Achieving safer sex with choice: studying a women's sexual risk reduction hierarchy in an STD clinic

Effectiveness of the female condom in preventing HIV and sexually transmitted infections: a systematic review and meta-analysis

BACKGROUND

The effectiveness of female condoms for preventing HIV and sexually transmitted infections (STIs) remains inconclusive. We examined the effects of female condoms on the acquisition of HIV and STIs.

METHODS

We searched four databases, two trial registries, and reference lists of relevant publications in October 2018 and updated our search in February 2020. We screened search output, evaluated study eligibility, and extracted data in duplicate; resolving differences through discussion. We calculated the effective sample size of cluster randomised trials using an intra-cluster correlation coefficient of 0·03. Data from similar studies were combined in a meta-analysis. We performed a non-inferiority analysis of new condoms relative to marketed ones using a non-inferiority margin of 3%. We assessed the certainty of evidence using GRADE.

RESULTS

We included fifteen studies of 6921 women. We found that polyurethane female condoms (FC1) plus male condoms may be as effective as male condoms only in reducing HIV acquisition (1 trial, n = 149 women, RR 0.07, 95%CI 0.00-1.38; low-certainty evidence). However, the use of FC1 plus male condoms is superior to male condoms alone in reducing the acquisition of gonorrhoea (2 trials, n = 790, RR 0.59, 95%CI 0.41-0.86; high-certainty evidence) and chlamydia (2 trials, n = 790, RR 0.67, 95%CI 0.47-0.94; high-certainty evidence). Adverse events and failure rates of FC1 were very low and decreased during follow up. Although the functionality of newer female condoms (Woman's, Cupid, Pheonurse, Velvet, and Reddy) may be non-inferior to FC2, there were no available studies assessing their efficacy in preventing HIV and STIs.

CONCLUSION

The use of female plus male condoms is more effective than use of male condoms only in preventing STIs and may be as effective as the male condom only in preventing HIV. There is a need for well conducted studies assessing the effects of newer female condoms on HIV and STIs.

PROSPERO REGISTRATION NUMBER

CRD42018090710.

An Exploratory Study of Acculturation and Reproductive Health Among Haitian and Haitian-American Women in Little Haiti, South Florida

There is unmet contraceptive need among Haitian immigrants and Haitian-American women (Haitian women). The study explored associations of three measures of acculturation with contraceptive/reproductive health history among Haitian women residing in the Little Haiti community of Miami. This was a cross-sectional, exploratory study among 57 Haitian women. We conducted descriptive univariate analyses, then bivariate analyses to investigate the association of acculturation with reproductive health risk behavior including contraceptive use, tampon use, and parity, as well as interest in a female-initiated barrier contraceptive method. The most commonly ever-used contraceptive methods were male condoms (78.9 %) and oral contraceptives (OC 19.3 %). Women who primarily spoke Créole at home were less likely than those who did not to use OC (11.9 vs. 42.9 %, p = .01). Among women who resided in the U.S. ≥10 years, tampon use was 51.9 % compared to 16.7 % among those who were in the U.S. for less time (p = .005). Among U.S. born women, 60 % were tampon users compared to 22.7 % among those born in Haiti (p = .05). Women not speaking primarily Créole at home (p = .06) and those born in U.S. (p = .008) had fewer children. Contraceptive use was low among Haitian women but influenced by acculturation, where greater acculturation was associated with protective reproductive health behavior. Despite traditional norms discouraging contraceptive use, and little experience with female barriers, Haitian women indicated an interest in learning about and using a female-initiated barrier contraceptive. Increasing contraceptive uptake of potential multipurpose technologies is a potential point of intervention for decreasing HIV/STI transmission in this at-risk population.

Women's willingness to experiment with condoms and lubricants: A study of women residing in a high HIV seroprevalence area

The objective of this study was to investigate women's willingness to experiment with new condoms and lubricants, in order to inform condom promotion in a city with high rates of poverty and HIV. One hundred and seventy-three women (85.9% Black) sexually transmitted infection clinic attendees in Jackson, Mississippi, United States completed a questionnaire assessing willingness to experiment with condoms and lubricants and sexual pleasure and lubrication in relation to last condom use. Most women were willing to: (1) experiment with new types of condoms and lubricants to increase their sexual pleasure, (2) touch/handle these products in the absence of a partner, and (3) suggest experimenting with new condoms and lubricants to a sex partner. Previous positive sexual experiences with lubricant during condom use predicted willingness. The role women may play in male condom use should not be underestimated. Clinicians may benefit women by encouraging them to try new types of condoms and lubricants to find products consistent with sexual pleasure.

Estimating the hypothetical dual health impact and cost-effectiveness of the Woman's Condom in selected sub-Saharan African countries

BACKGROUND

Female condoms are the only currently available woman-initiated option that offers dual protection from pregnancy and sexually transmitted infections, including HIV. The Woman's Condom is a new female condom designed to provide dual protection and to be highly pleasurable and acceptable.

