Alcohol use before sex and HIV risk: situational characteristics of protected and unprotected encounters among high-risk African women

Addressing Unhealthy Alcohol Use and the HIV Pre-exposure Prophylaxis Care Continuum in Primary Care: A Scoping Review

Individuals with unhealthy alcohol use are at increased risk for HIV acquisition and may benefit from receiving HIV pre-exposure prophylaxis (PrEP) in primary care settings. To date, literature synthesizing what is known about the impact of unhealthy alcohol use on the PrEP care continuum with a focus on considerations for primary care is lacking. We searched OVID Medline and Web of Science from inception through March 19, 2020, to examine the extent, range, and nature of research on PrEP delivery among individuals with unhealthy alcohol use in primary care settings. We identified barriers and opportunities at each step along the PrEP care continuum, including for specific populations: adolescents, people who inject drugs, sex workers, and transgender persons. Future research should focus on identification of candidate patients, opportunities for patient engagement in novel settings, PrEP implementation strategies, and stigma reduction.

Effectiveness of opiate substitution treatment in reducing HIV risk behaviors among African, Caribbean and black people: a systematic review protocol

OBJECTIVE

This systematic review aims to identify, appraise and synthesize the best available evidence on the effectiveness of methadone maintenance treatment or buprenorphine therapy in reducing sex- and drug-related HIV risk among African, Caribbean and black people.

INTRODUCTION

Substance use plays an important role in HIV transmission and acquisition among African, Caribbean and black people by increasing risky sexual behavior and the risk of HIV acquisition. Pharmacological interventions targeting drug use, injection-related risk behaviors and HIV risk behaviors have been found to be effective measures in minimizing HIV transmission attributable to opioid addiction.

INCLUSION CRITERIA

This review will consider studies that have evaluated the impact of methadone maintenance treatment or buprenorphine therapy on sex- and drug-related HIV risks. All interventions conducted in any clinical setting will be included.

METHODS

Multiple sources of published and gray literature will be searched, including Embase, MEDLINE, PsycINFO, Cochrane Central Register of Controlled Trials, OpenGrey, Grey Matters, New York Academy of Medicine's Grey Literature Report, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform. All titles and abstracts identified will be reviewed independently by two reviewers and potentially relevant studies will be retrieved in full. Papers selected for retrieval will be assessed by two independent reviewers for methodological validity. Data will be extracted from papers and will include details about the interventions, populations, study methods and outcomes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019126954.

The efficacy of a brief intervention to reduce alcohol use in persons with HIV in South Africa, a randomized clinical trial

Background

Since there is a high prevalence of high risk alcohol use in patients with HIV in Africa, with negative health effects, there is a need for short interventions to reduce alcohol use.

Methods

We studied the efficacy of a short intervention aiming to reduce alcohol use based on the Information-Motivation-Behavioural Skills Model in patients with HIV with high alcohol use (measured by AUDIT). The study was performed in three outpatient clinics in South Africa. The intervention group received in one-session intervention a personalized feedback on AUDIT results trying to make people aware that they are in the medium- or high-risk drinking category. Both the intervention and the control group received a health education leaflet.

Results

A total of 560 patients participated in the study with a follow up of 1 year. There was a significant decrease in total AUDIT scores between baseline and follow up points 1 (5 months) and 2 (1 year) in both groups. There was no significant decrease between time points 1 and 2. However, between the intervention and control groups there was no difference in reduction of alcohol use to abstinence or low risk alcohol use over time as there was no difference in absolute decrease in AUDIT-score or percentage of change in AUDIT score. The intervention had no influence on the quality of life outcomes, depression scores, stigma, tobacco use, viral load and therapy adherence at both time points. In all secondary outcomes, there was no significant interaction between intervention and time.

Conclusion

The brief intervention was not successful at reducing alcohol use both 5 and 12 months after the intervention. However, there was a beneficial effect on reported hazardous or harmful alcohol use at least over a short term follow up period in both study groups. It might be that only an interview and/or the distribution of a health leaflet can be successful in reducing alcohol use but this needs to be investigated with more objective measures of alcohol use. To sustain an effect, most likely repetitive contacts with hazardous or harmful alcohol drinkers will be needed during a long follow up period.

Exploring the associations between physical and sexual gender-based violence and HIV among women who use substances in South Africa: the role of agency and alcohol

Objective: South Africa has the highest prevalence of HIV among women, the highest prevalence of gender-based violence (GBV), and the highest rates of per capita alcohol consumption in the world. The nuanced associations between GBV, alcohol misuse, and HIV must be explored and protective factors identified. This study examines the associations between physical and sexual GBV and HIV infection and explores how alcohol misuse and sexual agency may mediate the GBV-HIV association. Method: Participants were 361 Black African women (Mean age=28.39, SD = 7.92) who reported using alcohol and/or drugs weekly in the past 3 months, engaging in condomless sex, and having a boyfriend. Women were recruited from disadvantaged communities in Pretoria, South Africa. Individuals who met the eligibility criteria and enrolled in the study consented and completed a computer-assisted personal interview assessing GBV, alcohol misuse, and sexual agency and underwent HIV testing (i.e., blood test). Results: The indirect effect of physical assault on HIV status at enrollment through alcohol misuse was significant (log odds = 0.23, SE = 0.12, 95% CI [0.0151, 0.4998]). Conclusions: HIV prevention efforts focusing on reducing alcohol misuse may be more effective, which might reduce the HIV burden among this group of vulnerable South African women.

Alcohol Use and Unprotected Sex Among HIV-Infected Ugandan Adults: Findings from an Event-Level Study

While alcohol is a known risk factor for HIV infection in sub-Saharan Africa (SSA), studies designed to investigate the temporal relationship between alcohol use and unprotected sex are lacking. The purpose of this study was to determine whether alcohol used at the time of a sexual event is associated with unprotected sex at that same event. Data for this study were collected as part of two longitudinal studies of HIV-infected Ugandan adults. A structured questionnaire was administered at regularly scheduled cohort study visits in order to assess the circumstances (e.g., alcohol use, partner type) of the most recent sexual event (MRSE). Generalized estimating equation logistic regression models were used to examine the association between alcohol use (by the participant, the sexual partner, or both the participant and the partner) and the odds of unprotected sex at the sexual event while controlling for participant gender, age, months since HIV diagnosis, unhealthy alcohol use in the prior 3 months, partner type, and HIV status of partner. A total of 627 sexually active participants (57% women) reported 1817 sexual events. Of these events, 19% involved alcohol use and 53% were unprotected. Alcohol use by one's sexual partner (aOR 1.70; 95% CI 1.14, 2.54) or by both partners (aOR 1.78; 95% CI 1.07, 2.98) during the MRSE significantly increased the odds of unprotected sex at that same event. These results add to the growing event-level literature in SSA and support a temporal association between alcohol used prior to a sexual event and subsequent unprotected sex.

