Factors associated with female condom use among HIV-seropositive women

Female condoms are an effective option for preventing sexually transmitted diseases (STDs), including HIV transmission. Little is known, however, about female condom use in women living with HIV/AIDS. Ninety HIV-positive women completed measures of demographic characteristics, exposure and use of female condoms, attitudes toward female and male condoms, sexual behaviours, and substance use. Most women (77%) had been exposed to female condoms, however only 30% reported lifetime use, 16% reported recent use, and only 6% of the sample used female condoms as much or more than they used male condoms. The only factors consistently associated with female condom use were positive attitudes toward female condoms. Women who recently used female condoms were also more likely to have multiple male sex partners and reported fewer unprotected intercourse occasions. Female condoms are therefore used by a small number of HIV-infected women, particularly those with more than one male sex partner. Female condom use may be enhanced by removing barriers to their use, increasing cooperation of male partners, and enhancing proficiency of use.

Functional health literacy is associated with health status and health-related knowledge in people living with HIV-AIDS

BACKGROUND

Poor health literacy is a prevalent barrier to medical care and people with lower health literacy experience greater illness severity than people with higher health literacy. Health literacy may therefore be an important factor in the health and treatment of people living with HIV-AIDS.

METHODS

A community-recruited sample of 339 HIV-infected men and women completed surveys and interviews that assessed functional health literacy, health status, AIDS-related disease and treatment knowledge, and health care perceptions and experiences. Medical records were available for chart abstraction of health status for a subsample of participants.

RESULTS

About 1 of 4 people living with HIV-AIDS demonstrated difficulty comprehending simple medical instructions and therefore lower health literacy. HIV-infected people with lower health literacy had lower CD4 cell counts, higher viral loads, were less likely to be taking antiretroviral medications, reported a greater number of hospitalizations, and reported poorer health than those with higher health literacy. In addition, after adjusting for years of formal education, lower health literacy was associated with poorer knowledge of one's HIV-related health status, poorer AIDS-related disease and treatment knowledge, and more negative health care perceptions and experiences.

CONCLUSIONS

Health literacy is a significant factor in the health and treatment of persons living with HIV-AIDS. Interventions are needed to improve medical care and the health status of people with lower health literacy that are living with HIV-AIDS.

Distinguishing between overlapping somatic symptoms of depression and HIV disease in people living with HIV-AIDS

HIV-AIDS is a prevalent medical diagnosis in U.S. cities, and symptoms of depression are common in persons with HIV infection. This study examined the effects of overlapping symptoms of HIV disease and somatic depression that can inflate scores on the Beck Depression Inventory (BDI) and the Centers for Epidemiological Studies Depression Scale (CESD). Results from 357 HIV positive men and women identified discrete subsets of depression symptoms that correspond with symptoms of HIV infection. Removing somatic subsets of depression symptoms improved the clinical utility of the BDI and CESD. Clearer symptom separation occurred with the BDI than the CESD, but the CESD may be more sensitive than the BDI to depression associated with progression of HIV disease. Findings suggest that depression scales that include somatic symptoms will inflate depression scores in people living with HIV infection, and available methods for distinguishing overlapping symptoms should be employed when assessing people living with HIV infection.

Sexually transmitted infections among HIV seropositive men and women

OBJECTIVES

To determine the prevalence of identified STIs and recognised symptoms of STIs and their association with health status, substance use, and sexual risk behaviour in a sample of HIV seropositive men and women.

METHODS

223 men, 112 women, and five transsexual people living with HIV infection completed confidential surveys. Participants were recruited through community based services, community health clinics, and snowball (chain) recruitment techniques in Atlanta, GA, USA in December 1999.

RESULTS

We found that (263) 78% of participants had been sexually active in the previous 3 months. For the entire sample, 42 (12%) participants reported an STI in the past 3 months and 40 (11%) experienced symptoms of an STI without indicating a specific diagnosis in that time. Gonorrhoea, chlamydia, syphilis, and newly diagnosed herpes simplex virus (HSV) were identified at similar rates among men, whereas trichomonas, gonorrhoea, and newly diagnosed HSV occurred most often in women. STIs were associated with substance use in men and women, with "crack" cocaine users having the greatest likelihood of an STI relative to non-crack users. STIs were also associated with continued practice of sexual risk behaviours.

CONCLUSIONS

This sample of people living with HIV-AIDS reported high rates of diagnoses and symptoms of STIs. There were significant associations between STIs, substance use, and continued high risk sexual practices in men and women. These findings support the need for studies that confirm prevalence of STIs using clinical laboratory tests.

