State of Condom Use in HIV Prevention Science and Practice

Safe sex negotiation and HIV risk reduction among women: A cross-sectional analysis of Burkina Faso 2021 Demographic and Health Survey

Women are biologically more susceptible to the Human Immunodeficiency Virus (HIV) and other sexually transmitted Infections (STIs) because receptive sex is riskier than insertive. Despite condom use being the staple preventive method for HIV infection (over 80% efficacy), in Sub-Saharan African countries like Burkina Faso, a high burden of HIV and the unmet need for condom use coexist. Moreover, even though women in SSA are disproportionately HIV positive, they are reportedly less capable of negotiating condom use for HIV risk reduction. Thus, using the Health Believe Model (HBM), this study explored the factors that influence condom use among women within the context of HIV prevention, with a key interest in condom use negotiation. Using the women's dataset of the 2021 Burkina Faso Demographic and Health Survey and applying logistic regression models, this study examined the factors associated with condom use for HIV risk reduction. Women who had confidence to negotiate condom use with their partners (OR = 1.57, P<0.001, 95%CI: 1.29, 1.91), those with secondary education (OR = 1.38, P<0.05, 95%CI: 1.07 1.77), from richest households (OR = 1.64, P<0.05, 95%CI: 1.08, 2.47), the employed (OR = 1.23, P<0.05, 95%CI: 1.02, 1.49), women with knowledge of sexually transmitted infections (OR = 1.58, P<0.001, 95%CI: 1.26, 1.97), those who have ever been tested for HIV (OR = 1.85, P<0.001, 95%CI: 1.52 2.24), as well as those who knew that a healthy-looking person can have HIV (OR = 2.64, P<0.001, 95%CI: 2.15, 3.24) were all significantly more likely to practice condom use for HIV risk reduction. Also, religion and geographical location of participants significantly predicted condom use for HIV risk reduction in the study context. The ability to negotiate condom use, knowledge of HIV and STIs, the socioeconomic status of women, as well as their geographical location, influence their practice of safer sex for HIV risk reduction in Burkina Faso.

How to Safeguard University Students Against HIV Transmission? Results of a Cross-Sectional Study in Southern Italy

Introduction

Young people represent a growing share of the group living with HIV, and monitoring the sexual behaviors of this vulnerable age group is necessary to control and prevent the HIV/AIDS pandemic. The present study has been conducted to investigate the level of knowledge and attitudes toward HIV infection and sexual behaviors among a sample of undergraduate university students in Southern Italy.

Methods

Data were collected through an anonymous online questionnaire between 1st to 31st July 2020 and included questions on socio-demographic and sexual history characteristics, knowledge and attitudes toward HIV infection, sexual behaviors, and sources of information about HIV. The eligibility criteria for the study were: age between 18 and 30 years and registered as an undergraduate student at the university.

Results

Among the 1,318 students who completed the survey, 62.5% knew that HIV can be transmitted through blood, vaginal secretions and semen. The overall median knowledge score was 10, and the main determinants of knowledge were being younger and attending to medical or life science majors. Less than half of the students (45.8%) reported that they always wear a condom during any sexual activity. Predictors of consistent condom use were being younger, having a later sexual debut and a good knowledge score.

Conclusions

The study findings showed a not completely satisfactory level of knowledge and unsafe sex practices among university students. These results reiterate the need to tailor HIV prevention strategies among young individuals. Such a change could dispel misconceptions about HIV transmission and prevention that affect risk-taking sexual behaviors. These strategies may ultimately contribute to lessing the effect of HIV/AIDS transmission in Italy.

Efficacy of Psychological Interventions Towards the Reduction of High-Risk Sexual Behaviors Among People Living with HIV: A Systematic Review and Meta-analysis, 2010-2020

People living with HIV/AIDS (PLWH) may be vulnerable to mental illness. As sexual transmission is the leading cause of HIV infection, evidence-based study for the effect of psychological interventions on the change of sexual is needed. To estimate the efficacy of psychological interventions towards reducing unprotected sex and increasing condom use among PLWH. We systematically searched PubMed, Web of Science, EMBASE (OVID), and PsycINFO (OVID) for studies reporting psychological intervention effects on the outcomes of condom use and/or unprotected sex from 2010 to 2020. This review is registered with PROSPERO, CRD42020193640. Of 949 studies, 17 studies were included in this systematic review. Overall, participants in the intervention group reduced sexual risk or condomless sex relative to control groups. The effect was higher for people having sex with HIV-positive partners comparing with those who had sex with HIV-negative or unknown status partners. Psychological interventions might positively affect the condom use of PLWH and should be prioritized and regularly.

