Alcohol abuse, sexual risk behaviors, and sexually transmitted infections in women in Moshi urban district, northern Tanzania

"When a man drinks alcohol it's cool but when a woman drinks she is a hoe": A qualitative exploration of alcohol, gender, stigma, and sexual assault in Moshi, Tanzania

Alcohol's ever-increasing global use poses a distinct threat to human well-being, with intake and associated burdens rising especially quickly in low- and middle-income countries like Tanzania. Prior research has shown alcohol use and related consequences differ by gender in Moshi, Tanzania, with important implications for both clinical care and future alcohol-reduction interventions. This study builds upon this knowledge by providing a deeper understanding of how gender differences affect alcohol-related stigma and sexual assault among Emergency Department (ED) and Reproductive Health Center (RHC) patients at Kilimanjaro Christian Medical Center (KCMC) in Moshi. In-depth interviews were conducted among ED and RHC KCMC patients (n = 19) selected for participation via purposive sampling. A mix of inductive and deductive coding schemes was used to identify themes and subthemes. All data were analyzed through a grounded theory approach. Gender roles that linked men with financial responsibilities and women with child caretaking led to different expectations on alcohol intake, with alcohol use encouraged for men but vilified for women. Women who drank, for example, were deemed poor mothers and undesirable spouses. Patients likewise emphasized that both alcohol-related stigma and sexual violence disproportionately impacted women, the latter fueled through alcohol use, with serious and lasting acts of discrimination and isolation from community members seen among women alcohol users but not for men. Women alcohol users in Moshi are subject to severe social consequences, facing disproportionate stigma and sexual violence as compared to men. Alcohol-related treatment for women should be mindful of the disproportionate burdens present in this context while treatment for men should be cognizant of the social pressures to drink. Strategies to address and/or mitigate these factors should be incorporated in subsequent care and interventions.

Assessing the link between hygienic material use during menstruation and self-reported reproductive tract infections among women in India: a propensity score matching approach

Background

Reproductive tract infections (RTIs) present a substantial health concern for women, especially in developing nations such as India, where inadequate access to proper sanitation and hygiene facilities frequently results in suboptimal menstrual health and hygiene (MHH), exacerbating the risk of RTIs. In this study, we analysed the self-reported prevalence of RTIs among young women in India and evaluated the impact of hygienic menstrual material usage on these RTIs.

Methods

The study used information on 27,983 women aged 15-24 years, from the National Family Health Survey (NFHS-5) (2019-21). The prevalence of RTIs was calculated for all the states and UTs of India, and propensity score matching (PSM) technique was used to evaluate the impact of hygienic material use on RTIs among women in India.

Results

Every four out of 100 women reported RTIs in India in 2019-21. Notably, RTI prevalence displayed substantial state-level disparities. West Bengal exhibited the highest RTI prevalence at 9.3%, followed by Meghalaya, Arunachal Pradesh, and Himachal Pradesh, all surpassing 6%. In contrast, the lowest RTI rates were recorded in Puducherry at 0.9%, succeeded by Andaman and Nicobar Islands, Odisha, and Jammu & Kashmir, all registering rates below 2%. The PSM analysis revealed that women who utilized hygienic materials during menstruation exhibited a reduced prevalence of RTIs (referred to as the "treated group" with an Average Treatment Effect on the Treated (ATT) of 0.0315) compared to those who did not utilize such materials (referred to as the "control group" with an ATT of 0.0416).

Conclusions

The study underscores the critical significance of using hygienic materials during menstruation as a preventive measure against RTIs among women in India. The findings suggest the need for targeted interventions focused at promoting hygienic menstrual materials to reduce the prevalence of RTIs among women in India.

"A Man Never Cries": A Mixed-Methods Analysis of Gender Differences in Depression and Alcohol Use in Moshi, Tanzania

Background

Unhealthy alcohol use negatively impacts many components of health and wellness, including mental health conditions like major depressive disorder (MDD). Globally, gender differences are common for both alcohol use behaviors and MDD, but these differences have not been studied within Moshi, Tanzania. To provide more effective and culturally appropriate mental health treatments, gender nuances around these conditions must be known. As such, this study aims to explore gender differences in MDD, alcohol use, and other aspects of mental well-being among patients at Kilimanjaro Christian Medical Center (KCMC) in Moshi.

Methods

Six hundred and seventy-six patients presenting for care at the KCMC Emergency Department (ED) and Reproductive Health Centre (RHC) were enrolled in this mixed-methods study between October 2021 and May 2022. Patients were selected through systematic random sampling and completed quantitative surveys including the Alcohol Use Disorder Identification Test (AUDIT) and the Patient Health Questionnaire 9 (PHQ-9). Nineteen patients were purposively chosen from the study population to participate in in-depth interviews (IDIs) exploring topics related to alcohol use, gender, and depression. Descriptive frequencies, univariate log-binomial regressions, and a linear regression model were used to analyze quantitative data, all of which were analyzed in RStudio. A grounded theory approach was used to analyze all IDIs in NVivo.

Results

Average [SD] PHQ-9 scores were 7.22 [5.07] for ED women, 4.91 [4.11] for RHC women, and 3.75 [4.38] among ED men. Similarly, ED women held the highest prevalence of MDD (25%) as compared to RHC women (11%) and ED men (7.9%) (p<0.001). Depressive symptoms were associated with higher AUDIT scores only for ED men (R2 = 0.11, p<0.001). Our qualitative analysis showed that while present for women, social support networks were notably absent for men in Moshi, the lack of which was seen to play a role in alcohol use. For men, alcohol was described as a coping mechanism for stress.

Conclusion

Intersectionality of gender, alcohol use, and depression is influenced by sociocultural and behavioral norms in Moshi. As such, multi-layered, gender-differentiated programming should be considered for the treatment of substance use and mental health conditions in this region.

A mixed-methods comparison of gender differences in alcohol consumption and drinking characteristics among patients in Moshi, Tanzania

Excessive alcohol use stands as a serious threat to individual and community well-being, having been linked to a wide array of physical, social, mental, and economic harms. Alcohol consumption differs by gender, a trend seen both globally and in Moshi, Tanzania, a region with especially high rates of intake and few resources for alcohol-related care. To develop effective gender-appropriate treatment interventions, differences in drinking behaviors between men and women must be better understood. Our study aims to identify and explore gender-based discrepancies in alcohol consumption among Kilimanjaro Christian Medical Center (KCMC) patients. A systematic random sampling of adult patients presenting to KCMC's Emergency Department (ED) or Reproductive Health Center (RHC) was conducted from October 2021 until May 2022. Patients answered demographic and alcohol use-related questions and completed brief surveys, including the Alcohol Use Disorder Identification Test (AUDIT). Through purposeful sampling, 19 individuals also participated in in-depth interviews (IDIs) that focused on identifying gender differences in alcohol use. Quantitative data was analyzed in RStudio through descriptive frequencies, proportions, ANOVA, and Chi-squared tests, while IDIs were analyzed in Nvivo following a grounded theory approach. During the 8-month data collection timeline, 676 patients were enrolled. Men and women patients at KCMC's ED and RHC were found to have significant differences in their alcohol use behaviors. For our quantitative data, this included lower average AUDIT scores among women (average [SD] AUDIT scores were 6.76 [8.16] among ED men, 3.07 [4.76] among ED women, and 1.86 [3.46] among RHC women). A subsequent IDI analysis revealed greater social restrictions around women's drinking and more secretive alcohol use behaviors for where and when women would drink. For men, excess drinking was normalized within Moshi, tied to men's social interactions with other men, and generally motivated by stress, social pressure, and despair over lack of opportunity. Significant gender differences in drinking behaviors were found, primarily influenced by sociocultural norms. These dissimilarities in alcohol use suggest that future alcohol-related programs should incorporate gender in their conceptualization and implementation.