Coping strategies and emotional wellbeing among HIV-infected men and women experiencing AIDS-related bereavement

AIDS influences the psychological coping not only of the person with the disease but also those close to that individual. Following a death from AIDS, family members and friends may experience atypical bereavement. Bereavement coping challenges can be especially difficult and pronounced for persons who are themselves HIV-positive. The prevalence of AIDS-related bereavement and psychosocial predictors of grief severity were examined in an ethnically diverse sample of 199 HIV-infected men and women. Eighty per cent of HIV-positive respondents had experienced the loss of someone close to AIDS, the majority of whom had sustained multiple and repetitive losses. Two-thirds of the participants who had experienced an AIDS-related loss reported grief symptoms in the past month. Hierarchical regression analyses revealed that grief was most closely associated with emotional suppression and avoiding coping strategies, with residual variance related to depression. Interventions for AIDS-related bereavement that reduce distress and maladaptive ways of coping are needed in order to meet the secondary prevention needs of bereaved people living with HIV/AIDS.

Reliability and validity of self-reported CD4 lymphocyte count and viral load test results in people living with HIV/AIDS

Self-reporting is a common, convenient, and inexpensive method for collecting health status information in HIV/AIDS research, but the reliability and validity of these data remain suspect. HIV-positive persons (n=174) completed self-report measures of demographics, health status, and health literacy, and provided permission to collect CD4 cell counts and viral load results from provider charts. Clinically meaningful categories of CD4 cell counts were reliably and validly assessed using self-report measures. Self-reported viral load, however, demonstrated only marginally acceptable reliability and validity, with the greatest validity occurring for recall of undetectable viral load. Self-reported health status was most reliable and valid for persons with higher levels of education and literacy. CD4 cell counts can therefore be reliably and validly assessed through self-reporting, particularly when collected in clinically meaningful units from persons with higher education. Self-reported viral load should be interpreted with caution and is most reliable when dichotomized into detectable/undetectable categories.

Late middle-aged and older men living with HIV/AIDS: race differences in coping, social support, and psychological distress

Although AIDS mental health research has recently devoted more attention to the psychosocial needs of older adults living with human immunodeficiency virus (HIV) disease, studies of this population have typically combined older African-American and white participants into one large sample, thereby neglecting potential race differences. The current study examined race differences in stressor burden, ways of coping, social support, and psychological distress among late middle-aged and older men living with HIV/AIDS. Self-administered surveys were completed by 72 men living with HIV/AIDS in New York City and Milwaukee, WI (mean age = 53.4 years). Older African-American and white men experienced comparable levels of stress associated with AIDS-related discrimination, AIDS-related bereavement, financial dilemmas, lack of information and support, relationship difficulties, and domestic problems. However, in responses to these stressors, older African-American men more frequently engaged in adaptive coping strategies, such as greater positive reappraisal and a stronger resolve that their future would be better. Compared to their African-American counterparts, HIV-infected older white men reported elevated levels of depression, anxiety, interpersonal hostility, and somatization. African-American men also received more support from family members and were less likely to disclose their HIV serostatus to close friends. As AIDS becomes more common among older adults, mental health-interventions will increasingly be needed for this group. The development of intervention programs for this group should pay close attention to race-related differences in sociodemographic, psychosocial, and behavioral characteristics.

Depression and thoughts of suicide among middle-aged and older persons living with HIV-AIDS

OBJECTIVE

This study examined the prevalence and characteristics of suicidal ideation among middle-aged and older persons who have HIV infection or AIDS.

METHODS

A total of 113 subjects older than age 45 who had HIV-AIDS were recruited from AIDS service organizations in Milwaukee, Wisconsin, and New York City. Participants completed confidential questionnaires covering suicidal ideation, emotional distress, quality of life, coping, and social support.

RESULTS

Twenty-seven percent of respondents reported having thought about taking their own life in the previous week. Those who had thought about suicide reported greater levels of emotional distress and poorer health-related quality of life than those who had not considered suicide. They were also significantly more likely to use escape and avoidance strategies for coping with HIV infection and less likely to use positive-reappraisal coping. Those who had thought about suicide also were more likely to have disclosed their HIV status to the people close to them, and yet they perceived receiving significantly less social support from friends and family. With the exceptions of physical functioning and coping strategies, differences between those who had contemplated suicide and those who had not remained unchanged after controlling for symptoms of depression.

CONCLUSIONS

Persons who are in midlife and older and are living with HIV-AIDS experience significant emotional distress and thoughts of suicide, suggesting a need for targeted interventions to improve mental health and prevent suicide.