Meta-Analysis of Alcohol and Serodiscordant Condomless Sex Among People Living with HIV

While observational studies have found that alcohol consumption is associated with serodiscordant condomless sex among people living with HIV (PLHIV), no meta-analysis has yet examined this trend. We conducted a meta-analysis to synthesize empirical evidence on the association between alcohol and condomless sex with partners at risk of HIV acquisition. To meet inclusion criteria, studies: (1) specifically targeted PLHIV or provided stratified data for HIV-infected participants; (2) provided a quantitative measure of alcohol use; (3) provided a quantitative measure of condomless sex with serodiscordant partners; and (4) reported the results of statistical tests examining the relationship between alcohol use and serodiscordant condomless sex. Using random-effects models, weighted effect sizes were calculated. Three separate analyses were conducted to examine serodiscordant condomless sex in association with any alcohol consumption, binge/problematic drinking, and alcohol in a sexual context. A total of 36 independent effect sizes from 27 studies (including 25,065 HIV-infected participants) were pooled in the meta-analysis. Any alcohol consumption, binge/problematic drinking, and alcohol use in a sexual context were each associated with condomless sex with serodiscordant partners [OR 1.64 (95% CI 1.46-1.85); OR 1.65 (95% CI 1.14-2.39); OR 2.88 (95% CI 2.01-4.12), respectively]. Meta-analytic findings demonstrate a consistent positive relationship between alcohol use and serodiscordant condomless sex among PLHIV. Future public health programming for HIV-infected individuals needs to address the role of alcohol consumption in sexual risk-taking behavior.

Alcohol and Sexual Risk Behaviors Among Male Central Asian Labor Migrants and Non-migrants in Kazakhstan: Implications for HIV Prevention

This paper examines the association between alcohol consumption and sexual risk behaviors (unprotected sex, multiple sex partners, sex under influence of drugs or alcohol and commercial sex) in a sample of Central Asian migrant and non-migrant laborers in the largest marketplace in Kazakhstan. We used data from The Silk Road Health Project, conducted from 2010 to 2013 with 1342 male migrant and non-migrant market workers. Participants were selected through respondent driven sampling at the Baraholka Market in Almaty, Kazakhstan. We used regression analyses adjusting for potential confounders to examine the relationship between alcohol consumption and sexual risk behavior. We found that hazardous drinking was associated with an increase in the odds of sex under the influence of drugs (aOR = 6.09, 95% CI 3.48, 10.65; p < .001) and purchasing commercial sex (aOR = 2.02, 95% CI 1.02, 4.02; p < .05). We identified potential targets for HIV interventions to reduce sexual risk behaviors among this key population.

Alcohol use and sexual risk behaviour among men and women in inner-city Johannesburg, South Africa

BACKGROUND

Alcohol misuse is a key factor underlying the remarkable vulnerability to HIV infection among men and women in sub-Saharan Africa, especially within urban settings. Its effects, however, vary by type of drinking, population group and are modified by socio-cultural co-factors.

METHODS

We interviewed a random sample of 1465 men living in single-sex hostels and 1008 women in adjacent informal settlements in inner-city, Johannesburg, South Africa. Being drunk in the past week was used as an indicator of heavy episodic drinking, and frequency of drinking and number of alcohol units/week used as measures of volume. Associations between dimensions of alcohol use (current drinking, volume of alcohol consumed and heavy episodic drinking patterns) and sexual behaviours were assessed using multivariate logistic regression.

RESULTS

Most participants were internal migrants from KwaZulu Natal province. About half of men were current drinkers, as were 13% of women. Of current male drinkers, 18% drank daily and 23% were drunk in the past week (women: 14% and 29% respectively). Among men, associations between heavy episodic drinking and sexual behaviour were especially pronounced. Compared with non-drinkers, episodic ones were 2.6 fold more likely to have transactional sex (95%CI = 1.7-4.1) and 2.2 fold more likely to have a concurrent partner (95%CI = 1.5-3.2). Alcohol use in men, regardless of measure, was strongly associated with having used physical force to have sex. Overall effects of alcohol on sexual behaviour were larger in women than men, and associations were detected between all alcohol measures in women, and concurrency, transactional sex and having been forced to have sex.

CONCLUSIONS

Alcohol use and sexual behaviours are strongly linked among male and female migrant populations in inner-city Johannesburg. More rigorous interventions at both local and macro level are needed to alleviate alcohol harms and mitigate the alcohol-HIV nexus, especially among already vulnerable groups. These should target the specific dimensions of alcohol use that are harmful, assist women who drink to do so more safely and address the linkages between alcohol and sexual violence.

Sex-related substance use and the externalizing spectrum

BACKGROUND

Substance use before and during sexual activity is associated with many negative health outcomes. Estimates suggest that at least 4.3 million American adults annually engage in regular sex-related alcohol consumption, indicating that the intersection of substance use and sexual behavior is of public health concern. However, it is likely that when considering broader sex-related substance use, estimates would be notably higher. While substance use disorders and antisocial personality disorder have been associated with sex-related alcohol consumption, no study has investigated how regular sex-related substance use is associated with the broader transdiagnostic externalizing spectrum. Further, no studies have assessed whether or not sexual risk-taking behaviors can be integrated into the externalizing spectrum.

METHODS

In a large internet sample (N=936), we used confirmatory factor analysis, item response theory, and logistic regression to link sex-related alcohol and drug use to an externalizing latent variable; identified psychometric characteristics of these behaviors; and determined the extent to which one's externalizing level was associated with changes in odds of regular sex-related substance use. We then replicated these findings in a nationally representative sample (N=34,653).

RESULTS

Results highlighted the close association between sex-related substance use and externalizing, with externalizing increases being associated with significantly increased odds of regular sex-related substance use.

CONCLUSIONS

These findings bear notable implications for conceptualization and treatment of sex-related substance use. Transdiagnostic intervention can be an efficient means of addressing this problematic behavior as well as other comorbid presentations. Results expand the current conceptualization of the externalizing spectrum.

Borderline personality disorder and regularly drinking alcohol before sex

INTRODUCTION AND AIMS

Drinking alcohol before sex increases the likelihood of engaging in unprotected intercourse, having multiple sexual partners and becoming infected with sexually transmitted infections. Borderline personality disorder (BPD), a complex psychiatric disorder characterised by pervasive instability in emotional regulation, self-image, interpersonal relationships and impulse control, is associated with substance use disorders and sexual risk behaviours. However, no study has examined the relationship between BPD and drinking alcohol before sex in the USA. This study examined the association between BPD and regularly drinking before sex in a nationally representative adult sample.