OBJECTIVE

We sought to estimate the potential dual health impact and cost-effectiveness of a Woman's Condom distribution program in 13 sub-Saharan African countries with HIV prevalence rates >4% among adults aged 15-49 years. We used two separate, publicly available models for this analysis, the Impact 2 model developed by Marie Stopes International and the Population Services International disability-adjusted life years (DALY) calculator program. We estimated the potential numbers of pregnancies and DALYs averted when the Woman's Condom is used as a family planning method and the HIV infections and DALYs averted when it is used as an HIV prevention method.

RESULTS

Programming 100,000 Woman's Condoms in each of 13 countries in sub-Saharan Africa during a 1-year period could potentially prevent 194 pregnancies and an average of 21 HIV infections in each country. When using the World Health Organization CHOosing Interventions that are Cost-Effective (WHO-CHOICE) criteria as a threshold to infer the potential cost-effectiveness of the Woman's Condom, we found that the Woman's Condom would be considered cost-effective.

CONCLUSION

This was a first and successful attempt to estimate the impact of dual protection of female condoms. The health impact is greater for the use of the Woman's Condom as an HIV prevention method than for contraception. Dual use of the Woman's Condom increases the overall health impact. The Woman's Condom was found to be very cost-effective in all 13 countries in our sample.

Sexual health and dissociative experiences among abused women

Sexually transmitted infections are a significant public health issue impacting women. Intimate partner violence (IPV) is one risk factor for STIs/HIV. Women who are the victims of IPV often experience psychological difficulties, including dissociation. Dissociative symptoms may play a role in women's ability to practice safe sex and negotiate condom use, although this has been underexplored. This mixed methods study examined the dissociative symptoms of 22 women experiencing IPV and examined the ways in which these women described their own sexual health and behaviors as well as how they protected themselves from sexually transmitted infections and HIV.

Active Drug-Using Women Use Female-Initiated Barrier Methods to Reduce HIV/STI Risk: Results from a Randomized Trial

Background. We tested an original, woman-focused intervention, based on body empowerment, and female-initiated barrier methods, including the female condom (FC) and cervical barriers. Methods. Eligible women were >= 18 years of age, HIV seronegative, and active drug users, reporting 30% or greater unprotected sex acts. Both controls (C) and intervention (I) participants received enhanced HIV/STI harm reduction counseling. I participants underwent 5 additional weekly group sessions. We compared change in frequency of unprotected vaginal intercourse across arms at 12 months. Results. Among 198 enrolled women, over 95% completed followup. Two-thirds were African-American; most of them used crack, had a primary partner, and reported sex exchange. In paired t-tests from baseline to followup, the frequency of unprotected vaginal sex dropped significantly for I (primary P < 0.00, nonprimary P < 0.002) and C (primary P < 0.008, nonprimary P < 0.000) arms with all partners. The difference in change across arms was of borderline significance for primary partner (P = 0.075); no difference was seen for nonprimary partner (P = 0.8). Use of male condom and FC increased with both partner types over time, but more consistently among I women. Conclusion: The “value-added” impact of the intervention was observed mainly with primary partners. Body knowledge with routine FC counseling should be incorporated into interventions for drug-using women.

Three city feasibility study of a body empowerment and HIV prevention intervention among women with drug use histories: Women FIT

BACKGROUND

New intervention models are needed for HIV prevention among drug-using women.

METHODS

The Women Fighting Infection Together (Women FIT) feasibility study enrolled 189 women in three U.S. cities (Providence, New York, Philadelphia) with drug-using histories, who also reported risky sexual behavior. Eligible women had participated previously in a yearlong study of HIV Counseling and Testing (HIV-CT) and limited case management. Two thirds of the sample were black, most were unemployed, and about two thirds reported prior or current crack use. Women were randomized into two groups. In one group, women participated in a manualized, four-session, peer-led, interactive group intervention that stressed body knowledge, woman-initiated HIV/sexually transmitted infection (HIV/STI) prevention, including a focus on women's health (reproductive health screening, sexual violence, self-breast examination, STI signs, symptoms), which aimed to increase comfort with and pride in their bodies. Control group women received HIV-CT enriched by female condom counseling. Outcomes included study retention, session attendance and ratings, changes in knowledge, and use of protection methods.

RESULTS

The study successfully retained 95% of the participants for a 2-month follow-up. Positive assessments from participants and peer leaders exceeded preset thresholds for success. Pre-post changes in body knowledge (p < 0.0001) and protection methods knowledge (p < 0.01) was greater among the intervention women than the control women.

CONCLUSIONS

The body empowerment model deserves further elaboration in interventions focusing on women at high risk of HIV/STI acquisition.

