HIV prevention heuristics and condom use among African-Americans at risk for HIV

Multifaceted Barriers to Rapid Roll-out of HIV Pre-exposure Prophylaxis in China: A Qualitative Study Among Men Who Have Sex with Men

BACKGROUND

Oral pre-exposure prophylaxis (PrEP) as a safe and effective antiretroviral medicine-based prevention against HIV has not been widely adopted by gay, bisexual, and other men who have sex with men (MSM) in China. A deeper understanding of barriers and facilitators to PrEP uptake is needed to inform the development of effective interventions.

METHOD

During July-August 2020, we conducted one-on-one semi-structured interviews with 31 Chinese MSM with varied PrEP use experiences (PrEP-naïve, former, and current PrEP users). Interviews were digitally recorded and transcribed in Chinese. Informed by the Information-Motivation-Behavioral Skills Model (IMB), we analyzed the data using a thematic analysis approach to identify the barriers and facilitators to PrEP uptake among Chinese MSM.

RESULTS

Major barriers to PrEP uptake among MSM in the sample included uncertainty about PrEP efficacy and lack of PrEP education (information), concerns over potential side effects and cost (motivation), and difficulties in identifying authentic PrEP medications and managing PrEP care (behavioral skills). Facilitators include the perceived benefit of PrEP in improving the quality of sex life and control over health. At the contextual level, we also identified barriers to PrEP access from a thriving informal PrEP market and stressors related to being MSM.

CONCLUSION

Our findings identified a need to invest in non-discriminatory public health messaging of PrEP, explore options for MSM-friendly provision of PrEP outside of traditional HIV care settings, and be attentive to the unique context of an established informal PrEP market in future PrEP initiatives.

Barriers and Motives for Complying With "Sexual Distancing" Among Men Who Have Sex With Men During the First COVID-19 Pandemic Lockdown in Amsterdam: A Qualitative Study

BACKGROUND

Between March 15 and May 31, 2020, the Dutch government imposed lockdown and health measures to curb the coronavirus disease 2019 (COVID-19) pandemic. As part of social distancing, sexual distancing was one of these measures. Sexual distancing implied refraining from sex with partners outside of one's household. We aimed to elucidate barriers and motives for complying with sexual distancing and related factors that could have led to (non)compliance among men who have sex with men.

METHODS

In this exploratory qualitative study, we interviewed men who have sex with men who visited the center for sexual health in Amsterdam during the first COVID-19 lockdown using a semistructured interview guide from March to May 2020. We interviewed both men who complied and did not comply with sexual distancing. The interviews were transcribed verbatim and analyzed using an open-coding process in MAXQDA.

RESULTS

We included 18 noncompliers and 4 compliers to COVID-19 sexual distancing. Barriers to compliance were the following: lack of information on, or understanding of, the need for sexual distancing; being single; having had an active sex life before COVID-19; a high perceived importance of the social aspect of sex; a strong urge for sex; using sex to cope with the negative impact of the pandemic; being under the influence of alcohol or drugs; and not perceiving COVID-19 as a serious health threat. Motives for compliance were the following: perceiving COVID-19 as a serious health threat, direct confrontation with critically ill COVID-19 patients, protecting someone dear from COVID-19, and being convinced of the importance of social and/or sexual distancing measures.

CONCLUSIONS

Information on sexual distancing needs to be made more explicit, accessible, understandable, inclusive, customized to individual barriers, and relatable to the key populations. This may improve the effectiveness of measures and health recommendations in both the current COVID-19 pandemic and future respiratory outbreaks.

Integrating Individual and Contextual Factors to Explain Disparities in HIV/STI Among Heterosexual African American Youth: A Contemporary Literature Review and Social Ecological Model

Heterosexual African American youth face substantial disparities in sexual health consequences such as HIV and STI. Based on the social ecological framework, the current paper provides a comprehensive, narrative review of the past 14 years of literature examining HIV/STI risk, including risky sexual behavior, among heterosexual African American youth and a conceptual model of risk among this population. The review found that individual psychological and biological factors are insufficient to explain the sexual health disparities faced by this group; instead, structural disadvantage, interpersonal risk, and community dysfunction contribute to the disparity in HIV/STI outcomes directly and indirectly through individual psychological factors. The conceptual model presented suggests that for African American youth, (1) HIV/STI risk commonly begins at the structural level and trickles down to the community, social, and individual levels, (2) risk works in a positive feedback system such that downstream effects compound the influence of structural risks, and (3) contextual and individual risk factors must be considered within the advanced stage of the epidemic facing this population. Despite advanced HIV and STI epidemics among heterosexual African American youth, multisystemic interventions that target structural risk factors and their downstream effects are posited to reduce the disparity among this high-risk population.

