more likely to have used condoms with neither sex partner.
Results
The duration of overlap was <1 month in 32%, 1–3 months in 19%, and >12 months in 25% of concurrency pairs. Half (55%) of the pairs (whites, 64%; Blacks, 41%) involved unprotected sex at the last sexual intercourse with at least one partner. The 35% of men who were more likely to use condoms with neither sex partner at the last sexual intercourse were older, white (48%), married/cohabitating (55%), and during the previous 12 months were incarcerated (49%), or used crack/cocaine (51%).
Conclusions
Although Blacks generally experience higher rates of STIs and HIV, in this representative sample of men in the US, Blacks in concurrent partnerships appeared to use the only available protection (condoms) against infection (apart from abstinence) more than other racial/ethnic groups. Continued investigation of features of sexual partnership patterns is critical for curbing STI and HIV transmission.
doi:10.1097/OLQ.0b013e318191ba2a
PMCID: PMC2791954  PMID: 19265736
concurrency; condom use; partnerships; overlap; sexually transmitted infections
10.  Adherence and Risk Behaviour in Patients with HIV Infection Receiving Antiretroviral Therapy in Bangkok 
It could be postulated that due to lifestyle factors, patients with poor antiretroviral therapy (ART) adherence may also have risky sexual behaviour potentially leading to HIV transmission. There are limited data regarding unprotected sex risk and ART adherence in resource limited settings and our study set out to investigate these in an HIV clinic in Bangkok. Patients completed an anonymous questionnaire regarding their relationship details, ART adherence, sexual behaviour, alcohol and drug use and HIV transmission beliefs. Laboratory findings and medical history were also collected. Unprotected sex risk (USR) was defined as inconsistent condom use with a partner of negative or unknown HIV status. Five hundred and twelve patients completed the questionnaire. Fifty seven per cent of patients reported having taken ARV >95% of the time in the last month and 58% had been sexually active in the previous 30 days. Only 27 patients (5%) were classified as having USR in our cohort. Multivariate analysis showed USR was associated with female gender (OR 2.9, 95% CI 1.2-7.0, p0.02) but not with adherence, age, type or number of partners, recreational drug or alcohol use nor beliefs about HIV transmission whilst taking ART. Levels of USR in this resource limited setting were reassuringly low and not associated with poor ART adherence; as all USR patients had undetectable viral loads onward HIV transmission risk is likely to be low but not negligible. Nonetheless condom negotiation techniques, particularly in women, may be useful in this group.
doi:10.2174/1874357901206010023
PMCID: PMC3296110  PMID: 22423306
Adherence; Antiretroviral therapy (ART); HIV-1 infection; Unprotected sex risk; Thailand.
11.  Use of AUDIT, and measures of drinking frequency and patterns to detect associations between alcohol and sexual behaviour in male sex workers in Kenya 
BMC Public Health  2011;11:384.
Background
Previous research has linked alcohol use with an increased number of sexual partners, inconsistent condom use and a raised incidence of sexually transmitted infections (STIs). However, alcohol measures have been poorly standardised, with many ill-suited to eliciting, with adequate precision, the relationship between alcohol use and sexual risk behaviour. This study investigates which alcohol indicator - single-item measures of frequency and patterns of drinking ( > = 6 drinks on 1 occasion), or the Alcohol Use Disorders Identification Test (AUDIT) - can detect associations between alcohol use and unsafe sexual behaviour among male sex workers.
Methods
A cross-sectional survey in 2008 recruited male sex workers who sell sex to men from 65 venues in Mombasa district, Kenya, similar to a 2006 survey. Information was collected on socio-demographics, substance use, sexual behaviour, violence and STI symptoms. Multivariate models examined associations between the three measures of alcohol use and condom use, sexual violence, and penile or anal discharge.
Results
The 442 participants reported a median 2 clients/week (IQR = 1-3), with half using condoms consistently in the last 30 days. Of the approximately 70% of men who drink alcohol, half (50.5%) drink two or more times a week. Binge drinking was common (38.9%). As defined by AUDIT, 35% of participants who drink had hazardous drinking, 15% harmful drinking and 21% alcohol dependence. Compared with abstinence, alcohol dependence was associated with inconsistent condom use (AOR = 2.5, 95%CI = 1.3-4.6), penile or anal discharge (AOR = 1.9, 95%CI = 1.0-3.8), and two-fold higher odds of sexual violence (AOR = 2.0, 95%CI = 0.9-4.9). Frequent drinking was associated with inconsistent condom use (AOR = 1.8, 95%CI = 1.1-3.0) and partner number, while binge drinking was only linked with inconsistent condom use (AOR = 1.6, 95%CI = 1.0-2.5).