"When a man drinks alcohol it's cool but when a woman drinks she is a hoe": A Qualitative Exploration of Alcohol, Gender, Stigma, and Sexual Assault in Moshi, Tanzania

Background

Alcohol's ever-increasing global use poses a distinct threat to human well-being, with intake and associated burdens rising especially quickly in low- and middle-income countries like Tanzania. Prior research has shown alcohol use and related consequences differ by gender in Moshi, Tanzania, with important implications for both clinical care and future alcohol-reduction interventions. This study builds upon this knowledge by providing a deeper understanding of how gender differences affect alcohol-related stigma and sexual assault among Emergency Department (ED) and Reproductive Health Center (RHC) patients at Kilimanjaro Christian Medical Center (KCMC) in Moshi.

Methods

In-depth interviews (IDIs) were conducted among ED and RHC KCMC patients (n = 19) selected for participation via purposive sampling. A mix of inductive and deductive coding schemes was used to identify themes and subthemes. All data were analyzed through a grounded theory approach.

Results

Gender roles that linked men with financial responsibilities and women with child caretaking led to different expectations on alcohol intake, with alcohol use normalized for men but vilified for women. Women who drank, for example, were deemed poor mothers and undesirable spouses. Patients likewise emphasized that both alcohol-related stigma and sexual violence disproportionately impacted women, the latter fueled through alcohol use, with serious and lasting acts of discrimination and isolation from community members seen among women alcohol users but not for men.

Conclusion

Women alcohol users in Moshi are subject to severe social consequences, facing disproportionate stigma and sexual violence as compared to men. Alcohol-related treatment for women should be mindful of the disproportionate burdens present in this context and incorporate strategies to address and/or mitigate these harms in subsequent care and interventions.

A Mixed-Methods Comparison of Gender Differences in Alcohol Consumption and Drinking Characteristics among Patients in Moshi, Tanzania

Background

Excessive alcohol use stands as a serious threat to individual and community well-being, having been linked to a wide array of physical, social, mental, and economic harms. Alcohol consumption differs by gender, a trend seen both globally and in Moshi, Tanzania, a region with especially high rates of intake and few resources for alcohol-related care. To develop effective gender-appropriate treatment interventions, differences in drinking behaviors between men and women must be better understood. Our study aims to identify and explore gender-based discrepancies in alcohol consumption among Kilimanjaro Christian Medical Center (KCMC) patients.

Methods

A systematic random sampling of adult patients presenting to KCMC's Emergency Department (ED) or Reproductive Health Center (RHC) was conducted from October 2020 until May 2021. Patients answered demographic and alcohol use-related questions and completed brief surveys including the Alcohol Use Disorder Identification Test (AUDIT). Through purposeful sampling, 19 subjects also participated in in-depth interviews (IDIs) focused on identifying gender differences in alcohol use.

Results

During the 8-month data collection timeline, 655 patients were enrolled. Men and women patients at KCMC's ED and RHC were found to have significant differences in their alcohol use behaviors including lower rates of consumption among women, (average [SD] AUDIT scores were 6.76 [8.16] among ED men, 3.07 [4.76] among ED women, and 1.86 [3.46] among RHC women), greater social restrictions around women's drinking, and more secretive alcohol use behaviors for where and when women would drink. For men, excess drinking was normalized within Moshi, tied to men's social interactions with other men, and generally motivated by stress, social pressure, and despair over lack of opportunity.

Conclusion

Significant gender differences in drinking behaviors were found, primarily influenced by sociocultural norms. These dissimilarities in alcohol use suggest that future alcohol-related programs should incorporate gender in their conceptualization and implementation.

Adaptation of a model for integration of interventions for alcohol use disorders in primary health care in Tanzania

BACKGROUND

Integrating evidence-based interventions for people with alcohol use disorder (AUD) into primary healthcare (PHC) can increase access to care and reduce morbidity, mortality, and population burden. However, for the integration to be feasible, acceptable, and sustainable, there is a need to contextualize the approach and involve stakeholders. Therefore, this study aimed to use participatory methods to adapt a model for integrating AUD interventions in Tanzania's PHC system at the community, facility, and organizational levels.

METHODS

A mixed-methods study was used. Participants include key mental health stakeholders, experts, and PHC providers. We conducted a situational analysis to investigate opportunities and constraints in the existing systems of care, utilizing data available from the routine collection and/or in the public domain, individual semi-structured interviews (n = 11), and focus group discussions (3 groups; total n = 26 participants) and a series of theory of change (ToC) workshops (n = 32). Data from the three methods were triangulated to develop the adapted model for integrating interventions for AUD in PHC.

RESULTS

A situational appraisal revealed limited community, facility, and organizational resources and infrastructures for supporting services delivery of integrated AUD interventions. Also, shortage of health workforce, inadequate health management information systems, and limited medical supply and financing. Nevertheless, the theory of change proposed integrated AUD intervention packages and strategies to facilitate integrated care for people with AUD. Additionally, the barriers and facilitators for implementing these integrated AUD interventions and how to overcome them were explored.

CONCLUSIONS

The adapted model for the integrated AUD intervention in Tanzanian PHC revealed limited resources and system functioning for facilitating integrated AUD services. Nevertheless, it proposes the needed integrated AUD interventions and its barriers, facilitators, and strategies for overcoming them. There is a need to pilot the adapted model to inform plans for more comprehensive implementation or scaling up.

Missed opportunity for alcohol use disorder screening and management in primary health care facilities in northern rural Tanzania: a cross-sectional survey

Objective

The study aimed to identify the missed opportunity for detection and management of alcohol use disorder by primary health care workers.

Design

A cross-sectional survey

Setting

Outpatient services in the six governmental primary health care facilities in Moshi district council in Tanzania.

Participants

A total of 1604 adults were screened for alcohol use disorder (AUD) using the Alcohol Use Disorder Identification Test (AUDIT). Participants scoring 8 or above then provided details about their help-seeking behavior and barriers to seeking care. Participants’ records were reviewed to assess the screening and management of AUD.