Sources of occupational stress and coping strategies among nurses working in AIDS care

Nurses working in AIDS care experience high rates of occupational stress and therefore are vulnerable to emotional exhaustion and occupational burnout. This study surveyed 499 members of the Association of Nurses in AIDS Care regarding their work-related stress experiences and coping strategies for managing stress. Qualitative analyses identified a hierarchical structure of occupational stress, with two supraclusters representing workplace and patient care-related stress and eight specific subclusters of stressors: institutions, personnel, biohazards, death, informing patients, challenging patients, families, and treatment dilemmas. Analyses showed that nurses experiencing stress from their workplace were significantly more likely to use wishful thinking, planful problem solving, and avoidance as coping strategies, whereas stress originating from patient care was more likely to be dealt with using positive appraisal and acceptance. Interventions designed to assist nurses in managing occupational stress and to prevent occupational burnout must include the sources of work-related stress among nurses in AIDS care.

Health literacy and health-related knowledge among persons living with HIV/AIDS

BACKGROUND

Functional health literacy is associated with illness-related knowledge, understanding, and treatment perceptions for several chronic illnesses. This study examined health literacy in relation to knowledge and understanding of HIV/AIDS.

METHODS

Persons living with HIV/AIDS recruited from AIDS service organizations and HIV clinics completed the Test of Functional Health Literacy for Adults (TOFHLA) reading comprehension scale and measures of health status, knowledge and understanding of health status, perceptions of primary care givers, and perceptions of anti-HIV treatments.

RESULTS

Eighteen percent of the sample scored below the cutoff for marginal functional health literacy on the TOFHLA. Controlling for years of education, persons of lower health literacy were significantly less likely to have an undetectable HIV viral load, somewhat less likely to know their CD4 cell count and viral load, and lower health-literacy persons who knew their CD4 count and viral load were less likely to understand their meaning. Lower health literacy was also related to misperceptions that anti-HIV treatments reduce risks for sexually transmitting HIV and beliefs that anti-HIV treatments can relax safer-sex practices.

CONCLUSIONS

Poor health literacy creates barriers to fully understanding one's health, illness, and treatments. Misperceptions of treatment in the case of HIV infection creates danger for potentially transmitting treatment-resistant strains of HIV. These results have implications for patient education and treatment programming for people who have poor health-literacy skills and are living with HIV/AIDS.

Work-related stress and occupational burnout in AIDS caregivers: test of a coping model with nurses providing AIDS care

Occupational stress and burnout are potential threats to quality of care for people living with HIV/AIDS. A total of 445 nurses who provide care to people living with HIV/AIDS responded to an anonymous postal survey that consisted of: demographic and work history questions, the Maslach Burnout Inventory, Rotter's Internal-External Locus of Control scale, and internal and external coping styles as measured by the Ways of Coping scale. Path analyses showed that both external (13.6% of the variance) and internal (3.1% of the variance) coping styles significantly predicted levels of burnout among AIDS caregivers, over and above participants' age, perceived workload and locus of control. Mediation analyses further showed that external coping mediates the effect of locus of control on burnout, but internal coping styles do not exhibit mediation. Results therefore replicate and extend previous research demonstrating the important roles of cognitive and behavioural coping styles in understanding burnout among providers of AIDS care.

Randomized community trial of a breast self-examination skills-building intervention for inner-city African-American women

OBJECTIVE

Breast cancer is the most common cancer in women, and African-American women are less likely to detect breast cancer at its early stages. Few controlled trials of interventions to increase breast self-examination (BSE) among low-income minority women have been conducted. Our objective was to test a small-group workshop intended to build BSE skills and promote BSE among low-income African-American women.

METHODS

A randomized community field trial tested a BSE skills-building workshop based on social cognitive theory of behavior change compared to a matched sexually transmitted diseases prevention workshop, with one- and three-month follow-ups for assessing increased practice of BSE.

RESULTS

Women who did not regularly practice BSE and participated in a BSE skills-building workshop were more likely to practice BSE than women in the comparison intervention at the one- (OR = 3.5, p = 0.04) and three-month follow-ups (OR = 4.9, p = 0.01). These results were not related to risk perceptions heightened by the intervention. Across conditions and controlling for covariates in a multivariate model, performing regular BSE was most closely associated with having received any formal BSE instruction.

CONCLUSION

BSE skills building can effectively increase use of BSE among low-income African-American women who face multiple and competing health risks. The small-group experience is an important element in fostering norms for practicing BSE and enhancing BSE practices.

