HIV/AIDS risks among men and women who drink at informal alcohol serving establishments (Shebeens) in Cape Town, South Africa

HIV/AIDS is devastating southern Africa and the spread of HIV is fueled in some populations by alcohol use. Alcohol serving establishments, such as informal drinking places or shebeens, often serve as high-risk venues for HIV transmission. The current study examined the HIV risks of men (N = 91) and women (N = 248) recruited from four shebeens in a racially integrating township in Cape Town South Africa. Participants completed confidential measures of demographic characteristics, HIV risk history, alcohol and drug use, and HIV risk behaviors. Comparisons of 94 (28%) participants who reported meeting sex partners at shebeens to the remaining sample of shebeen goers, controlling for potential confounds, demonstrated a pattern of higher risk for HIV infection among persons who met sex partners at shebeens. Few differences, however, were observed between men (N = 47) and women (N = 47) who had met sex partners at shebeens, suggesting greater gender similarities than gender differences in this important subpopulation. These results indicate an urgent need for multi-level HIV prevention interventions targeting shebeens and the men and women who drink in these settings.

Cognitive strategies affecting recall of sexual behavior among high-risk men and women

OBJECTIVE

Most sexual health research depends on self-reported information, but little is known about the ways in which individuals arrive at their responses to sexual behavior questions. The purpose of the present research was to investigate the cognitive strategies and contextual cues used to recall sexual behaviors among men and women at high risk for HIV.

DESIGN

102 men and 106 women were recruited from a public health sexually transmitted disease clinic (mean age = 31 years; 45% African American, 50% White) and asked to think aloud as they responded to questions about number of lifetime sexual partners and frequency of vaginal and oral sex (in the past 2 weeks or 3 months).

MAIN OUTCOME MEASURES

Transcripts of participant interviews were coded for the different types of cognitive strategies and contextual cues that were used to recall counts of sexual partners and behaviors.

RESULTS

Multivariate logistic regressions indicated that respondents tended to enumerate each instance of behavior when recalling low frequencies of behavior and small numbers of partners and to use rate-based estimates or general impression strategies when recalling high frequencies and numbers. Most respondents did not use self-generated contextual cues.

CONCLUSION

Results suggest that reports of high frequencies of sexual behavior or large numbers of partners are approximations. For valid and reliable assessment, researchers should direct respondents to recall sexual behavior in small, manageable chunks through the use of interviewer prompts.

Frequency, quantity, and contextual use of alcohol among sexually transmitted infection clinic patients in Cape Town, South Africa

Alcohol use is prevalent in South Africa and alcohol use may be associated with higher risk for HIV transmission. This article reports a study of the association between alcohol use and HIV risk-related behavior among 614 men and 157 women receiving sexually transmitted infection (STI) clinic services in Cape Town, South Africa. Participants completed anonymous surveys of demographic information, substance use, and sexual risk behaviors. Results for men showed that drinking in sexual contexts as well as their partner's drinking were related to higher rates of unprotected intercourse. However, the number of sex partners men reported was only associated with their own use of alcohol before sex. In contrast, women's partners drinking before sex was related to higher frequencies of unprotected intercourse, but it was their own drinking before sex that was related to women's number of sex partners. Results therefore suggest that the context of alcohol use is more closely related to sexual risks than are the quantity or frequency of use. Interventions are needed that integrate HIV risk reduction with alcohol risk reduction in South Africa.

Serosorting sexual partners and risk for HIV among men who have sex with men

OBJECTIVE

The purpose of the current study was to assess whether men who have sex with men (MSM) who limit their unprotected anal sexual partners to those who are of the same HIV status (serosort) differ in their risk for HIV transmission than MSM who do not serosort.

METHODS

Cross-sectional surveys administered at a large Gay Pride festival in June 2006 (80% response rate) were collected from MSM. Univariate and multivariate logistic regressions were used to identify predictors of serosorting. Analyses were conducted in 2006.

RESULTS

Participants were self-identified as HIV-negative MSM (N=628); about one third of them engaged in serosorting (n=229). Men who serosort were more likely to believe that it offered protection against HIV transmission, perceived themselves as being at no relatively higher risk for HIV transmission, and had more unprotected anal intercourse partners. Over half the sample reported their frequency of HIV testing as yearly or less frequently; this finding did not differ between serosorters and nonserosorters.

CONCLUSIONS

Men who identify as HIV-negative and serosort are no more likely to know their HIV status than men who do not serosort and are at higher risk for exposure to HIV. Interventions targeting MSM must address the limitations of serosorting.

Changes in HIV treatment beliefs and sexual risk behaviors among gay and bisexual men, 1997-2005

OBJECTIVE

Beliefs about HIV treatment effectiveness and the impact of HIV treatments on HIV transmission risks were initially related to sexual risk-taking in the late 1990s when multidrug HIV treatments first became available. This study examined changes in beliefs about the effects of HIV treatment for preventing HIV transmission and their association to sexual risk behaviors between the years 1997 and 2005.

DESIGN

Anonymous surveys were administered to a convenience sample of gay and bisexual men attending a large community event in Atlanta, Georgia in 1997 (N = 498) and again at the same community event in 2005 (N = 448). Analyses were performed for men living with HIV/AIDS and for men who have not been diagnosed with HIV/AIDS.

MAIN OUTCOME MEASURES

Rates of unprotected anal intercourse in the previous 3 months.