Results

In the last 12 months, 60.7% reported alcohol use, and heavy episodic drinking (HED) was reported by 37.3%. AUD (AUDIT ≥ 8) was present in 23.9%. Males were more likely to have HED (aPR = 1.43;95% CI:1.3 to 1.4) or AUD (aPR = 2.9; 95% CI 1.9 to 4.2). Both HED and AUD increased with age. Only one participant (0.3%) had documented AUD screening and management. Only 5% of participants screening positive for AUD had sought help. Reasons for not seeking care were thinking that the problem would get better by itself (55.0%), wanting to handle the problem alone (42.0%), or not being bothered by the problem (40.0%).

Conclusion

While reported alcohol use, HED, and AUD are common among patients presenting to primary healthcare facilities in northern Tanzania, help-seeking behavior and detection are very low. Not screening for AUD in primary health care is a missed opportunity for early detection and management. There is an urgent need to develop interventions to increase the detection of AUD by health care providers, while also addressing help-seeking behavior and barriers to seeking care.

Prevalence of Neisseria gonorrhoeae infection among women of reproductive age in sub-Saharan Africa: a systematic review and meta-analysis

OBJECTIVE

Neisseria gonorrhoeae infection is a global, major public health problem. It is the second leading bacterial sexually transmitted infection (STI) in sub-Saharan Africa and worldwide. As study findings on the topic are inconsistent, we conducted a systematic review and meta-analysis to determine the pooled prevalence of N. gonorrhoeae infection in sub-Saharan Africa among reproductive-aged women.

METHODS

Published studies were systematically retrieved from PubMed, Embase, CINHAL and Science Direct. Their quality was measured using the Joanna Briggs Institute critical appraisal checklist for studies reporting prevalence data, and the score of each included study had to meet at least 4.5 out of 9 indicators of quality.

RESULTS

The meta-analysis of 35 studies showed that the pooled prevalence of N. gonorrhoeae infection among reproductive-aged women in sub-Saharan Africa was 3.28% (95% confidence interval 2.61%, 3.94%).

CONCLUSION

The prevalence of N. gonorrhoeae infection was higher than that found in other studies carried out in the region. The results suggest that greater attention should be paid to the primary prevention of N. gonorrhoeae. We recommend the implementation of STI education for reproductive-aged women and the use of specific and rapid diagnostic testing for N. gonorrhoeae infection in STI clinics. N. gonorrhoeae screening and treatment should be integrated into in- and outpatient clinics to reduce infection among reproductive-aged women.

Marked reduction in fertility among African women with urogenital infections: A prospective cohort study

BACKGROUND

There is paucity of data on risk factors for reduced fertility in low-income countries.

OBJECTIVE

To investigate factors associated with fertility among women in rural north eastern Tanzania.

SUBJECTS AND METHODS

A cohort of 1248 non-pregnant women was followed with urine pregnancy testing every third month or more regularly if they reported a missed menstrual period. Pregnancy was confirmed with trans-abdominal ultrasound. Information regarding general health, socioeconomic status and obstetric-gynaecological history was collected. Factors associated with conceiving within 180 days were identified using multivariate logistic regression analyses.

RESULTS

Among the 1248 women, 736 were followed for 180 days and 209 of these had an ultrasound confirmed pregnancy. During the follow-up period, 169/736 women were diagnosed with urogenital infections, including suspected sexually transmitted or reproductive tract infections, urinary tract infection, and vaginal candidiasis. Urogenital infections were significantly associated with reduced odds of conceiving within 180 days (adjusted OR (AOR) 0.21, 95% CI 0.11-0.36). Being above 30 years of age was also negatively associated with odds of conceiving (AOR 0.45, 95% CI 0.26-0.77). In contrast, women who recently stopped using hormonal contraceptives (AOR 2.86, 95% CI 1.45-5.70) and women with low socioeconomic status (AOR 1.56, 95% CI 1.04-2.33) were significantly more likely to become pregnant within 180 days.

CONCLUSION

Urogenital infection seems to be a major health factor associated with reduced chances of conceiving. Considering the availability of effective treatment options for these diseases, public health authorities should increase awareness of diagnostic tools in settings with limited resources in order to improve fertility.

Cross-Cultural Adaptation and Psychometric Properties of the AUDIT and CAGE Questionnaires in Tanzanian Swahili for a Traumatic Brain Injury Population

Aims

To develop Swahili versions of the Alcohol Use Disorders Identification Test (AUDIT) and CAGE questionnaires and evaluate their psychometric properties in a traumatic brain injury (TBI) population in Tanzania.

Methods

Swahili versions of the AUDIT and CAGE were developed through translation and back-translation by a panel of native speakers of both English and Swahili. The translated instruments were administered to a sample of Tanzanian adults from a TBI registry. The validity and reliability were analyzed using standard statistical methods.

Results

The translated versions of both the AUDIT and CAGE questionnaires were found to have excellent language clarity and domain coherence. Reliability was acceptable (>0.85) for all tested versions. Confirmatory factor analysis of one, two and three factor solution for the AUDIT and one factor solution for the CAGE showed adequate results. AUDIT and CAGE scores were strongly correlated to each other (R > 0.80), and AUDIT scores were significantly lower in non-drinkers compared to drinkers.

Conclusions

This article presents the first Swahili and Tanzanian adaptations of the AUDIT and CAGE instruments as well as the first validation of these questionnaires with TBI patients. Both instruments were found to have acceptable psychometric properties, resulting in two new useful tools for medical and social research in this setting.

Genital Chlamydia trachomatis and Neisseria gonorrhoeae infections among women in sub-Saharan Africa: A structured review

Chlamydia trachomatis and Neisseria gonorrhoeae constitute major public health problems among women, but the burden of infection in sub-Saharan Africa is poorly documented. We conducted a structured review of the prevalence and incidence of genital, oral and anal C. trachomatis and N. gonorrhoeae infection in women in sub-Saharan Africa. We searched Medline, EMBASE and Web of Science over a 10-year period for studies on epidemiology of genital, oral and anal chlamydial infection and gonorrhoea in women in all countries of sub-Saharan Africa. We assessed geographic and demographic differences in prevalence and incidence of infection; weighted mean prevalence estimates were calculated with a random-effect model. A total of 102 study results were included, with data available for 24/49 of sub-Saharan countries. The weighted prevalence of chlamydial infection was lower among women in community-based studies (3.9%; 95% CI: 2.9-5.1%) than for women recruited at primary healthcare facilities (6.0%; 95% CI: 4.2-8.4%, p < 0.001); the same was observed for gonorrhoea (2.2%; 95% CI: 1.2-4.0% vs. 4.2%; 95% CI: 3.2-5.6%, p < 0.001). Prevalence of Chlamydia among sex workers was 5.5% (95% CI: 4.2-7.3%) and gonorrhoea 7.6% (95% CI: 5.4-11%). Seven studies reported on incidence which varied between 0.75-28 and 2.8-17 per 100 person-years-at-risk for chlamydial infection and gonorrhoea, respectively. Only two studies reported on anal infections and one on oral infection. This overview underscores the considerable incidence and prevalence of genital C. trachomatis and N. gonorrhoeae in women in different settings in sub-Saharan Africa. Better control strategies are warranted to reduce the burden of infection and to prevent long-term complications of these infections.