Use of Rapid HIV Self-Test to Screen Potential Sexual Partners: Results of the ISUM Study

ISUM ("I'll show you mine") was a randomized controlled trial in which 272 transgender women and men who have sex with men in New York, NY (NYC) and San Juan, Puerto Rico (SJU) were assigned to an intervention group (n = 136), in which they had access to free HIV self-testing (ST) kits, or to a control group (n = 136). The trial aimed to determine whether the intervention group would use ST to screen sexual partners and have fewer condomless anal intercourse (CAI) occasions with serodiscordant or unknown status partners than the control group. The intervention group had on average 10 (32%) fewer CAI occasions; though clinically relevant, this difference fell short of statistical significance (p = .08). In NYC (n = 166) intervention participants had significantly fewer CAI occasions, whereas in SJU (n = 106) they reported non-significantly more CAI occasions. Two devastating hurricanes hit SJU during the study and may have impacted results in unmeasured ways.

Women's Decision-Making about PrEP for HIV Prevention in Drug Treatment Contexts

Despite pre-exposure prophylaxis's (PrEP) efficacy for HIV prevention, uptake has been low among women with substance use disorders (SUDs) and attributed to women's lack of awareness. In semistructured interviews with 20 women with SUD and 15 key stakeholders at drug treatment centers, we assessed PrEP awareness and health-related decision-making. Women often misestimated their own HIV risk and were not aware of PrEP as a personally relevant option. Although women possessed key decision-making skills, behavior was ultimately shaped by their level of motivation to engage in HIV prevention. Motivation was challenged by competing priorities, minimization of perceived risk, and anticipated stigma. Providers were familiar but lacked experience with PrEP and were concerned about women's abilities to action plan in early recovery. HIV prevention for women with SUD should focus on immediately intervenable targets such as making PrEP meaningful to women and pursuing long-term systemic changes in policy and culture. Efforts can be facilitated by partnering with drug treatment centers to reach women and implement PrEP interventions.

An Information-Motivation-Behavioral Skills Model of PrEP Uptake

Despite documented effectiveness of pre-exposure prophylaxis (PrEP), PrEP uptake remains low among at-risk populations. The 2015 CDC report estimates that about 1.2 million people in the US have indications for PrEP. However, only 49,158 or 4% of the targeted population are currently using PrEP. Efforts to optimize uptake of PrEP may be facilitated by the development of a comprehensive theoretical framework which can be used to understand reasons for poor uptake and to develop interventions to maximize PrEP uptake and adherence. This article reviews research on correlates of PrEP uptake and presents findings organized within an Information-Motivation-Behavioral Skills (IMB) model framework. In the context of PrEP uptake, the IMB model asserts that to the extent that at-risk groups are well-informed about PrEP, motivated to act on their knowledge, and have necessary behavioral skills to seek out and initiate PrEP regimen, they will successfully overcome obstacles to initiate and adhere to PrEP. The article proposes an adaptation the IMB model for PrEP uptake, provides empirical support for the adapted IMB model extracted from related research, and discusses its application in PrEP uptake interventions.

Exploring the Effect of Sharing Common Facebook Friends on the Sexual Risk Behaviors of Tinder Users

An increasing number of young adults are using online dating sites and mobile apps. The "common connections" feature on Tinder displays mutual Facebook friends between users and might serve as an unintentional validation of a user's character. This study investigates condom use differences between partners met via mobile dating apps or in-person; and if the "common connections" feature affects the perceived sexual risk Tinder users have toward partners met online. College students who met a partner online or in-person in the past year were recruited from a large metropolitan university to complete an online survey. Participants answered questions about sexual risk behavior, condom use, Tinder use, and the effect "common connections" could have on sexual risk behaviors. The likelihood of condomless vaginal sex was no different if participants met their partner through an app or in-person. Among a subset of participants who reported using Tinder, having "common connections" with a potential date decreased the likelihood that they would talk to their date about HIV (p = 0.004) or STI testing (p = 0.001). The "common connections" feature on Tinder might influence sexual decision-making because users are able to evaluate potential dates based on their social network. Our findings suggest that Tinder users may (1) perceive partners with whom they share "common connections" as familiar or "safe," which may give users a false sense of security about the sexual health risks that a potential date may pose or (2) be hesitant to discuss sexual health matters with partners who are within their sexual network due to fear of potential gossip. Both lines of thought may reduce safer sex behaviors among sex partners who meet on Tinder.

Predicting Condom Use: A Comparison of the Theory of Reasoned Action, the Theory of Planned Behavior and an Extended Model of TPB

ABSTRACT It was our goal to give a contribution to the prediction of condom use using socio-cognitive models, comparing classic theories to an extended model. A cross-sectional study was conducted using a questionnaire of self-reported measures. From the students who agreed to participate in the study, 140 were eligible for the full study. A confirmatory analysis was used to assess the predictive value of the researched model. The model tested had slightly better fit indexes and predictive value than classic Theories of Reasoned Action and Planned Behaviour. Although the results found, discussion continues to understand the gap between intention and behaviour, as further investigation is necessary to fully understand the reasons for condom use inconsistency.