Conclusions
Male sex workers have high levels of hazardous and harmful drinking, and require alcohol-reduction interventions. Compared with indicators of drinking frequency or pattern, the AUDIT measure has stronger associations with inconsistent condom use, STI symptoms and sexual violence. Increased use of the AUDIT tool in future studies may assist in delineating with greater precision the explanatory mechanisms which link alcohol use, drinking contexts, sexual behaviours and HIV transmission.
doi:10.1186/1471-2458-11-384
PMCID: PMC3128017  PMID: 21609499
alcohol; sexual behaviour; Kenya; indicators; men who have sex with men; sex worker
12.  Psychological and behavioural factors associated with sexual risk behaviour among Slovak students 
BMC Public Health  2009;9:15.
Background
Knowledge about the prevalence of sexual risk behaviour (SRB) in adolescence is needed to prevent unwanted health consequences. Studies on SRB among adolescents in Central Europe are rare and mostly rely on a single indicator for SRB. This study aims to assess the association of behavioural and psychological factors with three types of SRB in adolescents in Central Europe.
Methods
We obtained data on behavioural factors (having been drunk during previous month, smoking during previous week, early sexual initiation), psychological factors (self-esteem, well-being, extroversion, neuroticism, religiousness), and SRB (intercourse under risky conditions, multiple sexual partners, and inconsistent condom use) in 832 Slovak university students (response 94.3%).
Results
Among those with sexual experience (62%), inconsistent condom use was the most prevalent risk behaviour (81% in females, 72% in males). With the exception of having been drunk in males, no factor was associated with inconsistent condom use. Regarding the other types of SRB, early sexual initiation was most strongly associated. In addition, other, mostly behavioural, factors were associated, in particular having been drunk.
Conclusion
Results suggest that behavioural factors are more closely related to SRB than psychological factors. Associations differ by type of SRB and gender but offer few clues to target risk groups for inconsistent condom use. Results show a high need for health-promotion programmes in early adolescence that target SRB in conjunction with other health risk behaviours such as alcohol abuse.
doi:10.1186/1471-2458-9-15
PMCID: PMC2630938  PMID: 19144112
13.  Role of risk and protective factors in risky sexual behavior among high school students in Cambodia 
BMC Public Health  2010;10:477.
Background
In many developing countries, adolescents have become increasingly prone to engage in habitual risky sexual behavior such as early sexual initiation and unprotected sex. The objective of this study was to identify the operation of risk and protective factors in individual, family, peer, school, and community domains in predicting risky sexual behavior among male and female adolescents in Cambodia.
Methods
From October 2007 to January 2008, we collected data from 1,049 students aged 14 to 20 years. Risky sexual behavior was measured using a scale consisting of four items: sexual intercourse during the past three months, number of sex partners during the past three months, age at first experience of sexual intercourse, and use of condom in last sexual intercourse. The risk factors examined included substance use, depression, peer delinquency, family violence, and community violence. Studied protective factors included family support function, frequency of family dinner, and school attachment.
Results
Of the 1,049 students surveyed, 12.7% reported sexual intercourse during the past three months. Out of those sexually active students, 34.6% reported having two or more sex partners over the same period, and 52.6% did not use a condom during their last sexual intercourse. After controlling for other covariates, a higher likelihood of risky sexual behavior remained significantly associated among male participants with higher levels of substance use, higher levels of peer delinquency, and higher family income. In contrast, risky sexual behavior did not retain its associations with any of the measured protective factors among male participants. Among female participants, a higher likelihood of risky sexual behavior remained significantly associated with higher levels of substance use, higher levels of community-violence witnessing, and lower levels of family support.
Conclusions
The findings suggest the importance of considering gender-related differences in the effects of risk and protective factors when designing and implementing prevention programs. In interventions for both male and female adolescents, prevention of substance use and risky sexual behavior should be integrated. For boys, efforts should focus on the reduction of peer delinquency, while, for girls, improvement of family support should be emphasized.
doi:10.1186/1471-2458-10-477
PMCID: PMC2928204  PMID: 20701808
14.  Epidemiology of male same-sex behaviour and associated sexual health indicators in low- and middle-income countries: 2003–2007 estimates 
Sexually Transmitted Infections  2008;84(Suppl_1):i49-i56.