RESULTS

There were significant increases in high-risk sexual practices that coincided with increased beliefs that HIV treatments can reduce the chance of transmitting HIV. However, optimistic beliefs about the health benefits of HIV treatments decreased over the 8 years and were not related to risk behaviors.

CONCLUSIONS

Beliefs about how HIV treatments impact HIV infectiousness remain associated with HIV transmission risk behavior and interventions targeting at-risk as well as HIV-positive men who have sex with men must directly address these beliefs and perceptions.

HIV/AIDS case managers and client HIV status disclosure: perceived client needs, practices, and services

People living with HIV/AIDS often need assistance in deciding whether or how to disclose their HIV status to others, and case managers are in a unique position to offer this assistance. The current study surveyed 223 case managers providing services to people living with HIV/ AIDS in NewYork State. The survey was conducted anonymously, and case managers were sampled at the agency level. Results showed that two-thirds of case managers routinely discuss disclosure issues with their HIV-positive clients. However, case managers often felt that they lacked the resources to provide assistance with disclosure decisions, and 66 percent of those who routinely discuss disclosure issues had not received training in assisting with disclosure to sex and injection drug-sharing partners. HIV disclosure issues were also seen by case managers as only one of many pressing issues facing their HIV-positive clients; other pressing issues were housing, food, medical care, mental health treatment, and preventing HIV transmission. These results indicate a need for training and resources to facilitate HIV status disclosure assistance services offered by case managers.

Alcohol expectancies and risky drinking among men and women at high-risk for HIV infection in Cape Town South Africa

This study examined the differential patterns of alcohol outcome expectancies in relation to drinking before sex and having sex partners who drink before sex among men (N=614) and women (N=158) sexually transmitted infections clinic patients in Cape Town South Africa. Hierarchical regressions, controlling for age, education, and alcohol use showed that men's sexual enhancement alcohol expectancies were associated with drinking before sex and having sex partners who drank before sex. Behavioral disinhibition expectancies were inversely related to drinking before sex. For women, there were no associations between alcohol expectancies and drinking before sex, although sexual enhancement expectancies were related to having sex partners who drank before sex. We conclude that alcohol outcome expectancies, particularly expectancies that alcohol will enhance sexual experiences, are related to HIV transmission risks. Sexual risk reduction interventions for those at greatest risk for HIV/AIDS should directly address alcohol expectancies.

Lowering obstacles to HIV prevention services: effects of a brief, telephone-based intervention using motivational enhancement therapy

BACKGROUND

Brief and low-burden HIV risk reduction counseling interventions are needed for populations at greatest risk for HIV infection.

PURPOSE

This randomized controlled trial tested a brief theory-based counseling intervention delivered entirely over the telephone for men who engage in unprotected intercourse with men.

METHODS

Participants received either risk reduction counseling that included information, motivational enhancement and behavior skills building, or brief HIV education counseling. A total of 319 participants completed follow-up assessments over a 10-month period. Descriptive and random effects mixed models are used to evaluate findings.

RESULTS

Results demonstrate that a brief telephone intervention can reach and engage high-risk men in risk reduction counseling. Nearly one third of participants identified as men of color; the median age was 33 years. Participants in both counseling conditions increased their motivation and behavioral skills to practice safer sex and reduced their number of sex partners and frequencies of engaging in unprotected anal sex over the study observation period. However, there were few differences between intervention conditions.

CONCLUSIONS

The effects of repeated measurement reactivity and brief interpersonal consciousness raising may account for the lack of differences between counseling conditions and the decrease in risk for all participants over time.

Alcohol and risks for HIV/AIDS among sexually transmitted infection clinic patients in Cape Town, South Africa

Alcohol use is prevalent in South Africa and alcohol use may be associated with higher risk for HIV transmission. This paper reports a study of the association between alcohol use and HIV risk-related behavior among 134 men and 92 women receiving sexually transmitted infection (STI) clinic services in Cape Town, South Africa. Participants completed anonymous surveys of demographic information, substance use, and sexual risk behaviors. Results showed that problem drinking was common among STI clinic patients; 58% of men and 28% of women scored above a cut-off of 9 on the Alcohol Use Disorders Identification Test (AUDIT) suggesting possible problem drinking and 46% of men and 19% of women scored above 12 on the AUDIT indicating probable drinking problems. For men, heavier alcohol use was associated with having multiple sex partners in the past month, less condom use, and having a history of sexually assaulting women. Among women, higher scores on the AUDIT were also related to having multiple sex partners as well as a history of exchanging sex for money or materials. The association between alcohol use and sexual risk behaviors in a population at high-risk for HIV transmission demonstrates the need for integrating alcohol risk reduction counseling with HIV prevention counseling among STI clinic patients in South Africa.

Beliefs about treatments for HIV/AIDS and sexual risk behaviors among men who have sex with men, 1997-2006

Beliefs that HIV treatments reduce HIV transmission risks are related to increases in sexual risk behaviors, particularly unprotected anal intercourse among men who have sex with men (MSM). Changes in unprotected anal intercourse and prevention-related treatment beliefs were recently reported for surveys of mostly white gay men collected in 1997 and 2005. The current study extends this previous research by replicating the observed changes in behaviors and beliefs in anonymous community surveys collected in 2006. Results indicated clear and consistent increases in beliefs that HIV treatments reduce HIV transmission risks and increases in unprotected anal intercourse. These changes were observed for both HIV positive and non-HIV positive men. African American men endorsed the belief that HIV treatments protect against HIV transmission to a greater degree than White men. Results show that HIV prevention messages need to be updated to educate MSM about the realities of HIV viral concentrations and HIV transmission risks.