Increasing condom use in heterosexual men: development of a theory-based interactive digital intervention

Increasing condom use to prevent sexually transmitted infections is a key public health goal. Interventions are more likely to be effective if they are theory- and evidence-based. The Behaviour Change Wheel (BCW) provides a framework for intervention development. To provide an example of how the BCW was used to develop an intervention to increase condom use in heterosexual men (the MenSS website), the steps of the BCW intervention development process were followed, incorporating evidence from the research literature and views of experts and the target population. Capability (e.g. knowledge) and motivation (e.g. beliefs about pleasure) were identified as important targets of the intervention. We devised ways to address each intervention target, including selecting interactive features and behaviour change techniques. The BCW provides a useful framework for integrating sources of evidence to inform intervention content and deciding which influences on behaviour to target.

The Strategies of Heterosexuals from Large Metropolitan Areas for Assessing the Risks of Exposure to HIV or Other Sexually Transmitted Infections from Partners Met Online

Heterosexuals' use of the Internet for meeting romantic or sexual partners is rapidly increasing, raising concerns about the Internet's potential to facilitate encounters that place individuals at risk for acquiring HIV or other sexually transmitted infections (STIs). For example, online sharing of personal information and self-revelations can foster virtual intimacy, promoting a false sense of familiarity that might accelerate progression to unprotected sex. Therefore, it is critical to understand how those who meet sexual partners online attempt to assess the possible risk of acquiring HIV or STIs posed by having unprotected sex with a new partner and decide whether to use a condom. To investigate this issue, in-depth interviews were conducted with a diverse sample of heterosexual male and female participants from large metropolitan cities who had had unprotected vaginal or anal sex with at least two partners met online in the past 3 months. With few exceptions, participants relied on faulty strategies and heuristics to estimate these risks; yet, most engaged in unprotected sex at their first meeting or very soon afterward. While some seemed to try to make a genuine effort to arrive at a reliable assessment of the HIV risk posed, most appeared to be looking for a way to justify their desire and intention to have unprotected sex. The findings suggest the need for more HIV and sexual health education targeted at heterosexuals, especially for those who go online to meet partners.

Context of First Same-Sex Condom Use and Nonuse in Young Black Gay and Bisexual Males

Despite high human immunodeficiency virus (HIV) rates among young Black men who have sex with men (YBMSM), there are limited data about condom use during first same-sex (FSS). This study sought to understand socio-contextual factors of 50 YBMSM aged 15-19 years that influenced condom use during FSS. Condom use was influenced by individual, partner, and community factors. Individual factors-recent illness or sexually transmitted infections (STI)-prompted condom use, while frequent HIV testing prompted nonuse. Partner factors-proactive encouragement from partners-prompted condom use, while trust and condom discomfort prompted nonuse. Larger community factors-such as presence of females-were key for use, while limited sexual health information combined with peers who discouraged condoms prompted nonuse. A multilevel approach may be useful in developing sexual health programming for these young men.

Social and psychological correlates of unprotected anal intercourse among Hispanic-American women: implications for STI/HIV prevention

Heterosexual anal intercourse is associated with increased risk for HIV and other sexually transmitted infections. Research on the social and psychological risk factors associated with heterosexual unprotected anal intercourse among Hispanic women in the USA is limited. We examined demographic, mental health, relationship power, sexual self-efficacy, self-esteem, acculturation and HIV knowledge as correlates of unprotected anal intercourse among 514 HIV-negative Hispanic women, 18 to 59 years of age, residing in one urban county in southern Florida. In both unadjusted and adjusted results, the likelihood of engaging in unprotected anal intercourse was associated with food insecurity in the past 30 days (adjusted odds ratio [AOR] = 1.57, 95% confidence interval [CI] 1.03, 2.40) and more interpersonal power attributed to the male partner (AOR = 1.63, 95%CI 1.08, 2.45). Not significant, yet of possible importance, were ever having engaged in exchange sex (AOR = 1.96, 95%CI = 0.97, 3.98) and lower HIV knowledge (AOR = 0.80, 95%CI = 0.63, 1.01). Interventions aimed at reducing heterosexual unprotected anal intercourse risk for HIV infection among Hispanic women may benefit by addressing socioeconomic and interpersonal issues, and assessing HIV knowledge and comprehension.