Objectives:
To conduct a systematic review of published and unpublished data from research and public health information systems on the prevalence of male-to-male sex in the total male population; as well as among men who have sex with men (MSM), data on prevalence of heterosexual activity and heterosexual unions; prevalence of condom use with male and female partners; and prevalence of HIV infection and other sexually transmitted infections (STIs).
Methods:
Key indicators were defined (a) among men in the general population: prevalence of sex with a man ever and last year; (b) among MSM: prevalence of heterosexual experiences ever and last year; proportion of male-female transgenders; proportion of sex workers; prevalence of HIV and other STIs, condom use in last sexual encounter; consistent condom use with men last year; never used a condom with a man. With help from key informants, study searches were conducted in Pubmed, LILLACS, institutional databases, conference records and other sources. Methodology and quality of information were assessed, and the best data available for 2003–7 were selected. Indicator estimates from each study were used to propose regional estimate ranges.
Results:
A total of 83 new entries were entered into the database in addition to the previous 561, totalling 644. Of these, 107 showing 2003–7 data were selected. Many new studies came from sub-Saharan Africa, portraying hidden HIV epidemics among MSM. The most frequently reported estimate was HIV infection, with high estimate ranges in most of the regions, except for Middle East and North Africa and Eastern Europe. The next most frequently reported was lifetime frequency of heterosexual sex, showing that roughly 50% of MSM ever had sex with a woman. The small number of newer studies reporting prevalence of “sex with a man in last 12 months” between 2003 and 2007, did not warrant enough new evidence to revise our 2005 size estimates for MSM populations.
Conclusions:
A considerable number of new studies with estimates of relevance to understanding sexual behaviour and HIV among MSM were identified, with an encouraging amount of new data coming from sub-Saharan Africa. However, limitations in the quality, utility and comparability of available information persist. At least three measures could be promoted for use in surveillance and academic studies: standardised indicators for MSM studies; standardised operational definitions of, and instructions to describe, variables; and standardised research designs and data gathering strategies. A prerequisite for this all is intense advocacy to ensure a social climate in which research into such matters is prioritised, resources are made available as needed and the human rights of MSM are respected.
doi:10.1136/sti.2008.030569
PMCID: PMC2569188  PMID: 18647866
15.  Sexual Risk Taking Among Transgender Male-to-Female Youths With Different Partner Types 
American journal of public health  2009;100(8):1500-1505.
Objectives
We examined associations between partner types (categorized as main, casual, or commercial) and sexual risk behaviors of sexually active male-to-female (transgender female) youths.
Methods
We interviewed 120 transgender female youths aged 15 to 24 years recruited from clinics, community-based agencies, club and bar venues, referrals, and the streets of Los Angeles, California, and Chicago, Illinois.
Results
Sexual risk behaviors varied by partner type. Transgender female youths were less likely to use condoms during receptive anal intercourse with their main partner and were less likely to use condoms with a main partner while under the influence of substances. Youth participants were also more likely to talk to a main partner about their HIV status. Our data identified no demographic or social factors that predicted condom use during receptive anal intercourse by partner type.
Conclusions
Research and interventions that focus on understanding and mitigating risk behaviors by partner type, especially those that tackle the unique risks incurred with main partners, may make important contributions to risk reduction among transgender female youths.
doi:10.2105/AJPH.2009.160051
PMCID: PMC2901273  PMID: 20622176
16.  Migrant men: a priority for HIV control in Pakistan? 
Sexually Transmitted Infections  2006;82(4):307-310.
Objectives
To assess sexual risk behaviour and prevalence of treatable sexually transmitted infections (STI) in migrant male workers in Lahore, Pakistan.
Methods
Behavioural interviews were conducted on a representative sample of 590 migrant men aged 20–49 years. Biological samples were collected from a subsample of 190 and tested for chlamydia, gonorrhoea, and syphilis.