The emerging AIDS crisis in Russia: review of enabling factors and prevention needs

Eastern Europe is experiencing increased rates of HIV/AIDS, and the Russian Federation is among the countries with the most alarming case rate increases. Behavioural and biological studies demonstrate that the transmission of HIV in Russia is occurring as a result of injection drug use, homosexual, and heterosexual risk behaviours. Factors that promote risk and therefore enable HIV transmission in Russia parallel those found in other countries, including epidemics of other sexually transmitted infections, economic instability, poverty, and social factors such as gender roles. Research is urgently needed to better understand and forecast the HIV epidemic in Russia, as well as to develop effective interventions to prevent a Russian AIDS crisis.

Effectiveness of a video-based motivational skills-building HIV risk-reduction intervention for inner-city African American men

Interventions to reduce HIV risk behavior have shown promise but have demonstrated inconsistent effects with heterosexual men. This article reports a cognitive-behavioral HIV risk reduction intervention designed for heterosexually active African American men. Men (N = 117) recruited from a public clinic were randomly assigned to either (a) a 6-hr video-based small group motivational-skills intervention or (b) a 6-hr video-based contact-matched HIV education comparison group. Results showed men in the motivational-skills intervention reported lower rates of unprotected vaginal intercourse and higher rates of condom use at the 3-month follow-up. However, because of increased condom use in the comparison condition, differences between groups dissipated 6 months following the intervention. These findings are among the first to demonstrate effects from a motivational-skills intervention for reducing HIV risk in men who have sex with women using a model designed to facilitate transferring prevention technology to community settings.

Secondary HIV transmission rates in a mixed-gender sample

Information about the sexual behaviour of HIV-infected individuals is needed to predict the course of the sexually transmitted HIV epidemic in the US. The present study provides model-based estimates of the secondary transmission rate (i.e. the number of infections expected among the sex partners of already infected individuals) for a sample of HIV-positive persons in Atlanta. A mathematical model was used to estimate the secondary transmission rate of HIV infection for a sample of HIV-positive men and women in Atlanta, based on their self-reported sexual behaviour, extrapolated over a 15-year horizon. Separate rates were calculated for different transmission routes, including: from women to men-who-have-sex-with women (MSW) and from men-who-have-sex-with-men (MSM) to other MSM. Sensitivity analyses were conducted to assess the impact of different parametric and modelling assumptions. Restricted to the sub-sample that reported transmission risk behaviours, the mean number of secondary infections was 0.14 for transmission from women to MSW; 0.31 for transmission from MSW to women; and 0.84 for MSM to MSM transmission. Bisexual men were at especially high transmission risk, with 1.59 and 0.54 secondary infections expected among their male and female partners, respectively. The main analysis indicates that, in this sample, each current infection will lead to fewer than one future infection for all groups other than bisexual men, which suggests that the epidemic is contracting in this community, although this analysis cannot rule out the possibility of a growing epidemic among MSM. This method can be used to identify groups at high risk for HIV transmission and thereby to better target HIV prevention resources.

Effectiveness of a video-based motivational skills-building HIV risk-reduction intervention for inner-city African American men

Interventions to reduce HIV risk behavior have shown promise but have demonstrated inconsistent effects with heterosexual men. This article reports a cognitive-behavioral HIV risk reduction intervention designed for heterosexually active African American men. Men (N = 117) recruited from a public clinic were randomly assigned to either (a) a 6-hr video-based small group motivational-skills intervention or (b) a 6-hr video-based contact-matched HIV education comparison group. Results showed men in the motivational-skills intervention reported lower rates of unprotected vaginal intercourse and higher rates of condom use at the 3-month follow-up. However, because of increased condom use in the comparison condition, differences between groups dissipated 6 months following the intervention. These findings are among the first to demonstrate effects from a motivational-skills intervention for reducing HIV risk in men who have sex with women using a model designed to facilitate transferring prevention technology to community settings.

