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

Cocreating First Steps, a Toolkit to Improve Adolescent Sexual and Reproductive Health Services: Qualitative Human-Centered Design Study With Hispanic and Black Adolescent Mothers in New York City

BACKGROUND

Adolescent voices are frequently excluded from sexual and reproductive health (SRH) research. Despite progressive policies and access to SRH care, adolescents in New York City who live in neighborhoods with high poverty and those who identify as Black or Hispanic experience poor SRH outcomes, including high rates of unplanned pregnancies and sexually transmitted infections.

OBJECTIVE

This qualitative study aims to guide Black and Hispanic adolescent mothers in identifying problem areas in SRH care and cocreate health service recommendations with input from health care stakeholders to address those problems and improve SRH experiences.

METHODS

Through ethnographic interview methods, adolescent mothers in New York City shared their experiences from before pregnancy through parenting and identified problem areas in adolescent SRH services and education. Data were analyzed inductively and using situational analysis. Adolescent participants attended 2 cocreation workshops. In the first workshop, they confirmed interview findings, set priorities, and created rough prototypes. Following the first workshop, health care providers were interviewed to inform refinement of the rough prototypes. Adolescents further developed prototypes in the second cocreation workshop and named the resulting toolkit.

RESULTS

A total of 16 adolescent mothers participated in 47 interviews, and 10 (63%) participants attended at least 1 cocreation workshop. They highlighted deficiencies in sexual health education and emphasized the roles of health care providers and parents, rather than schools, in improving it. Adolescent participants designed recommendations for adolescents and health care providers to support quality conversations between adolescents, parents, and health care providers and created a preappointment checklist to help young patients initiate conversations with health care providers. Young participants stressed that sex education should address topics beyond sexually transmitted infections and pregnancy, such as emotional health and relationships. They created guidelines for health care providers outlining communication strategies to provide respectful, unbiased care and contraceptive counseling that encourages adolescent autonomy. Participants shared specific suggestions for how to support young parents respectfully. Health care stakeholders recommended adding information on confidential care; supporting lesbian, gay, bisexual, transgender, and queer youth; and focusing on improving communication between health care providers and patients rather than creating educational materials. In the second workshop, adolescent participants revised the prototypes based on feedback from health care stakeholders and named the toolkit of recommendations First Steps.

CONCLUSIONS

This study highlighted the important roles that parents and health care workers play in adolescent sexual health education. Cocreated toolkits offer a practical approach for health care providers to engage adolescents and their parents in meaningful, adolescent-centered conversations that can promote health, safety, and well-being.

Condom Use Beliefs Differ According to Regulatory Focus: A Mixed-Methods Study in Portugal and Spain

Reports worldwide have been showing increasing rates of sexually transmitted infections (STIs) and condomless sex in recent years. Research has identified several individual and situational variables that can determine the decision to use condoms or forgo their use. We argue that such a decision can also be shaped by motives related to pleasure and safety (i.e., regulatory focus in sexuality). Using open ended questions, we asked 742 Portuguese and Spanish adults to indicate situations and reasons that could inform the decision making process with casual partners and the functions/attributes related to condoms. Using thematic analyses, we coded the drivers of condomless sex and condom use into themes and subthemes, and computed their frequencies. Using quantitative measures, we also asked participants to indicate their condom use expectancies and perceived barriers. Comparing participants according to regulatory focus revealed some differences. Pleasure promotion participants were more likely to consider that condom use decision making is driven by unexpectedness, pleasure, and intimacy pursuit, attached more pleasure reduction functions to condoms, expected more negative outcomes in condom use, and endorsed more sensation and partner barriers in condom use. In contrast, disease prevention participants were more likely to consider that condom use decision making is driven by adequate sexual education, responsibility, and behavioral control, and attached more health protective functions to condoms. These differences can inform the development of tailored intervention and awareness campaigns aimed at helping people to use condoms more consistently with casual partners and to avoid behaviors that put them at risk of STI transmission.

DépistaFest: The evaluation of an inclusive, positive, and playful STBBI screening campaign's effectiveness

OBJECTIVES

Young adults are disproportionately affected by sexually transmitted and blood-borne infections (STBBIs), and rates of STBBI screening in this population are persistently low. The present study examined the effectiveness of Club Sexu's social marketing campaign, DépistaFest, in increasing STBBI screening, screening intentions, and general STBBI and STBBI screening knowledge among young adults in Quebec, Canada. Grounded in the health belief model, the campaign provided practical and scientifically accurate information on STBBIs and screening using an inclusive, positive, and playful approach.