Basic body knowledge in street-recruited, active drug-using women enrolled in a "body empowerment" intervention trial

BACKGROUND

Drug-using women remain at high risk for HIV infection. Female condoms (FC) have proven potential and cervical barriers have promise to reduce HIV risk; their effective use may be boosted by familiarity and confidence about female anatomy. Women with high levels of crack cocaine use were assessed for their knowledge about reproductive anatomy, HIV/STI risk, as well as cancer screening behaviors.

METHODS

Women were recruited for a randomized trial of a behavioral intervention via mobile vans in Philadelphia known for high crack use and sex exchange. Knowledge and behavioral data on 198 women were collected via interviewer-administered questionnaire. Women were randomized into control (n=99) and intervention (n=99) arms. Five weekly, small-group, intervention sessions stressed "body empowerment" and teaching use of female-initiated barrier methods. Follow-up body knowledge data were collected at 12 months. Changes in and correlates of body knowledge were analyzed and compared.

RESULTS

Most participants were African-American (66%); their mean age was 39.6 years. At baseline, 44% of the sample erroneously believed women have sex and urinate from the same place; 62% erroneously believed that tampons could get lost in the abdominal cavity. Only 27% knew douching increased STI transmission risk; only 10% knew condoms reduce cervical cancer risk. At follow-up, overall body knowledge improved substantially, across both arms. Race was associated with high body knowledge at baseline but not at follow-up.

CONCLUSIONS

Knowledge favoring use of women-initiated methods and cervical cancer prevention was very low in this hard-to-reach sample. Body knowledge improved substantially with enhanced voluntary counseling and testing (VCT) as well as the women-focused intervention. Body knowledge education must be targeted and tailored to drug-using women.

Living with uncertainty: acting in the best interests of women

A recent multi-country study on hormonal contraceptives (HC) and HIV acquisition and transmission among African HIV-serodiscordant couples reported a statistically significant doubling of risk for HIV acquisition among women as well as transmission from women to men for injectable contraceptives. Together with a prior cohort study on African women seeking health services, these data are the strongest yet to appear on the HC-HIV risk. This paper will briefly review the Heffron study strengths and relevant biological and epidemiologic evidence; address the futility of further trials; and propose instead an alternative framework for next steps. The weight of the evidence calls for a discontinuation of progestin-dominant methods. We propose here five types of productive activities: (1) scaling injectable hormones down and out of the contraceptive mix; (2) strengthening and introducing public health strategies with proven potential to reduce HIV spread; (3) providing maximal choice to reduce unplanned pregnancy, starting with quality sexuality education through to safe abortion access; (4) expanding provider training, end-user counseling and access to male and female barriers, with a special renewed focus on female condom; (5) initiating a serious research agenda to determine anti-STI/HIV potential of the contraceptive cervical cap. Trusting women to make informed choices is critical to achieve real progress in dual protection.

Moving beyond safe sex to women-controlled safe sex: a concept analysis

AIM

This paper is a report of a conceptual analysis of women-controlled safe sex.

BACKGROUND

Women bear disproportionate burdens from sexually related health compromising outcomes. Imbalanced societal gender and power positions contribute to high morbidities. The expression, women-controlled safe sex, aims to empower women to gain control of their sexual lives. Few researchers focus on contextualized socio-cultural definitions of sexual safety among women.

DATA SOURCES

The sample included scientific literature from Scopus, CINAHL, PubMed, PsychINFO and Sociological Abstracts. Papers were published 2000-2010.

REVIEW METHODS

Critical analyses of literature about women-controlled safe sex were performed in May 2011 using Rodgers' evolutionary concept analysis methods. The search focused on social and cultural influences on sexual practices aimed at increasing women's control over their sexual safety.

RESULTS

The analysis uncovered five attributes of women-controlled safe sex: technology; access to choices; women at-risk; 'condom migration' panic; and communication. Three antecedents included: male partner influence; body awareness; and self-efficacy. Consequences were categorized as positive or negative. Nine surrogate terms included: empowerment; gender power; female-controlled sexual barrier method; microbicides; diaphragm; sexual negotiation and communication; female condom; women-initiated disease transmission prevention; and spermicides. Finally, a consensus definition was identified: a socio-culturally influenced multi-level process for initiating sexual safety by women deemed at-risk for sexually related dangers, usually sexually transmitted infections and/or HIV/AIDS.

CONCLUSION

This concept analysis described current significance, uses, and applications of women-controlled safe sex in the scientific literature. The authors clarified its limited nature and conclude that additional conceptual refinement in nursing is necessary to influence women's health.

A brief intervention for prevention of sexually transmitted infection among battered women

OBJECTIVE

To test the feasibility and acceptability of a combined brief nursing intervention (BNI) to prevent sexually transmitted infections (STIs) and intimate partner violence (IPV) among rural women attending a family planning clinic. The primary outcomes of interest were frequency and severity of IPV, the number of safety behaviors implemented by women, and the number of safer sex strategies used at 3 months postintervention.

DESIGN

A one-group pretest/posttest design.