Sexual compulsivity and substance use in HIV-seropositive men who have sex with men: prevalence and predictors of high-risk behaviors

Most persons aware of their HIV-positive serostatus refrain from sexual behavior that could transmit HIV infection to others. However, a minority of men who test HIV-seropositive continue to engage in transmission risk behavior. One factor that may play a role in high-risk sexual activity involves sexual behavior self-management. The present study investigated the role of sexual compulsivity as a contributing factor to high-risk sexual behavior in HIV seropositive men who have sex with men (N = 112). Participants also completed measures of factors known to be related to risky sexual behavior including: personal substance use, sexual partner substance use, pleasure associated with high-risk activities, beliefs about transmission risks, intentions to avoid future instances of risky behavior, and self-esteem. Men scoring high on sexual compulsivity reported engaging in more frequent unprotected sexual acts with more partners, reported greater use of cocaine in conjunction with sexual activity, rated high-risk sexual acts as more pleasurable, and reported lower self-esteem. Mediational analyses indicated that the relationship between sexual compulsivity and high-risk sexual behavior was partially mediated by both personal cocaine use and partner cocaine use in conjunction with sexual activity. The results suggest a need to integrate HIV risk-reduction services and substance use treatment for those persons living with HIV who have difficulty avoiding transmission risk behavior.

Self-efficacy and disclosure of HIV-positive serostatus to sex partners

HIV-positive persons face significant challenges to disclosing their HIV serostatus, and failure to disclose can place their sex partners at risk. The current study examined HIV serostatus disclosure in 266 sexually active HIV-positive persons recruited from the community. Results showed that 41% had not disclosed their HIV serostatus to sex partners. Men who had not disclosed to partners indicated lower rates of condom use during anal intercourse and scored significantly lower on a measure of self-efficacy for condom use compared to individuals who had disclosed. Emotional distress was also greatest among persons who had not recently disclosed. Having not disclosed to sex partners was closely associated with lower self-efficacy for disclosing, with women who had not disclosed reporting the lowest disclosure self-efficacy. As people living with HIV-AIDS are encouraged to disclose their HIV status, interventions are needed to facilitate disclosure decision making.

Male polyurethane condoms do not enhance brief HIV-STD risk reduction interventions for heterosexually active men: results from a randomized test of concept

The current study examined the effects of a brief HIV risk reduction intervention for men. Participants were recruited (n = 108) from an urban public health clinic and randomly assigned to one of 3 experimental intervention conditions: (1) 3 h HIV-STD risk reduction behavioural skills building latex condom intervention; (2) the same 3 h skills workshop but focused on male polyurethane condoms; or (3) a 3 h HIV education workshop. Results showed all 3 interventions increased AIDS knowledge and positively influenced attitudes, but men who received the polyurethane condom skills intervention were more likely to request condoms at follow ups. In addition, men who received either of the 2 skills interventions evidenced increased condom use at the one-month follow up, with no differences at 3-month follow up. This study is among the first to test a brief HIV risk reduction intervention for men and is the first to test whether polyurethane male condoms enhance HIV risk reduction efforts.

Barriers to HIV/AIDS treatment and treatment adherence among African-American adults with disadvantaged education

African Americans are disproportionately affected by acquired immunodeficiency syndrome (AIDS). New treatments that slow the progression of human immunodeficiency virus (HIV) infection offer hope for individuals living with HIV/AIDS, but lack of access to care and poor treatment adherence remain significant obstacles to HIV treatment. This study investigated the association between education literacy to HIV treatment adherence and barriers to care among African Americans living with HIV/AIDS. A community-recruited sample of 85 African-American men and 53 women receiving HIV treatment completed measures of health literacy, health status, treatment adherence, emotional well-being, and barriers to care. Nearly one-third (29%) of the participants had < 12 years of education or were functionally illiterate, and those with low-education literacy were less likely to be adherent to HIV medications within the previous two days. Lower-education literacy also was related to reasons for missing medications and barriers to accessing medical care. Individuals of law-education literacy also were more emotionally distressed, lacked social support, and were less optimistic than those with higher education. These results indicate that education and health literacy are important factors in HIV-treatment adherence and access to medical care. Interventions are needed for improving treatment adherence among law-income minorities, and such interventions will need tailoring for individuals with limited reading ability.

Psychological and social correlates of high-risk sexual behaviour among men and women living with HIV/AIDS

Men and women living with HIV/AIDS who experience difficulty maintaining safer sex practices place their sex partners as well as themselves at considerable risk for sexually transmitted infections. Psychological correlates of continued sexual risk behaviours provide important information for intervention development. Continued sexual risk behaviour was investigated in a sample of 203 HIV-positive men and 129 HIV-positive women recruited from infectious disease clinics and AIDS service agencies. The study showed that 42% of men and 42% of women reported at least one occasion of unprotected anal or vaginal intercourse in the preceding six months. Unprotected intercourse frequently occurred outside of long-term relationships and with partners who were not known to be HIV-infected. Similar to populations at primary risk, HIV-infected men and women reported alcohol and drug use, including use before sexual episodes. However, the association between substance use and unprotected sex was modest for men and absent for women. Contrary to previous research, emotional distress and maladaptive coping were not related to continued sexual risk. Interventions are urgently needed to support men and women living with HIV/AIDS in maintaining long-term safer sex practices.