DESIGN AND METHODS

Participants were 17 491 sexually active drinkers from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. Logistic regression models estimated effects of BPD diagnosis, specific borderline diagnostic criteria and BPD criterion count on the likelihood of regularly (mostly or always) drinking alcohol before sex, adjusted for controls.

RESULTS

Borderline personality disorder diagnosis doubled the odds of regularly drinking before sex [adjusted odds ratio (AOR) = 2.26; confidence interval (CI) = 1.63, 3.14]. Of nine diagnostic criteria, impulsivity in areas that are self-damaging remained a significant predictor of regularly drinking before sex (AOR = 1.82; CI = 1.42, 2.35). The odds of regularly drinking before sex increased by 20% for each endorsed criterion (AOR = 1.20; CI = 1.14, 1.27) DISCUSSION AND CONCLUSIONS: This is the first study to examine the relationship between BPD and regularly drinking alcohol before sex in the USA. Substance misuse treatment should assess regularly drinking before sex, particularly among patients with BPD, and BPD treatment should assess risk at the intersection of impulsivity, sexual behaviour and substance use. [Thompson Jr RG, Eaton NR, Hu M-C, Hasin DS Borderline personality disorder and regularly drinking alcohol before sex Drug Alcohol Rev 2017;36:540-545].

Female sex workers use power over their day-to-day lives to meet the condition of a conditional cash transfer intervention to incentivize safe sex

Female Sex Workers are a core population in the HIV epidemic, and interventions such as conditional cash transfers (CCTs), effective in other health domains, are a promising new approach to reduce the spread of HIV. Here we investigate how a population of Tanzanian female sex workers, though constrained in many ways, experience and use their power in the context of a CCT intervention that incentivizes safe sex. We analyzed 20 qualitative in-depth interviews with female sex workers enrolled in a randomized-controlled CCT program, the RESPECT II pilot, and found that while such women have limited choices, they do have substantial power over their work logistics that they leveraged to meet the conditions of the CCT and receive the cash award. It was through these decisions over work logistics, such as reducing the number of workdays and clients, that the CCT intervention had its greatest impact on modifying female sex workers' behavior.

Gender differences in the association between childhood sexual abuse and risky sexual behaviours: A systematic review and meta-analysis

This meta-analytic review examines the association between childhood sexual abuse and risky sexual behaviours with sub-group analyses by gender. Systematic searches of electronic databases including MEDLINE, PubMed, EMBASE, and PsycINFO were performed using key terms. We used a priori criteria to include high quality studies and control for heterogeneities across eligible studies. The review was registered with PROSPERO and used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The final meta-analysis applied fixed-effects model to generate pooled odds ratio (OR). Subgroup analyses were conducted to identify potential methodological moderators. The meta-analysis included 8 eligible studies (N=38,989, females=53.1%). The overall syndemic of risky sexual behaviors at adulthood was 1.59 times more common in childhood sexual abuse victims. There was a similar association between childhood sexual abuse in general and subsequent risky sexual behaviors in both females and males. However, in cases of substantiated childhood sexual abuse, there was a greater odds of risky sexual behaviors in females (OR=2.72) than males (OR=1.69). The magnitude of association of childhood sexual abuse and risky sexual behaviors was similar for males and females regardless of study time, study quality score and method of childhood sexual abuse measurement. There were nonsignificant overall and subgroup differences between males and females. Childhood sexual abuse is a significant risk factor for a syndemic of risky sexual behaviors and the magnitude is similar both in females and males. More research is needed to explore possible mechanisms of association.

High-risk alcohol use and associated socio-demographic, health and psychosocial factors in patients with HIV infection in three primary health care clinics in South Africa

Alcohol use may have a negative impact on the course of HIV disease and the effectiveness of its treatment. We studied patients with HIV who use alcohol and associated socio-demographic, health and psychosocial factors. Outcomes from this study may help in selecting patients from clinical practice with high-risk alcohol use and who are likely to benefit most from alcohol reduction interventions. In a cross sectional study in three primary health care clinics in Pretoria, South Africa, from January 2012 to June 2012, patients with HIV infection were interviewed and patients' medical files were reviewed to obtain data on levels of alcohol use (Alcohol Use Disorder Identification Test), patients' socio-demographic characteristics, HIV-related information, health related quality of life (WHOQoL-HIVBref), internalized AIDS stigma, symptoms of depression and adherence to antiretroviral therapy. Analyses consisted of descriptive statistics, bi- and multivariate logistic regression models. A total of 2230 patients (1483 [66.5%] female) were included. The median age was 37 years (interquartile range 31-43), 99.5% were black Africans, 1975 (88.6%) had started ART and the median time on ART was 22 months (interquartile range 9-40). No alcohol was used by 64% of patients, 8.9% were low risk drinkers, 25.1% of patients were hazardous or harmful drinkers and 2.0% had possible alcohol dependence. In multivariate analysis high-risk drinking was positively associated with male gender, never being married, tobacco use, a higher score for the 'level of independence'-domain measured with the WHOQoL-HIVBref questionnaire, and with more depressive symptoms compared to low-risk drinking. This study shows a high prevalence of hazardous or harmful drinking in patients with HIV infection (especially men) attending primary health care clinics in South Africa. Routine screening for alcohol use should be introduced in these clinics and harm reduction interventions should be evaluated, taking into account associated factors.

Pornography, Sexual Enhancement Products, and Sexual Risk of Female Sex Workers and their Clients in Southern India

Despite their large numbers, and important role in the HIV epidemic in India, male clients of female sex workers (FSWs) are a difficult to reach population and little is known about their sexual behaviors. Using data from an integrated behavioral and biological assessment of 684 clients in Bangalore in 2012, we examined factors associated with their reports of having sex with three or more different female sex workers in the last month, and anal sex with sex workers. We included sociodemographic and sexual behavior factors and, for the first time in client studies in India, included data on the use of pornography and sexual enhancement products (SEPs) such as pills, oils, and sprays, in our multivariable analyses of client risk. Seventy-eight percent of clients had seen pornographic material and 8% reported ever having used SEPs. The profiles of men practicing the two risk behaviors examined were quite different. Travel in the past year, drunkenness in the past month, young age at first commercial sex, non-use of condoms at last sex, and finding sex workers in public places (but not use of pornography and SEPs) were independently associated with multiple partnering. Sex with a man or transsexual, being a white collar worker, seeking out FSWs at home, pornography and SEP use, and condom use at last FSW sex, were all independently associated with anal sex with an FSW. More research is needed to better understand the links between pornography and SEPs, and HIV risk behaviors, and HIV prevention programs need to be cognizant of the importance of ensuring that condom use is adequately promoted and supported in the context of anal sex in female sex worker-client interactions.