Relationship Dynamics and Sexual Risk Reduction Strategies Among Heterosexual Young Adults: A Qualitative Study of Sexually Transmitted Infection Clinic Attendees at an Urban Chicago Health Center

Few studies have examined risk-reduction alternatives to consistent condom use for HIV prevention among heterosexual young adults. We used qualitative methodology to explore risk reduction strategies and contextual factors influencing attempts to reduce risk in an urban, high morbidity sexually transmitted infection (STI) clinic. Focus groups were conducted October-December 2014 with heterosexually identified men (n = 13) and women (n = 20) aged 18-29 seeking STI screening at an urban clinic. Groups were audio recorded, transcribed verbatim, and analyzed for thematic content using Atlas.ti software. Quantitative information included sociodemographics, HIV/STI testing history, and 6-month sexual behaviors. Among 33 predominantly African-American participants with a median age of 22, risk-reduction strategies included monogamy agreements, selective condom use with casual and high-risk partners, and frequent HIV/STI testing, though testing was commonly used as a post-hoc reassurance after risk exposure. Many men and women used implicit risk assessment strategies due to mistrust or difficulty communicating. Concurrency was common but rarely discussed within partnerships. Despite attempts to reduce risk, monogamy agreements were often poorly adhered to and not openly discussed. Alcohol and substance use frequently interfered with safer sexual decisions. Participants were aware of HIV/STI risk and commonly practiced risk-reduction strategies, but acknowledged faulty assumptions and poor adherence. This work provides insights into risk-reduction approaches that are already used and may be strengthened as part of effective HIV/STI prevention interventions.

The effects of alcohol, relationship power, and partner type on perceived difficulty implementing condom use among African American adults: an experimental study

African American adults are disproportionately affected by HIV in the United States, underscoring the need for additional research on barriers to condom use. Guided by the theory of gender and power, this experimental study used a series of vignettes to test causal hypotheses regarding the influence of event-level alcohol use (present and absent), partner type (serious and casual), and relationship power (low and equal) on perceived difficulty implementing condom use. A total of 299 (151 women and 148 men) heterosexual African American adults indicated how "difficult" it would be to use a condom after reading 8 hypothetical sexual encounters, presented in a random order. A 2 × 2 × 2 × 2 repeated measures analysis of covariance with one between subjects factor (gender) and one covariate (condom use self-efficacy) was used to estimate the effects of these variables on an index of perceived difficulty. The women in the study reported significantly higher ratings of difficulty implementing condom use in vignettes characterized by low relationship power (p < .001) and presence of alcohol use (p < .001); the manipulated independent variables did not produce any main effects for men. Both men and women's ratings of perceived difficulty decreased as condom use self-efficacy increased (p < .001). This is the first study to use an experimental methodology to test hypotheses about barriers to condom use among a community-based sample of African American adults. These data can be used to enhance existing HIV prevention interventions.

Comparative analysis between condom use clusters and risk behaviours among Portuguese university students

The research on condom use has been focused on high-risk individuals, paying less attention to those who have moderate risk or safe sexual conducts. In order to design accurate interventions, potential differences among the condom use behavior groups must be considered. The goal was to assess possible differences in individuals presenting different types of risk behavior. 140 heterosexual university students answered a self-reported questionnaire about their sexual history, condom use habits, sexual self-esteem, sexual satisfaction, sexual control, attitudes towards condoms, self-efficacy to condom use, and emotions and feelings during sexual intercourse. A cluster analysis was conducted using the results about condom use and risk behaviors. Three groups with different risk levels emerged, presenting differences over sexual self-efficacy, attitudes towards condoms, socio-demographic variables, and sexual history. The results suggest the condom use inconsistency is highly associated with other risk behaviors but the contrary does not necessarily happens. Condom use consistent users also presented risk behaviors as smoking and drinking. The group differences suggest the risks were more affected by the combination of lack of skills with a negative attitude toward condoms than by contextual or personal variables. These differences sustain the need of an intervention adjusted to the individual's risk levels, since they differ on skills and beliefs that may hinder or promote the adoption of health behaviors.

An examination of the principles of influence on condom use decision making during casual sex encounters

Cialdini's (1984) principles of influence were employed to inform the decision-making process with respect to using condoms during casual sex. In the current study, focus groups (n = 9) were conducted to understand the relationship between the six principles of influence (authority, consistency, liking, reciprocity, scarcity, and social proof) and condom use in casual sex relationships. Results revealed that authority, consistency, and social proof were endorsed often as influencing condom use. Gender differences in the endorsement of the principles were also observed. The results speak to how these principles of influence aide the condom decision-making process during these often spontaneous sexual encounters and are discussed with an emphasis on the theoretical and practical implications for using these principles in future health campaigns.