Results
Over half (55%) of single men were sexually experienced and 36% of married men reported premarital sex. The median ages at first intercourse and first marriage were 21 years and 28 years, respectively. In the total sample (including virgins), 13% reported any female non‐marital partner in the past 12 months, 7% contact with a female sex worker, and 2% sex with a man. Only 10% reported using a condom during most recent contact with a sex worker. STI symptoms in the past 3 months were reported by 8% of men. Laboratory tests disclosed that STI prevalence was 3.2%.
Conclusions
If and when HIV infection spreads among sex workers in Lahore, the reported behaviour of migrant men suggests that they may act as a conduit for further transmission to the general population. Condom promotion focused on the sex trade is likely to be the most effective way of reducing this risk.
doi:10.1136/sti.2005.018762
PMCID: PMC2564715  PMID: 16877580
Pakistan; migrants; sex workers; sexual behaviour; condoms; HIV
17.  Sex and sexual health: A survey of Canadian youth and mothers 
Paediatrics & Child Health  2008;13(1):25-30.
INTRODUCTION
Apparent changes in adolescent sexual behaviours have led to debate in recent years. A survey on adolescent sexuality was designed to determine mainstream Canadian adolescents’ current knowledge and sources of sexual health information, to identify their needs, and to understand the perceptions and the role of parents in sexual health education.
METHODOLOGY
In October 2005, on-line interviews were conducted by Ipsos Reid (Ipsos Canada) with 1171 Canadian teenagers (14 to 17 years of age) and 1139 mothers of teenagers.
RESULTS
Twenty-seven per cent of teens were sexually active at a mean age of 15 years, with an average of 2.5 lifetime partners, and had been in their current relationship for longer than eight months. The last time that they had had sex, 76% had used a condom. Teens and mothers overestimated the percentages of teens sexually active at any age. Most valuable sources of information were school, parents, friends and doctors. Sixty-nine per cent of teens could not find the information that they were looking for, and 62% reported obstacles in getting information. Teens lacked knowledge about sexually transmitted infections and their consequences. Seventy-five per cent of mothers believed that their teenagers’ friends were significant role models when it came to sexuality, and 50% mentioned entertainment celebrities at par with them. However, 45% of teenagers regarded their parents as their role models, far ahead of friends (32%) and entertainment celebrities (15%). Despite saying that they had positive relationships with their mothers, 38% of teens had not discussed sexuality with them. Most teens trusted the information given by health professionals (94%) and believed that it was their role to provide sexual health information.
CONCLUSIONS
Most adolescents are responsible when it comes to sexuality, but there are still areas of concern. Adolescents identify barriers to getting information and lack knowledge about sexually transmitted infections. Parents should feel more comfortable when it comes to discussing sexuality, especially the more value-based issues. Health care professionals and teachers have a role to play, and should ensure that teens are getting correct information. It is important to have diverse sources of information. All teens are not ready at the same time to receive the information; thus, it should be repeated. Governments, health, education and public health authorities have an essential role to play to make sexual health information accurate, accessible, inclusive and salient to the reality of Canadian adolescents.
PMCID: PMC2528827  PMID: 19119349
18.  Intimate partner violence perpetration, standard and gendered STI/HIV risk behaviour, and STI/HIV diagnosis among a clinic-based sample of men 
Sexually transmitted infections  2009;85(7):555-560.
Background
The estimated one in three women worldwide victimised by intimate partner violence (IPV) consistently demonstrate elevated STI/HIV prevalence, with their abusive male partners’ risky sexual behaviours and subsequent infection increasingly implicated. To date, little empirical data exist to characterise the nature of men's sexual risk as it relates to both their violence perpetration, and STI/HIV infection.
Methods
Data from a cross-sectional survey of men ages 18–35 recruited from three community-based health clinics in an urban metropolitan area of the northeastern US (n = 1585) were analysed to estimate the prevalence of IPV perpetration and associations of such violent behaviour with both standard (eg, anal sex, injection drug use) and gendered (eg, coercive condom practices, sexual infidelity, transactional sex with a female partner) forms of sexual-risk behaviour, and self-reported STI/HIV diagnosis.