Toward Development of Enhanced Preventive Interventions for HIV Sexual Risk among Alcohol-Using Populations: Confronting the 'Mere Pause from Thinking'

The papers in this issue detail state-of-the science knowledge regarding the role of alcohol use in HIV/AIDS risk, as well as offer suggestions for ways forward for behavioral HIV prevention for at-risk alcohol-using populations. In light of recent evidence suggesting that the anticipated uptake of the newer biomedical HIV prevention approaches, prominently including pre-exposure prophylaxis, has been stalled owing to a host of barriers, it has become ever more clear that behavioral prevention avenues must continue to receive due consideration as a viable HIV/AIDS prevention approach. The papers collected here make a valuable contribution to "combination prevention" efforts to curb HIV spread.

Substance Use and Risky Sexual Behaviors Among Young Men Working at a Rural Roadside Market in Malawi

Using an ecological model, we describe substance use and sexual risk behaviors of young male laborers at a roadside market in Malawi. Data included observations and interviews with 18 key market leaders and 15 laborers (ages 18-25 years). Alcohol, marijuana, and commercial sex workers (CSWs) were widely available. We identified three patterns of substance use: 6 young men currently used, 6 formerly used, and 3 never used. Substance use was linked to risky sex, including sex with CSWs. The market supported risky behaviors through availability of resources; supportive norms, including beliefs that substance use enhanced strength; and lack of restraints. Community-level poverty, cultural support for alcohol, interpersonal family/peer influences, early substance use, and school dropout also contributed to risky behaviors. Parental guidance was protective but not often reported. Local programs addressing substance use and risky sex simultaneously and better national substance use policies and mental health services are needed.

Regularly Drinking Alcohol Before Sexual Activity in a Nationally Representative Sample: Prevalence, Sociodemographics, and Associations With Psychiatric and Substance Use Disorders

OBJECTIVES

We addressed regular drinking before sex and its associated risk factors.

METHODS

From the wave 2 National Epidemiologic Survey on Alcohol and Related Conditions, a nationally representative adult US sample (fielded 2004-2005), we determined the 12-month prevalence of regularly drinking alcohol before sexual activity. Among 17,491 sexually active drinkers, we determined the sociodemographic, psychiatric, and substance use correlates of regularly drinking before sex.

RESULTS

Regular presex drinking's 12-month prevalence was 1.8%. Significant bivariate sociodemographic correlates were age, gender, race/ethnicity, education, family income, marital status, and employment status. Generalized anxiety disorder and alcohol dependence were associated with significantly increased odds of being a regular presex drinker after controlling for covariates.

CONCLUSIONS

We estimate that 4.3 million American adults are regular presex drinkers. Future research should examine this public health issue at the population level, with particular focus on pathways that link it to psychopathology.

Women, drug dependency and consequences: a study from a developing country

Introduction. Addiction in women can expose them to malnutrition, high blood pressure, cancer, and some other dangerous diseases like hepatitis, AIDS, or other sexual transmitted diseases. The aim of this study was to assess illegal sexual relations in three groups of women. Methods. This is a cross-sectional study that was done on 236 girls and young women aged 16–25 years in 2012 in three groups: vulnerable women who have substance dependency (crimes that had made women incarcerated were considered as vulnerability in this study), invulnerable women who have substance dependency (substance dependent women without a history of incarceration), and a control group (women with no history of substance dependency or being in prison). Results. 43.8% of vulnerable women who have substance dependency had extramarital sexual relations; this percentage was 55.8% in invulnerable women who have substance dependency and 1.4% in the control group. Crystal and methamphetamine abuse was higher in addicts who had extramarital sexual relations and alcohol abuse was correlated with unsafe sexual intercourse (r = 0.36, P = 0.001). There was a statistically significant difference in extramarital sexual relation based on marital status (P < 0.001). Conclusions. Poverty, drug dependency, divorce, and alcohol consumption make women prone to other high risk behaviors that need more attention.

Changes in sexual risk behavior in the Mombasa cohort: 1993-2007

The Mombasa Cohort is an open cohort study following HIV-seronegative women reporting transactional sex. Established in 1993, the cohort provides regular HIV counseling and testing at monthly visits. Over time, HIV acquisition risk has declined steadily in this cohort. To evaluate whether this decline may reflect changes in sexual risk behavior, we investigated trends in condom use and partner numbers among women who participated in the Mombasa Cohort between 1993 and 2007. Multinomial logistic regression and generalized estimating equations were used to evaluate the association of calendar time and follow-up time with key risk behaviors, after adjustment for potential confounding factors. At enrollment visits by 1,844 women, the adjusted probability of never using condoms decreased over time, from 34.2% to 18.9%. Over 23,911 follow-up visits, the adjusted probabilities of reporting >2 partners decreased from 9.9% to 4.9% and inconsistent condom use decreased from 7.9% to 5.3% after ≥12 cohort visits. Important predictors of risk behavior were work venue, charging low fees for sex, and substance abuse. Women with a later sexual debut had less risky behavior. Although sexual risk has declined among women participating in the Mombasa Cohort, HIV acquisition continues to occur and interventions to promote and reinforce safer sex are clearly needed.

Regularly drinking alcohol before sex in the United States: effects of relationship status and alcohol use disorders

BACKGROUND

Drinking alcohol before sex increases the likelihood of engaging in sexual risk behaviors and risk for HIV infection. Relationship status (single versus partnered) and alcohol use disorders (AUD) are associated with each other and sexual risk behaviors, yet have not been examined as predictors of drinking alcohol before sex, using national data. This study examined whether relationship status and AUD increased the likelihood of regularly drinking alcohol before sex in a nationally representative sample.

METHODS

The main and additive interaction effects of relationship status and AUD on regularly drinking alcohol before sex were analyzed among sexually active drinkers (N=17,491) from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Regularly drinking alcohol before sex was defined as drinking alcohol most or all of the time before sex.

RESULTS

After adjustment for controls, relationship status (AOR=3.51; CI=2.59-4.75) and AUD (AOR=6.24; CI=5.16-7.53) increased the likelihood of regularly drinking alcohol before sex and interacted to differentially increase this risk, with the effect of being single on the likelihood of regularly drinking alcohol before sex increased among participants with AUD (p<.001).

CONCLUSIONS

This study reinforces the importance of relationship status and AUD to the risk for regularly drinking alcohol before sex. Public health efforts should target alcohol and HIV prevention messages to single adults, particularly those with AUD, highlighting their risk for regularly drinking alcohol before sex.

Alcohol and drug abuse and risky sexual behaviours in young adult women

OBJECTIVE

To assess alcohol abuse as a predictor of risky sexual behavior among adolescents and young adult women, a high-risk population for unintended pregnancies.