Recent multiple sexual partners and HIV transmission risks among people living with HIV/AIDS in Botswana

BACKGROUND

HIV prevalence in Botswana is among the highest in the world and sexual networking patterns represent an important dimension to understanding the spread of HIV/AIDS.

AIM

To examine risk behaviour associated with recent multiple sexual partnerships among people living with HIV/AIDS in Botswana.

METHODS

Confidential brief interviews were administered to 209 HIV positive men and 291 HIV positive women recruited conveniently from HIV/AIDS support groups and antiretroviral clinics. Measures included demographics, duration of HIV diagnosis, sexual partnerships, condom use, and HIV status disclosure.

RESULTS

The response rate was 63% and 309 (62%) participants were currently sexually active, of whom 247 (80%) reported only one sex partner in the previous 3 months and 62 (20%) reported two or more partners during that time. Condom use exceeded 80% across partner types and regardless of multiple partnerships. Steady sex partners of participants with multiple partnerships were significantly less likely to be protected by condoms than steady partners of individuals with only one sex partner. Individuals with multiple sex partners were also significantly less likely to have disclosed their HIV status.

CONCLUSIONS

Multiple sexual partnerships, many of which are probably concurrent, are not uncommon among sexually active people living with HIV in Botswana. HIV prevention is needed for all individuals who are at risk and assistance should be provided to HIV infected people who continue to practise unprotected sex with uninfected partners or partners of unknown HIV status.

Adherence to antiretroviral therapy assessed by unannounced pill counts conducted by telephone

BACKGROUND

Unannounced pill counts conducted in patients' homes is a valid objective method for monitoring medication adherence that is unfortunately costly and often impractical. Conducting unannounced pill counts by telephone may be a viable alternative for objectively assessing medication adherence.

PURPOSE

To test an unannounced pill count assessment of adherence conducted by telephone.

METHODS

HIV-positive men and women (N = 77) in Atlanta GA completed an unannounced telephone-based pill count immediately followed by a pill count conducted in an unannounced home visit.

RESULTS

A high degree of concordance was observed between phone and home-based number of pills counted (Intraclass correlation, ICC = .997, 95% CI .995-.998, P < .001) and percent of pills taken (ICC = .990, 95% CI .986-.992, P < .001). Concordance between adherence above/below 90% and phone/home counts was 95%, Kappa coefficient = .995. Concordance between pill counts was not influenced by participant education or health literacy and was maintained when the data were censored to remove higher levels of adherence. Analyses of discordant pill counts found the most common source of error resulted from overcounted doses in pillboxes on the telephone.

CONCLUSIONS

Unannounced phone-based pill counts offer an economically and logistically feasible objective method for monitoring medication adherence.

HIV/AIDS risk reduction counseling for alcohol using sexually transmitted infections clinic patients in Cape Town, South Africa

BACKGROUND

HIV is ravaging southern Africa, and HIV transmission risk behaviors are facilitated by alcohol use in sexual contexts. There are no known interventions that directly target HIV risk behavior among people who drink and are at risk for HIV in Africa.

PURPOSE

To test a behavioral risk reduction counseling intervention for use in sexually transmitted infection (STI) clinics in southern Africa.

METHODS

A randomized intervention trial was conducted with 143 STI clinic patients in Cape Town, South Africa. Participants received an experimental 60-minute HIV and alcohol risk reduction behavioral skills intervention or a control 20-minute HIV education condition. Participants were followed for 3 and 6 months after the intervention, with 73% retention.

RESULTS

Overall, the experimental intervention demonstrated more than a 25% increase in condom use and a 65% reduction in unprotected intercourse over the 6-month follow-up period, with risk reduction significantly greater for the experimental condition than for the control condition at both follow-ups. Alcohol use in sexual contexts [F(1,94) = 6.2; P < 0.05] and expectancies that alcohol enhances sexual experiences [F(1,94) = 8.3; P < 0.01] were also significantly lower for the experimental condition at the 3-month follow-up.

CONCLUSIONS

An HIV prevention counseling intervention reduced HIV transmission risks for up to 6 months in this STI clinic population. Effects may be sustained with structural interventions to reduce alcohol use in sexual contexts and support risk reduction behavior changes over the long-term.

Positive prevention: HIV transmission risk reduction interventions for people living wiht HIV/AIDS

No abstract available.

Sexual assault, sexual risks and gender attitudes in a community sample of South African men

Sexual assault against women and HIV infection are both prevalent and related social problems in South Africa. The current study examined hostile attitudes toward women, acceptance of violence against women and masculine ideological beliefs in relation to sexual assault history among men in a Cape Town township in South African. Men (n=435) completed anonymous surveys of sexual assault history, HIV risk history and gender-based attitudes. More than one in five men in this community sample reported that they had either threatened to use force or used force to gain sexual access to a woman in their lifetime. Men with a history of sexual assault were at significantly higher risk for HIV transmission than their non-sexually assaultive counterparts. Men with a history of sexual assault were also more likely to endorse hostile attitudes toward women and were more likely to accept violence against women, although these attitudes and beliefs were prevalent and pervasive across men with and without histories of sexual assault. These findings extend previous research to show that men who have a history of sexual assault also exhibit elevated risks for HIV infection and transmission. Interventions are needed to address hostile attitudes toward women, sexual assault and sexual risks for HIV among South African men.