Results
Approximately one-third of participants (32.7%) reported perpetrating physical or sexual violence against a female intimate partner in their lifetime; one in eight (12.4%) participants self-reported a history of STI/HIV diagnosis. Men's IPV perpetration was associated with both standard and gendered STI/HIV risk behaviours, and to STI/HIV diagnosis (OR 4.85, 95% CI 3.54 to 6.66). The association of men's IPV perpetration with STI/HIV diagnosis was partially attenuated (adjusted odds ratio (AOR) 2.55, 95% CI 1.77 to 3.67) in the multivariate model, and a subset of gendered sexual-risk behaviours were found to be independently associated with STI/HIV diagnosis—for example, coercive condom practices (AOR 1.67, 95% CI 1.04 to 2.69), sexual infidelity (AOR 2.46, 95% CI 1.65 to 3.68), and transactional sex with a female partner (AOR 2.03, 95% CI 1.36 to 3.04).
Conclusions
Men's perpetration of physical and sexual violence against intimate partners is common among this population. Abusive men are at increased risk for STI/HIV, with gendered forms of sexual-risk behaviour partially responsible for this association. Thus, such men likely pose an elevated infection risk to their female partners. Findings indicate the need for interwoven sexual health promotion and violence prevention efforts targeted to men; critical to such efforts may be reduction in gendered sexual-risk behaviours and modification of norms of masculinity that likely promote both sexual risk and violence
doi:10.1136/sti.2009.036368
PMCID: PMC3623286  PMID: 19625287
19.  Self-reported history of sexually transmissible infections (STIs) and STI-related utilization of the German health care system by men who have sex with men: data from a large convenience sample 
BMC Infectious Diseases  2011;11:132.
Background
In Germany, testing and treatment of sexually transmissible infections (STIs) services are not provided by one medical discipline, but rather dispersed among many different providers. Common STIs like gonorrhoea or Chlamydia infection are not routinely reported. Although men who have sex with men (MSM) are particularly vulnerable to STIs, respective health care utilization among MSM is largely unknown.
Methods
A sexual behaviour survey among MSM was conducted in 2006. Questions on self-reported sexual behaviour, STI-related health care consultation and barriers to access, coverage of vaccination against hepatitis, screening for asymptomatic STIs, self-reported history of STIs, and partner notification were analysed. Analysis was stratified by HIV-serostatus (3,511 HIV-negative/unknown versus 874 positive).
Results
General Practitioners, particularly gay doctors, were preferred for STI-related health care. Low threshold testing in sex-associated venues was acceptable for most respondents. Shame and fear of homophobic reactions were the main barriers for STI-testing. More than half of the respondents reported vaccination against hepatitis A/B. HIV-positive MSM reported screening offers for STIs three to seven times more often than HIV-negative or untested MSM. Unlike testing for syphilis or hepatitis C, screening for asymptomatic pharyngeal and rectal infections was rarely offered. STIs in the previous twelve months were reported by 7.1% of HIV-negative/untested, and 34.7% of HIV-positive respondents.
Conclusions
Self-reported histories of STIs in MSM convenience samples differ significantly by HIV-serostatus. Higher rates of STIs among HIV-positive MSM may partly be explained by more testing. Communication between health care providers and their clients about sexuality, sexual practices, and sexual risks should be improved. A comprehensive STI screening policy for MSM is needed.
doi:10.1186/1471-2334-11-132
PMCID: PMC3121611  PMID: 21592342
Sexual Behaviour [MeSH]; Delivery of Health Care [MeSH]; Health Surveys [MeSH]; Sexually Transmitted Diseases [MeSH]; Men who have sex with men (MSM) [non-MeSH]
20.  Correlates of condom use among sexually experienced secondary school male students in Nairobi, Kenya 
This study aimed to examine perceptual factors associated with condom use, and the relationship between condom use and the timing of sexual debut, among male secondary-school students in Nairobi, Kenya. Data are from the TeenWeb study, a school-based project that used the World Wide Web to assess the health needs of secondary-school students, and tested the web's utility as a teaching and research modality. Analyses are based on 214 sexually experienced males aged 14 to 20 years who completed web-based questionnaires about their sexual attitudes and behaviour. Results indicate that students did not see themselves as susceptible to HIV/AIDS and believed condom effectiveness in preventing HIV to be low. Consequently, only a marginal association was found between agreeing that buying condoms is embarrassing and condom use at first sexual intercourse. However, contrary to expectation, agreeing that condoms often break (almost half of participants) was associated with a higher likelihood of condom use at first sex. Each year of delay in sexual debut increased the likelihood of using a condom at first sex by 1.44 times. In turn, having used a condom at first sex increased the likelihood of using one at the most recent sex by 4.81 times, and elevated general condom use (“most or all the time”) by 8.76 times. Interventions to increase awareness about the role of condoms in preventing HIV, delay sexual initiation, and teach proper condom use among secondary-school students in Nairobi are needed.