SETTING

Rural health department family planning clinics.

PARTICIPANTS

Eighty-eight women were screened for IPV. Nineteen (21.4%) screened positive for past-year history of IPV, and 18 completed the intervention and data collection (baseline and 3 months).

METHODS

Women who screened positive for IPV were given a BNI addressing IPV and STI prevention. Severity and frequency of violence, IPV safety behaviors, and safer sex behaviors were measured at baseline and 3 months.

RESULTS

The frequency of physical (p = .02) and sexual (p = .05) violence decreased from baseline to 3-month follow-up. Although not statistically significant the number of safer sex behaviors reported increased from baseline to follow-up.

CONCLUSIONS

This BNI shows promise, though findings must be interpreted with caution due to small sample, lack of a control group, and no randomization. It was feasible to deliver the intervention in clinic settings.

Promoting male involvement to improve PMTCT uptake and reduce antenatal HIV infection: a cluster randomized controlled trial protocol

BACKGROUND

Despite the availability of a dual therapy treatment protocol and infant feeding guidelines designed to prevent mother to child transmission (PMTCT) of HIV, of the over 1 million babies born in South Africa each year, only 70% of those born to HIV positive mothers receive dual therapy. Similar to other resource-poor nations facing the integration of PMTCT into routine pregnancy and infant care, efforts in South Africa to scale up PMTCT and reduce transmission to < 5% have fallen far short of the United Nation's goal of 50% reductions in paediatric HIV by 80% coverage of mothers.

METHODS/DESIGN

This study proposes to evaluate the impact of combining two evidence-based interventions: a couple's risk reduction intervention with an evidence based medication adherence intervention to enhance male participation in combination with improving medication and PMTCT adherence in antenatal clinics to increase PMTCT overall reach and effectiveness. The study will use a group-randomized design, recruiting 240 couples from 12 clinics. Clinics will be randomly assigned to experimental and control conditions and effectiveness of the combined intervention to enhance PMTCT as well as reduce antenatal seroconversion by both individuals and clinics will be examined.

DISCUSSION

Shared intervention elements may decrease sexual risk and enhance PMTCT uptake, e.g., increased male participation, enhanced communication, HIV counselling and testing, adherence, serostatus disclosure, suggest that a combined sexual risk reduction and adherence intervention plus PMTCT can increase male participation, increase couples' communication and encourage adherence to the PMTCT process. The findings will impact public health and will enable the health ministry to formulate policy related to male involvement in PMTCT, which will result in PMTCT.

TRIAL REGISTRATION

PACTR201109000318329.

Sexual barrier acceptability among multiethnic HIV-positive and at-risk women

BACKGROUND

Sexual behavior interventions have been found to reduce sexual risk among HIV-seropositive and high-risk HIV-seronegative women.

METHODS

This study examined the influence of ethnicity and HIV serostatus on sexual barrier acceptability and use at short-term and long-term follow-up among African American and Hispanic (n=457) women participating in a gender and culturally tailored sexual risk reduction intervention. We hypothesized that sexual barrier acceptability and use would differ between ethnic groups but that this difference would dissipate after intervention participation. We further postulated that HIV-seropositive women would report greater acceptability and use of sexual barriers than seronegative women at baseline and that after participation in the intervention, acceptability and use would increase for both serostatus groups.

RESULTS

We enrolled 317 African American and 140 Hispanic women, 273 (60%) seropositive and 184 (40%)seronegative. Ethnic differences in the frequency of male and female condom use existed at baseline but were not found at 12-month follow-up. Male condom acceptability was higher among African American women than Hispanic women at baseline and 12-month follow-up. Seropositive women reported higher levels of consistent male condom use, but both ethnic and serostatus groups reported high levels (positive, 40%; negative, 52%) of inconsistent condom use. Most women had little experience with female condoms or lubricating gels and suppositories at baseline. No differences between ethnicities were identified in lubricant use.

CONCLUSIONS

Results support the use of a culturally tailored intervention among these populations to increase sexual barrier use and reduce sexual risk.

Interventions for encouraging sexual behaviours intended to prevent cervical cancer

BACKGROUND

Human papillomavirus (HPV) is the key risk factor for cervical cancer. Continuing high rates of HPV and other sexually transmitted infections (STIs) in young people demonstrate the need for effective behavioural interventions.

OBJECTIVES

To assess the effectiveness of behavioural interventions for young women to encourage safer sexual behaviours to prevent transmission of STIs (including HPV) and cervical cancer.

SEARCH STRATEGY

Systematic literature searches were performed on the following databases: Cochrane Central Register of Controlled Trials (CENTRAL Issue 4, 2009) Cochrane Gynaecological Cancer Review Group (CGCRG) Specialised Register, MEDLINE, EMBASE, CINAHL, PsychINFO, Social Science Citation Index and Trials Register of Promoting Health Interventions (TRoPHI) up to the end of 2009. All references were screened for inclusion against selection criteria.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of behavioural interventions for young women up to the age of 25 years that included, amongst other things, information provision about the transmission and prevention of STIs. Trials had to measure behavioural outcomes (e.g. condom use) and/or biological outcomes (e.g. incidence of STIs, cervical cancer).