METHODS

A sample of 686 participants (M = 28.0 years old) was recruited through Club Sexu's social media to complete an online survey assessing campaign exposure, recent STBBI screening, screening intentions, and general STBBI and screening knowledge. Logistic regressions and ANCOVAs were performed to examine group differences on outcome variables.

RESULTS

Compared to nonexposed participants, those who were exposed to the campaign were 2.11 times more likely to report having been tested in the past 6 months, and 2.07 times more likely to report planning to get tested in the next 6 months. Exposed participants were also more likely to correctly answer general STBBI knowledge questions and reported higher levels of self-perceived STBBI screening knowledge than nonexposed participants.

CONCLUSION

The findings support the effectiveness of an STBBI prevention campaign grounded in the health belief model. Future STBBI prevention campaigns aimed at young adults would benefit from destigmatizing STBBIs and normalizing STBBI screening using an inclusive, positive, and playful approach.

Use of "Strengthening Our Vows" Video Intervention to Encourage Negotiated Explicit Sexual Agreements in Zambian Heterosexual HIV Seroconcordant-Negative Couples

Negotiating sexual agreements in combination with couples' voluntary HIV counseling and testing (CVCT) may help further reduce HIV transmission in Zambian concordant HIV-negative couples (CNC). Though CVCT has been shown to reduce HIV transmission in CNC by 47%, approximately half of residual infections occur in this group. We developed a "Strengthening Our Vows" video session to foster communication and negotiation of explicit sexual agreements to reduce concurrent sexual exposures and prevent HIV transmission to the spouse due to unprotected, extramarital sex. CNC were recruited through CVCT services at five clinics in Lusaka and Ndola in 2016. Enrolled CNC attending the facilitated group video sessions were encouraged to discuss sexual agreements at home and return 1-2 weeks later for follow-up assessment. One-fourth of the 580 CNC returning reported a history of extramarital partners and/or a sexually transmitted infection (STI) prior to enrollment. More than 95% reported a friendly, supportive 15-60 min negotiation culminating in an agreement to remain monogamous or disclose sexual contacts and use condoms together until a repeat HIV test 30 days after an outside sexual exposure. Two-thirds of participants identified at least one threat to adherence of their agreements including alcohol use, financial pressures, travel, discord in the home, and post-partum or menstrual abstinence. CNC negotiated explicit sexual agreements to avoid exposure to HIV through concurrent partnerships and protect the spouse in the event of an outside sexual contact. Open communication was a consistent theme to facilitate mutual protective efforts. Long-term follow-up of HIV/STI incidence is ongoing to assess the impact of these agreements.Trial registration This sub-study is part of a trial retrospectively registered on ClinicalTrials.gov (Identifier: NCT02744586) on April 20, 2016.

A Dyadic Analysis Exploring the Mediating Role of Relationship Quality on Discrimination and HIV/STI Risk Among Young Black and Latino Expecting Couples

Encounters with discrimination are a normative experience for many Black and Latino adolescents and young adults (AYAs); these experiences may be even more common for expecting AYAs. While the harmful effects of discriminatory experiences on mental and physical health have been well explored, relatively little is known regarding the impact of discrimination on relationship quality and sexual health-specifically HIV/STI risk.Using the Actor Partner Interdependence Model, we examined both actor and partner effects of discrimination on relationship quality and willingness to be non-monogamous in a sample of 259 pregnant adolescent and young adult couples. There was a significant indirect actor effect, such that one's own discrimination was associated with a decrease in their own relationship quality which, in turn, was associated with their own greater willingness to be non-monogamous. The partner effect for the association of one's partner's discrimination on one's own relationship quality was not significant. Findings highlight the need for more attention to the implications of discrimination on relational and sexual health.