Sexual Excitation and Sexual Inhibition in the Context of Sexual Risk-Taking

The current study examined the roles of sexual excitation and sexual inhibition in the context of sexual risk-taking among heterosexual women and men to better understand the link between sexual arousal and sexual risk-taking. We set out to determine which factors in the Sexual Excitation and Sexual Inhibition Inventory for women and men (SESII-W/M) were most predictive of sexual response and sexual risk-taking behavior. Participants (N = 266, women = 166) completed the SESII-W/M instrument and responded to items assessing their sexual risk-taking intentions and their risk-taking indicators. A sub-sample (n = 133, women = 83) also completed a sexual arousal manipulation. Sexual excitation was linked with higher levels of self-reported sexual arousal (among women and men) and greater risk-taking intentions (among women only). However, controlling for gender, sexual inhibition was a better predictor of sexual risk-taking intentions, compared to sexual excitation. The Dual Control Model offers unique insights into conceptualizations of sexual response to erotic stimuli and behavioral risk-taking. These findings can inform more effective interventions to promote risk reduction through sex positive approaches that capitalize on the pleasure enhancing capabilities of safer sex strategies.

Does Women's Autonomy Matter on Attitude Towards Condom Use in Reducing Risk for HIV Infection Among Married Women in Ethiopia?

Background

Condom utilization remains as the forefront guard to reduce the HIV/AIDS pandemic. However, evidence showed that the dynamics of gendered power, beliefs, and attitudes about condoms and sexuality retards condom use for a large proportion of Africa's people. Therefore, this study aimed to assess the association between women's autonomy in health decision making and attitude to condom use in reducing risk for HIV in Ethiopia using a nationally representative, population-based household survey data.

Methods

A cross-sectional study was carried out using 2016 nationally representative, population-based Ethiopia Demographic and Health Survey. SPSS version 21 was used to analyze the data. Multivariate logistic regression analysis was performed to assess the association between women's autonomy in health decision making and attitude to condom use by controlling confounders. To declare statistically significant associations, adjusted odds ratios (AOR) with 95% confidence interval (CI) were used.

Results

The present study enrolled 6787 weighted samples of married women. The study showed that the odds of attitude toward condom use were 1.39 times (AOR: 1.39; 95% CI: 1.04-1.85) higher among women who decide for their health care compared to its counterparts. Also, the odds of attitude toward condom use were positively associated among women who conquered higher education (AOR: 1.97; 95% CI: 1.17-3.33), who had the richest wealth index quintile (AOR: 1.45; 95% CI: 1.01-2.07), and who had ever been tested for HIV (AOR: 1.31; 95% CI: 1.09-1.57). However, the odds of attitudes toward condom use were negatively associated among Muslims (AOR: 0.58; 95% CI: 0.46-0.74) and Protestant religion (AOR: 0.69; 95% CI: 0.54-0.88) followers.

Conclusion

The study culminates that women's autonomy in health decision making improves attitudes toward condom use during sex for HIV prevention in Ethiopia. Besides, women's higher education gets better wealth index, and HIV testing perks up the attitudes toward condom use; but religious affiliation deters it. Therefore, efforts need to be done in promoting women's autonomy along with empowering women in education, economic as well as HIV detection. Furthermore, designing interventions that address primary prevention strategies like using condoms consistently along with addressing religious affiliation can have a significant effect on curtailing HIV/AIDS scourge.

Perceived partner beliefs about condoms and self-efficacy communication within the context of the theory of gender and power

The theory of gender and power provides a unique framework for understanding condom use by accounting for distinct challenges faced by minority women in particular. This study examined whether self-efficacy about condom use communication (SECC) and perceived partner's beliefs about condom (PPBC) use had an influence on condom use frequency; and whether these associations varied by gender. A sample of 252 African-American college students (101 males and 151 females) completed a confidential online survey assessing SECC, PPBC, and condom use behavior. SECC and PPBC showed significant associations with condom use behavior. Furthermore, there was a gender interaction effect with PPBC on condom use behavior. As PPBC increases toward positive associations about condom use, condom use behavior increased significantly more for females (B = 0.42; p = .02) as compared to males (B = 0.26; p = .19). This study supports the need to teach young women effective communication skills in order for them to accurately assess what their partner thinks about condom-related behaviors; and ultimately not allow partner discouragement to influence their decisions to use condoms. Interventions aimed at reducing risky sexual behavior on predominantly Black college campuses, in particular, may benefit from directly addressing relationship power and focusing on building self-efficacy in communicating condom use.