DATA COLLECTION AND ANALYSIS

A narrative synthesis was conducted. Meta-analysis was not considered appropriate due to heterogeneity between the interventions and trial populations.

MAIN RESULTS

A total of 5271 references were screened and of these 23 RCTs met the inclusion criteria. Most were conducted in the USA and in health-care clinics (e.g. family planning).The majority of interventions provided information about STIs and taught safer sex skills (e.g. communication), occasionally supplemented with provision of resources (e.g. free sexual health services). They were heterogeneous in duration, contact time, provider, behavioural aims and outcomes. A variety of STIs were addressed including HIV and chlamydia. None of the trials explicitly mentioned HPV or cervical cancer prevention.Statistically significant effects for behavioural outcomes (e.g. increasing condom use) were common, though not universal and varied according to the type of outcome. There were no statistically significant effects of abstaining from or reducing sexual activity. There were few statistically significant effects on biological (STI) outcomes. Considerable uncertainty exists in the risk of bias due to incomplete or ambiguous reporting.

AUTHORS' CONCLUSIONS

Behavioural interventions for young women which aim to promote sexual behaviours protective of STI transmission can be effective, primarily at encouraging condom use. Future evaluations should include a greater focus on HPV and its link to cervical cancer, with long-term follow-up to assess impact on behaviour change, rates of HPV infection and progression to cervical cancer. Studies should use an RCT design where possible with integral process evaluation and cost-effectiveness analysis where appropriate. Given the predominance of USA studies in this systematic review evaluations conducted in other countries would be particularly useful.

Adding the female condom to HIV prevention interventions for women with severe mental illness: a pilot test

We evaluated the efficacy of a gender-specific intervention to reduce sexual risk behaviors by introducing female-initiated methods to urban women with severe mental illness. Seventy-nine women received 10 sessions of an HIV prevention intervention or a control intervention. The primary outcome was unprotected oral, anal, or vaginal intercourse, expressed using the Vaginal Episode Equivalent (VEE) score. Knowledge and use of the female condom were also assessed. Women in the HIV prevention intervention showed a three-fold reduction in the VEE score at the 3-month follow-up compared to the control group, but the difference was not significant. These women were significantly more likely to know about female condoms, have inserted one and used it with a sexual partner at the 3-month follow-up and to have inserted it at 6 months compared to controls. The female condom may be a useful addition, for a subset of women with SMI, to comprehensive HIV prevention programs.

Sexual risk reduction interventions for patients attending sexually transmitted disease clinics in the United States: a meta-analytic review, 1986 to early 2009

Sexually transmitted disease (STD) patients are more likely to experience a future STD including human immunodeficiency virus (HIV). The aim of this study was to examine the efficacy of behavioral interventions to reduce sexual risk behavior and incident STDs among patients attending STD clinics in the United States. A meta-analysis of 32 studies with 48 separate interventions targeting STD patients (N = 67,538) was conducted. Independent raters coded study, sample, and intervention characteristics. Effect sizes, using both fixed- and random-effects models, were calculated. Potential moderators of intervention efficacy were assessed. Relative to controls, intervention participants increased their condom use and had fewer incident STDs, including HIV, across assessment intervals (d (+)s ranging from 0.05 to 0.64). Several sample (e.g., age and ethnicity) and intervention features (e.g., targeting intervention to a specific group) moderated the efficacy of the intervention. Behavioral interventions targeted to STD clinic patients reduce sexual risk behavior and prevent HIV/STDs. Widespread use of behavioral interventions in STD clinics should be a public health priority.

Correlates of trichomonas prevalence among street-recruited, drug-using women enrolled in a randomized trial

OBJECTIVES

Substance-using women need prevention technologies and programs to reduce risk of HIV/sexually transmitted infection (STI). We examined STI prevalence and identified risk correlates for female drug users.

METHODS

We used interviewer-administered and computer-assisted surveys, and tested specimens for four, treatable STIs (trichomonas, early syphilis, gonorrhea, chlamydia) on 198 HIV-seronegative, street-recruited, substance-using women enrolled in a randomized trial to reduce HIV/STI risk.

RESULTS

Most women were crack users (88%), reported sex exchange (80%) and were not in drug user treatment (74%). Two-thirds were African-American and nearly all were unemployed. Protection during sex was infrequent. African-American women reported fewer unprotected sex acts and fewer sexual partners, but greater crack use and more sex-for exchange, than whites or Hispanics. Trichomonas prevalence (36.9%) exceeded that for chlamydia (3.5%), syphilis (1.5%), and gonorrhea (0%). In multivariate logistic regression, having a primary and casual partner more than doubled (AOR 2.86) the risk of having trichomonas and being African-American raised the risk by more than 8 times (AOR 8.45).