Marital violence and sexually transmitted infections among women in post-revolution Egypt

OBJECTIVES

To explore the relationship between past year physical or sexual partner violence against women and women's self-report of sexually transmitted infection (STI) symptoms in post-revolution Egypt; and to examine the effects of men's and women's risky sexual behavioural characteristics and structural dimensions of poverty and gender inequality on this relationship.

STUDY DESIGN

This study uses the nationally representative cross-sectional demographic and health survey data conducted in 2014. Multivariate logistic regression was used to assess the relationship between past year partner violence and self-report of STI symptoms among currently married women.

MAIN OUTCOME MEASURES

women's self-report of STI was based on their responses to three questions; whether in the past year they had: got a disease through sexual contact?, a genital sore or ulcer?, or a bad smelling abnormal genital discharge? Women who gave an affirmative response to one or more of these questions were assumed to self-report STI.

RESULTS

Almost one-third of women self-reported symptoms of STI. Fourteen percent of women reported they had experienced physical or sexual violence by a male partner in the past 12months. Abused women had a 2.76 times higher odds of self-reported STI symptoms (95% CI 2.25-3.38). The significant relationship between self-reported STI and past year partner violence against women did not alter when adjusting for men's and women's behavioural characteristics and factors related to poverty and gender inequality.

CONCLUSIONS

Public health interventions that address women's sexual and reproductive health need to consider violence response and prevention strategies.

The Health and Social Impacts of Easy Access to Alcohol and Exposure to Alcohol Advertisements Among Women of Childbearing Age in Urban and Rural South Africa

OBJECTIVE

The purpose of this study was to analyze the impact of easy access to alcohol and exposure to alcohol advertisements on women's alcohol consumption, reproductive history, and health and social outcomes in an urban and rural site in South Africa.

METHOD

Trained fieldworkers conducted face-to-face interviews with 1,018 women of childbearing age in the Moot, Mamelodi, and Eesterus areas of the City of Tshwane (Gauteng province) and in the rural Cederberg, Bergrivier, and Swartland municipalities (Western Cape province), recruited through random sampling and stratified cluster random sampling, respectively. Multivariate logistic regression analyses were conducted, stratified according to the urban and rural sites and controlled for four demographic factors.

RESULTS

In Tshwane, complications in the last pregnancy (odds ratio [OR] = 7.84, 95% CI [1.77, 34.80]), interpartner binge drinking (OR = 6.50, 95% CI [3.85, 10.94]), and community drinking (OR = 7.92, 95% CI [4.59, 13.65]) were positively associated with alcohol accessibility. Interpartner violence (OR = 4.16, 95% CI [1.99, 8.70]) and community drinking (OR = 3.39, 95% CI [2.07, 5.53]) were positively associated with exposure to alcohol advertisements. In Western Cape, community drinking (OR = 10.26, 95% CI [4.02, 26.20]) was positively associated with alcohol accessibility, whereas ability to pay for health care (OR = 0.48, 95% CI [0.24, 0.96]) was inversely associated. Hazardous drinking on the Alcohol Use Disorders Identification Test (AUDIT; OR = 2.26, 95% CI [1.03, 4.95]) and CAGE (OR = 4.51, 95% CI [1.30, 15.61]), interpartner violence (OR = 1.69, 95% CI [1.04, 2.76]), and community drinking (OR = 3.39, 95% CI [2.07, 5.53]) were positively associated with exposure to alcohol advertisements.

CONCLUSION

Easy access to alcohol and exposure to alcohol advertisements are positively associated with adverse health and social outcomes. Although further studies are needed, these findings lend support to emphasizing upstream policy interventions to limit access to alcohol and advertisements.

High Rates of Herpes Simplex Virus Type 2 Infection in Homeless Women: Informing Public Health Strategies

BACKGROUND

Homeless and unstably housed women living in an urban setting are at risk for sexually transmitted diseases, yet the seroprevalence and correlates of herpes simplex virus type 2 (HSV-2) specific to impoverished women are poorly understood.

MATERIALS AND METHODS

Between April and October 2010, we conducted a cross-sectional analysis of sociodemographic, structural, and behavioral factors associated with prevalent HSV-2 infection (recent and historical infections) within a community-recruited cohort of homeless and unstably housed women. Logistic regression modeling was used to identify independent sociobehavioral correlates of HSV-2 infection.

RESULTS

Among 213 women (114 HIV positive and 99 HIV negative), the median age was 49, 48% were African American, and 63% had completed high school. HSV-2 seroprevalence was 88%, and only 17% of infected women were aware of their infection. In adjusted analysis, odds of HSV-2 infection were significantly higher for those reporting at-risk drinking (adjusted odds ratio [AOR] = 7.04; 95% confidence interval [CI] = 1.59, 67.91), heterosexual orientation (AOR = 4.56; 95% CI = 1.81, 11.69), and for those who were HIV positive (AOR = 3.64; 95% CI = 1.43, 10.30). Odds of HSV-2 infection decreased as current income increased (AOR for each $500 monthly increase = 0.90; 95% CI = 0.78, 0.997).

CONCLUSIONS

There is an extremely high seroprevalence of HSV-2 infection among homeless and unstably housed women, and most are unaware of their HSV-2 status. Screening all unstably housed women for HSV-2 infection, with additional counseling for sexual risk and alcohol use, may lead to the identification of more infections and be a first step in reducing additional disease transmission.

Alcohol Use and Transactional Sex among Women in South Africa: Results from a Nationally Representative Survey

BACKGROUND

Transactional sex is a risk factor for HIV infection. Alcohol use may increase the risk of transactional sex. No nationally-representative studies have examined the relationship between multiple dimensions of alcohol use and transactional sex in women in South Africa. The aim of the study was to examine the relationship between alcohol dependence, binge drinking and frequency of drinking in the past month and transactional sex in adult women in South Africa.

METHODS

A cross-sectional study using multi-stage, cluster sampling collected data from a nationally representative sample of 5,969 women aged 16-55 years in 2012. The analysis conducted for this paper was restricted to women reporting sexual activity in the past 12 months (n = 3,594). Transactional sex was defined as having received money/gifts in exchange for sex with any sex partner in the past year. Alcohol use measures included: alcohol dependence (≥2 positive responses to the CAGE questionnaire); binge drinking (≥4 drinks for women on one occasion); and drinking frequency in the previous month. Logistic regression models were built to test the hypotheses that each dimension of alcohol use was associated with transactional sex.