Condom use with serious and casual heterosexual partners: findings from a community venue-based survey of young adults

Given the racial/ethnic disparities that characterize STI trends and recent increases in heterosexually transmitted HIV infection in the US, an understanding of factors underlying condom use among young adults in minority communities is vitally important. To this end, this paper presents findings from a community venue-based survey examining the influence of motivations, heuristics, and relationship factors on condom behaviors with serious and casual heterosexual partners in a sample of urban African American and Puerto Rican males and females ages 18-25 (n = 380). Condom use rates at time of last sex were considerably higher with casual partners (n = 87) than with serious (n = 313) partners, 77.9% vs. 38.7%. While dual pregnancy/STI prevention was the most frequently cited reason for use at last sex with casual partners, pregnancy prevention was the most frequently cited reason for use with serious partners. Bivariate conditional logistic regression analyses found two factors to be associated with condom use at last sex with casual partners: use at first sex with the partner and belief that neighborhood peers worried some/a lot about HIV. In contrast, such factors as condom heuristics (e.g., nonuse symbolizes trust), contraceptive status, and markers of emotional intimacy were associated with condom use with serious partners in both bivariate and multivariable analyses.

Gender Differences in HIV-Related Sexual Behavior among College Students from Spain and Portugal

Under the perspective of the Theory of Planned Behavior, the objective of this study was to know the gender differences in the variables involved in the use of effective preventive measures in sexual relations against HIV in a sample of university students from Spain and Portugal. Furthermore, it is examined whether these factors produce different predictions concerning the adoption of safe sexual behaviour for young man and women in each country. The sample consisted of 683 university students, 319 Portuguese (64% female and 36% male) from the University of Algarve and 364 Spanish students (51% female and 49% male) from the University of Huelva. Data were obtained by means of a questionnaire. The data revealed that there are gender differences which apply in both countries, highlighting that the young women have more positive attitudes, greater perceived behavioural control and intention of condom use than young men. However, they protect themselves less that their male counterparts: the percentage of females who say using condoms as a contraceptive method is less than the percentage of males, and especially with their steady partners. The results are discussed in relation to gender role norms, to have a steady partner or not, gender relations, the associated meaning to sexual relations for men and women and their implications for the design of sexual educational programmes for them.

Norms governing urban African American adolescents' sexual and substance-using behavior

Using a probability-based neighborhood sample of urban African American youth and a sample of their close friends (N = 202), we conducted a one-year longitudinal study to examine key questions regarding sexual and drug using norms. The results provide validation of social norms governing sexual behavior, condom use, and substance use among friendship groups. These norms had strong to moderate homogeneity; and both normative strength and homogeneity were relatively stable over a one-year period independent of changes in group membership. The data further suggest that sex and substance using norms may operate as a normative set. Similar to studies of adults, we identified three distinct "norm-based" social strata in our sample. Together, our findings suggest that the norms investigated are valid targets for health promotion efforts, and such efforts may benefit from tailoring programs to the normative sets that make up the different social strata in a given adolescent community.

Condom Use Trajectories in Adolescence and the Transition to Adulthood: The Role of Mother and Father Support

Few studies have investigated how mother and father support differ on predicting youths' sexual risk behavior. We therefore examined the influence of parental support on condom use trajectories and its correlates in a predominantly African American sample [(N=627; 53% female; M = 14.86 years (SD=. 64)] from adolescence to young adulthood. We used hierarchical growth curve modeling to examine the relationship between condom use, substance use, psychological distress and parental support prospectively. We found that consistent condom use decreased over time and was associated negatively with psychological distress and substance use. Furthermore, both maternal and paternal support were associated with more condom use over time. We discuss the implications of our findings for HIV prevention programs.

HIV risk and perceptions of masculinity among young black men who have sex with men

PURPOSE

Young black men who have sex with men (YBMSM) are known to have the highest rates of HIV infection in the United States. Although reported rates of unprotected anal intercourse are similar to the rates of men who have sex with men of other racial/ethnic backgrounds, YBMSM aged 15-22 years are five times more likely to be HIV-infected than the comparably aged white men who have sex with men. We explored contextual social-environmental factors that may influence how YBMSM assess risk, choose partners, and make decisions about condom use.

METHODS

We analyzed semi-structured interviews with 35 YBMSM (age: 18-24 years) in New York City, Upstate New York, and Atlanta. We used structured analytic coding based on a theoretical scheme that emerged from the data.

RESULTS

Perception of masculinity was the primary contextual factor influencing partner selection, risk assessment, and decision-making with regard to condom usage. Four primary themes emerged: (1) greater preference for partners perceived as masculine; (2) discomfort with allowing men perceived as feminine to be the insertive partner in anal intercourse; (3) a power dynamic such that partners perceived as more masculine made condom-use decisions within the dyad; and (4) use of potential partners' perceived masculinity to assess HIV risk.

CONCLUSIONS

Perceived masculinity may play a significant role in HIV risk for YBMSM and may be an important concept to consider in prevention strategies directed toward this population.