CONCLUSIONS

African-American, drug-using women, and women with multiple partner types, are in urgent need of effective STI/HIV prevention interventions.

Protecting Against Both Pregnancy and Disease: Predictors of Dual Method Use Among a Sample of Women

Although male condoms are the best form of protection against HIV/STDs, they are not the most effective method for preventing unintended pregnancy. Consequently, use of condoms and a highly effective contraceptive-referred to as dual use-is recommended as the optimal protection against both disease and pregnancy. However, little is known about the factors that promote dual use. This study examined associations of dual method use with women's background characteristics, intrapersonal factors, and relationship characteristics. Data are from a random sample of women selected from a large managed care organization in the Pacific Northwest. The analytic sample contained 371 women who completed a telephone survey and reported use of contraceptives in the past 3 months. Three mutually exclusive method use groups were constructed: effective contraceptive only (hormonal methods, intrauterine device, surgical sterilization) (59%), condom only (24%), and dual use (18%). Variables hypothesized to influence dual use were compared across the three groups in bivariate and multivariate analyses. Findings indicate that women who were younger, reported more than one sexual partner in the past year, and were highly motivated to avoid HIV/STDs--were more likely to use dual methods rather than condoms only or an effective contraceptive method. Women confident about using condoms without feeling embarrassed or breaking the sexual mood were more likely to use dual methods rather than a single effective method. Finally, women with confidence in their ability to use condoms correctly are more likely to rely solely on condoms. Policy and practice implications are discussed.

A neglected population: drug-using women and women's methods of HIV/STI prevention

Women drug users are at extremely high risk of HIV and sexually transmitted infections (STIs) from sexual transmission, but remain seriously neglected in intervention research promoting women-initiated methods of HIV/STI prevention. Sparse available data indicate a high interest and enthusiasm for women-initiated methods among these women. Moreover, drug-using women may be in a position to capitalize most on the myriad advantages of women-initiated methods and be the least hindered by their disadvantages, as compared with other populations of at-risk women. These advantages include, for example, the potential for prior placement and use of a female condom without being noticed by a drunk or "high" partner, long-term and/or clandestine use of cervical barriers, and the "contraceptive justification" to partners or clients initially unwilling to accede to use of a female barrier. Targeted, community-based outreach and educational efforts to this extremely hard-to-reach group as well as expanded public funding for women's methods are urgent priorities.

Exploring diaphragm use as a potential HIV prevention strategy among women in the United States at risk

Given the immediate need for physical cervical barrier methods like the diaphragm to protect against HIV/STIs, understanding what factors influence the acceptability of these products and how to overcome obstacles to their use is important. We explored perceptions of the diaphragm and factors that might enhance its acceptability in 25 focus groups with racially/ethnically diverse young women in the U.S. at risk for HIV/STIs (N = 140). Women believed the diaphragm has positive attributes, and most indicated they would be more likely to use the diaphragm if they were confident they could use it correctly and it protected against HIV. They also considered it messy to use and difficult to insert or remove. Findings suggest that the diaphragm could be a desirable option for pregnancy and disease prevention for some women at risk for HIV/STIs. Although disadvantages to diaphragm use were identified, many could be eliminated through changes in product design and provider intervention.

Effectiveness of health education on Toxoplasma-related knowledge, behaviour, and risk of seroconversion in pregnancy

We conducted a bibliographic literature search using MEDLINE to review the effectiveness of health education on Toxoplasma-related knowledge, behaviour, and risk of seroconversion in pregnant women. We pre-selected studies that used comparative study designs (randomized clinical trial, quasi-experimental design or historical control), that were conducted among pregnant women, and which employed specific, Toxoplasma-related outcome measures: knowledge, behaviour, or Toxoplasma infection rate. Four studies met the inclusion criteria. All had serious methodological flaws. A Belgian study reported a significant decrease in the incidence of Toxoplasma seroconversion after the introduction of intensive counselling for pregnant women about toxoplasmosis. In Poland, a significant increase in knowledge was observed after a multi-pronged, public health educational program was launched. In Canada, an increase in knowledge and prevention behaviours was reported in the intervention group receiving counselling by trained facilitators compared with the control group. In France, no significant changes in risk behaviour were observed following a physician-delivered intervention. This review highlights the weakness of the literature in the area and the lack of studies measuring actual seroconversion. There is suggestive evidence that health education approaches may help reduce risk of congenital toxoplasmosis but this problem requires further study using more rigorous research design and methodology.