HIV-serodifferent couples' perspectives and practices regarding HIV prevention strategies: A mixed methods study

A substantial proportion of heterosexually acquired HIV infections in the U.S. occur between partners in primary relationships characterized by mixed HIV status. The U.S. Centers for Disease Control and Prevention have issued guidelines prioritizing HIV-serodifferent couples for primary HIV prevention, including treatment-as-prevention and pre-exposure prophylaxis (PrEP). Yet, very little research has been conducted to understand the perspectives and practices of HIV-serodifferent couples regarding HIV prevention strategies in the U.S. To help fill this gap, we conducted a mixed methods study with 27 mostly Black/African American and Latinx HIV-serodifferent heterosexual couples residing in New York City to explore their knowledge, attitudes, practices, and perspectives regarding combination HIV prevention, including condoms, PrEP and viral control. All couples expressed the desire to maintain viral suppression in the HIV-positive partner, which was not always achieved. There was considerable heterogeneity in the use of HIV prevention methods by couples; and several patterns emerged that were largely driven by gender and relationship dynamics. Female partners, in particular, expressed high levels of anxiety around transmission of HIV and thus desired multiple methods of protection. Healthcare providers should consider couples' psychosocial well-being, relationship quality, and other motivational factors when helping to tailor HIV preventative care for mixed-status couples.

Perspectives on a Couples-Based, e-Health HIV Prevention Toolkit Intervention: A Qualitative Dyadic Study with Black, Heterosexual Couples in New York State

Web-based technology provides an unparalleled opportunity to increase access and uptake of couples-based HIV prevention interventions. e-Health HIV prevention interventions for US Black heterosexual couples have largely been understudied. To address this gap, we applied the Assessment Phase of the ADAPT-ITT Framework to investigate Black heterosexual couples' perspectives on an existing e-Health, couples-based HIV prevention intervention. Applying a qualitative descriptive approach, joint dyadic interviews were conducted with 28 Black heterosexual couples from three jurisdictions in New York State. Content dyadic analysis revealed three descriptive categories: perspectives of the toolkit intervention (sub-codes: perceived relevance, reactions to core components), recommendations to enhance intervention relevancy (sub-codes: tailoring to relationship type, adding new content), and lasting intervention considerations (sub-codes: toolkit usability and language use). Overall, couples found the toolkit intervention content and usability acceptable and reflected on its potential to build sexual and relationship health. Couples recommended to enhance toolkit adaptability for varied couple's motivation and types re-consider terms like sexual agreements, and include content to facilitate communication regarding sensitive topics (e.g., childhood sexual trauma, co-parenting, family planning) and other issues that may have more relevance to the experience of US Black persons (i.e., wealth building).

Regulatory Focus and Sexual Health: Motives for Security and Pleasure in Sexuality are Associated with Distinct Protective Behaviors

We examined if motives for security (i.e., prevention focus) or pleasure (i.e., promotion focus) were uniquely associated with intentions to get tested for STIs and behavioral control over condom use, over and above variables already identified in theoretical models. We conducted an online survey with Portuguese adults (N = 836; M_age = 22.27, SD = 5.14). Overall, 99.4% of the participants knew at least one of eight STIs, but only 25.2% got tested in the last six months. Participants more focused on prevention had condomless sex less frequently, whereas participants more focused on promotion knew more STIs and got tested for more STIs. Furthermore, participants had stronger intentions to get tested for STIs if they got tested for more STIs in the past, were more concerned about STIs, perceived greater susceptibility to STI acquisition, and were more focused on promotion (but not prevention). Participants had greater behavioral control over condom use if they had condomless sex less often and were more focused on prevention (but not promotion). These findings suggest that promotion-focused people are more likely to consider the consequences of having condomless sex. In contrast, prevention-focused people are more likely to take control of their sexual health.

A cluster randomized trial to reduce HIV risk from outside partnerships in Zambian HIV-Negative couples using a novel behavioral intervention, "Strengthening Our Vows": Study protocol and baseline data

BACKGROUND

Heterosexual couples contribute to most new HIV infections in areas of generalized HIV epidemics in sub-Saharan Africa. After Couples' Voluntary HIV Counseling and Testing (CVCT), heterosexual concordant HIV negative couples (CNC) in cohabiting unions contribute to approximately 47% of residual new infections in couples. These infections are attributed to concurrent sexual partners, a key driver of the HIV epidemic in Zambia.

METHODS/DESIGN

Ten Zambian government clinics in two of the largest cities were randomized in matched pairs to a Strengthening Our Vows (SOV) intervention or a Good Health Package (GHP) comparison arm. SOV addressed preventing HIV infection from concurrent partners and protecting spouses after exposures outside the relationship. GHP focused on handwashing; water chlorination; household deworming; and screening for hypertension, diabetes and schistosomiasis. CNC were referred from CVCT services in government clinics. Follow-up includes post-intervention questionnaires and outcome assessments through 60 months. Longitudinal outcomes of interest include self-report and laboratory markers of condomless sex with outside partners and reported sexual agreements. We present baseline characteristics and factors associated with study arm and reported risk using descriptive statistics.