Altering key characteristics of a disseminated effective behavioral intervention for HIV positive adults: the "healthy relationships" experience

HIV prevention programs targeted to people living with HIV/AIDS are the US national HIV prevention priority. Healthy Relationships is a nationally disseminated HIV prevention program for HIV positive adults. Key characteristics of the intervention package include gender separated groups facilitated by a mental health professional and a HIV positive peer counselor, both of which cause considerable barriers to implementation. We examined an alteration of the original Healthy Relationships intervention (HR-O) that delivered the intervention to mixed gender groups by non-mental health and non-HIV positive facilitators. Process measures from the altered Healthy Relationships intervention (HR-A) were compared to the same measures taken in the HR-O trial. Intervention completion rates were better in the HR-A model (84%) than HR-O (70%). Results showed that HR-A was comparable to HR-O in social support, group cohesion, and group openness. Facilitators in HR-A were viewed somewhat more positive than in HR-O. We found no empirical basis for conducting separate groups by gender or for constraining the facilitators in terms of their professional and HIV statuses. Research is needed to test the assumptions of other evidence-based HIV prevention programs.

Disclosure of HIV status to sex partners and sexual risk behaviours among HIV-positive men and women, Cape Town, South Africa

BACKGROUND

The HIV epidemic continues to amplify in southern Africa and there is a growing need for HIV prevention interventions among people who have tested HIV positive.

METHODS

Anonymous surveys were completed by 413 HIV-positive men and 641 HIV-positive women sampled from HIV/AIDS services; 73% were <35 years old, 70% Black African, 70% unemployed, 75% unmarried, and 50% taking antiretroviral treatment.

RESULTS

Among the 903 (85%) participants who were currently sexually active, 378 (42%) had sex with a person to whom they had not disclosed their HIV status in the previous 3 months. Participants who had not disclosed their HIV status to their sex partners were considerably more likely to have multiple partners, HIV-negative partners, partners of unknown HIV status and unprotected intercourse with non-concordant sex partners. Not disclosing their HIV status to partners was also associated with having lost a job or a place to stay because of being HIV positive and feeling less able to disclose to partners.

CONCLUSIONS

HIV-related stigma and discrimination are associated with not disclosing HIV status to sex partners, and non-disclosure is closely associated with HIV transmission risk behaviours. Interventions are needed in South Africa to reduce the AIDS stigma and discrimination and to assist people with HIV to make effective decisions on disclosure.

Alcohol use and sexual risks for HIV/AIDS in sub-Saharan Africa: systematic review of empirical findings

Alcohol consumption is associated with risks for sexually transmitted infections (STI), including HIV/AIDS. In this paper, we systematically review the literature on alcohol use and sexual risk behavior in southern Africa, the region of the world with the greatest HIV/AIDS burden. Studies show a consistent association between alcohol use and sexual risks for HIV infection. Among people who drink, greater quantities of alcohol consumption predict greater sexual risks than does frequency of drinking. In addition, there are clear gender differences in alcohol use and sexual risks; men are more likely to drink and engage in higher risk behavior whereas women's risks are often associated with their male sex partners' drinking. Factors that are most closely related to alcohol and sexual risks include drinking venues and alcohol serving establishments, sexual coercion, and poverty. Research conducted in southern Africa therefore confirms an association between alcohol use and sexual risks for HIV. Sexual risk reduction interventions are needed for men and women who drink and interventions should be targeted to alcohol serving establishments.

Coital bleeding and HIV risks among men and women in Cape Town, South Africa

BACKGROUND

South Africa has one of the world's fastest growing HIV epidemics. Genital bleeding during sexual intercourse may play a role in facilitating HIV transmission in South Africa.

PURPOSE

The purpose of this study was to examine the prevalence and sources of coital bleeding among men and women living in a Cape Town South Africa township.

METHODS

A purposive sample of 464 men and 531 women completed anonymous street intercept surveys of HIV risk history and sexual behaviors.

RESULTS

Thirty-one percent of men and 26% of women had a lifetime history of engaging in sexual intercourse that involved genital bleeding, and 21% of men and 16% of women reported coital bleeding in the previous 3 months. Over 75% of coital bleeding was attributed to menses. Across genders and controlling for demographic, sexual behavior, and life history factors, coital bleeding in the previous 3 months was associated with being an indigenous African, having multiple sexual partners, and higher rates of unprotected intercourse during that time period. People who reported coital bleeding were over 3 times more likely to have been diagnosed with a sexually transmitted infection even after controlling for having had genital ulcers.

CONCLUSIONS

Coital bleeding may be common in South Africa. Prevention messages that promote condom use or refraining from sex when there is genital bleeding are therefore needed.

Sensation seeking, alcohol use, and sexual behaviors among sexually transmitted infection clinic patients in Cape Town, South Africa

Alcohol use is associated with risks for HIV/AIDS. The association between alcohol and sexual risk may be accounted for by sensation seeking personality. However, sensation seeking in relation to substance use and HIV risk has not been examined in Africa. In this study, 292 men and 219 women receiving sexually transmitted infection (STI) diagnostic and treatment services in Cape Town, South Africa, completed anonymous behavioral surveys. Structural modeling was used to test a model of alcohol use and sensation seeking in relation to sexual risk behaviors. Results showed that sensation seeking and alcohol use in sexual contexts were related to HIV risks, controlling for gender and marital status. The association between sensation seeking and HIV risk was partly accounted for by alcohol use in proximity to sex. In contrast to studies conducted in the United States, sensation seeking was not related to alcohol-sex outcome expectancies. These findings suggest that alcohol use is an important HIV transmission risk factor for many STI clinic patients and that interventions for individuals who are characterized as sensation seekers are urgently needed in South Africa.