Is monogamy or committed relationship status a marker for low sexual risk among men in substance abuse treatment? Clinical and methodological considerations

BACKGROUND

HIV prevention interventions often promote monogamy to reduce sexual risk. However, there is little consensus about how to define monogamy.

OBJECTIVE

To determine the extent to which recent monogamy and/or being in a committed relationship serve as markers for low sexual risk among men in substance abuse treatment.

METHODS

Participants were 360 men enrolled in the National Institute on Drug Abuse Clinical Trials Network "Real Men Are Safe" protocol who completed all assessments (baseline, 3 months, and 6 months). Self-reported behaviors included number of sexual partners, type of relationships, frequency of vaginal/anal intercourse, and percentage of condom use.

RESULTS

The rate of self-reported monogamy in the prior 90 days was stable across assessments (54.2%, 53.1%, 58.3%). However, at each assessment 7.5-10% of monogamous men identified their partner as a casual partner, and only 123 (34.2%) reported being monogamous at every assessment. Of these, 20 (5.6%) reported being monogamous with different partners across assessments. Men with both committed relationship and casual partners reported more condom use with their committed relationship partners than men with only a committed relationship partner.

CONCLUSION

Clinicians and researchers should consider individual relationship context and behavior and avoid assuming that recent monogamy or being in a committed relationship denotes low risk.

SCIENTIFIC SIGNIFICANCE

This study provides evidence that, in male drug users, monogamy does not necessarily reflect low sexual risk. Rather, "monogamous" men actually encompass various combinations of partner types and levels of risk behavior that are unstable, even over brief time periods. Clinicians and researchers must take these variations into account.

The relative role of perceived partner risks in promoting condom use in a three-city sample of high-risk, low-income women

We examined the effect of women’s perceptions of sexual partner risks on condom use. Women from three US cities (n = 1,967) were recruited to provide data on HIV risks. In univariate models, increased odds of condom use were associated with perceiving that partners had concurrent partners and being unaware of partners': (a) HIV status, (b) bisexuality, (c) concurrency; and/or (d) injection drug use. In multivariate models, neither being unaware of the four partner risk factors nor perceiving a partner as being high risk was associated with condom use. Contextual factors associated with decreased odds of condom use were having sex with a main partner, homelessness in the past year, alcohol use during sex, and crack use in the past 30 days. Awareness of a partner’s risks may not be sufficient for increasing condom use. Contextual factors, sex with a main partner in particular, decrease condom use despite awareness of partner risk factors.

Sexual decision making for the "better than average" college student

OBJECTIVES

to examine the impact of downward social comparison and the "known partner is a safe partner" heuristic on college students' sexual decisions.

PARTICIPANTS

One hundred-eighty heterosexual or bisexual undergraduate college students.

METHODS

participants read dating vignettes that varied on perspective and familiarity and then rated the likelihood the couple would engage in sexual intercourse and use a condom.

RESULTS

there were no differences in rated likelihood based on familiarity, suggesting that the students did not view the 2 partner types as significantly different. Students rated the likelihood of sexual intercourse lower and condom use higher when the vignette was presented from the second person perspective.

CONCLUSIONS

the students' use of downward social comparison is consistent with the "better than average effect," suggesting that the students perceive their own behavior as safe. The implication is that safer sex messages might be most effective if they focus on what students will gain by practicing safer sex behaviors, not just avoidance of a risk behavior.

A little thing called love: condom use in high-risk primary heterosexual relationships

CONTEXT

Condoms are less likely to be used in primary relationships than in other relationship types. An understanding of what women and men expect when entering into these relationships, as well as how they make decisions about condom use and other prevention behaviors, is essential to efforts to curb the spread of HIV.

METHODS

Qualitative in-depth interviews were conducted with 25 high-risk heterosexual couples, including HIV-serodiscordant couples, participating in a trial of the female condom in Hartford in 2004-2007. Data were coded and analyzed in an iterative inductive and deductive process.

RESULTS

Participants described nonuse of condoms as a strategy to fi nd and maintain a primary relationship, establish trust and increase intimacy. Many had unprotected intercourse while recognizing their risk of HIV and other STDs, placing their love for their partner and other emotional needs over concerns about their health. Several couples reduced their STD risk by practicing negotiated safety (i.e., using condoms until their serostatus had been determined) or similar strategies, including sharing sexual or drug use history, disclosing HIV test results and using condoms until they decided that their relationship would be monogamous.

CONCLUSIONS

HIV prevention approaches must recognize the importance of love and the needs that primary relationships satisfy if they are to be considered relevant by those at greatest risk. Negotiated safety and similar strategies may be an important risk reduction tool for heterosexuals, particularly those in HIV-affected relationships, but their potential effectiveness may vary.