PMCID: PMC2788491  PMID: 19399311
Adolescents; HIV/STDs; condom use; Kenya; Africa; Internet
21.  Intimate partner violence perpetration, standard and gendered STI/HIV risk behaviour, and STI/HIV diagnosis among a clinic-based sample of men 
Sexually Transmitted Infections  2009;85(7):555-560.
Background:
The estimated one in three women worldwide victimised by intimate partner violence (IPV) consistently demonstrate elevated STI/HIV prevalence, with their abusive male partners’ risky sexual behaviours and subsequent infection increasingly implicated. To date, little empirical data exist to characterise the nature of men’s sexual risk as it relates to both their violence perpetration, and STI/HIV infection.
Methods:
Data from a cross-sectional survey of men ages 18–35 recruited from three community-based health clinics in an urban metropolitan area of the northeastern US (n = 1585) were analysed to estimate the prevalence of IPV perpetration and associations of such violent behaviour with both standard (eg, anal sex, injection drug use) and gendered (eg, coercive condom practices, sexual infidelity, transactional sex with a female partner) forms of sexual-risk behaviour, and self-reported STI/HIV diagnosis.
Results:
Approximately one-third of participants (32.7%) reported perpetrating physical or sexual violence against a female intimate partner in their lifetime; one in eight (12.4%) participants self-reported a history of STI/HIV diagnosis. Men’s IPV perpetration was associated with both standard and gendered STI/HIV risk behaviours, and to STI/HIV diagnosis (OR 4.85, 95% CI 3.54 to 6.66). The association of men’s IPV perpetration with STI/HIV diagnosis was partially attenuated (adjusted odds ratio (AOR) 2.55, 95% CI 1.77 to 3.67) in the multivariate model, and a subset of gendered sexual-risk behaviours were found to be independently associated with STI/HIV diagnosis—for example, coercive condom practices (AOR 1.67, 95% CI 1.04 to 2.69), sexual infidelity (AOR 2.46, 95% CI 1.65 to 3.68), and transactional sex with a female partner (AOR 2.03, 95% CI 1.36 to 3.04).
Conclusions:
Men’s perpetration of physical and sexual violence against intimate partners is common among this population. Abusive men are at increased risk for STI/HIV, with gendered forms of sexual-risk behaviour partially responsible for this association. Thus, such men likely pose an elevated infection risk to their female partners. Findings indicate the need for interwoven sexual health promotion and violence prevention efforts targeted to men; critical to such efforts may be reduction in gendered sexual-risk behaviours and modification of norms of masculinity that likely promote both sexual risk and violence
doi:10.1136/sti.2009.036368
PMCID: PMC3623286  PMID: 19625287
22.  Validation of the worry about sexual outcomes scale for use in STI/HIV prevention interventions for adolescent females 
Health Education Research  2008;24(1):140-152.
This study examined the psychometric properties of a new scale to measure adolescents’ worry regarding outcomes of risky sexual behavior (i.e. sexually transmitted infections, including HIV [STI/HIV], and unintended pregnancy). The 10-item worry about sexual outcomes (WASO) scale, resulting in two subscales STI/HIV worry and pregnancy worry, was administered to a sample of 522 African-American female adolescents ranging in age from 14 to 18, residing in the southeast United States and participating in a sexual risk reduction intervention. The WASO demonstrated internal consistency across multiple administrations and yielded satisfactory construct validity. Worry was found to negatively correlate with sexual communication self-efficacy (with a new male partner and a steady male partner), frequency of sexual communication with male partner, attitudes about condom use and social support; worry was positively correlated with perceived barriers to condom use, condom negotiation, locus of control and depression. Overall, the results indicate that the WASO is a reliable and valid measure of assessing adolescents’ worry about STIs, HIV and pregnancy. The WASO represents a brief self-administered instrument that can be easily integrated into sexual risk reduction assessments and interventions. Future studies employing the WASO might consider testing it with more diverse samples in terms of gender, race/ethnicity, age and sexual orientation.
doi:10.1093/her/cyn006
PMCID: PMC2721668  PMID: 18353760
23.  Condom use with steady and casual partners in inner city African‐American communities 
Sexually Transmitted Infections  2006;82(3):238-242.