RESULTS

The mean age of men was 32 and 26 for women. On average, couples cohabited for 6 years and had 2 children. Baseline analyses demonstrated some failures of randomization by study arm which will be considered in future primary analyses of longitudinal data. An HIV/STI risk factor composite was not different in the two study arms. Almost one-quarter of couples had an HIV risk factor at baseline.

DISCUSSION

In preparation for future biomedical and behavioral interventions in sub-Saharan Africa, it is critical to understand and decrease HIV risk within CNC.

Factors influencing HIV-risk perception among MSM students at a university in Durban, South Africa

Risk perception is embedded in attitudes and beliefs that determine how one ultimately behaves. In relation to HIV-risk behaviours, risk perception is a key dimension in most health behaviour models used to construct health promotion campaigns. This study aimed to understand HIV-risk perception and associated factors among men who have sex with men (MSM). The qualitative data used in this study came from 15 in-depth interviews with MSM studying at the University of KwaZulu-Natal in Durban, South Africa. The findings show that MSM perceive themselves to be at risk for HIV due to their awareness of the main routes of infection. This perception exists because HIV has affected them through the loss of close family members. With each sexual encounter, risk perception changed based on factors such as the sexual role being assumed (insertive versus receptive), the socio-economic status of the partner, perceived level of discriminatory dating patterns, and the use of preventive measures. High levels of risk perception among the men did not translate into positive attitudes towards condoms as many of them preferred to have unprotected sex with trusted partners. Despite perceiving their risk of HIV infection to be high, MSM continue to engage in multiple sexual partnerships and high partner turnover. However, the men in this study were keen to protect their health; with time, they have developed more positive attitudes towards HIV and they understand that it is possible to protect oneself before and after infection.

Development and Validation of the Couple Sexual Satisfaction Scale for HIV and Sexual Health Research

Sexual satisfaction is an important dimension of relationship quality with implications for sexual and reproductive health (SRH), and HIV prevention, care, and treatment. We developed and validated the Couple Sexual Satisfaction Scale (CSSS) with heterosexual couples in sub-Saharan Africa. Using data from qualitative interviews with 94 partnered women and men in Swaziland and Malawi, we generated a 22-item scale and administered it to 211 couples with at least one partner living with HIV in Malawi. We performed an exploratory factor analysis (EFA) to identify and confirmatory factor analysis (CFA) to test the factor structure. To assess validity, we tested for associations between the CSSS and relationship quality, consistent condom use, and intimate partner violence (IPV) using generalized estimating equations. The EFA yielded two factors, general sexual satisfaction (13-item CSSS-Gen subscale, e.g., "I am satisfied with the sweetness of sex in our relationship") and HIV-specific sexual satisfaction (4-item CSSS-HIV subscale, e.g., "My appetite for sex has gone down due to HIV"), accounting for 78% of the shared variance. The CFA supported the two-factor solution: χ²(118) = 203.60; CFI = 0.909; SRMR = 0.057; RMSEA = 0.058. Participants with higher CSSS-Gen scores reported higher coital frequency and relationship quality (intimacy, trust, unity, equality, relationship satisfaction, commitment, partner social support), and less consistent condom use, physical IPV, and emotional IPV. Participants with higher CSSS-HIV scores reported higher coital frequency and relationship quality (trust, partner support), and less consistent condom use, and sexual IPV. The CSSS demonstrated good psychometric properties and provides new opportunities to study sexual reproductive health and HIV-related health behaviors among couples in sub-Saharan Africa.

A Qualitative Investigation of Facilitators to Black and Latino Adolescent and Young Adults' Participation in a Couple-Based HIV Prevention Study

PURPOSE

Recruitment and retention of adolescents and young adults (AYAs) in couple-based HIV prevention research can be difficult. This study's primary objective is to identify factors that influenced Black and Latino AYAs to participate in couple-based HIV/STI prevention research.

DESIGN

In-depth, semi-structured qualitative interviews.

SETTING

Face-to-face interviews with couples recruited from the South Bronx, New York.

PARTICIPANTS

Twenty-three heterosexual couples (46 individuals) aged 16-28 (M = 20.1, SD = 3.01).

METHODS

Participants completed 60 to 90-minute individual and dyadic interviews. All interviews were audio-recorded and transcribed. Thematic analysis was conducted to identify key themes.