Internet-based health information consumer skills intervention for people living with HIV/AIDS

Medical information can improve health, and there is an enormous amount of health information available on the Internet. A randomized clinical trial tested the effectiveness of an intervention based on social- cognitive theory to improve information use among people living with HIV/AIDS. Men and women (N = 448) were placed in either (a) an 8-session intervention that focused on Internet information consumer skills or (b) a time-matched support group and were followed to 9 months postintervention. The Internet skills group demonstrated greater Internet use for health, information coping, and social support compared with the control group. The authors conclude that people with HIV infection may benefit from increased access to health information on the Internet and that vulnerability to misinformation and fraud can be reduced through behavioral interventions.

HIV treatment beliefs and sexual transmission risk behaviors among HIV positive men and women

People are living longer and healthier with HIV infection because of successful combination antiretroviral therapies. HIV treatment beliefs are often associated with sexual practices among people living with HIV/AIDS but these associations may depend on the HIV status of sex partners. In a sample of 158 HIV positive men and women who were receiving HIV treatments, we examined the association between HIV treatment beliefs, HIV transmission risk perceptions, medication adherence, viral load and engaging in unprotected intercourse with any sex partners and specifically with sex partners who were not HIV positive (non-concordant). Results showed having missed medications in the past two days and treatment-related beliefs were significantly associated with engaging in unprotected intercourse with all sex partners as well as non-concordant partners. However, multivariate models showed that only treatment beliefs were significantly associated with engaging in unprotected intercourse with non-concordant partners. These results extend past research by demonstrating that the HIV status of sex partners sets the context for whether prevention-related treatment beliefs are associated with HIV transmission risk behaviors among people living with HIV/AIDS.

Generalizing a model of health behaviour change and AIDS stigma for use with sexually transmitted infection clinic patients in Cape Town, South Africa

We tested the Information-Motivation-Behavioural Skills (IMB) model of AIDS preventive behaviour in South Africa. Prospective path analyses were performed on measures collected from 131 men and 60 women with sexually transmitted infections (STI) in Cape Town. Results showed that IMB constructs collected at baseline predicted risk reduction behaviour 3 months later. Risk reduction intentions were positively associated with risk reduction self-efficacy and self-efficacy was in turn positively associated with protective behaviour 3 months later. In a second model, AIDS-related stigmas correlated inversely with AIDS knowledge and there was a trend toward AIDS stigmas correlating inversely with behavioural intentions. Accounting for AIDS-related stigmas did not improve model fit. These findings parallel similar tests of the IMB model in US samples and suggest that the IMB model may generalize to South Africa and may therefore be useful in guiding HIV risk reduction interventions.

Correlates of nonparticipation in an HIV prevention program for MSM

Providing HIV prevention services to high-risk individuals remains challenging. We assessed factors associated with nonparticipation among high-risk, sexually active MSM found eligible to participate in a brief, telephone-delivered HIV prevention trial designed to evaluate the efficacy of motivational enhancement therapy (the Sex Check). Two levels of nonparticipation are evaluated: eligible participants who did versus those who did not complete their baseline/enrollment interview, and enrolled participants who did versus those who did not attend any of their counseling sessions. Nonenrollers were younger, less educated, more closeted, and were more likely to report sex with an injection drug using partner. Enrolled participants who did not engage in their counseling session(s) were less educated, reported greater use of alcohol and drugs during sex and use of injection drugs. Innovative methods to reduce barriers to engaging high-risk, sexually active MSM in risk reduction counseling are needed.

HIV/AIDS risks among South African men who report sexually assaulting women

OBJECTIVE

To examine HIV risks among South African men who report having been sexually assaultive.

METHODS

Men (N = 412) in Cape Town completed anonymous surveys.

RESULTS

Twenty-three percent reported a history of sexual assault. Men who had been sexually assaultive were younger, reported more sex partners, were more likely to have a history of genital ulcers, and more likely to have exchanged money for sex. Sexually assaultive men were also more likely to endorse rape myths.

CONCLUSIONS

Interventions that target men as the agents of change in reducing sexual assaults and HIV transmission are urgently needed.

Marketing the 'Sex Check': evaluating recruitment strategies for a telephone-based HIV prevention project for gay and bisexual men

Designing effective marketing and recruitment strategies for HIV prevention research requires attention to cultural relevance, logistical barriers, and perceived psychosocial barriers to accessing services. McGuire's communication/persuasion matrix (1985) guided our evaluation, with particular attention to success of each marketing "channel" (i.e., strategy) vis-à-vis the number of all callers, eligible callers, and enrolled callers, as well as reaching so-called "hard-to-serve" individuals. Nearly all channels offered success in reaching specific subgroups. Latinos responded favorably to posters, bisexuals responded favorably to paid media in an alternative (non-gay) publication, and precontemplators responded to referrals by family and friends. Although multiple recruitment strategies were used, three were crucial to the success of the project: (a) recruiters' presence in gay venues, (b) referrals by family and friends (snowball technique), and (c) paid advertisements in alternative (non-gay) local newspapers. Resource allocation and costs are also presented for each channel.