SUBJECTS

Totally 3163 adolescent and young adult women, 18-29 years, were assessed on sociodemographics, alcohol and drug use and risky sexual behaviors.

INTERVENTIONS

Participants answered a structured questionnaire on their leisure habits, drug and alcohol consumption, contraception and sexual behaviors.

RESULTS

Most of the young adult women perceive that sexuality is an important part of their life but not a main concern (77.6%) and that alcohol removes the barriers to have sex (62.3%). Additionally, 77.0% claimed that contraception had "a lot" (53.4%) and "quite" (23.6%) influence on the quality of their sexuality. However, up to a 38.4% of the interviewed women had had sex without using any contraception and 29.6% of them acknowledged that had taken alcohol and of these, 40.7% said that alcohol was responsible for not using contraception. Alcohol abuse predicted an increase in risky sexual behaviours (4.45 CI: 2.01-9.75, p < 0.0001). The effect of alcohol was independent of age.

CONCLUSIONS

These findings suggest that contraception-related behavioural interventions for young adult women should discuss the link between alcohol and sexual risk behavior.

Effects of hazardous and harmful alcohol use on HIV incidence and sexual behaviour: a cohort study of Kenyan female sex workers

AIMS

To investigate putative links between alcohol use, and unsafe sex and incident HIV infection in sub-Saharan Africa.

METHODS

A cohort of 400 HIV-negative female sex workers was established in Mombasa, Kenya. Associations between categories of the Alcohol Use Disorders Identification Test (AUDIT) and the incidence at one year of unsafe sex, HIV and pregnancy were assessed using Cox proportional hazards models. Violence or STIs other than HIV measured at one year was compared across AUDIT categories using multivariate logistic regression.

RESULTS

Participants had high levels of hazardous (17.3%, 69/399) and harmful drinking (9.5%, 38/399), while 36.1% abstained from alcohol. Hazardous and harmful drinkers had more unprotected sex and higher partner numbers than abstainers. Sex while feeling drunk was frequent and associated with lower condom use. Occurrence of condom accidents rose step-wise with each increase in AUDIT category. Compared with non-drinkers, women with harmful drinking had 4.1-fold higher sexual violence (95% CI adjusted odds ratio [AOR] = 1.9-8.9) and 8.4 higher odds of physical violence (95% CI AOR = 3.9-18.0), while hazardous drinkers had 3.1-fold higher physical violence (95% CI AOR = 1.7-5.6). No association was detected between AUDIT category and pregnancy, or infection with Syphilis or Trichomonas vaginalis. The adjusted hazard ratio of HIV incidence was 9.6 comparing women with hazardous drinking to non-drinkers (95% CI = 1.1-87.9).

CONCLUSIONS

Unsafe sex, partner violence and HIV incidence were higher in women with alcohol use disorders. This prospective study, using validated alcohol measures, indicates that harmful or hazardous alcohol can influence sexual behaviour. Possible mechanisms include increased unprotected sex, condom accidents and exposure to sexual violence. Experimental evidence is required demonstrating that interventions to reduce alcohol use can avert unsafe sex.

Patterns of alcohol consumption and risky sexual behavior: a cross-sectional study among Ugandan university students

BACKGROUND

As reflected in elevated rates of sexually transmitted infections, there is a high prevalence of risky sexual behavior among Ugandan university students. It has been assumed that alcohol contributes to risky sexual behavior. However, perhaps owing to methodological issues, this relationship has found only mixed support in empirical research. The present study analyzes the association between alcohol use and risky sexual behavior at the global, situational, and event level among Uganda university students with sexual experience.

METHODS

A cross-sectional survey was carried out in 2010 among 1954 students at Mbarara University of Science and Technology, Uganda, using a self-administered questionnaire. Alcohol use was measured as consumption over the previous 12 months, during situations related to sexual activity and on the most recent occasion of sexual intercourse. Risky sexual behavior was defined as having two or more sexual partners in the previous 12 months or inconsistent condom use with new partners. Bivariate and multivariate logistic regression was performed to analyze the association between alcohol use and risky sexual behavior separately for males and females.

RESULTS

Even after adjusting for confounders, the odds ratio (OR) of having two or more sexual partners in the past year indicated a statistically significant association with alcohol use on all levels (global, situational, and event) for both males and females. The ORs of inconsistent condom use with a new partner were significant for males who often consumed alcohol in relation to sexual activity--even after adjusting for potential confounders (OR, 1.75; confidence interval, 1.01-3.08). The risk of inconsistent condom use with a new partner was twice as high for females who often consumed alcohol in relation to sexual activity, although this association was not statistically significant.

CONCLUSIONS

The study supports previous research that alcohol consumption is associated with having multiple sexual partners. Inconsistent condom use was associated with the situational use of alcohol in relation to sexual activity and was similar for both genders. Interventions to reduce alcohol-related risky sexual behavior should target both male and female drinkers, particularly subgroups of students, who often consume alcohol in relation to sexual activity.

Reported physical and sexual abuse in childhood and adult HIV risk behaviour in three African countries: findings from Project Accept (HPTN-043)

Childhood sexual and physical abuse have been linked to adolescent and adult risky sexual behaviors, including early sexual debut, an increased number of sexual partners, unprotected sex, alcohol and drug use during sex and sexual violence. This paper explores these relationships among both men and women who report histories of childhood abuse from representative samples of communities in three countries in southern and eastern Africa (South Africa, Zimbabwe and Tanzania). Data were collected as part of a 3-year randomized community trial to rapidly increase knowledge of HIV status and to promote community responses through mobilisation, mobile testing, provision of same-day HIV test results and post-test support for HIV. The results indicate that reported childhood sexual and physical abuse is high in all three settings, also among men, and shows strong relationships with a range of sexual risk behaviors, including age at first sex (OR -0.6 (CI: -0.9, -0.4, p < 0.003)-among men, OR -0.7 (CI: -0.9, -0.5, p < 0.001)-among women), alcohol (OR 1.43 (CI: 1.22, 1.68, p < 0.001)-men, OR 1.83 (CI: 1.50, 2.24, p < 0.001)-women) and drug use (OR 1.65 (CI: 1.38, 1.97, p < 0.001)-men, OR 3.14 (CI: 1.95, 5.05, p < 0.001)-women) and two forms of partner violence-recent forced sex (OR 2.22 (CI: 1.66, 2.95, p < 0.001)-men, OR 2.76 (CI: 2.09, 3.64, p < 0.001)-women) and ever being hurt by a partner (OR 3.88 (CI: 2.84, 5.29, p < 0.001)-men, OR 3.06 (CI: 2.48, 3.76, p < 0.001)-women). Individuals abused in childhood comprise between 6 and 29 % of young adult men and women living in these African settings and constitute a population at high risk of HIV infection.