Dealing with pre-exposure prophylaxis-associated condom migration: changing the paradigm for men who have sex with men

The behavioural aspects of pre-exposure prophylaxis (PrEP) are challenging, particularly the issue of condom migration. Three vital questions are: (1) at the population-level, will condom migration lead to increases in non-viral sexually transmissible infections?; (2) how can clinic-based counselling best promote the dual use of condoms and PrEP?; and (3) in future PrEP trials, what are the 'best practices' that should be used to avoid type 1 and type 2 errors that arise without accounting for condom use behaviours? This communication piece addresses each question and suggests the risk of a 'PrEP only' focus to widening health disparities.

Addressing Gaps in HIV Preexposure Prophylaxis Care to Reduce Racial Disparities in HIV Incidence in the United States

The potential for human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) to reduce the racial disparities in HIV incidence in the United States might be limited by racial gaps in PrEP care. We used a network-based mathematical model of HIV transmission for younger black and white men who have sex with men (BMSM and WMSM) in the Atlanta, Georgia, area to evaluate how race-stratified transitions through the PrEP care continuum from initiation to adherence and retention could affect HIV incidence overall and disparities in incidence between races, using current empirical estimates of BMSM continuum parameters. Relative to a no-PrEP scenario, implementing PrEP according to observed BMSM parameters was projected to yield a 23% decline in HIV incidence (hazard ratio = 0.77) among BMSM at year 10. The racial disparity in incidence in this observed scenario was 4.95 per 100 person-years at risk (PYAR), a 19% decline from the 6.08 per 100 PYAR disparity in the no-PrEP scenario. If BMSM parameters were increased to WMSM values, incidence would decline by 47% (hazard ratio = 0.53), with an associated disparity of 3.30 per 100 PYAR (a 46% decline in the disparity). PrEP could simultaneously lower HIV incidence overall and reduce racial disparities despite current gaps in PrEP care. Interventions addressing these gaps will be needed to substantially decrease disparities.

Concurrence and selection of sexual partners as predictors of condom use among Mexican indigenous migrant workers

OBJECTIVE

To identify if the selection of mixed sexual partners and the existence of concurrent partners are predictors of condom use in indigenous migrant agricultural workers from Colima, Mexico.

METHODS

Analytical cross-sectional study using an egocentric sexual network approach. Community interviewers applied a structured questionnaire to 192 indigenous migrant workers in a sugarcane agro-industrial context. Data were analyzed with binary logistic regression; odds ratios (OR) and 95% confidence intervals (CI 95%) were estimated.

RESULTS

In the logistic regression model, adjusted odds (OR; 95% CI) of steady condom use were lower within partnerships of the same indigenous ethnicity compared to other partnerships (0.30; 0.17-0.53), partnerships that were concurrent to other partnerships (0.27; 0.15-0.50), and partnerships that used illegal drugs during sex to other partnerships (0.23; 0.11-0.49). Those variables were actually associated with increased risk of unprotected sex (occasionally or never using condoms), and therefore exposures were unprotected.

CONCLUSION

Sexual partners of the same ethnicity, concurrent partnerships and partnerships that use illegal drugs favor the low frequency of constant condom use and, in turn, the vulnerability to STIs and HIV transmission in indigenous migrant agricultural workers.

[From evidence to action: challenges for the Brazilian Unified National Health System in offering pre-exposure prophylaxis (PrEP) for HIV to persons with the greatest vulnerability]

Pre-exposure prophylaxis (PrEP) has been considered a promising strategy for controlling the global HIV epidemic. However, it is necessary to translate the knowledge accumulated from clinical trials and demosntration studies to the reality of health services and the groups most vulnerable to infection in order to achieve broad coverage with PrEP. The article proposes a reflection on this challenge, focusing on three dimensions: users of prophylaxis, with an emphasis on the contexts of sexual practices and the potential exposures to HIV; the advantages of prophylaxis as compared to other methods and the challenges for protective and safe use; and health services, considering the organizational principles to ensure greater success in the supply and incorporation of PrEP as part of combination prevention strategies. The following principles were analyzed: uniqueness of care, freedom of choice and non-hierarchization of prevention methods, sexual risk management, scheduling flexibility, and complementary and multidisciplinary care. These principles can foster organization of the health service and care, facilitating linkage and retention in care. Some comments were offered on the relative incompatibility between the existing structure of services and the Brazilian Ministry of Health guidelines for offering PrEP. The conclusion was that the success of PrEP as a public health policy depends on two essential factors: ensuring that health services are culturally diverse settings, free of discrimination, and the intensification of community-based interventions, including social networks, in order to reduce inequalities in access to PrEP and health services as a whole.