RESULTS

Two levels of influence emerged from participants' interviews regarding their reasons for study participation: 1) individual factors (interest in the study topic, study incentives, opportunity to help their community, and opportunity to learn something new), 2) interpersonal factors (positive interactions with the research team, partner's desire to participate and relationship strengthening). There were key differences by gender and recruitment order.

CONCLUSION

Black and Latino AYAs report multiple reasons for participating in couple-based research. Highlighting the benefits of study participation to themselves, their relationships, and their communities may be an important strategy for engaging AYAs in couple-based research.

The effects of intimate relationship characteristics on unprotected anal intercourse among same-sex male couples in China: a dyadic analysis using the actor-partner interdependence model

BACKGROUND

Unprotected anal intercourse (UAI) within the context of concurrent sexual relationship are prevalent among men who have sex with men (MSM) who have regular male sex partners and it aggravates the risk of HIV infection among this community. The aim of this study was to assess the effect of intimate relationship characteristics on UAI among MSM couples at the dyadic level.

METHODS

Two hundred four MSM couples were recruited from a HIV testing clinic from April 2017 to April 2018 in Guangzhou, China. The actor-partner interdependence model (APIM) was applied for dyadic analysis. Each MSM couple was divided into the insertive role and the receptive role according to their regular anal sex role. In this context, actor effect is the impact of an MSM's intimate relationship characteristics on his own UAI, and partner effect is the impact of his partner's intimate relationship characteristics on his UAI.

RESULTS

Of the 408 participants, 58.82% had UAI with regular male sex partner (UAI-RP) and 8.09% had concurrent UAI. Intimate relationship characteristics were associated with concurrent UAI, but not associated with UAI-RP. For the receptive role, his relationship investment exerted significant actor and partner effects on concurrent UAI (AOR actor = 1.31, P < 0.001; AOR partner = 1.17, P < 0.001). Meanwhile, receptive role's violence experience within relationship exerted significant actor effects on his own concurrent UAI (AOR actor = 6.43, P = 0.044).

CONCLUSIONS

Relationship investment and violence experience influenced concurrent UAI among MSM couples and it varied in different sex roles. Additional assistance on empowerment, relationship therapy and sexual agreement is urgently needed to reduce their high possibility on engagement of HIV-related risk behaviors.

Interpartner Concordance on Relationship Quality and Sexually Transmitted Infections Among Young Pregnant and Parenting Couples

BACKGROUND

This study examined agreement between partners on perceptions of relationship quality and its impact on later (sexually transmitted infection [STI]) diagnosis in a sample of pregnant (adolescents and young adults [AYAs]) couples.

METHODS

Two hundred ninety-six AYA couples completed structured surveys on relationship quality (satisfaction, cohesion, consensus, affectional expression) and STI diagnosis. An actor-partner interdependence model was used to assess actor effects (whether an individual's perceived relationship quality influenced their getting STI), partner effects (whether a partner's perceived relationship quality influenced the individual getting an STI), and interactive effects (whether an individual's perceived relationship quality interacted with a partner's perceived relationship quality and influenced in the individual getting an STI).

RESULTS

No significant actor or partner effects were observed for positive STI screen. However, there was a significant interaction between actor and partner satisfaction (B = -0.47, exp(B) = 0.63 [95% confidence interval, 0.43-0.93], P = 0.020). When actor satisfaction was high, greater partner satisfaction was associated with lower odds of a positive STI screen at 12 months. A significant interaction between actor and partner affectional expression was also found (B = -4.40, exp(B) = 0.01 [95% confidence interval, 0.00-0.87], P = 0.043). When partner affectional expression was high, greater actor affectional expression was associated with lower odds of a positive STI screen at 12 months.

CONCLUSIONS

Findings suggest that concordant reports of relationship satisfaction and affectional expression are protective against future STI risk. Strengthening romantic relationships may be a promising strategy for preventing STIs in pregnant/parenting AYA couples.

Heterosexual Men Anticipate Risk Compensatory Behaviors With Future Preexposure Prophylaxis Initiation: Findings From an Exploratory Cross-Sectional Study

Among 146 urban heterosexuals screening negative for human immunodeficiency virus, one third anticipated increased sexual risk taking with human immunodeficiency virus preexposure prophylaxis. Men (vs. women) and black (vs. white) participants had increased odds for anticipating decreased condom use. Men and persons reporting transactional sex expected to increase sexual partnerships. Risk compensation could affect reproductive health and disease control.