Factors associated with sexually transmitted infections in men and women

BACKGROUND

Sexually transmitted infections (STIs) remains a serious healthcare problem costing approximately 13 billion dollars annually to treat. Men and women who contract STIs have a higher risk for reinfection and for developing human immunodeficiency virus (HIV). Determining the risk factors associated with STIs in a community would be helpful in designing culturally appropriate tailored interventions to reduce spread of STIs.

PURPOSE

The purpose of this retrospective chart review was to determine the frequency and type of STIs, as well as to determine the predictor variables associated with STIs among those seeking treatment at a local inner city health unit.

METHOD

A total of 237 medical records were reviewed from a STI clinic. The sample comprised 119 men and 118 women, of whom 70.9% were African American. The mean age was 27, and 38% had a prior STI. Men used significantly more condoms (chi(2) = 24.28, p = 0.000), had more sexual partners (chi(2) = 18.36, p = 0.003), and had more prior infections of gonorrhea (chi(2) = 10.04, p =0.002) than women. Women had significantly more prior infections of Chlamydia (chi(2) = 11.74, p = 0.001). Using no type of birth control measures (pills, diaphragm, implants) was a significant predictor of number of sexual partners (t = 2.441, p < 0.015), but negatively associated with condom use (t = -12.290, p < 0.000).

CONCLUSIONS

Over one-third had a prior STI, indicating that individuals do not perceive themselves to be at risk for another STI, and choose not to use condoms. Reasons why individuals continue to put themselves at risk need to be explored in gender specific focus groups so that tailored sexual risk reduction programs can be designed to meet the needs of different communities.

Perceptions of sexual partner safety

BACKGROUND

Many individuals select sexual partners based on assumed partner STI/HIV safety, yet few studies have investigated how these assumptions are formed. The objective of this research was to determine the extent to which partner safety beliefs were used to evaluate partner safety, and whether these beliefs influenced perceptions of personal STI/HIV risk.

METHODS

Participants (n = 317) recruited from an STI clinic completed a structured self-report questionnaire. A Partner Safety Beliefs Scale (PSBS) was developed to determine the factors that most influenced perceived partner safety. Exploratory factor analysis showed that a single factor accounted for 46% of the variance in the PSBS; with an internal consistency of 0.92. Linear regression was used to determine factors predictive of perceived personal STI/HIV risk.

RESULTS

Participants endorsed statements indicating that knowing or trusting a sexual partner influences their beliefs about their partner's safety. Linear regression analysis indicated that education, income, number of sexual partners, and PSBS scores were significant predictors of perceived personal STI/HIV risk.

CONCLUSIONS

The results of this study indicate that many individuals are relying on partner attributes and relationship characteristics when assessing the STI/HIV status of a sexual partner, and that this reliance is associated with a decreased perception of personal STI/HIV risk. Prevention campaigns need to acknowledge that people are likely to evaluate sexual partners whom they know and trust as safe. Dispelling erroneous beliefs about the ability to select safe partners is needed to promote safer sexual behavior.

Determinants of perceived barriers to condom use among HIV-infected middle-aged and older African-American men

AIM

This paper is a report of a study to describe which determinants best predict perceived barriers to condom use during sexual encounters among human immunodeficiency virus human immunodeficiency virus-infected African-American men, middle-aged and older, living in the United States of America.

BACKGROUND

While the global epidemic of acquired immunodeficiency syndrome infection is a well-documented phenomenon with national and international implications, prevalence statistics indicate that middle-aged and older African-American (non-Hispanic) men have not benefited from the prevention efforts implemented during the past two decades.

METHOD

A cross-sectional design using a survey and convenience sampling was adopted between September 2003 and July 2004 to recruit n = 130 middle-aged human immunodeficiency virus-infected African-American men from infectious disease clinics from the Mid-Atlantic region in the United States of America. The survey covered demographics, perceived health beliefs, spiritual well-being and symptoms related to human immunodeficiency virus.

FINDINGS

Stepwise multiple regression showed having fewer human immunodeficiency virus-related symptoms associated with the human immunodeficiency virus (P = 0.004) and being single (P = 0.05) were perceived as barriers to condom use during sexual encounters (R(2) = 0.029, P = 0.046).

CONCLUSION

Tailored interventions are needed for African-American men, middle-aged and older, infected with human immunodeficiency virus nationally and worldwide that are designed to decrease perceived barriers in order to increase condom use.