Evaluation of the Condom Barriers Scale for Young Black Men Who Have Sex With Men: Reliability and Validity of 3 Subscales

BACKGROUND

Reliable and valid scale measures of barriers to condom use are not available for young black men who have sex with men (YBMSM). The purpose of this study was to evaluate the Condom Barriers Scales for application with YBMSM.

METHODS

A clinic-based sample of 600 YBMSM completed a computer-assisted self-interview. The primary measure was a 14-item abbreviated version of the Condom Barriers Scale. Reliability and criterion validity were assessed.

RESULTS

All 3 subscales were reliable: partner-related barriers (Cronbach α=0.73), sensation-related barriers (α=0.70), and motivation-related barriers (α =0.81). A complete absence of barriers was common: 47.0% (partner-related), 30.7% (sensation-related), and 46.5% (motivation-related). Dichotomized subscales were significantly associated with reporting any condomless insertive anal sex (all Ps < 0.001) and any condomless receptive anal sex (all Ps < 0.001). The subscales were significantly associated with these measures of condomless sex preserved at a continuous level (all Ps <0.001, except for sensation barriers associated with condomless receptive anal sex = 0.03). Further, the subscales were significantly associated with reporting any condom use problems (all Ps <0.001) and a measure of condomless oral sex (all Ps <0.001, except for partner-related barriers=0.31). Finally, the sensation-related barriers subscale was significantly associated with testing positive for Chlamydia and/or gonorrhea (P=0.049).

CONCLUSIONS

The 3 identified subscales yielded adequate reliability and strong evidence of validity, thereby suggesting the utility of these brief measures for use in observational and experimental research with YBMSM.

The effect of prevention methods on reducing sexual risk for HIV and their potential impact on a large-scale: a literature review

A spectrum of diverse prevention methods that offer high protection against HIV has posed the following challenge: how can national AIDS policies with high coverage for prevention and treatment make the best use of new methods so as to reverse the current high, and even rising, incidence rates among specific social groups? We conducted a narrative review of the literature to examine the prevention methods and the structural interventions that can have a higher impact on incidence rates in the context of socially and geographically concentrated epidemics. Evidence on the protective effect of the methods against sexual exposure to HIV, as well as their limits and potential, is discussed. The availability and effectiveness of prevention methods have been hindered by structural and psychosocial barriers such as obstacles to adherence, inconsistent use over time, or only when individuals perceive themselves at higher risk. The most affected individuals and social groups have presented limited or absence of use of methods as this is moderated by values, prevention needs, and life circumstances. As a result, a substantial impact on the epidemic cannot be achieved by one method alone. Programs based on the complementarity of methods, the psychosocial aspects affecting their use and the mitigation of structural barriers may have the highest impact on incidence rates, especially if participation and community mobilization are part of their planning and implementation.

Prevalence and correlates of condom use among single midlife Canadian women and men aged 40 to 59

Reported rates of sexually transmitted infections (STIs) among midlife Canadians have increased. However, there is little data on the STI behavioural risk of this age group. The current study investigated the prevalence and correlates of condom use at last penile vaginal intercourse (PVI) among sexually active single (never married, separated/divorced) Canadians aged 40 to 59 (n=830). Men were more likely than women to report using a condom at last PVI (35.3% vs. 27.6%). Number of partners, dating status, partner type at last sex, and concern about STI were significant bivariate predictors of condom use among men and women. Age, marital status, and erectile difficulties were additional bivariate predictors for men. In multivariate analysis, marital status, number of partners, and partner type predicted condom among men. Divorced and separated men were 53% less likely to use a condom than single, never married men. Men who reported 2 or more partners over the past year were almost 2 times more likely to use a condom than men who had one partner over the past year. As partner type at last sex moved from casual to more committed, men were 26% less likely to report condom use at last PVI. Among women, partner type at last sex was the only significant multivariate predictor of condom use, as partner type moved from casual to more committed, condom use was 33% less likely. Condom use was not associated with decreased pleasure during PVI. Educational STI prevention interventions targeting single midlife Canadians are needed.