The relationships among sexually transmitted infection, depression, and lifetime violence in a sample of predominantly African American women

This study was a secondary analysis of the relationships among lifetime experiences of violence, depressive symptoms, substance use, safer sex behaviors use, and past-year sexually transmitted infection (STI) treatment among a sample of 445 low income, primarily African American women (257 HIV-, 188 HIV+) reporting a male intimate partner within the past year. Twenty-one percent of HIV- and 33% of HIV+ women reported past-year STI treatment. Violence victimization increased women's odds of past-year STI treatment, controlling for HIV status and age. Depressive symptoms increased, and use of safer sex behaviors decreased, women's odds of past-year STI treatment. Results suggest that positive assessment for violence and/or depression indicates need for STI screening.

Randomised controlled trial of alternative male and female condom promotion strategies targeting sex workers in Madagascar

OBJECTIVES

To assess whether individual clinic-based counselling as a supplement to peer education for male and female condom promotion leads to greater use of protection and lower STI prevalence among sex workers in Madagascar already exposed to intensive male condom promotion.

METHODS

In two public dispensaries in Madagascar, a total of 901 sex workers were randomly allocated between two alternative male and female condom promotion

INTERVENTIONS

peer education only, or peer education supplemented with individual clinic-based counselling. Participants were followed for 12 months. Every 2 months they made clinic visits, where they were interviewed on condom use. Peer educators counselled all participants on condom use as they accompanied their assigned participants to study visits. Participants assigned to receive the supplemental intervention were counselled by a trained clinician following study interviews. Participants were tested and treated for chlamydia, gonorrhoea and trichomoniasis every 6 months. We used logistic regression to assess whether the more intensive intervention was associated with reduced STI prevalence. Use of protection with clients and non-paying partners was assessed by study arm, site, and visit.

RESULTS

There was no statistically significant association between study arm and aggregated STI prevalence. No substantial differences in levels of reported protection were noted between study groups.

CONCLUSIONS

This study found little evidence for gains from more thorough clinical counselling on male and female condom use. These findings suggest that less clinically intensive interventions such as peer education could be suitable for male and female condom promotion in populations already exposed to barrier method promotion.

Barrier method preferences and perceptions among Zimbabwean women and their partners

In Zimbabwe, adult HIV prevalence is over 25% and acceptable prevention methods are urgently needed. Sixty-eight Zimbabwean women who had completed a barrier-methods study and 34 of their male partners participated in focus group discussions and in-depth interviews to qualitatively explore acceptability of male condoms, female condoms and diaphragms. Most men and about half of women preferred diaphragms because they are female-controlled and do not detract from sexual pleasure or carry stigma. Unknown efficacy and reuse were concerns and some women reported feeling unclean when leaving the diaphragm in for six hours following sex. Nearly half of women and some men preferred male condoms because they are effective and limit women's exposure to semen, although they reportedly detract from sexual pleasure and carry social stigma. Female condoms were least preferred because of obviousness and partial coverage of outer-genitalia that interfered with sexual pleasure.

Results of a randomised trial of male condom promotion among Madagascar sex workers

OBJECTIVES

To test the effect of supplementing peer promotion of male condom use with clinic based counselling, measured in terms of STI prevalence and reported male condom use.

METHODS

1000 female sex workers in Madagascar were randomised to two study arms: peer education supplemented by individual risk reduction counselling by a clinician (peer + clinic) versus condom promotion by peer educators only (peer only). STI testing was conducted at baseline and 6 months. Behavioural interviews were administered at baseline, 2, 4, and 6 months.

RESULTS

At baseline, women in the peer only arm had prevalences of 16.0%, 23.6%, and 12.1% for chlamydia, gonorrhoea, and trichomoniasis respectively, with an aggregate prevalence of 38.2%. Baseline STI prevalences for the peer + clinic arm were slightly lower and 34.1% in aggregate. At 6 months, aggregate STI prevalence increased in the peer only arm to 41.4%, whereas the aggregate prevalence diminished slightly to 32.1% in the peer + clinic arm. In logistic regression analyses, the estimated odds ratios (ORs) for chlamydia, gonorrhoea, trichomoniasis, and aggregate STI were 0.7 (95% confidence interval 0.4 to 1.0), 0.7 (0.5 to 1.0), 0.8 (0.6 to 1.2), and 0.7 (0.5 to 0.9) respectively, comparing the peer + clinic arm with the peer only arm. The logistic regression OR for reported condom use with clients in the past 30 days increased from 1.1 at 2 months to 1.8 at 6 months, comparing the peer + clinic arm with the peer only arm, and was 1.4 overall (1.1 to 1.8). Adjustment for baseline factors changed the regression results little.

CONCLUSIONS

The impact of male condom promotion on behaviour can be heightened through more concentrated counselling on risk reduction. Persistently high STI prevalence despite increases in reported condom use by sex workers supports the need for multidimensional control programmes.

Current reproductive technologies: increased access and choice?

This article discusses key issues related to current reproductive technologies including contextual and personal barriers to use, complexity of decision making, limited access to technologies for poor women and women of color, and the politics and social controversy surrounding this area. New reproductive technologies have to be put to the same test as any other product--can and will women use them correctly? We need to not only know about the technology itself; we also need to know about the individuals who intend to use the technology and about contextual factors that influence use. Accordingly, the articles in this issue focus on the multiple determinants that influence acceptability of reproductive technologies and the policy, political, and legal implications associated with their use.