"Now that PrEP is reducing the risk of transmission of HIV, why then do you still insist that we use condoms?" the condom quandary among PrEP users and health care providers in Kenya

Communication around condom use in the context of PrEP services presents a potential conundrum for patients and providers. Within the Partners Scale-Up Project, which supports integration of PrEP delivery in HIV care clinics, we interviewed 41 providers and 61 PrEP users and identified themes relating to condom messaging and use. Most providers counselled PrEP initiators to always use both PrEP and condoms, except when trying to conceive. However, others reported contexts and rationales for not emphasizing condom use. Providers reported that PrEP users were sometimes confused, even frustrated, with their insistence on using condoms in addition to PrEP. PrEP users generally regarded PrEP as a more feasible and desirable HIV prevention method than condoms, enabling increased sexual pleasure and conception, and reducing the conflict and stigma associated with condom use. Innovative approaches to condom counselling in PrEP programs are needed.

Individual and Neighborhood Factors Associated With Sexual Behavior Classes in an Urban Longitudinal Sample

BACKGROUND

This study aimed to increase understanding of the clustering of sexual behaviors in an urban sample of emerging adults, and the individual and neighborhood factors associated with sexual behavior patterns to provide insight into reducing the disproportionate burden of poor sexual outcomes among urban African Americans.

METHODS

We draw on 2 cohorts of urban, predominantly African American youth first assessed at age 6 years and follow-up to emerging adulthood (mean age, 20 years; n = 1618). Latent class analyses by gender identified co-occurrence of sexual behavior.

RESULTS

We found 3 classes for both males and females: high-risk (13% of males, 15% of females), low-risk (54% of males, 56% of females) and no-risk (33% of males, 29% of females). Membership in the high-risk class was associated with school dropout, a substance use disorder diagnosis, having a criminal arrest, pregnancy, and sexually transmitted diseases for both males and females. High-risk females also had higher rates of depression. Low-risk males and females also had elevated risk of pregnancy and parenthood. Neighborhood factors distinguished the high- and no-risk classes for males and females, including the neighborhood environment scale, which assessed poverty, safety, drug activity, and crime/violence in the neighborhood. Neighborhood religiosity was inversely associated with membership in the high-risk class compared with the no-risk class for females only. Neighborhood racism distinguished those in the high-risk class compared with the no-risk class for males.

CONCLUSIONS

Future work should take into account the clustering of sexual risk behaviors. Specific neighborhood factors could be addressed to reduce sexual health disparities.

Predictors of Condomless Sex and Sexual Health Behaviors in a Sample of Portuguese Single Adults

INTRODUCTION

Several theoretical models and intervention programs overlook the importance of individual motivations for the decision to have condomless sex. For instance, people focused on promotion (ie, eager to pursue pleasure) report less intentions to use condoms, because they perceive a lower risk of acquiring sexually transmitted infections.

AIM

We aimed at understanding to what extent individual motivations are predictive of condomless sex behavior among single individuals.

METHODS

A sample of 415 Portuguese individuals (254 women) with ages ranging from 18-46 years (M = 23.30; SD = 5.28) were recruited to a cross-sectional study. All participants were neither dating nor in a romantic relationship at the time of the study. The link to an anonymous web survey was shared in social networking platforms.

MAIN OUTCOME MEASURE

The survey included self-reported demographic variables (eg, age and sex), recent condomless sex behavior, and previously validated measures assessing regulatory focus in sexuality, ability in sexual restraint, perceived control over condom use, perceived safety with sex partners, and salience of the condom use norm.

RESULTS

More than two-thirds of the sample had recently engaged in condomless sex. A logistic regression showed that condomless sex was more likely for participants predominantly focused on promotion in sexuality. It was also more likely among less educated participants, those with a lower ability to restrain their sexual behavior, those who perceive to have less control over condom use, those for whom the condom use norm was less salient, and those who perceived to be safer with their sex partners. No other results were significant.

CLINICAL IMPLICATIONS

Our results can be informative to sexual health care professionals when planning strategies to increase condom use awareness, by considering the role of specific individual motivations.

STRENGTHS & LIMITATIONS

This is the first study showing that individual motivations uniquely contribute to the decision to have condomless sex. This study has 2 main limitations that constraint the generalizability of the findings: (a) cross-sectional data prevents us from establishing causality, and (b) individual data does not account for dyadic processes in sexuality (eg, condom use negotiation).