Condom Breakage Among Young Black Men Who Have Sex With Men: An In-Depth Investigation Including Men Living With HIV/AIDS

Correlates of condom breakage (reported by 19% of 398 young black who have sex with men) for anal insertive sex included the following: condoms drying out (P = 0.018), erection loss during application (P = 0.03), and using erection-enhancing drugs (P = 0.003). Breakage was 2.7 times greater for HIV-positive men (P = 0.001). Breakage was associated with testing positive for urethral infections (P = 0.012).

Microbicide vaginal rings: Technological challenges and clinical development

Vaginal rings (VRs) are flexible, torus-shaped, polymeric devices designed to sustain delivery of pharmaceutical drugs to the vagina for clinical benefit. Following first report in a 1970 patent application, several steroid-releasing VR products have since been marketed for use in hormone replacement therapy and contraception. Since 2002, there has been growing interest in the use of VR technology for delivery of drugs that can reduce the risk of sexual acquisition of human immunodeficiency virus type 1 (HIV-1), the causative agent of acquired immunodeficiency syndrome (AIDS). Although no vaginally-administered product has yet been approved for HIV reduction/prevention, extensive research efforts are continuing and a number of VR devices offering sustained release of so-called 'HIV microbicide' compounds are currently being evaluated in late-stage clinical studies. This review article provides an overview of the published scientific literature within this important field of research, focusing primarily on articles published within peer-reviewed journal publications. Many important aspects of microbicide-releasing VR technology are discussed, with a particular emphasis on the technological, manufacturing and clinical challenges that have emerged in recent years.

Condom Use Errors and Problems: A Comparative Study of HIV-Positive Versus HIV-Negative Young Black Men Who Have Sex With Men

OBJECTIVES

To describe self-reported frequencies of selected condom use errors and problems among young (age, 15-29 years) black men who have sex with men (YBMSM) and to compare the observed prevalence of these errors/problems by HIV serostatus.

METHODS

Between September 2012 October 2014, electronic interview data were collected from 369 YBMSM attending a federally supported sexually transmitted infection clinic located in the southern United States. Seventeen condom use errors and problems were assessed. χ(2) Tests were used to detect significant differences in the prevalence of these 17 errors and problems between HIV-negative and HIV-positive men.

RESULTS

The recall period was the past 90 days. The overall mean (SD) number of errors/problems was 2.98 (2.29). The mean (SD) for HIV-negative men was 2.91 (2.15), and the mean (SD) for HIV-positive men was 3.18 (2.57). These means were not significantly different (t = 1.02, df = 367, P = 0.31). Only 2 significant differences were observed between HIV-negative and HIV-positive men. Breakage (P = 0.002) and slippage (P = 0.005) were about twice as likely among HIV-positive men. Breakage occurred for nearly 30% of the HIV-positive men compared with approximately 15% among HIV-negative men. Slippage occurred for approximately 16% of the HIV-positive men compared with approximately 9% among HIV-negative men.

CONCLUSIONS

A need exists to help YBMSM acquire the skills needed to avert breakage and slippage issues that could lead to HIV transmission. Beyond these 2 exceptions, condom use errors and problems were ubiquitous in this population regardless of HIV serostatus. Clinic-based intervention is warranted for these young men, including education about correct condom use and provision of free condoms and long-lasting lubricants.

Prediction of HIV Sexual Risk Behaviors Among Disadvantaged African American Adults Using a Syndemic Conceptual Framework

The focus of this paper is on HIV sexual risk taking among a community-based sample of disadvantaged African American adults. The objective is to examine multiple factors associated with sexual HIV risk behaviors within a syndemic conceptual framework. Face-to-face, computer-assisted, structured interviews were conducted with 1535 individuals in Atlanta, Georgia. Bivariate analyses indicated a high level of relationships among the HIV sexual risks and other factors. Results from multivariate models indicated that gender, sexual orientation, relationship status, self-esteem, condom use self-efficacy, sex while the respondent was high, and sex while the partner was high were significant predictors of condomless sex. Additionally, a multivariate additive model of risk behaviors indicated that the number of health risks significantly increased the risk of condomless sex. This intersection of HIV sexual risk behaviors and their associations with various other behavioral, socio-demographic, and psychological functioning factors help explain HIV risk-taking among this sample of African American adults and highlights the need for research and practice that accounts for multiple health behaviors and problems.