The influence of depressive symptoms on alcohol use among HIV-infected Russian drinkers

BACKGROUND

Depressive symptoms have been linked to HIV progression through a number of biobehavioral mechanisms including increased alcohol use. Although research supports an association between alcohol use and depressive symptoms among HIV patients, there have been few studies that have examined whether depressive symptoms predict subsequent drinking, especially among heavy drinking HIV-infected patients.

METHOD

Heavy drinking Russian HIV-infected patients (n=700) were recruited from addiction and HIV care settings for a randomized controlled trial of a risk reduction intervention [HERMITAGE]. GEE overdispersed Poisson regression analyses were conducted to assess the association between depressive symptoms and alcohol consumption 6-months later.

RESULTS

In adjusted analyses, depressive symptom severity was significantly associated with drinks per day (global p=.02). Compared to the non-depressed category, mild depressive symptoms were significantly associated with more drinks per day [IRR=1.55, (95% CI: 1.14, 2.09)], while moderate [IRR=1.14, (95% CI: 0.83, 1.56)] and severe [IRR=1.48, (95% CI: 0.93, 2.34)] depressive symptoms were not. Associations between depressive symptom severity and heavy drinking days were not statistically significant (global p=.19). Secondary analyses using the BDI-II screening threshold (BDI-II>14) and the BDI-II cognitive subscale suggested an association between depressive symptoms and drinks per day over time but not heavy episodic drinking.

CONCLUSIONS

Among heavy drinking HIV-infected patients, elevated depressive symptoms were associated with greater subsequent alcohol use. These findings suggest that depressive symptoms may be important to address in efforts to reduce alcohol-related risks among HIV-infected populations.

From coitus to concurrency: sexual partnership characteristics and risk behaviors of 15-19 year old men recruited from urban venues in Tanzania

Understanding the uptake and patterns of sexual partnerships of adolescent males reveals their risky behaviors that could persist into adulthood. Using venue-based sampling, we surveyed 671 male youth ages 15-19 from an urban Tanzanian neighborhood about their sexual partnerships during the past 6 months. The proportion of males who had ever had sex increased with age (21 % at age 15; 70 % at age 17; 94 % at age 19), as did the proportion who engaged in concurrency (5 % at age 15; 28 % at age 17; 44 % at age 19). Attendance at ≥2 social venues per day and meeting a sexual partner at a venue was associated with concurrency. Concurrency was associated with alcohol consumption before sex among 18-19 year olds and with not being in school among 15-17 year olds. We find that concurrency becomes normative over male adolescence. Venue-based sampling may reach youth vulnerable to developing risky sexual partnership patterns.

Alcohol and condom use among HIV-positive and HIV-negative female sex workers in Nagaland, India

This study examines the relationship between alcohol use, HIV status, and condom use among female sex workers in Nagaland, India. We analyzed data from a cross-sectional survey undertaken in 2009, using descriptive and multivariate statistics. Out of 417 female sex workers, one-fifth used alcohol daily and one-tenth were HIV-positive. HIV-positive female sex workers were more likely than HIV-negative female sex workers to consume alcohol daily (30.2% vs. 18.0%). HIV-positive daily alcohol users reported lower condom use at last sex with regular clients compared to HIV-positive non-daily alcohol users (46.2% vs. 79.3%), a relationship not evident among HIV-negative female sex workers. There is a need to promote awareness of synergies between alcohol use and HIV, and to screen for problematic alcohol use among female sex workers in order to reduce the spread of HIV.

Relationship between alcohol consumption prior to sex, unprotected sex and prevalence of STI/HIV among socially marginalized men in three coastal cities of Peru

This article presents data about the relationship between alcohol consumption prior to sex and unprotected sex and the prevalence of at least one sexually transmitted infection (STI) including HIV among socially marginalized men in three coastal Peruvians cities. During an epidemiological survey with 2,146 men, we assessed their STI prevalence, frequency of alcohol consumption prior to sex, unprotected sex and other sexual risk behaviors. The overall prevalence of at least one STI/HIV was 8.5 % (95 % CI 7.3-9.7), the prevalence of unprotected sex was 79.1 % (95 % CI 77.8-80.3) and alcohol consumption prior to sex with any of the last five sex partners in the previous 6 months was 68.9 % (95 % CI 66.9-70.9). Bivariate and multivariate analysis showed that alcohol consumption of participants or their partners prior to sex were associated with the prevalence of at least one STI, adjusted Prevalence Ratio (aPR) = 1.3 (95 % CI 1.01-1.68). Unprotected sex was significantly associated with alcohol consumption prior to sex when both partners used alcohol, aPR = 1.15 (95 % CI 1.10-1.20) or when either one of them used alcohol aPR = 1.14 (95 % CI 1.09-1.18). These findings concur with previous literature suggesting a relationship between alcohol consumption prior to sex and STI and HIV. These data improve our understanding of this relationship in this context and could be used to enhance STI and HIV prevention strategies for socially marginalized men in Peru.

Interrelationship of alcohol misuse, HIV sexual risk and HIV screening uptake among emergency department patients

Background

Emergency department (ED) patients comprise a high-risk population for alcohol misuse and sexual risk for HIV. In order to design future interventions to increase HIV screening uptake, we examined the interrelationship among alcohol misuse, sexual risk for HIV and HIV screening uptake among these patients.

Methods

A random sample of 18-64-year-old English- or Spanish-speaking patients at two EDs during July-August 2009 completed a self-administered questionnaire about their alcohol use using the Alcohol Use Questionnaire, the Alcohol Use Disorders Identification Test (AUDIT), and the HIV Sexual Risk Questionnaire. Study participants were offered a rapid HIV test after completing the questionnaires. Binging (≥ five drinks/occasion for men, ≥ four drinks for women) was assessed and sex-specific alcohol misuse severity levels (low-risk, harmful, hazardous, dependence) were calculated using AUDIT scores. Analyses were limited to participants who had sexual intercourse in the past 12 months. Multivariable logistic regression was used to assess the associations between HIV screening uptake and (1) alcohol misuse, (2) sexual risk for HIV, and (3) the intersection of HIV sexual risk and alcohol misuse. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were estimated. All models were adjusted for patient demographic characteristics and separate models for men and women were constructed.

Results

Of 524 participants (55.0% female), 58.4% identified as white, non-Hispanic, and 72% reported previous HIV testing. Approximately 75% of participants reported drinking alcohol within the past 30 days and 74.5% of men and 59.6% of women reported binge drinking. A relationship was found between reported sexual risk for HIV and alcohol use among men (AOR 3.31 [CI 1.51-7.24]) and women (AOR 2.78 [CI 1.48-5.23]). Women who reported binge drinking were more likely to have higher reported sexual risk for HIV (AOR 2.55 [CI 1.40-4.64]) compared to women who do not report binge drinking. HIV screening uptake was not higher among those with greater alcohol misuse and sexual risk among men or women.