Objectives
This study examined rates of and factors associated with consistent condom use with steady partner and with casual partners in inner city African‐American communities with high sexually transmitted infection (STI) prevalence.
Methods
Structured interviews were conducted using street intercept methods and venue based sampling with 997 African‐American residents of inner city neighbourhoods in Houston and Dallas, Texas; of which data were analysed for the 736 that reported having sex in past 2 months. Condom use was measured as a proportion of use in last five sex acts with steady and casual partners.
Results
Reported rates of consistent condom use were high—31.4% with steady partner and 29.5% with casual partner. Multivariate logistic models differed by type of partner. Married people and those with history of STI were less likely to use condoms with the main partner, while older people were less likely and males, and those visiting a doctor more likely to use condoms with casual partners.
Conclusions
The proportion of condom use with both partner types was relatively high reflecting a general trend towards increased condom use in the United States. The finding of lower reported rates with casual partners has been discussed. Factors associated with condom use differ according to type of partner. Precise measurement of actual condom use continues to be an elusive task but is required for the design of appropriate messages and evaluation of STI programmes.
doi:10.1136/sti.2005.018259
PMCID: PMC2564747  PMID: 16731677
African‐Americans; inner city; condom use; steady partners; casual partners; street intercept methods; sampling
24.  Age differences at sexual debut and subsequent reproductive health: Is there a link? 
Background
Experiences at sexual debut may be linked to reproductive health later in life. Additionally, young women with older sexual partners may be at greater risk for HIV and sexually transmitted infections. This study examines sexual debut with an older partner and subsequent reproductive health outcomes among 599 sexually experienced women aged 15–24 who utilized voluntary counseling and testing or reproductive health services in Port-au-Prince, Haiti.
Methods
Logistic regression models, controlling for socioeconomic and demographic factors, examined whether age differences at first sex were significantly associated with STI diagnosis in the previous 12 months and family planning method use at last intercourse.
Results
Sixty-five percent of women reported sexual initiation with a partner younger or less than 5 years older, 28% with a partner 5 to 10 years older, and 7% with a partner 10 or more years older. There was a trend towards decreased likelihood of recent use of family planning methods in women who had first sexual intercourse with a partner 5 to 9 years older compared to women with partners who were younger or less than 5 years older. Age differences were not linked to recent STI diagnosis.
Conclusion
Programs focusing on delaying sexual debut should consider age and gender-based power differentials between younger women and older men. Future research should examine whether wide age differences at sexual debut are predictive of continued involvement in cross-generational relationships and risky sexual behaviors and explore the mechanisms by which cross-generational first sex and subsequent reproductive health may be connected.
doi:10.1186/1742-4755-5-8
PMCID: PMC2585071  PMID: 18976477
25.  Trends in sexual health and risk behaviours among adolescent students in British Columbia 
Regular monitoring of trends in sexual health and sexual behaviours among adolescents provides strong evidence to guide intervention programs and health policies. Using the province-wide, school-based British Columbia (BC) Adolescent Health Surveys of 1992, 1998, and 2003, this study documented the trends in sexual health and risk behaviours among adolescents in grades 7 to 12 in BC, and explored the associations between sexual behaviours and key risk and protective factors. From 1992 to 2003, the percentage of youth who had ever had sexual intercourse decreased for both males (33.9% to 23.3%) and females (28.6% to 24.3%) and the percentage who used a condom at last intercourse increased for both males (64.4% to 74.9%) and females (52.9% to 64.2%). Among students who had ever had sexual intercourse, the percentage who had first intercourse before age 14 decreased for both sexes. These encouraging results may be related in part to concurrent decreases in the prevalence of sexual abuse or forced intercourse among both male and female adolescents. Protective factors such as feeling connected to family or school were also associated with lower odds of having engaged in risky sexual behaviours. These findings emphasize the importance of including questions about adolescent sexual health behaviours, risk exposures, and protective factors on national and provincial youth health surveys, to monitor trends, inform sexual health promotion strategies and policies, and to document the effectiveness of population-level interventions to foster sexual health among Canadian adolescents.
PMCID: PMC3483310  PMID: 23115485 CAMSID: cams1178

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