RESULTS

About 6.3% (n = 225) of sexually active women reported transactional sex. Almost a third (30.6%) of sexually active women had ever drunk alcohol, and 19.2% were current (past month) drinkers. Among lifetime drinkers, 28.0% were alcohol dependent and 56.6% were binge drinkers. Alcohol dependent women were twice as likely to report transactional sex (AOR 2.0, 95% CI 1.1-4.3, p<0.05) than those not alcohol dependent. Binge drinkers were 3.1 times more likely to have had transactional sex (95% CI 1.5-6.6, p<0.01) than non-binge drinkers. There was no significant relationship between frequency of drinking in the past month and transactional sex.

CONCLUSION

Alcohol dependency and binge drinking are significantly associated with transactional sex in South African women. HIV prevention programmes need to target these women, and address both their alcohol use, as well as the HIV risks associated with transactional sex.

HIV and alcohol knowledge, self-perceived risk for HIV, and risky sexual behavior among young HIV-negative men identified as harmful or hazardous drinkers in Katutura, Namibia

Background

Namibia’s HIV prevalence is 13.3 %. Alcohol is associated with sexual risk-taking, leading to increased HIV risk. Baseline sexual behaviors, HIV and alcohol knowledge, and self-perceived HIV risk were examined among men reporting high-risk drinking in Katutura, Namibia.

Methods

HIV negative men, ≥ 18 years, were screened for harmful or hazardous levels of drinking and >1 recent sex partner prior to randomization into control or intervention arm. SAS 9.3 and R 3.01 were used for descriptive baseline cohort analyses.

Results

A total of 501 participants who met criteria were included in analysis (mean Alcohol Use Disorders Identification Test [AUDIT] =12.4). HIV and alcohol knowledge were high with the majority (>85 and 89.8–98 %, respectively) of respondents correctly answering assessment questions. Despite high knowledge levels, 66.7 % of men felt they were at some or high risk of HIV acquisition. Among those respondents, 56.5 % stated often wanting to have sex after drinking and 40.3 % stated sex was better when drunk. Among respondents with non-steady partners [n = 188], 44.1 % of last sexual encounters occurred while the participant was drunk and condoms were not used 32.5 % of those times. Among persons who were not drunk condoms were not used 13.3 % of those times.

Conclusions

Sex with casual partners was high. Inconsistent condom use and alcohol use before sex were frequently reported. Increased emphasis on alcohol risk-reduction strategies, including drinking due to peer pressure and unsafe sexual behaviors, is needed.

Microbiological Characteristics of Chlamydia trachomatis and Neisseria gonorrhoeae Infections in South African Women

We analyzed data of 263 women with at least one genital or anorectal sexually transmitted infection from a cross-sectional study conducted in rural South Africa. We provide new insights concerning the concurrence of Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, and Trichomonas vaginalis infections as well as the characteristics of bacterial loads.

Sex-related alcohol expectancies and high-risk sexual behaviour among drinking adults in Kampala, Uganda

Alcohol consumption, a risk factor for HIV transmission in sub-Saharan Africa, is considered high in Uganda. A cross sectional study was conducted to determine whether sex-related expectations about the effects of alcohol explain the association between alcohol use and risky sexual behaviours in a population-based sample of adults in Kampala. Associations between alcohol use (current and higher risk drinking) and high-risk sexual behaviours (multiple regular partners and casual sex) were tested. In age-sex-adjusted models, having multiple regular partners was associated with current drinking (odds ratio [OR] = 2.76, 95% confidence intervals [CIs] = 1.15, 6.63) and higher risk drinking (OR = 3.35, 95% CI = 1.28, 8.71). Associations were similar but not statistically significant for having a causal sex partner. Sex-related alcohol outcome expectancy was associated with both alcohol use and high-risk sexual behaviour and attenuated relationships between multiple regular partners and both current drinking (OR = 1.94, 95% CI = 0.57, 6.73) and higher risk drinking (OR = 2.44, 95% CI = 0.68, 8.80). In this setting sexual behaviours related with alcohol consumption were explained, in part, by sex-related expectations about the effects of alcohol. These expectations could be an important component to target in HIV education campaigns.

Sero-conversion rate of Syphilis and HIV among pregnant women attending antenatal clinic in Tanzania: a need for re-screening at delivery

BACKGROUND

Despite the available cost effective antenatal testing and treatment, syphilis and human immunodeficiency virus (HIV) are still among common infections affecting pregnant women especially in developing countries. In Tanzania, pregnant women are tested only once for syphilis and HIV during antenatal clinic (ANC) visits. Therefore, there are missed opportunities for syphilis and HIV screening among those who were not tested during ANC visits and those acquiring infections during the course of pregnancy. This study was designed to determine the syphilis and HIV seroprevalence at delivery and seroconversion rate among pregnant women delivering at Bugando Medical Centre (BMC).

METHODS

A cross sectional, hospital-based study involving pregnant women attending Bugando Medical Centre (BMC) antenatal clinic was done from January to March 2012. Serum samples were collected and tested for HIV and syphilis using HIV and syphilis rapid tests. Demographic and clinical data were collected using a standardized data collection tool and analysed using STATA version 11.

RESULTS

A total of 331 and 408 women were screened for syphilis and HIV during antenatal respectively. Of 331 women who screened negative for syphilis at ANC, nine (2.7%) were seropositive at delivery while of 391who tested negative for HIV during ANC eight (2%) were found to be positive at delivery. Six (1.8%) and 23 (9%) of women who did not screen for syphilis and HIV at ANC were seropositive for syphilis and HIV at delivery respectively. There was significant difference of seroprevalence for HIV, among women who tested negative at ANC and those who did not test at ANC (2% vs.9%, P,<0.001). The overall prevalence of syphilis and HIV at delivery was 15 (2.3%) and 48 (7.2%) respectively. Syphilis seropositivity at delivery was significantly associated with HIV co-infection (p < 0.001), male partner circumcision (p = 0.011) and alcohol use among women (p < 0.001).

CONCLUSIONS

The current protocol of screening for syphilis and HIV only once during pregnancy as practiced in Tanzania may miss women who get re-infected and seroconvert during pregnancy. Re-screening for syphilis and HIV during the course of pregnancy and at delivery is recommended in Tanzania as it can help to identify such women and institute appropriate treatment.

Alcohol use, sexual relationship power, and unprotected sex among patrons in bars and taverns in rural areas of North West province, South Africa

We examined the relative importance of alcohol consumption and sexual relationship power (SRP) in predicting unprotected sex among 406 bar patrons in North West province, South Africa. We assessed participants' demographic characteristics, alcohol consumption, SRP, and number of unprotected sexual episodes in the past 6 months. In correlational analyses, alcohol consumption was significantly associated with frequency of unprotected sex for both males and females. SRP was significantly associated with frequency of unprotected sex for males and marginally associated for females. In multivariate regression analyses, alcohol consumption was significantly associated with frequency of unprotected sex for both males and females. SRP's association was marginally significant for females and not significant for males. Alcohol consumption is more strongly associated with unprotected sex than is SRP among bar patrons. Combination HIV prevention approaches to curb problem drinking and increase condom accessibility, and regular and effective use are needed in tavern settings. SRP needs further examination among tavern populations.