Conclusions

The apparent disconnection between HIV screening uptake and alcohol misuse and sexual risk for HIV among ED patients in this study is concerning. Brief interventions emphasizing these associations should be evaluated to reduce alcohol misuse and sexual risk and increase the uptake of ED HIV screening.

Alcohol use and HIV serostatus of partner predict high-risk sexual behavior among patients receiving antiretroviral therapy in South Western Uganda

BACKGROUND

Antiretroviral treatment restores the physical and immunological function for patients with HIV/AIDS and the return of sexual desire. The frequency and correlates of sexual activity among patients receiving ART have not been widely studied. There is concern that widespread availability of ART may result in sexual disinhibition including practice of high-risk sexual behavior. We determined the correlates of sexual activity and high-risk sexual behavior in an ART-treated population in rural and urban Uganda.

METHODS

We conducted a cross-sectional study among 329 ART-treated adult patients at two hospitals, one located in rural and another in urban western Uganda. We collected data on sexual activity, frequency of condom use, pregnancy, viral load (VL) and CD4. Patients were considered sexually active if they had had sexual intercourse in the last 6 months. Any unprotected sex was considered high-risk sex. A two-stage logistic regression was performed to determine factors associated with sexual activity and high-risk sex among those sexually active.

RESULTS

Overall, 222 (67%) patients were women, 138 (41.2%) had been on ART for at least one year, and 168 (51.4%) were sexually active of whom 127 (75.6%) used condoms at the last intercourse. Younger age (<=30 years) (Odds ratio; OR=2.3, 95% CI 1.2, 4.2), higher monthly income (OR=4.1, 95% CI 2.4, 7.4), and being married (OR=22.7, 95% CI 8.2, 62.9) were associated with being sexually active. Undetectable VL, CD4 count and treatment duration were not significantly associated with sexual activity. Among the sexually active, alcohol consumption (OR=3.3, 95% CI 1.2, 9.1) and unknown serostatus of partner (OR=5.8, 95% CI 1.5, 21.4) were significant predictors of high-risk sexual behavior. The frequency of unprotected sex at the last intercourse was 25.9% and 22.1% among the men and women respectively and was not significantly different (p value for chi square test =0.59).

CONCLUSION

Younger persons receiving ART are more likely to be sexually active. ART clients are more likely to engage in unprotected sex when sero-status of partner is unknown or report use of alcohol. Counseling on alcohol use and disclosure of sero-status may be useful in reducing high risk sexual behavior.

Factors associated with risky sexual practices among female sex workers in Karnataka, India

Introduction

The objectives of this study are to develop a summary measure of risky sexual practice and examine the factors associated with this among female sex workers (FSWs) in Karnataka, India.

Materials and Methods

Data were drawn from special behavioral surveys (SBS) conducted in 2007 among 577 FSWs in two districts of Karnataka, India: Belgaum and Bangalore. FSWs were recruited using the two-stage probability sampling design. FSWs' sexual practice was considered risky if they reported inconsistent condom use with any sexual partner and reported experience of one of the following vulnerabilities to HIV risk: anal sex, alcohol consumption prior to sex and concurrent sexual relationships.

Results

About 51% of FSWs had engaged in risky sexual practice. The odds of engaging in risky sex were higher among FSWs who were older (35+ years) than younger (18–25 years) (58% vs. 45%, Adjusted Odds Ratio (AOR): 2.0, 95% confidence interval (CI): 1.2–3.4), who were currently married than never married (61% vs. 51%, AOR: 4.8, 95% CI: 2.5–9.3), who were in sex work for 10+ years than those who were in sex work for less than five years (66% vs. 39%, AOR: 2.6, 95% CI: 1.6–4.2), and who had sex with 3+ clients/day than those who had sex with fewer clients (67% vs. 38%, AOR: 3.7, 95% CI:2.5–5.5).

Conclusion

FSWs who are older, currently married, practicing sex work for longer duration and with higher clientele were more likely to engage in risky sexual practices. HIV prevention programs should develop strategies to reach these most-at risk group of FSWs to optimize the effectiveness of such programs.

Priority interventions to reduce HIV transmission in sex work settings in sub-Saharan Africa and delivery of these services

Introduction

Virtually no African country provides HIV prevention services in sex work settings with an adequate scale and intensity. Uncertainty remains about the optimal set of interventions and mode of delivery.

Methods

We systematically reviewed studies reporting interventions for reducing HIV transmission among female sex workers in sub-Saharan Africa between January 2000 and July 2011. Medline (PubMed) and non-indexed journals were searched for studies with quantitative study outcomes.

Results

We located 26 studies, including seven randomized trials. Evidence supports implementation of the following interventions to reduce unprotected sex among female sex workers: peer-mediated condom promotion, risk-reduction counselling and skills-building for safer sex. One study found that interventions to counter hazardous alcohol-use lowered unprotected sex. Data also show effectiveness of screening for sexually transmitted infections (STIs) and syndromic STI treatment, but experience with periodic presumptive treatment is limited. HIV testing and counselling is essential for facilitating sex workers’ access to care and antiretroviral treatment (ART), but testing models for sex workers and indeed for ART access are little studied, as are structural interventions, which create conditions conducive for risk reduction. With the exception of Senegal, persistent criminalization of sex work across Africa reduces sex workers’ control over working conditions and impedes their access to health services. It also obstructs health-service provision and legal protection.

Conclusions

There is sufficient evidence of effectiveness of targeted interventions with female sex workers in Africa to inform delivery of services for this population. With improved planning and political will, services – including peer interventions, condom promotion and STI screening – would act at multiple levels to reduce HIV exposure and transmission efficiency among sex workers. Initiatives are required to enhance access to HIV testing and ART for sex workers, using current CD4 thresholds, or possibly earlier for prevention. Services implemented at sufficient scale and intensity also serve as a platform for subsequent community mobilization and sex worker empowerment, and alleviate a major source of incident infection sustaining even generalized HIV epidemics. Ultimately, structural and legal changes that align public health and human rights are needed to ensure that sex workers on the continent are adequately protected from HIV.

Falling through the cracks: a qualitative study of HIV risks among women who use drugs and alcohol in Northeast India

Background

HIV risks for women who inject drugs and those who engage in sex work are well documented. Women who are dependent on non-injecting drugs and alcohol are also likely to have increased vulnerability to HIV infection, but until they actually inject drugs or engage in sex work, are unlikely to come to the attention of HIV prevention programs.