Health information on the Internet and people living with HIV/AIDS: Information evaluation and coping styles

Individuals who seek information on the Internet to cope with chronic illness may be vulnerable to misinformation and unfounded claims. This study examined the association between health-related coping and the evaluation of health information. Men (n = 347) and women (n = 72) who were living with HIV/AIDS and reported currently using the Internet completed measures assessing their Internet use. Health Web sites downloaded from the Internet were also rated for quality of information. HIV-positive adults commonly used the Internet to find health information (66%) and to learn about clinical trials (25%); they also talked to their physicians about information found online (24%). In a multivariate analysis, assigning higher credibility to unfounded Internet information was predicted by lower incomes, less education, and avoidant coping styles. People who cope by avoiding health information may be vulnerable to misinformation and unfounded claims that are commonly encountered on the Internet.

Nurse-delivered antiretroviral treatment adherence intervention for people with low literacy skills and living with HIV/AIDS

People living with HIV/AIDS who have lower health literacy show poorer treatment adherence and more adverse health outcomes. The authors undertook the development and pilot testing of a brief HIV treatment adherence improvement counseling intervention for people with lower health literacy who were taking antiretroviral medications. Guided by a theory of health behavior change, health education principles for lower literacy populations, and formative research, the authors designed a two-session plus one booster session nurse-delivered HIV treatment adherence intervention. Results from a pilot test with 30 HIV-positive men and women with lower health literacy showed that the intervention increased HIV/AIDS knowledge, intentions to improve adherence, and self-efficacy for adhering to medications. Participants exposed to the intervention also showed improvement in medication adherence, with reductions in numbers of missed pills and reductions in numbers of doses taken off-schedule. These results suggest that relatively brief behavioral interventions that are tailored for people with lower health literacy may have a significant impact on health-related behaviors.

PERCEPTIONS OF THE COMBINATION OF HIV/AIDS AND ALCOHOL AS A RISK FACTOR AMONG STI CLINIC ATTENDERS IN SOUTH AFRICA: IMPLICATIONS FOR HIV PREVENTION

With the emergence of HIV/AIDS as a global health threat, there has been increasing interest among researchers in understanding sexual risk-taking behavior. The finding of a strong link between sexually transmitted infections (STIs) and HIV suggests that individuals with STIs may be at greatest risk for HIV infection. This study sought to gain insight regarding STI clinic attenders' perceptions of HIV/AIDS and alcohol as a risk factor with regard to HIV infection. Twenty-one men and women who were self-referrals at an STI dedicated clinic in Cape Town, South Africa, participated in the study. The findings showed that HIV/AIDS was cognitively represented as an STI, transmitted through risky sexual behavior such as casual sex, multiple sexual partners, and inconsistent condom use. Alcohol was implicated as a major risk factor to HIV infection because it was perceived as the main tool for transactional sex, lowering of sexual inhibitions and inconsistent use of condoms. The implications of these findings for the development of effective HIV/AIDS prevention programs are discussed.

Sexual exposure to blood and behavioural risks among STI clinic patients in Cape Town, South Africa

BACKGROUND

Exposure to blood during sexual intercourse is potentially important and yet understudied in HIV transmission.

METHODS

The study included 415 men and 127 women receiving diagnostic and treatment services at a sexually transmitted infections (STI) clinic in Cape Town, South Africa, who completed anonymous sexual health behaviour surveys.

RESULTS

More than 30% of both men and women reported engaging in sexual intercourse involving genital bleeding in the previous 3 months. Individuals who had engaged in sexual intercourse involving blood had significantly greater numbers of sex partners in the previous 3 months (OR = 1.6, 95%, CI = 1.1-2.3), engaged in higher rates of unprotected vaginal intercourse (OR = 1.2, 95%, CI = 1.1-1.2), were significantly more likely to have exchanged sex for money or materials (OR = 3.1, 95%, CI = 1.7-5.5) and were significantly more likely to have experienced condom breaks during intercourse (OR = 1.7, 95%, CI = 1.2-2.4).

CONCLUSIONS

These findings suggest that exposure to blood during vaginal intercourse is prevalent among STI clinic patients in Cape Town and may be an important contributing factor to the rapid spread of HIV in South Africa.

Psychosocial and behavioral correlates of seeking sex partners on the internet among hiv-positive men

BACKGROUND

The Internet is revolutionizing how people access and use information; for some people, the Internet is also redefining interpersonal relationships, including sexual relationships.

PURPOSE

The objective of this study was to extend the understanding of HIV-positive men who use the Internet to meet sex partners.

METHODS

This study examined the use of the Internet for meeting sex partners among 141 sexually active HIV-positive men who completed anonymous surveys.

RESULTS

Results showed that 37% of sexually active HIV-positive men who were using the Internet had gone online to seek potential sex partners in the previous 3 months. Seeking sex partners online was associated with greater likelihood of having HIV-negative sex partners and engaging in unprotected intercourse with HIV-negative or unknown HIV status partners. Multivariate analyses showed that seeking sex partners online was associated with greater education, higher CD4 cell counts, using the Internet for sexual entertainment, and higher Sexual Compulsivity scale scores over and above demographic, health, Internet use, sexual behavior, and other psychosocial characteristics including optimism and depression.