Adherence to combination antiretroviral therapies in HIV patients of low health literacy

OBJECTIVE

To test the significance of health literacy relative to other predictors of adherence to treatment for HIV and AIDS.

PARTICIPANTS

Community sample of HIV-seropositive men (n = 138) and women (n = 44) currently taking a triple-drug combination of antiretroviral therapies for HIV infection; 60% were ethnic minorities, and 73% had been diagnosed with AIDS.

MEASUREMENTS

An adapted form of the Test of Health Literacy in Adults (TOFHLA), a comprehensive health and treatment interview that included 2-day recall of treatment adherence and reasons for nonadherence, and measures of substance abuse, social support, emotional distress, and attitudes toward primary care providers.

MAIN RESULTS

Multiple logistic regression showed that education and health literacy were significant and independent predictors of 2-day treatment adherence after controlling for age, ethnicity, income, HIV symptoms, substance abuse, social support, emotional distress, and attitudes toward primary care providers. Persons of low literacy were more likely to miss treatment doses because of confusion, depression, and desire to cleanse their body than were participants with higher health literacy.

CONCLUSIONS

Interventions are needed to help persons of low literacy adhere to antiretroviral therapies.

Self-efficacy and disclosure of HIV-positive serostatus to sex partners

HIV-positive persons face significant challenges to disclosing their HIV serostatus, and failure to disclose can place their sex partners at risk. The current study examined HIV serostatus disclosure in 266 sexually active HIV-positive persons recruited from the community. Results showed that 41% had not disclosed their HIV serostatus to sex partners. Men who had not disclosed to partners indicated lower rates of condom use during anal intercourse and scored significantly lower on a measure of self-efficacy for condom use compared to individuals who had disclosed. Emotional distress was also greatest among persons who had not recently disclosed. Having not disclosed to sex partners was closely associated with lower self-efficacy for disclosing, with women who had not disclosed reporting the lowest disclosure self-efficacy. As people living with HIV-AIDS are encouraged to disclose their HIV status, interventions are needed to facilitate disclosure decision making.

An empirical investigation of the relationship between spirituality, coping, and emotional distress in people living with HIV infection and AIDS

Evaluates levels of psychological distress, coping mechanisms, and their relationship with the religious beliefs and spiritual practices of people (N=65) living with HIV and AIDS. Results of the research indicate a strong relationship for spiritual dimensions with mental health, psychological adjustment, and coping. Concludes that a blending of spiritual traditions and mental health approaches are needed to facilitate the coping of people living with HIV and AIDS.

Brief behavioural skills building intervention for female controlled methods of STD-HIV prevention: outcomes of a randomized clinical field trial

The need for female controlled methods for preventing HIV infection is well recognized and women have been found to accept the female condom for these purposes. Women (n = 105) were randomly assigned to receive either (a) a 3-h behavioural skills building intervention that concentrated on educating women about the female condom, motivating female condom use, and building behavioural skills relevant to using the female condom, or (b) a time-matched broadly defined women's health education intervention. Women who received the female controlled skills building intervention used the female condom to a greater extent than did women in the health education condition. Importantly, the effects of the behavioural skills intervention were most pronounced for women who reported only one male sex partner in the previous 6 months compared to women with multiple sex partners. However, female condom use was modest, with only one in 5 vaginal intercourse acts being protected by female condoms among women with one partner who received skills training. Interventions are needed to further enhance use of the female condom and new female controlled methods are needed for the majority of women at risk who did not adopt the female condom.

HIV risk differences between African-American and white men who have sex with men

African-American men who have sex with men remain at disproportionately greater risk for contracting human immunodeficiency virus (HIV) infection. While high HIV seroincidence has been documented among homosexual African-American men, behavioral research has rarely studied the HIV risk issues confronting these men. This study assessed a sample of 253 men who have sex with men to determine if African-American (n = 79) and white (n = 174) men report different rates of HIV risk behaviors and differ in characteristics indicative of risk. African-American men who have sex with men were more likely to be HIV-seropositive, to report past treatment for gonorrhea and syphilis, and to have a recent unprotected sex partner known or believed to be HIV-seropositive. Multivariate analyses of covariance, controlling for group differences in age, education, and income, revealed that African-American men who have sex with men were less open about their sexual orientation, scored lower in HIV risk behavior knowledge, had more female sexual partners, and more frequently used cocaine in association with sex relative to white men who have sex with men. Human immunodeficiency virus prevention programs tailored to the needs and risk issues of African-American men who have sex with men are needed.