The Syndromic versus Laboratory Diagnosis of Sexually Transmitted Infections in Resource-Limited Settings

Sexually transmitted infections (STIs) are highly prevalent in sub-Saharan Africa, where there is a severe HIV epidemic. Thus, accurate recognition and diagnosis of STIs are essential for successful HIV prevention programs in the region. Due to lack of trained personnel and adequate laboratory infrastructure in the region, information regarding the profile of STIs relies essentially on self-reported or physician-diagnosed symptoms. The main objective of the study was to assess the effectiveness of the syndromic diagnosis of STIs, which is often used as a proxy for laboratory diagnosis of STIs in sub-Saharan Africa and other resource-limited settings. The study builds on previously collected data from a community-based survey in Northern Tanzania. We found no significant agreements between patient-reported STIs symptoms and laboratory-confirmed STIs tests. The reported STIs symptoms had high specificity (range = 85-99%) and poor sensitivity (range = 2-17%). Knowledge gained from our study will have significant public health implications, and can help improve the syndromic diagnosis of STIs.

Systematic review and meta-analysis: prevalence of alcohol use among young people in eastern Africa

Objective

Systematic review and meta-analysis of published studies of alcohol use among young people (age 15–24 years) in eastern Africa to estimate prevalence of alcohol use and determine the extent of use of standardised screening questionnaires in alcohol studies.

Methods

Five databases (MEDLINE, EMBASE, Global Health, Africa-wide, and PsycINFO) were searched for publications until 30th June 2013. Results were summarised using the guidelines on preferred reporting items for systematic reviews and meta-analyses (PRISMA) and on quality assessment using the modified quality assessment tool for systematic reviews of observational studies (QATSO). Heterogeneity was assessed using the I² statistic (DerSimonian-Laird).

Results

We identified 2785 potentially relevant studies, of which 56 were eligible for inclusion. Only two studies (4%) used the standardised Alcohol Use Disorder Identification Test (AUDIT) questionnaire, and six studies (13%) used the Cut down, Annoyed, Guilt, Eye opener (CAGE) questionnaire. The reported median prevalence of alcohol use was ever-use 52% [interquartile range (IQR): 20–58%], use in the last month 28% (IQR: 17–37%), use in the last year 26% (IQR: 22–32%), and problem drinking as defined by CAGE or AUDIT 15% (IQR: 3–36%). We observed high heterogeneity between studies, with the highest prevalence of ever use of alcohol among university students (82%; 95%CI: 79–85%) and female sex workers (66%; 95%CI: 58–74%). Current use was most prevalent among male sex workers (69%; 95%CI: 63–75%).

Conclusions

Reported alcohol use and problem drinking were common among diverse groups of young people in eastern Africa, indicating the urgent need for alcohol-focused interventions in this population. Few studies have used standardised alcohol screening questionnaires. Epidemiological research to investigate alcohol-focused interventions in young people should aim to apply such questionnaires that should be validated for use in this population.

Factors associated with problem drinking among women employed in food and recreational facilities in northern Tanzania

BACKGROUND

There is growing evidence that alcohol consumption is associated with increased risk of HIV infection. To determine factors associated with problem drinking, we analyzed data collected in two prospective cohorts of at-risk female food and recreational facility workers in northern Tanzania.

METHODS

We enrolled HIV seronegative women aged 18-44 years and employed in the towns of Geita, Kahama, Moshi, and Shinyanga. At enrolment, women were interviewed to obtain information about alcohol use, using CAGE and AUDIT screening scales, and risk factors for HIV infection. Blood and genital samples were collected for detection of HIV and sexually transmitted infections (STIs). We characterized alcohol use, concordance, and agreement of the scales, and examined the associations between characteristics of participants and problem drinking as defined by both scales using logistic regression. Lastly, we assessed problem drinking as a risk factor for recent sexual behavior and prevalent STIs.

RESULTS

Among enrollees, 68% women reported ever drinking alcohol; of these 76% reported drinking alcohol in the past 12 months. The prevalence of problem drinking was 20% using CAGE and 13% using AUDIT. Overall concordance between the scales was 75.0% with a Kappa statistic of 0.58. After adjusting for age, independent factors associated with problem drinking, on both scales, were marital status, occupation, facility type, increasing number of lifetime sexual partners, and transactional sex in the past 12 months. In addition, women who were problem drinkers on either scale were more likely to report having ≥ 1 sexual partner (CAGE: aOR = 1.56, 95% confidence interval, CI: 1.10-2.23;

AUDIT

aOR = 2.00, 95% CI: 1.34-3.00) and transactional sex (CAGE: aOR = 1.79, 95% CI: 1.26-2.56;

AUDIT

aOR = 1.51, 95% CI: 1.04-2.18), in the past 3 months.

CONCLUSION

These findings suggest that interventions to reduce problem drinking in this population may reduce high-risk sexual behaviors and contribute in lowering the risk of HIV infection.

The relationship between physical intimate partner violence and sexually transmitted infection among women in India and the United States

To investigate the association between physical intimate partner violence (IPV) and sexually transmitted infection (STI) in two national samples. Data came from the National Epidemiologic Survey on Alcohol and Related Conditions Wave 2 (n=34,653) and the National Family Health Survey-3 (n=124 385). Ever-married women between the ages of 20 and 49 were asked if they had experienced physical violence by their partner in the past year. Outcomes were presence of doctor confirmed HIV and self-reported STI. Age at first intercourse was examined as a mediator of the relationship between IPV and STI. Logistic regression examined associations between IPV, age at first intercourse and STI. Compared to individuals with no physical IPV, risk for STI was higher for individuals who experienced past year IPV living in the United States and India, however once controlling for age at first intercourse, age, education, household wealth/income and past year sexual violence, the relationship between IPV, and STI was significant in the American sample [(AOR)=1.65, 95% (CI)=1.21-2.26], however not for individuals living in India [(AOR)=1.75, 95% (CI)=0.84-3.65]. Individuals with exposure to physical IPV are at increased odds for STI. Age at first intercourse although a marker of risk, may not be an accurate marker of risky sexual behavior in both samples.

Prevalence and associations with hepatitis B and hepatitis C infection among HIV-infected adults in South Africa

We assessed prevalence and factors associated with hepatitis B in a cross section of HIV-infected primary care and antinatal clinic patients in South Africa and evaluated a rapid hepatitis B surface antigen (HBsAg) assay. We enrolled 998 patients; 88% were women, median age was 29 years and median CD4 count was 354 cells/mm(3). HBsAg enzyme-linked immunosorbent assay (ELISA), anti-hepatitis B core (HBc) antibodies and hepatitis C virus antibody were positive among 4.2%, 37% and 0.1% of subjects, respectively. Univariate and multivariate associations were assessed using logistic regression. Anti-HBc antibodies were associated with alcohol use, traditional medicines and higher CD4 counts; HBsAg positivity was associated with lower CD4. Compared with the HBsAg ELISA, a rapid HBsAg test had a sensitivity of 75.0% and specificity of 99.6%. In conclusion, we identified a moderate prevalence of both HBsAg and anti-HBc. Importantly, we found that subjects with HBsAg positivity had lower CD4 counts.