CONCLUSIONS

Results suggest a continued need for interventions targeting HIV transmission risk reduction among HIV-positive men who use the Internet to meet potential sex partners.

Pillboxes and antiretroviral adherence: prevalence of use, perceived benefits, and implications for electronic medication monitoring devices

HIV treatment adherence is improved by behavioral interventions, including medication organizers such as pillboxes, which can also interfere with adherence electronic monitoring devices (EMD). This study examined the characteristics of pillbox users and the implications of pillbox use for research using EMD adherence research. Men and women (n = 160) currently taking antiretroviral medications (ARVs) completed anonymous surveys in a community research setting. Sixty-three (39%) of individuals taking ARVs were currently using a pillbox. Pillbox users were significantly more likely to have an undetectable viral load and less likely to have missed their medications within a day of the assessment. Pillbox users indicated feeling that they benefited from using their pillbox and 76% reported they would likely stop using their pillbox if required to participate in a research study that paid them. Adherence EMD pose methodological limitations to research when pillbox users are excluded and ethical implications when pillbox users stop using their pillbox to participate.

Gender attitudes, sexual violence, and HIV/AIDS risks among men and women in Cape Town, South Africa

This study examined gender attitudes and sexual violence-supportive beliefs (rape myths) in a sample of South African men and women at risk for HIV transmission. Over 40% of women and 16% of men had been sexually assaulted, and more than one in five men openly admitted to having perpetrated sexual assault. Traditional attitudes toward women's social and gender roles, as well as rape myths, were endorsed by a significant minority of both men and women. Multivariate analyses showed that for men, sexual assault history and rape myth acceptance, along with alcohol and other drug use history, were significantly related to cumulative risks for HIV infection. In contrast, although we found that women were at substantial risk for sexually transmitted infection (STI), including HIV, women's risks were only related to lower levels of education and alcohol use history. We speculate that women's risks for STI/HIV are the product of partner characteristics and male-dominated relationships, suggesting the critical importance of intervening with men to reduce women's risks for sexual assault and STI/HIV.

Associations of poverty, substance use, and HIV transmission risk behaviors in three South African communities

The majority of the world's HIV infections occur in communities ravished by poverty. Although HIV/AIDS and poverty are inextricably linked, there are few studies of how poverty-related stressors contribute to HIV risk behavior practices. In this study, surveys were conducted in three South African communities that varied by race and socio-economic conditions: people living in an impoverished African township (N = 499); an economically impoverished but well infrastructured racially integrating township (N = 995); and urban non-impoverished neighborhoods (N = 678). Results showed that HIV/AIDS risks were closely related to experiences of poor education, unemployment, discrimination, violence, and crime. Although poverty-related stressors were associated with a history of alcohol and drug use, substance use did not moderate the association between poverty-related stressors and HIV risk behaviors. The findings suggest that HIV prevention strategies should not treat AIDS as a singled out social problem independent of other social ills.

A prospective study of sensation seeking and alcohol use as predictors of sexual risk behaviors among men and women receiving sexually transmitted infection clinic services

Sensation seeking, the propensity to seek optimal stimulation and engage in risk behaviors, correlates with alcohol expectancies, which are related to alcohol use in sexual situations, potentially increasing risks for sexually transmitted infections (STIs). In the current prospective study of 313 male and 140 female STI clinic patients, path analyses showed that sensation seeking predicted unprotected intercourse 6 months later. Sensation seeking also predicted alcohol outcome expectancies, which predicted alcohol use in sexual contexts 6 months later, which in turn predicted unprotected sex. Tests for mediation showed that alcohol expectancies accounted for the association between sensation seeking and alcohol use in sexual contexts. These findings replicate previous research, with the prospective design confirming directional hypotheses and supporting causal conclusions.

Experimental components analysis of brief theory-based HIV/AIDS risk-reduction counseling for sexually transmitted infection patients

An experimental components analysis of brief HIV risk-reduction counseling based on the information-motivation-behavioral skills (IMB) model was conducted with 432 men and 193 women receiving sexually transmitted infection (STI) clinic services. Following baseline assessments, participants were randomly assigned to 1 of 4 90-min risk-reduction counseling sessions that deconstructed the IMB model within a full factorial design. Participants were followed for 9 months, with STI diagnoses monitored over 12 months. Men who received the full IMB session evidenced relatively greater use of risk-reduction behavioral skills and relatively lower rates of unprotected intercourse over 6-months follow-up and had fewer new STIs. For women, however, the motivational counseling demonstrated the most positive outcomes. Results suggest that brief single-exposure HIV prevention counseling can reduce HIV transmission risks.

Development of an HIV risk reduction counselling intervention for use in South African sexually transmitted infection clinics

South Africa urgently needs HIV prevention interventions that can be disseminated for use in clinical and community settings. A brief theory-based HIV risk reduction counselling intervention originally developed in the USA has recently been adapted for use in a South African sexually transmitted infection clinic. The 60-minute risk reduction counselling intervention was grounded in the Information-Motivation-Behavioural Skills (IMB) model of HIV preventive behaviour change, adapted through a series of interdisciplinary collaborative workshops. This paper reports the process of developing and culturally adapting the brief risk reduction counselling intervention. The processes used for adapting the HIV risk reduction counselling for South Africa provides a potential model for conducting technology transfer activities with other HIV prevention interventions. Several lessons learned from this process may help guide future efforts to transfer HIV prevention technologies.