AIDS treatment advances and behavioral prevention setbacks: preliminary assessment of reduced perceived threat of HIV-AIDS

Recent advances in AIDS treatment have brought renewed optimism for prolonging the lives of those infected with HIV. This article examined beliefs about how new treatments may reduce HIV transmission risk among 298 HIV-negative gay and bisexual men attending a gay pride festival. Results from an anonymous survey showed that men who practiced unprotected anal intercourse as the receptive partner (UAR intercourse) were younger, less well educated, and more likely to believe that it is safe to have UAR intercourse with an HIV-positive man who has an undetectable viral load and that new treatments for HIV relieve their worries about unsafe sex. As HIV treatments continue to advance, new challenges for HIV prevention will likely emerge.

Psychosocial differences between urban and rural people living with HIV/AIDS

During the past decade, many investigations have examined the life circumstances of people living with HIV disease. Most of these studies, however, have focused on HIV-infected people in large metropolitan areas. This study compares the psychosocial profiles of rural and urban people living with HIV disease. Anonymous, self-administered surveys were completed by 276 people with HIV/AIDS in a Midwestern state. The assessment instrument measured respondents' quality of life, perceptions of loneliness, social support, experiences with AIDS-related discrimination, access to services, and illness-related coping strategies. Compared with their urban counterparts, rural people with HIV reported a significantly lower satisfaction with life, lower perceptions of social support from family members and friends, reduced access to medical and mental health care, elevated levels of loneliness, more community stigma, heightened personal fear that their HIV serostatus would be learned by others, and more maladaptive coping strategies. Programs that are designed to improve the life circumstances of people with HIV disease in rural areas--particularly those that facilitate access to adequate health care, increase perceptions of social support, and improve illness-related coping--are urgently needed.

Post-exposure prophylaxis for HIV infection in gay and bisexual men. Implications for the future of HIV prevention

OBJECTIVE

To assess the psychological and behavioral characteristics of gay and bisexual men who intend to use antiretroviral post-exposure prophylaxis (PEP) to prevent HIV infection.

METHODS

Gay and bisexual men who had not tested HIV seropositive and were not in long-term exclusive sexual relationships (n = 327) completed anonymous surveys consisting of demographic characteristics, gay community acculturation, experience with and attitudes toward PEP, substance use, and sexual behavior in the past 6 months.

SETTING

A large annual Gay Pride festival in Atlanta, Georgia.

RESULTS

There were 8 (3%) men who had already used PEP and 85 (26%) who planned to use PEP to prevent themselves from becoming HIV infected. Compared to the 242 (74%) men who did not indicate plans to use PEP, those planning to use PEP were younger, less well educated, more likely to have used illicit substances in the past 6 months, and were more likely to have a history of injection drug use. Men intending to use PEP were also more likely to have practiced unprotected anal and oral intercourse as the receptive partner and were more likely to have multiple anal intercourse partners with whom they were receptive.

CONCLUSIONS

Gay and bisexual men are generally supportive of the immediate use of PEP and a significant number of men are planning to use PEP, particularly less educated men who use multiple substances and practice the highest-risk sexual behaviors. Concurrent behavioral interventions must, therefore, be considered critical in the advancement of PEP.

Reinforcement value of unsafe sex as a predictor of condom use and continued HIV/AIDS risk behavior among gay and bisexual men

The pleasure or reinforcement value of high-risk sex may be an important influence on success in risk reduction efforts. Seronegative gay and bisexual men (N = 297) completed measures assessing their unprotected and safer sex practices, as well as measures of cognitive and skill factors and a measure assessing the subjective reinforcement value of unprotected anal intercourse. Regression analyses showed that the reinforcement value of unprotected anal intercourse accounted for variance in predicting levels of condom use above that that could be accounted for by factors such as knowledge, behavior change intentions, perceived vulnerability, condom attitudes, and sexual communication skills. Only reinforcement value of unprotected sex and substance use significantly predicted how frequently participants engaged in high-risk sex. Increased attention to the valence of sexual reinforcers will improve HIV risk reduction models and enhance AIDS prevention efforts.

