Patterns and Trajectories of Anal Intercourse Practice Over the Life Course Among US Women at Risk of HIV

Does the approach used to measure sexual identity affect estimates of health disparities differently by race? A randomized experiment from the National Survey of Family Growth

The inclusion of "something else" as a response option for survey questions about sexual identity has been shown to significantly moderate estimated differences between sexual identity subgroups in the distributions of various health outcomes in national health surveys, specifically for substance use/misuse and reproductive health. This moderation effect may be larger depending on the respondent's race, possibly due to the intersectionality of multiple minority identities and compounding minority stressors. To test this hypothesis, we conducted secondary analyses of data from five consecutive years of the National Survey of Family Growth (2015-2019) [n = 18,903 (8510 males, 10,393 females)] in the United States, where respondents were randomly assigned to receive either a four-category version of the sexual identity question that included "something else" as a response option along with lesbian/gay, bisexual, and heterosexual, or a three-category version that omitted "something else." We focused on model-based estimates of distributions of health outcomes across subgroups defined by both race and sexual identity and tested the race moderation hypothesis using three-way interactions involving sexual identity, question type received (four-category vs. three-category), and race (Black, White, and other). Based on this randomized experiment, we found evidence of significant differences between the four-category and three-category question versions of sexual identity, in terms of the associations between sexual identity and several health outcomes, along with moderation of these differences by the respondent's race. For some outcomes, such as wanting a child or another child, the magnitudes of the estimated sexual identity differences among racial minority individuals, specifically between bisexual and heterosexual women, were sensitive to the measurement of sexual identity. These results further suggest a need for improved sexual minority measurement, especially among racial minorities. These differences were also mostly found among women, suggesting further intersectionality of groups exposed to specific stressors.

The Association Between Heterosexual anal Intercourse and HIV Acquisition in Three Prospective Cohorts of Women

The extent to which receptive anal intercourse (RAI) increases the HIV acquisition risk of women compared to receptive vaginal intercourse (RVI) is poorly understood. We evaluated RAI practice over time and its association with HIV incidence during three prospective HIV cohorts of women: RV217, MTN-003 (VOICE), and HVTN 907. At baseline, 16% (RV 217), 18% (VOICE) of women reported RAI in the past 3 months and 27% (HVTN 907) in the past 6 months, with RAI declining during follow-up by around 3-fold. HIV incidence in the three cohorts was positively associated with reporting RAI at baseline, albeit not always significantly. The adjusted hazard rate ratios for potential confounders (aHR) were 1.1 (95% Confidence interval: 0.8-1.5) for VOICE and 3.3 (1.6-6.8) for RV 217, whereas the ratio of cumulative HIV incidence by RAI practice was 1.9 (0.6-6.0) for HVTN 907. For VOICE, the estimated magnitude of association increased slightly when using a time-varying RAI exposure definition (aHR = 1.2; 0.9-1.6), and for women reporting RAI at every follow-up survey (aHR = 2.0 (1.3-3.1)), though not for women reporting higher RAI frequency (> 30% acts being RAI vs. no RAI in the past 3 months; aHR = 0.7 (0.4-1.1)). Findings indicated precise estimation of the RAI/HIV association, following multiple RVI/RAI exposures, is sensitive to RAI exposure definition, which remain imperfectly measured. Information on RAI practices, RAI/RVI frequency, and condom use should be more systematically and precisely recorded and reported in studies looking at sexual behaviors and HIV seroconversions; standardized measures would aid comparability across geographies and over time.

Longitudinal determinants of anal intercourse among women with, and without HIV in the United States

BACKGROUND

Anal intercourse (AI) is not uncommon among U.S. women and, when condomless, confers a far greater likelihood of HIV transmission than condomless vaginal intercourse. We aim to identify determinants preceding AI, among women with, and women without HIV.

METHODS

3708 women living with (73%), and without HIV (27%) participating in the Women's Interagency HIV Study provided sexual behavior and other data at 6-monthly visits over a median of 9 years (1994-2014). We used generalized estimating equation models to examine sociodemographic, structural and behavioral determinants reported in the visit preceding (1) AI, and (2) condomless AI.

RESULTS

AI was reported at least once over follow-up by 31% of women without, and 21% with HIV. AI was commonly condomless; reported at 76% and 51% of visits among women living without HIV, and with HIV, respectively. Women reporting AI were more likely to be younger (continuous variable, adjusted odds ratio (aOR) = 0.97, 95% confidence interval (CI):0.96-0.98), Hispanic (aOR = 1.88, CI:1.47-2.41) or White (aOR = 1.62, CI:1.15-2.30) compared to Black, and have at least high school education (aOR = 1.33, CI:1.08-1.65). AI was more likely following the reporting of either (aOR = 1.35, CI:1.10-1.62), or both (aOR = 1.77, CI:1.13-2.82) physical and sexual violence, excessive drinking (aOR = 1.27, CI:1.05-1.66) or any drug use (aOR = 1.34, CI:1.09-1.66), multiple male partners (aOR = 2.64, CI:2.23-3.11), exchange sex (aOR = 3.45, CI:2.53-4.71), one or more female sex partners (aOR = 1.32, CI:1.01-1.75), condomless vaginal intercourse (aOR = 1.80, CI:1.53-2.09), and high depressive symptoms (aOR = 1.23, CI:1.08-1.39).

CONCLUSION

AI disproportionally follows periods of violence victimization, substance use, multiple sex partners and depression. Better prevention messaging and biomedical interventions that reduce acquisition or transmission risk are needed, but when AI occurs in the context of violence against women, as our findings indicate, focusing on gender-based violence reduction and immediate treatment to reduce HIV transmission risk is important.

Promoting safer sex in the context of heterosexual anal intercourse: A scoping review

AIMS AND OBJECTIVES

To locate and summarise existing literature regarding safer sex practices specific to heterosexual anal intercourse and identify promising health promotion strategies.

BACKGROUND

Much of the literature regarding anal intercourse and safer sex is related to men who have sex with men. However, some studies suggest there are more women than men engaging in unprotected receptive anal intercourse. The risks associated with this sexual practice have been well documented, although many healthcare providers fail to ask about anal intercourse while addressing safer sex in the heterosexual population.

DESIGN

The study was based on Arksey and O'Malley's 2005 five-step methodology.

METHODS

A search was conducted of MEDLINE; CINAHL; PsycInfo; Cochrane; and PubMed. Databases were searched from 1990-2020. The 72 studies selected were classified according to their main area of focus. A grey literature search was also included. This scientific submission has been assessed for accuracy and completeness using the PRISMA-ScR guideline criteria (File S1).

RESULTS

The literature in this area is heterogeneous in terms of method and topic. Prevalence and incidence (n = 26) in addition to sexually transmitted infection risks (n = 26) related to heterosexual anal intercourse are well understood. However, there is limited information on condom use (n = 6), factors that influence heterosexual anal intercourse (n = 10) and health promotion strategies for this population and practice (n = 4). Two websites that mentioned heterosexual anal intercourse risk reduction activities were included.

CONCLUSIONS

Although heterosexual anal intercourse appears to be an increasingly common sexual practice, very little is known about health promotion strategies nurses might use for encouraging safer sex in this population.

RELEVANCE TO CLINICAL PRACTICE

Increased awareness of the prevalence and risks of heterosexual anal intercourse could enhance nurses' harm reduction strategies. Screening for sexually transmitted infections may be based on incorrect assumptions about sexual practices or due to stigma linked with anal intercourse. Reducing unprotected heterosexual anal intercourse will reduce sexually transmitted infections and their long-term sequelae.