Methods

We undertook a qualitative study involving nine focus group discussions (FGDs) and 27 key informant interviews to investigate the context of female drug and alcohol use in two high HIV prevalence states of India (Manipur and Nagaland) and to describe their HIV risks. The FGD and interview transcripts were thematically analyzed

Results

The women were relatively young (mean age 31 years in Manipur and 28 years in Nagaland), but 64% in Manipur and 35% in Nagaland were widowed or divorced. Both heroin and alcohol were commonly used by the women from Manipur, while alcohol was primarily used by the women from Nagaland, especially in the context of ‘booze joints’ (illicit bars). Reasons for drug and alcohol use included: to avoid symptoms of withdrawal, to suppress emotional pain, to overcome the shame of sex work, pleasure, and widowhood. HIV vulnerability was clearly described, not only in relation to injecting drug use and sex work, but also alcohol consumption.

Conclusions

The contribution of alcohol use to the HIV vulnerability of women is not currently considered when HIV prevention programs are being designed and implemented leaving a group of high-risk women uncovered by much needed services such as treatment for a range of health problems including alcohol dependence.

The efficacy of a brief intervention to reduce alcohol misuse in patients with HIV in South Africa: study protocol for a randomized controlled trial

Background

Alcohol abuse comes with risks for increased morbidity and mortality among patients with HIV. This study aims to determine the prevalence of alcohol use and other risk factors in a sample of primary care patients with HIV in South Africa and to assess a brief intervention to reduce the use of alcohol in this group.

Methods/Design

A single-blinded randomized controlled trial is designed to determine the efficacy of a brief intervention to reduce hazardous alcohol use in patients with HIV. The study will be carried out on out-patients with HIV in two primary healthcare HIV clinics near Pretoria, South Africa. Alcohol use will be assessed with the Alcohol Use Disorder Identification Test questionnaire. Other data that will be collected relate to health-related quality of life, depression, sexual behavior, internalized AIDS stigma, HIV-related information and adherence to antiretroviral therapy (self-reported 7-day recall of missed doses, Visual Analog Scale and pill count). The intervention consists of a brief counseling session to reduce alcohol risk; the control group receives a health education leaflet.

Discussion

The findings will be important in the public health setting. If the intervention proves to be efficient, it could potentially be incorporated into the HIV care policy of the Ministry of Health.

Trial registration

Pan African Clinical trial Registry: PACTR201202000355384

Alcohol misuse and multiple sexual partners

INTRODUCTION

We examine the association between self-reported alcohol misuse and alcohol use within 2 hours of having sex and the number of sexual partners among a sample of African-American and Latino emergency department (ED) patients.

METHODS

Cross-sectional data were collected prospectively from a randomized sample of all ED patients during a 5-week period. In face-to-face interviews, subjects were asked to report their alcohol use and number of sexual partners in the past 12 months. Data were analyzed using multiple variable negative binomial regression models, and effect modification was assessed through inclusion of interaction terms.

RESULTS

The 395 study participants reported an average of 1.4 (standard error = 0.11) sexual partners in the past 12 months, 23% reported misusing alcohol, and 28% reported consuming alcohol before sex. There was no statistically significant association between alcohol misuse and the number of sexual partners; however, alcohol before sex was associated with a larger number of sexual partners in the past year. Moreover, among those who misused alcohol, participants who reported alcohol before sex were 3 times more likely to report a higher number of sexual partners (risk ratio = 3.2; confidence interval [CI] =1.9-5.6). The association between alcohol use before sex and number of sexual partners is dependent upon whether a person has attributes of harmful drinking over the past 12 months. Overall, alcohol use before sex increases the number of sexual partners, but the magnitude of this effect is significantly increased among alcohol misusers.

CONCLUSION

Alcohol misusers and those who reported having more than 1 sexual partner were more likely to cluster in the same group, ie, those who used alcohol before sex. Efforts to reduce the burden of sexually transmitted diseases, including human immunodeficiency virus, and other consequences of risky sexual behavior in the ED population should be cognizant of the interplay of alcohol and risky sexual behaviors. EDs should strive to institute a system for regular screening, brief intervention, and referral of at-risk patients to reduce negative consequences of alcohol misuse, including those of risky sexual behaviors.

The Extent and Nature of Fluidity in Typologies of Female Sex Work in Southern India: Implications for HIV Prevention Programs

These authors examine the nature and extent of fluidity in defining the typology of female sex work based on the place of solicitation or place of sex or both places together, and whether sex workers belonging to a particular typology are at increased risk of HIV in southern India. Data are drawn from a cross-sectional survey conducted during 2007-2008 among mobile female sex workers (N = 5301) in four Indian states. Findings from this study address an important policy issue: Should programmatic prevention interventions be spread to cover all places of sex work or be focused on a few places that cover a large majority of sex workers? Results indicate that most female sex workers, including those who are usually hard to reach such as those who are mobile or who use homes for soliciting clients or sex, can be reached programmatically multiple times by concentrating on a smaller number of categories, such as street-, lodge-, and brothel-based sex workers.

Determinants of condom breakage among female sex workers in Karnataka, India

Background

Condoms are effective in preventing the transmission of HIV and other sexually transmitted infections, when properly used. However, recent data from surveys of female sex workers (FSWs) in Karnataka in south India, suggest that condom breakage rates may be quite high. It is important therefore to quantify condom breakage rates, and examine what factors might precipitate condom breakage, so that programmers can identify those at risk, and develop appropriate interventions.

Methods

We explored determinants of reported condom breakage in the previous month among 1,928 female sex workers in four districts of Karnataka using data from cross-sectional surveys undertaken from July 2008 to February 2009. Using stepwise multivariate logistic regression, we examined the possible determinants of condom breakage, controlling for several independent variables including the district and client load.

Results

Overall, 11.4% of FSWs reported at least one condom break in the previous month. FSWs were much more likely to report breakage if under 20 years of age (AOR 3.43, p = 0.005); if divorced/ separated/widowed (AOR 1.52, p = 0.012); if they were regular alcohol users (AOR 1.63, p = 0.005); if they mostly entertained clients in lodges/rented rooms (AOR 2.99, p = 0.029) or brothels (AOR 4.77, p = 0.003), compared to street based sex workers; if they had ever had anal sex (AOR 2.03, p = 0.006); if the sex worker herself (as opposed to the client) applied the condom at last use (AOR 1.90, p < 0.001); if they were inconsistent condom users (AOR 2.77, p < 0.001); and if they had never seen a condom demonstration (AOR 2.37, p < 0.001).

Conclusions

The reported incidence of condom breakage was high in this study, and this is a major concern for HIV/STI prevention programs, for which condom use is a key prevention tool. Younger and more marginalized female sex workers were most vulnerable to condom breakage. Special effort is therefore required to seek out such women and to provide information and skills on correct condom use. More research is also needed on what specific situational parameters might be important in predisposing women to condom breakage.