Revitalizing condom-centered HIV prevention strategies

HIV infection rates remain steady in the USA despite the numerous prevention programs and tools available. Condoms play a central role in HIV prevention because they are highly effective, readily available, and affordable. Unfortunately, condom promotion efforts often incite fear as a motive force, while also taking the common "one-size-fits-all" approach. Reframing condom promotion through a sexual health framework, focusing on pleasure and highlighting condom fit issues, improves intervention efficacy. Condom distribution policies may further perpetuate condom users' difficulty, by withholding particular condom styles, brands, and information highlighting the nuances in shape, size, and material. Condom education and distribution practices focused on pleasure, proper fit, and condom access issues might increase condom utilization among high-risk populations.

Structure and agency in long-distance truck drivers' lived experiences of condom use for HIV prevention

Condom promotion has emerged as a mainstay of targeted HIV prevention interventions in India, with its emphasis on individual behaviour change and personal responsibility. However, such approaches often do not account for marginalised populations' structural vulnerability to HIV, arising from social, economic and political factors in the lived environment. In this paper, I use a critical health communication framework to analyse how structure and agency interact in influencing condom use among long-distance truck drivers in India. Drawing on an abductive discourse analysis of condom-use discourses among truckers and peer educators in two Indian cities, findings reveal that while truckers understand the biomedical logic of condoms as barriers, they also express anxiety about condom breakage and experience structural barriers to condom use. The paper concludes by calling for greater attention to structural vulnerabilities in future HIV prevention efforts with truck drivers.

Habitual condom use across partner type and sexual position among younger gay and bisexual men: findings from New Zealand HIV behavioural surveillance 2006-2011

Objectives

Our objectives were to investigate demographic and behavioural factors associated with condom use and to examine how habitual condom use was across partner types and sexual positions among younger men who have sex with men (YMSM), aged 16–29, surveyed in New Zealand.

Methods

We analysed the 2006–2011 national HIV behavioural surveillance data from YMSM who reported anal intercourse in four scenarios of partner type and sexual position: casual insertive, casual receptive, regular insertive and regular receptive. For each, respondents’ condom use was classified as frequent (always/almost always) or otherwise, with associated factors identified with multivariate mixed-effect logistic regression. Habitual condom use across scenarios was examined using a latent variable technique that estimated the intraclass correlation coefficient (ICC).

Results

Frequent condom use was reported for 63.6% of 5153 scenarios reported from 2412 YMSM. Frequent use increased from boyfriend to fuckbuddy to casual partners. Infrequent use was associated with online recruitment, Pacific ethnicity, less education, HIV positivity, sex with women, having ≥20 sexual partners versus 1 and reporting insertive and receptive sexual positions. Frequent condom use was associated with having two to five sexual partners versus one and shorter regular partnerships. The ICC=0.865 indicated highly habitual patterns of use; habitual infrequent condom use was most prevalent with regular partners (53.3%) and habitual frequent condom use was most prevalent with casual partners (70.2%) and for either sexual position (50.5% and 49.1%).

Conclusions

Habitual condom use among YMSM highlights the value of early, engaging and sustained condom promotion. Public health should provide better and more compelling condom education, training and promotion for YMSM.

Global HIV epidemiology: A guide for strategies in prevention and care

Global trends in HIV incidence are estimated typically by serial prevalence surveys in selected sentinel populations or less often in representative population samples. Incidence estimates are often modeled because cohorts are costly to maintain and are rarely representative of larger populations. From global trends, we can see reason for cautious optimism. Downward trends in generalized epidemics in Africa, concentrated epidemics in persons who inject drugs (PWID), some female sex worker cohorts, and among older men who have sex with men (MSM) have been noted. However, younger MSM and those from minority populations, as with black MSM in the United States, show continued transmission at high rates. Among the many HIV prevention strategies, current efforts to expand testing, linkage to effective care, and adherence to antiretroviral therapy are known as "treatment as prevention" (TasP). A concept first forged for the prevention of mother to child transmission, TasP generates high hopes that persons treated early will derive considerable clinical benefits and that lower infectiousness will reduce transmission in communities. With the global successes of risk reduction for PWID, we have learned that reducing marginalization of the at-risk population, implementation of nonjudgmental and pragmatic sterile needle and syringe exchange programs, and offering of opiate substitution therapy to help persons eschew needle use altogether can work to reduce the HIV epidemic. Never has the urgency of stigma reduction and guarantees of human rights been more urgent; a public health approach to at-risk populations requires that to avail themselves of prevention services and they must feel welcomed.