Sexual diversity among black men who have sex with men in an inner-city community

Dramatic increases in HIV-incidence rates have been documented for Black men who have sex with men (MSM). Moreover, MSM has become a more visible HIV-transmission route in the Black community, in part due to public interest in the "down low" (i.e., "straight" men who also have sex with men). Interviews were conducted with 21 Black MSM in central Brooklyn, New York City, in efforts to understand the diversity of MSM experience in a low income, high HIV-prevalence community. Two thirds of the men identified as either heterosexual (43%) or bisexual (24%) and 15 (71%) MSM reported recent sex with women. Conformity to masculine social role expectations made it difficult to identify sex partners in the community; therefore, men relied on private sex clubs and the Internet. The findings suggest that stigma surrounding both HIV and homosexuality may effectively insure that nonheterosexual preferences and practices remain hidden in the Black community. A focus on sexual orientation and bisexuality has obscured the issue of race in the HIV/AIDS epidemic among Black MSM. In the long term, public health promotion and HIV prevention will require greater tolerance and acceptance of sexual diversity in the Black community.

Barrier contraceptive method acceptability and choice are not reliable indicators of use

BACKGROUND

The need for safe and effective female-controlled methods that protect against sexually transmitted pathogens is widely recognized. Product effectiveness is inextricably bound to use, and, therefore, the needs and preferences of potential consumers must be considered. The degree to which measures of acceptability correlate with actual barrier method use remains unexamined.

GOAL

The goal was to evaluate associations between measures of acceptability and use of existing over-the-counter barrier methods.

STUDY DESIGN

In the San Francisco Bay Area, 510 females aged 15 to 30 years were recruited from reproductive health clinics for this longitudinal study.

RESULTS

Neither hypothetical acceptability nor product choice predicted use. Fewer than 50% of participants who chose a female-controlled method used it. Similarly, method satisfaction was not associated with use (14.3-51.4% of satisfied users used the method again). However, dissatisfaction was predictive of low levels of subsequent use (0-15.3% used the method again). Male condoms were used despite dissatisfaction.

CONCLUSION

The lack of association among assessments of acceptability, choice, satisfaction, and use suggests a need to reframe how product acceptability is evaluated in prevention research so it is more predictive of method use.

Shifts in condom use following microbicide introduction: should we be concerned?

OBJECTIVES

Abandoning condoms for microbicides is termed 'condom migration'. This study estimated the reduction in condom use that can be tolerated following the introduction of an HIV- and sexually transmitted disease (STD)-efficacious microbicide without increasing an individual's risk of HIV infection, and explored how microbicide use affects HIV-risk.

DESIGN

Development of a static mathematical model to compare how different combinations of condom and microbicide use affect individual risk of HIV and STD infection at a particular point in time.

METHODS

The model is used to identify the 'break-even point' at which any increased risk associated with condom migration is counter-balanced by the protection afforded with microbicides. Data from Benin is used as a case-example.

RESULTS

Considering a 50% HIV- and STD-efficacious microbicide, groups that use condoms with 25% consistency or less could cease using condoms without increasing their risk if they use microbicides in 50% or more of sex acts. However, migration may increase risk if the initial condom-consistency is high (> 70%) and microbicide-consistency is low (< 50% of non-condom-protected acts). For the Benin case-example, if condoms are initially used in 70% or less of sex acts, and if consistency of condom use is sustained following microbicide introduction, there will be a 20% or greater reduction in HIV-risk if the microbicide is used in 50% of non-condom-protected sex acts.

CONCLUSIONS

There are likely to be many situations in which the benefits of microbicide use outweigh the negative impact of condom migration, and where microbicides could substantially reduce HIV-risk.

Psychosocial predictors of risky sexual behaviors in African American men: implications for prevention

Psychosocial predictors of sexual risk taking were investigated in a community sample of 502 HIV-positive and HIV-negative African American men enrolled in the African American Health Project. Poisson regression analyses were used to estimate the relative contributions of psychosocial risk and protective factors in predicting sexual risk as measured by a sexual risk behavior index. HIV-negative men, men who have sex with men and women (MSM/W), and men who have sex with men (MSM) engaged in more high-risk sexual behaviors than heterosexuals and HIV-positive men, but men who were HIV-positive carried a heavier burden of psychosocial risk factors. High psychological distress, being HIV-negative, older age, low socioeconomic status (SES), and being an MSM/W were the best predictors of sexual risk. HIV serostatus and sexual orientation differences were obtained, with high psychological distress being the most consistent predictor regardless of serostatus or sexual orientation. Results confirm previous findings of riskier sexual lifestyle among MSM/W, men with low SES, and men who are experiencing significant psychological distress.