Internet use among people living with HIV/AIDS: coping and health-related correlates

People living with HIV/AIDS may experience health benefits from using the Internet for accessing health information as well as potential health hazards, including seeking sex partners online. This study examined how people with HIV/AIDS are using the Internet and how their Internet use may be associated with health behaviors. HIV-positive men (n = 347) and HIV-positive women (n = 72) who reported using the Internet were recruited from community services to complete an anonymous survey of their Internet use and associated factors. HIV-positive Internet users reported using the Internet for a wide range of purposes, with health related searches for information accounting for 1 of 3 Internet activities. People with greater income and more education were more likely to use the Internet for health functions. Health-related Internet use was related to a broader spectrum of health behaviors including HIV treatment adherence and health-related Internet use was associated with active coping strategies and indicators of better health. HIV-positive men and women are frequently using the Internet to access health-related information as well as for other nonhealth-related functions. Searching the Internet for health information can be conceptualized as an active coping strategy, occurring with other health-related behaviors and offering potential health benefits.

Poverty-related stressors and HIV/AIDS transmission risks in two South African communities

Community stress associated with poverty is related to health risks and poor health outcomes. Perceived community stress is specifically related to HIV transmission risk behaviors in the United States, but research has not examined these relationships in southern Africa, the region of the world with the highest rates of HIV infection and among the greatest poverty. Men (N=464) and women (N=531) living in impoverished adjacent communities distinguished by race (e.g., indigenous African and Coloured) completed anonymous surveys of perceptions of 10 poverty-related community stressors and measures of HIV risk-related behaviors. Indigenous African and Coloured communities differed in their perceptions of stressors, with Africans consistently viewing the 10 community stressors as more serious problems. In addition, perceived seriousness of lacking basic living resources was related to higher risk for HIV among Africans. Perceived community stress was also related to alcohol and drug use, but substance use did not mediate the association between perceived community stress and HIV risks. In the Coloured community, perceived community stressors were related to drug use, but perceived community stressors were not associated with HIV risks. These findings extend the findings of previous research to show that poverty-related stressors are associated with HIV transmission risks in some poverty-stricken communities and that these associations are not mediated by substance use.

Development of a brief scale to measure AIDS-related stigma in South Africa

Although there has been progress in AIDS stigma research, there are no multi-item AIDS stigma scales that have been shown reliable and valid in Africa. The current research reports the development of the nine-item AIDS-Related Stigma Scale. Research conducted in five South African communities (N = 2306) found the scale internally consistent, alpha = 0.75 and time stable over 3 months, r = 0.67. The scale was also reliable in three different languages (English, Xhosa, and Afrikaans). Correlations showed that the AIDS-Related Stigma Scale was moderately inversely correlated with years of education and AIDS knowledge. In addition, individuals who stated that HIV positive persons should conceal their HIV status had higher AIDS-Related Stigma Scale scores. Also supporting the scale's construct validity, individuals who refused to report whether they had been tested for HIV scored higher on the AIDS-Related Stigma Scale.

Patterns of sexual risk behavior change among sexually transmitted infection clinic patients

Effective interventions to reduce sexually transmitted infection (STI) risk behaviors are most potent in the short term and are not uniformly effective for all people. The present study examined patterns of sexual behavior change among 238 men and 104 women who received risk reduction counseling in a public STI clinic and were followed for 9 months with a 1-year retrospective clinic chart abstraction for newly diagnosed STI. A two-stage, multivariate cluster analysis was performed on four risk behavior difference scores (follow-up - baseline) for 1-month, 3-month, 6-month, and 9-month follow-up frequencies of unprotected vaginal and anal intercourse. Cluster analysis identified three profile subgroups: Subgroup 1 had lower levels of risk behavior at all time points; Subgroup 2 had significant reductions in risk over time; and Subgroup 3 demonstrated significant increases in risk over time. Analyses on variables external to the cluster analysis found that the three profile subgroups differed on numbers of sex partners, substance use, sensation seeking, indicators of risk reduction motivation and behavioral skills, and contracting new STI. STI clinic patients with varying profiles of sexual behavior change were, therefore, differentiated by factors relevant to STI interventions.

Perceptions of local HIV/AIDS prevalence and risks for HIV/AIDS and other sexually transmitted infections: Preliminary study of intuitive epidemiology

BACKGROUND

Risk perceptions are theoretically important in predicting health behavior but have only shown modest evidence in predicting sexual risk behavior.

PURPOSE

Our purpose is to investigate whether perceptions of the local prevalence of disease serve as a predictor of health behavior, particularly behaviors associated with infectious diseases such as HIV/AIDS.

METHODS

Four hundred eighty-seven men and 236 women receiving diagnostic and treatment services at a sexually transmitted infections (STI) clinic in a moderate-size U.S. city completed anonymous surveys of perceived prevalence of HIV/AIDS and other STI and sexual risk and protective behaviors.

RESULTS

Participants who estimated a lower AIDS burden in their city relative to other U.S. cities demonstrated greater numbers of sex partners, higher rates of sexual risk practices, and higher rates of STI. They were also less likely to have been tested for HIV.

CONCLUSIONS

This initial study of intuitive epidemiology suggests that STI clinic patients may have a sense for the relative burden of AIDS in their city and estimates of local disease prevalence may predict sexual risk behaviors.