Risk for HIV infection among bisexual men seeking HIV-prevention services and risks posed to their female partners

The present study interviewed gay (n = 473) and bisexual men (n = 146) as part of an HIV prevention program and investigated social cognitive factors associated with HIV risk. Results indicated that HIV risk in homosexual men was associated with sexual openness and connections to gay communities, factors not associated with risk for bisexual men. Compared with men at lower risk, those who practiced high-risk sex scored lower on measures of perceived safer sex norms, safer sex self-efficacy, and social skills. Bisexual men with primary female partners often had not disclosed their bisexuality to female partners (75%), and 64% had not modified their behavior to protect female partners. Bisexual men who engage in high-risk behaviors therefore pose a risk to female partners who may be unaware of their involvement with men.

Sexual coercion, domestic violence, and negotiating condom use among low-income African American women

Coercion to engage in unwanted sex places women at risk for human immunodeficiency virus (HIV) infection. A survey of 125 women living in low-income housing developments in Fulton County, Georgia, showed that 53 (42%) women had engaged in unwanted sex because a male partner threatened to use force or used force to obtain sexual access. Women who had been sexually coerced were more likely to have used marijuana and crack cocaine and to have abused alcohol. Coerced women were more likely to have been physically abused by a domestic partner. These women were also more likely to perceive that requesting male partners to use condoms would create a potentially violent situation. These results suggest that women experience an interactive constellation of social problems that create risks for HIV infection and, therefore, that efforts to prevent HIV infection among women will require multifaceted intervention strategies to reach both men and women at risk.

Randomised, controlled, community-level HIV-prevention intervention for sexual-risk behaviour among homosexual men in US cities. Community HIV Prevention Research Collaborative

BACKGROUND

Community-level interventions may be helpful in population-focused HIV prevention. If members of populations at risk of HIV infection who are popular with other members can be engaged to advocate the benefits of behaviour change to peers, decreases in risk behaviour may be possible. We assessed a community-level intervention to lower the risk of HIV infection, focusing on men patronising gay bars in eight small US cities.

METHODS

We used a randomised community-level field design. Four cities received the intervention and four control cities did not. Participants were men from each city who went to gay bars. Men completed surveys about their sexual behaviour on entering the bars during 3-night periods at baseline and at 1-year follow-up. In the control cities, HIV educational materials were placed in the bars. In the intervention cities, we recruited popular homosexual men in the community and trained them to spread behaviour-change endorsements and recommendations to their peers through conversation.

FINDINGS

Population-level of risk behaviour decreased significantly in the intervention cities compared with the control cities at 1-year follow-up, after exclusion of surveys completed by transients and men with exclusive sexual partners in a city-level analysis, in the intervention cities we found a reduction in the mean frequency of unprotected anal intercourse during the previous 2 months (baseline 1.68 occasions; follow-up 0.59: p = 0.04) and an increase in the mean percentage of occasions of anal intercourse protected by condoms (baseline 44.7%; follow-up 66.8%, p = 0.02). Increased numbers of condoms taken from dispensers in intervention-city bars corroborated risk-behaviour self-reports.

INTERPRETATION

Popular and well-liked members of a community who systematically endorse and recommend risk-reduction behaviour can influence the sexual-risk practices of others in their social networks. Natural styles of communication, such as conversations, brought about population-level changes in risk behaviour.

Enhancing motivation to reduce the risk of HIV infection for economically disadvantaged urban women

This research evaluated a motivation-based HIV risk reduction intervention for economically disadvantaged urban women. Participants completed a survey that assessed HIV-related knowledge, risk perceptions, behavioral intentions, sexual communication, substance use, and risk behavior. A total of 102 at-risk women (76% African American) were randomly assigned to either the risk reduction intervention or to a waiting list. Women were reassessed at 3 and 12 weeks. Results indicated that treated women increased their knowledge and risk awareness, strengthened their intentions to adopt safer sexual practices, communicated their intentions with partners, reduced substance use proximal to sexual activities, and engaged in fewer acts of unprotected vaginal intercourse. These effects were observed immediately, and most were maintained at follow-up.

Continued high-risk sex among HIV seropositive gay and bisexual men seeking HIV prevention services

The authors examined HIV risk-related sexual behaviors in an ethnically diverse sample of HIV seropositive gay and bisexual men (N = 86). Measures of sexual behavior, substance use, condom attitudes, behavior change intentions, and engagement in risk-reducing practices were completed. Thirty-nine percent of the men reported engaging in unprotected anal intercourse in the past 3 months. Unprotected anal intercourse was associated with using nitrite inhalants, sex partners who used substances before sex, and low intentions to change risk behavior. These results highlight the difficulties that people living with HIV infection face in maintaining a lifetime of safer sex and the necessity of integrating clinical and prevention interventions for these persons.