Patterns of reasoning and decision making about condom use by urban college students

HIV infection rates are rapidly increasing among young heterosexuals, making it increasingly important to understand how these individuals make decisions regarding risk in sexual encounters. Our objective in this study was to characterize young adults' safer sex behaviour and associate this behaviour with patterns of reasoning, using cognitive, information processing methods to understand the process of sexual risk taking. Sixty urban college students from NYC maintained diaries for two weeks and then were interviewed regarding lifetime condom use and sexual history. Using cognitive analysis, we characterized four patterns of condom use behaviour: consistent condom use (35.0%), inconsistent condom use (16.7%), shifting from consistent to inconsistent condom use (35.0%), and shifting from inconsistent to consistent condom use (13.3%). Directionality of reasoning (i.e. data-driven and hypothesis-driven reasoning) was analysed in the explanations provided for condom use decisions. The consistent and inconsistent patterns of condom use were associated with data-driven heuristic reasoning, where behaviour becomes automated and is associated with a high level of confidence in one's judgment. In the other two patterns, the shift in behaviour was due to a significant event that caused a change in type of reasoning to explanation-based reasoning, reflecting feelings of uncertainty and willingness to evaluate their decisions. We discuss these results within the framework of identifying potentially high-risk groups (e.g. heterosexual young adults) as well as intervention strategies for risk reduction. Further, our findings not only identify different patterns of condom use behaviour, but our investigation of the cognitive process of decision-making characterizes the conditions under which such behaviour and reasoning change.

Incorporating ethnographic methods in multidisciplinary approaches to risk assessment and communication: cultural and religious uses of mercury in Latino and Caribbean communities

The potential risk from cultural and religious practices involving mercury in Latino and Caribbean communities raises central methodological and ethical questions for risk assessment and risk communication. Here, specific cultural practices unfamiliar to most risk professionals carry significant inherent risks in the eyes of those professionals but not necessarily in the eyes of practitioners. Practitioners' past experience and history as targets of religious suppression and anti-immigrant sentiment create a reluctance to engage with researchers or public health officials in risk assessment or preventive risk communication efforts. The potential for the risk--in this case mercury contamination in dwellings--to extend beyond the practicing community to future occupants adds to public health concern. Understanding the risks of these practices requires both an understanding of the cultural and political context, beliefs, and behaviors of mercury users and an understanding of the fate and transport of mercury in typical use scenarios. In this study, we employed ethnographic methods (interviews and participant observation) to understand beliefs and behavior about mercury use as well as quantitative modeling and measurement to estimate and assess potential exposures. This represents a new methodology tailored to situations in which traditional activities or observances that are integral components of cultural identity pose risks in and of themselves. Our findings indicate that there are different types of mercury use stemming from different cultural and religious traditions that result in different levels of exposure. Many of the mercury uses that can result in the highest exposures to mercury vapors have previously been attributed to the religious tradition of Santeria, but appear instead to have their roots outside of the religion.

Men, multiple sexual partners, and young adults' sexual relationships: understanding the role of gender in the study of risk

Heterosexual transmission of HIV and other sexually transmitted infections has become a primary health concern worldwide. Gender roles for heterosexual interactions appear to sanction men's sexual risk-taking, especially the pursuit of multiple sexual partners. Using measures developed in this study, the current study assessed the associations between men's and women's relationship attitudes and experiences and their sexual risk encounters. Participants were 104 men and 103 women (18-24 years) from a large, urban college located in a high HIV risk neighborhood of New York City. All completed a survey assessing HIV risk and the battery of relationship measures assessing traditional sexual roles, sexual conflicts, significance of sex, relationship investment, need for relationship, and unwanted sex. For men, greater sexual conflict in their primary relationships was associated with more sexual partners and fewer unprotected vaginal intercourse encounters with a primary partner and across sex partners overall. In addition, men's endorsement of more traditional sexual roles and lower relationship investment were associated with higher numbers of sexual partners. Among women, compliance with men to engage in unwanted sex was associated with higher levels of participation in unprotected sex. For both men and women, greater significance given to sex in a relationship was associated with fewer extradyadic partners. This study demonstrates the utility of measures of relationship attitudes and experiences to characterize sexual risk, especially among men. Findings are discussed in terms of implications for prevention program targeting young urban adults.

Preventing HIV among Latino and African American gay and bisexual men in a context of HIV-related stigma, discrimination, and homophobia: perspectives of providers

HIV-related stigma, discrimination, and homophobia impede community-based efforts to combat HIV disease among Latino and African American gay and bisexual men. This commentary highlights ways to address these social biases in communities of color in Los Angeles, California, from the perspectives of staff from HIV prevention programs. Information was collected from HIV prevention program staff participating in a 2-day symposium. The outcomes from the symposium offer strategies for developing and implementing HIV prevention services for Latino and African American gay and bisexual men, which include: (1) addressing social biases present in a community that can hinder, and even prohibit, utilization of effective HIV prevention programs; (2) recasting HIV prevention messages in a broader social or health context; (3) developing culturally appropriate HIV prevention messages; (4) exploring new modalities and venues for delivering HIV prevention messages that are appropriate for gay and bisexual men of color and the communities in which they live; and (5) broadening the target of HIV prevention services to include service providers, local institutions and agencies, and the community at-large. These strategies underscore the need to consider the social and contextual factors of a community when designing and implementing HIV prevention programs.