Home-based chlamydia and gonorrhoea screening: a systematic review of strategies and outcomes

Background

In many countries, low Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) screening rates among young people in primary-care have encouraged screening programs outside of clinics. Nucleic acid amplification tests (NAATs) make it possible to screen people in homes with self-collected specimens. We systematically reviewed the strategies and outcomes of home-based CT/NG screening programs.

Methods

Electronic databases were searched for home-based CT and/or NG screening studies published since January 2005. Screening information (e.g. target group, recruitment and specimen-collection method) and quantitative outcomes (e.g. number of participants, tests and positivity) were extracted. The screening programs were classified into seven groups on the basis of strategies used.

Results

We found 29 eligible papers describing 32 home-based screening programs. In seven outreach programs, people were approached in their homes: a median of 97% participants provided specimens and 76% were tested overall (13717 tests). In seven programs, people were invited to receive postal test-kits (PTKs) at their homes: a median of 37% accepted PTKs, 79% returned specimens and 19% were tested (46225 tests). PTKs were sent along with invitation letters in five programs: a median of 33% returned specimens and 29% of those invited were tested (15126 tests). PTKs were requested through the internet or phone without invitations in four programs and a median of 32% returned specimens (2666 tests). Four programs involved study personnel directly inviting people to receive PTKs: a median of 46% accepted PTKs, 21% returned specimens and 9.1% were tested (341 tests). PTKs were picked-up from designated locations in three programs: a total of 6765 kits were picked-up and 1167 (17%) specimens were returned for screening. Two programs used a combination of above strategies (2395 tests) but the outcomes were not reported separately. The overall median CT positivity was 3.6% (inter-quartile range: 1.7-7.3%).

Conclusions

A variety of strategies have been used in home-based CT/NG screening programs. The screening strategies and their feasibility in the local context need to be carefully considered to maximize the effectiveness of home-based screening programs.

Married women's risk of STIs in developing countries: the role of intimate partner violence and partner's infection status

Data for nationally representative samples of cohabiting couples in six developing countries show that intimate partner violence (IPV) increases the risk of self-reported sexually transmitted infections (STIs) for currently married women (ORs = 1.4-2.2) in all six countries, and that the strength of this relationship is not diminished by controls for proximate determinants such as husband's self-reported STI status and men's and women's higher-risk behaviors. The robustness of the IPV-STI relationship suggests the need to acknowledge IPV as an STI risk factor for women on par with other recognized risk factors such as multiple sexual partners and unprotected sexual intercourse.

Chlamydia and Gonorrhea Infections in HIV-positive Women in Urban Lusaka, Zambia

BACKGROUND

Sexually transmitted infections (STIs) remain an important public health issue in sub-Saharan Africa. STIs in HIV-positive women are associated not only with gynecological complications but with increased risk of HIV transmission to HIV-negative partners and newborns.

AIMS

The aims of this study are to determine the prevalence of chlamydia (CT) and gonorrhea (GC) and examine the demographic characteristics and risk behaviors associated with these STIs in a group of HIV-positive women in Lusaka, Zambia.

SETTINGS AND DESIGN

Cross-sectional study of a sample of HIV-infected women enrolled in two large studies conducted in urban Lusaka, Zambia.

MATERIALS AND METHODS

HIV-seropositive women (n = 292) were assessed for demographic and behavioral risk factors and tested for CT and GC. Univariate analysis was used to determine the demographic characteristics and risk behaviors associated with having CT or GC.

RESULTS

The identified prevalence of CT was 1% and of GC was 1.4%. There was an association of CT/GC with the use of alcohol before sex (OR = 9.I, CI = 0.59-0.15, P = 0.03).

CONCLUSIONS

Rates of CT and GC are described in this sample of HIV-positive women. While being in HIV care may serve to increase medical care and condom use, alcohol use should be addressed in this population.

The effect of medical male circumcision on urogenital Mycoplasma genitalium among men in Kisumu, Kenya

BACKGROUND

We determined the prevalence of urethral Mycoplasma genitalium (MG) infection and whether infection was associated with circumcision status among men enrolled in the randomized trial of medical male circumcision to prevent HIV acquisition in Kisumu, Kenya.

METHODS

MG and Trichomonas vaginalis were detected in first void urine by APTIMA transcription-mediated amplification assay. first void urine and urethral swabs were assessed for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) by polymerase chain reaction assay. Herpes simplex virus type 2 antibodies were detected by IgG ELISA. Multivariable logistic regression identified factors associated with MG infection.

RESULTS

Specimens were collected between July and September 2010, and 52 (9.9%; 95% confidence interval [CI]: 7.3%-12.4%) MG infections were detected among 526 men. N. gonorrhoeae and T. vaginalis were not associated with MG. CT coinfection was 5.8% in MG-infected men, and 0.8% among MG-uninfected men (P = 0.02). MG infection was predominantly asymptomatic (98%). The prevalence of MG was 13.4% in uncircumcised men versus 8.2% in circumcised men (P = 0.06). Being circumcised nearly halved the odds of MG (adjusted odds ratio [aQR] = 0.54; 95% CI: 0.29-0.99), adjusted for other variables significant at the P < 0.05 level: herpes simplex virus type 2 infection (aOR = 2.05; 95% CI: 1.05-4.00), CT infection (aOR = 2.69; 95% CI: 1.44-5.02), and washing the penis ≤1 hour after sex (aOR = 0.47; 95% CI: 0.24-0.95).

CONCLUSIONS

MG infection was reduced among men who were circumcised, adding to the benefits of male circumcision in preventing several sexually transmitted infections.

High risk behaviors and sexually transmitted infections among men in Tanzania

We assessed the association between risk behaviors and sexually transmitted infections (STIs) among men. We interviewed 794 men randomly selected from Moshi district of Tanzania. Blood and urine samples were tested for STIs. About 46% of the men tested positive for at least one STI including human immunodeficiency virus (HIV-1), herpes simplex virus (HSV-2), syphilis, chlamydia, trichomonas, and mycoplasma infection. Multiple sexual partners, casual sex, alcohol abuse, and older age were associated with higher odds of having an STI. Effective STI prevention programs in sub-Saharan Africa should have components aimed at addressing modifiable risk behaviors in men.