Desire to father a child and condom use: a study of young black men at risk of sexually transmitted infections

To determine whether men's reported desire to father a child or their perception that someone wanted to have their child was associated with elevated rates of unprotected vaginal sex, we studied a sample of young Black men at high risk of sexually transmitted infection acquisition. Data were collected in clinics treating sexually transmitted infections in three southern U.S. cities. Men 15-23 years of age who identified as Black/African American and reported recent (past two months) penile-vaginal sex were eligible (N = 578). Logistic regression was used to examine whether desire to conceive a child (self and perception of partners' desire) predicted condom use, adjusting for age and whether they had previously impregnated someone. Their own level of desire to conceive a child was not significantly associated with unprotected vaginal sex or the proportion of times a condom was used. However, those who perceived higher level of someone wanting to conceive their child were 1.73 times more likely to report unprotected vaginal sex (P = .006) and 1.62 times more likely to report a lower proportion of times condoms were used (P = .019). Young Black men attending sexually transmitted infection clinics in the USA may forego condom use based on a perceived desire of their partners to become pregnant, putting themselves at risk for sexually transmitted infection acquisition and unplanned pregnancy. Findings provide initial support for the relevance of the idea that perceptions of women partners' desire to conceive may be a critical determinant of condomless sex.

Condom-Associated Erection Problems: A Study of High-Risk Young Black Males Residing in the Southern United States

Previous research indicates that young men may experience condom-associated erection loss and that these problems may lead to inconsistent or incomplete condom use. The primary aim of this study was to assess, using a retrospective recall period of 2 months, correlates of condom-associated erection problems among young Black men attending sexually transmitted infection (STI) clinics. Data were collected in clinics treating patients with STIs in three southern U.S. cities. Males 15 to 23 years of age who identified as Black/African American and reported recent (past 2 months) condom use were eligible. A total of 494 men participated. Nineteen percent reported that condom-associated erection problems during condom application occurred at least once, and 17.8% indicated erection difficulties occurred during sexual intercourse at least once in the past 2 months. Multivariate analyses identified that condom-associated erection problems were associated with reports of sex with more than one partner during the recall period, reported problems with condom fit and feel, lower motivation to use condoms, and attempts at condom application before having a full erection. Findings suggest that clinic interventions should address possible condom-associated erection problems among young Black men who are at risk of STIs. Encouraging men who may be vulnerable to erection loss when condoms are used to allow sufficient time for sexual arousal to build may be an effective strategy.

Barrier methods for human immunodeficiency virus prevention

Condoms remain the most effective barrier against the sexual transmission of the human immunodeficiency virus (HIV). Male condoms have proven to be 80% to 90% effective, and female condoms have similar results. Poor adherence and improper use limit their effectiveness. In addition to condoms, microbicides are a promising barrier against HIV transmission. More than 50 candidate topical microbicide compounds have undergone preclinical or clinical testing in the last 10 years, but there are currently no US Food and Drug Administration (FDA)-approved compounds. Rectal microbicides are also being developed, as anal receptive sex is an effective mode of HIV transmission.

Condoms are more effective when applied by males: a study of young black males in the United States

PURPOSE

To determine, among a sample of young black male (YBM), whether female application of male condoms for penile-vaginal intercourse would be associated with higher or lower rates of breakage or slippage. A secondary aim was to investigate if higher rates of breakage or slippage were associated with increased odds of acquiring chlamydia and/or gonorrhea.

METHODS

A cross-sectional study of 412 YBM, aged 15 to 23 years, was conducted in three US cities located in the Southern United States.

RESULTS

Among YBM reporting frequent female application of condoms, 43.5% reported one or more instance of breakage or slippage, compared with those reporting less frequent female application (27.2%, P = .003). Among YBM reporting one or more event of breakage or slippage, 25.4% tested positive for chlamydia and/or gonorrhea. In contrast, among those not reporting breakage or slippage, 17.2% tested positive (P = .047).

CONCLUSIONS

Findings suggest that educational and behavioral interventions should seek to improve young women's skills relative to condom application and use. Further studies could also investigate whether intervention efforts should encourage some YBM to be responsible for their own condom application.

Enhancing condom use among Black male youths: a randomized controlled trial

OBJECTIVES

We tested the efficacy of a brief intervention to promote correct and consistent use of condoms among Black male youths attending sexually transmitted infection (STI) clinics in 3 southern US cities.

METHODS

In 2010 to 2012, we screened (n = 1102) and enrolled (n = 702) youths aged 15 to 23 years who identified as Black and reported recent (past 2 months) sexual activity and randomized them to a private, brief, interactive intervention (n = 349) or an attention-equivalent control condition (n = 353). Assessments occurred at baseline and 2 and 6 months after the intervention.

RESULTS

At 6 months, with adjustment for age and pretest nonequivalence of the outcome variable, an estimated odds ratio (EOR) of 1.63 (95% confidence interval [CI] = 1.07, 2.49; P = .02) indicated efficacy for correct condom use. An adjusted generalized estimating equations model with both 2- and 6-month condom use variables produced an EOR of 1.49 (95% CI = 1.06, 2.08; P = .02). We did not observe significant effects on chlamydia and gonorrhea incidence.

CONCLUSIONS

This brief intervention, delivered as part of STI clinical care, could help alleviate the disproportionate STI-HIV burden among young Black men.

Condom use errors and problems: a study of high-risk young Black men residing in three Southern US cities

The primary aim of this study was to assess self-reported frequencies of selected condom use errors and problems, using a retrospective recall period of 2 months, among young Black men attending sexually transmitted infection clinics. A secondary objective was to determine whether more errors/problems occurred among men reporting sex with multiple partners compared with those reporting one sexual partner. Data were collected in clinics treating patients with sexually transmitted infections in three Southern US cities. Men, 15–23 years of age who identified as Black/African American and reported recent (past 2 months) condom use were eligible (N = 475). Condom use errors and problems were common, with some of the most critical errors occurring for greater than one of every five young Black men, such as late application, early removal, slipping off during sex, and re-using condoms. For 8 (33.3%) of the 24 errors/problems assessed, young Black men reporting more than one sexual partner in the previous 2 months experienced more errors and problems than men reporting only one partner. The disease protective value of condoms may be sub-optimal in this population. A need exists to improve the quality of condom use among young Black men at risk of sexually transmitted infection acquisition or transmission. Intensified clinic-based intervention that helps young Black men improve the quality of their condom use behaviours is warranted.

"I Don't Have a Problem With It, But Other Guys Do": An Exploration of Condom Negotiation among Young Black Men Who Have Sex with Men in the South

Condom negotiation among young Black men who have sex with men in the Southern United States was explored using the theory of reasoned action. Fifty-four (18- to 29-year-old) males participated in nine focus group interviews. Discussions elicited condom use and negotiation attitudes, beliefs and social norms. Positive personal attitudes (respect of self, personal health concerns) and high negotiation self-efficacy was emphasized. Conversely, social norms revealed non-prioritized condom use behavior. Divergence between individual and community indicates theoretical models targeting sexual communication must address external factors (social, economic, political context), which intersects with individual intentions, attitudes to influence HIV prevalence in this community.

Being drunk and high during sex is not associated with condom use behaviours: a study of high-risk young Black males

Objective To assess the relationship between the frequency of being drunk and high during sex, and condom use errors and problems (CUEP) among a sample of high-risk young Black males recruited from the United States.

METHODS

Data were collected in clinics treating sexually transmissible infections in three cities in the southern United States. Males 15-23 years of age (n=697) who identified as African-American and reported recent (past 2 months) condom use were eligible. Measures of alcohol and drug use, as well as condom use behaviours were assessed by audio-computer assisted self-interview. Eighteen CUEP were included in this assessment.

RESULTS

Sixteen bivariate correlations were obtained. The magnitude of the coefficients was small, ranging from 0.01 to 0.13. Only three were significant. These were positive associations between the frequency of being drunk and the frequency of unprotected vaginal sex, as well as the frequency of the 18-item measure of CUEP. A significant correlation was also found between the frequency of being high during sex and the frequency of unprotected vaginal sex. Adjustments for age did not change the findings.

CONCLUSIONS

Interventions designed to promote safer sex behaviours among young Black males attending sexually transmissible infection clinics are no more likely to benefit patients through the inclusion of messages and training attempting to dissuade the use of alcohol and drugs before or during sex.