Mycoplasma genitalium: an emerging cause of sexually transmitted disease in women

Mycoplasma genitalium is an emerging sexually transmitted pathogen implicated in urethritis in men and several inflammatory reproductive tract syndromes in women including cervicitis, pelvic inflammatory disease (PID), and infertility. This comprehensive review critically examines epidemiologic studies of M. genitalium infections in women with the goal of assessing the associations with reproductive tract disease and enhancing awareness of this emerging pathogen. Over 27,000 women from 48 published reports have been screened for M. genitalium urogenital infection in high- or low-risk populations worldwide with an overall prevalence of 7.3% and 2.0%, respectively. M. genitalium was present in the general population at rates between those of Chlamydia trachomatis and Neisseria gonorrhoeae. Considering more than 20 studies of lower tract inflammation, M. genitalium has been positively associated with urethritis, vaginal discharge, and microscopic signs of cervicitis and/or mucopurulent cervical discharge in seven of 14 studies. A consistent case definition of cervicitis is lacking and will be required for comprehensive understanding of these associations. Importantly, evidence for M. genitalium PID and infertility are quite convincing and indicate that a significant proportion of upper tract inflammation may be attributed to this elusive pathogen. Collectively, M. genitalium is highly prevalent in high- and low-risk populations, and should be considered an etiologic agent of select reproductive tract disease syndromes in women.

Risk factors of alcohol problem drinking among female bar/hotel workers in Moshi, Tanzania: a multi-level analysis

There is limited information on alcohol problem drinking, which has been associated with sexually transmitted infections (STIs), including HIV, among female bar/hotel workers in Africa. This paper aimed to identify the individual- and facility-level determinants of alcohol problem drinking in this setting. Problem drinking was defined based on the CAGE alcohol screening scale. Multi-level logistic regression was used to identify individual- and facility-level factors associated with problem drinking. About 37.3% of women (N = 1629) were classified as having probable or definite problem drinking. In multi-level analysis, main characteristics associated with problem drinking included: having 3-4 partners in the past 5 years compared to having 1-2, used a condom in the last sex comparing to non-use, history of transactional sex, having more pregnancies, and facilities whose employees do not live on the premises. Interventions which combine alcohol and sexual risk reduction counseling are urgently needed in this population.

Alcohol use and sex risk behaviors among HIV-infected female sex workers (FSWs) and HIV-infected male clients of FSWs in India

Unprotected heterosexual transactional sex plays a central role in the spread of HIV in India. Given alcohol's association with risky sex in other populations and alcohol's role in HIV disease progression, we investigated patterns of alcohol use in HIV-infected female sex workers (FSWs) and HIV-infected male clients of FSWs in Mumbai. Analyses identified factors associated with heavy alcohol use and evaluated the relationship between alcohol use and risky sex. We surveyed 211 female and 205 male individuals; 80/211 FSWs (38%) and 127/205 male clients (62%) drank alcohol in the last 30 days. Among females, 32 and 11% drank heavily and were alcohol-dependent, respectively; among males the respective proportions were 44 and 29%. Men's heavy alcohol use was significantly associated with inconsistent condom use over the last year (AOR 2.40, 95% CI 1.21-4.77, P = 0.01); a comparable association was not seen in women. These findings suggest a need to address alcohol use both to avoid the medical complications of its heavy use in this population and to mitigate inconsistent condom use, the latter issue possibly requiring gender specific approaches. Such efforts to reduce drinking will be an important dimension to secondary HIV prevention in India.

Causal links between binge drinking patterns, unsafe sex and HIV in South Africa: its time to intervene

South Africa has a massive burden of HIV and alcohol disease, and these pandemics are inextricably linked. Much evidence indicates that alcohol independently influences decisions around sex, and undermines skills for condom negotiation and correct use. Thus, not surprisingly, people with problem drinking in Africa have twofold higher risk for HIV than non-drinkers. Also, sexual violence incidents often coincide with heavy alcohol use, both among perpetrators and victims. Reducing alcohol harms necessitates both population- and individual-level interventions, especially raised taxation, regulation of alcohol advertising and provision of Brief Interventions. Alcohol counselling interventions must include discussion of linkages between alcohol and sex, and consequences thereof. Within positive-prevention services, alcohol reduction interventions could diminish HIV transmission. A trial is needed to definitively demonstrate that reduced drinking lowers HIV incidence. However, given available evidence, implementation of effective interventions could alleviate much alcohol-attributable disease, including unsafe sex, sexual violence, unintended pregnancy and, likely, HIV transmission.

Association of age at first sex with HIV-1, HSV-2, and other sexual transmitted infections among women in northern Tanzania

BACKGROUND

To examine the association between age at first sex and the prevalence of sexually transmitted infections (STIs), including HIV-1 and HSV-2, in women in Moshi urban district, northern Tanzania.

METHODS

A total of 2019 women aged 20 to 44 were randomly selected in a 2-stage sampling from Moshi urban district, northern Tanzania. Information on demographics and sexual behaviors were obtained. Blood and urine samples were drawn for testing of HIV-1, HSV-2, and other STIs.

RESULTS

Women who had their first sexual intercourse at age between 18 and 19 (OR = 0.66; 95% CI = 0.50-0.86) or 20+ (OR = 0.46; 95% CI = 0.36-0.60) were less likely to have STIs, including HIV-1 and HSV-2, than women who had their first intercourse before their 18th birthday. The hazards of having had first sex at an earlier age were significantly higher for women who tested positive for STIs (HR = 1.52; 95% CI: 1.37-1.69) or had STI symptoms (HR = 1.17; 95% CI: 1.05-1.30). Early age at first sex was associated with having a regular noncohabiting partner (HR = 1.40; 95% CI: 1.23-1.58), female circumcision (HR = 1.20; 95% CI: 1.02-1.40), and coercion at first intercourse (HR = 1.47; 95% CI: 1.15-1.89).

CONCLUSIONS

In sub-Saharan Africa, where the prevalence of HIV and other STIs is high, a better understanding of the determinants of the age at first sex is crucial for HIV/STI prevention programs. Prevention programs should not only aim at delaying the age at first sex but also address factors leading to early age at first sex.

HIV, alcohol, and noninjection drug use

PURPOSE OF REVIEW

Alcohol and noninjection drug use has been shown to be associated with increased risk of HIV infection in select populations. In this review, we discuss recent data on the prevalence of alcohol and noninjection drug use and the relationship to HIV acquisition and transmission risk.

RECENT FINDINGS

A strong association between alcohol use and HIV-infection risk has been demonstrated in multiple studies conducted in sub-Saharan Africa. Among men who have sex with men in the USA as well as other countries, substance use is highly prevalent and has been associated with high-risk sexual behavior. Substance use, mental health problems, and sexual risk behaviors conjoin in what is known as a syndemic to increase HIV risk among young men who have sex with men. Only a limited number of intervention studies provide promising results in reducing HIV-infection risk among substance users.

SUMMARY

Alcohol and noninjection drug use is prevalent in certain populations. There is a strong association between use of alcohol and noninjecting substances, including methamphetamines, amyl nitrates, cocaine, and other drugs, and HIV-infection risk. This underscores the need for a comprehensive HIV prevention strategy that addresses substance use, including screening and behavioral intervention, among those at risk.