CONCLUSION

Our findings showed that condomless sex results from an individual focus on seeking pleasure, a lack of control in sexual behavior, and a perception of sex partners as more trustworthy. Overall, these findings are likely to help researchers and health care professionals improving theoretical models predicting condom use and preventing the spread of sexually transmitted infections. Rodrigues DL, Lopes D, Pereira M, et al. Predictors of Condomless Sex and Sexual Health Behaviors in a Sample of Portuguese Single Adults. J Sex Med 2020;17:26-36.

Adolescents' Contraceptive Use with School-Discordant Partners: Exploring Individual- and Relationship-Level Characteristics

CONTEXT

Heterosexual adolescents are less likely to use contraceptives when their partners are of different backgrounds or social circles. It is unclear why risky behaviors are more common within these relationships, and characteristics associated with school-discordant partners-that is, partners who do not attend the adolescent's school-are particularly understudied.

METHODS

Characteristics of romantic relationships and contraceptive use were examined among 1,043 female and 961 male respondents in Waves 1 (1994-1995) and 2 (1996) of the National Longitudinal Study of Adolescent to Adult Health. Generalized linear regression and structural equation models identified individual- and relationship-level characteristics that were associated with school-discordant relationships and contraceptive use.

RESULTS

For females, the likelihood of ever having used a condom with a partner was reduced when that partner had not attended her school at the start of the relationship (odds ratio, 0.5) or when he was two or more years older (0.6). Notably, however, having a school- or age-discordant partner was not associated with ever having used hormonal or dual methods for females, or with any contraceptive measures for males. For females, lower emotional intimacy with school-discordant partners was positively associated with ever having used condoms with such partners (1.2).

CONCLUSIONS

Characteristics of school-discordant relationships are correlated with condom use in varying and sometimes countervailing ways. Future research examining the mechanisms linking school discordance to decreased condom use, particularly for females, would deepen understanding of the emotional and psychosocial processes involved in adolescents' sexual and contraceptive behavior.

High Prevalence of Inconsistent Condom Use With Regular Female Sex Partners Among Heterosexual Male Sexually Transmitted Disease Patients in Southern China

This study was to investigate the prevalence of and factors associated with inconsistent condom use with regular female sex partners (RPs) among heterosexual male STD patients (MSTDPs) in China. We interviewed 413 MSTDPs who had had sex with at least one RP and had received a diagnosis within the past week to six months. The prevalence of inconsistent condom use with RPs was 42.9% since STD diagnosis. Associated factors included perceptions related to condom use, regret about the decision of having unprotected sex with RP, and perceived personal partners' responsibility of using condoms.

Explaining HIV Risk Multiplexity: A Social Network Analysis

Risk multiplexity (i.e., overlap in drug-use, needle exchange and sexual relations) is a known risk factor for HIV. However, little is known about predictors of multiplexity. This study uses egocentric data from the Colorado Springs study to examine how individual, behavioral and social network factors influence engagement in multiplex risk behavior. Analyses revealed that compared to Whites, Hispanics were significantly more likely to engage in risk multiplexity and Blacks less so. Respondents who were similar to each other (e.g., in terms of race) had significantly higher odds of being in risk multiplex relationships, and respondents' risk perceptions and network size were significantly associated with engaging in multiplex risk behaviors. Findings from interaction analysis showed the effect of knowing someone with HIV on the odds of multiplexity depends partly on whether respondents' know their HIV status. Findings suggest that demographics, HIV behaviors and network factors impact engagement in multiplex risk behaviors, highlighting the need for multi-level interventions aimed at reducing HIV risk behavior.

Intimate relationships and patterns of drug and sexual risk behaviors among people who inject drugs in Kazakhstan: A latent class analysis

BACKGROUND

Multiple drug and sexual risk behaviors among people who inject drugs (PWID) in intimate relationships increase the risk of HIV and HCV transmission. Using data on PWID in intimate partnerships in Almaty, Kazakhstan, this study performed latent class analysis (LCA) on drug and sexual risk behaviors and estimated associations between dyadic relationship factors and membership in latent classes.

METHODS

LCA was performed on a sample of 510 PWID (181-females/FWID, 321-males/MWID) to identify levels of drug and sexual risk behaviors. Generalized structural equation modeling with multinomial regressions estimated associations between relationship factors (length risk reduction communication, risk reduction self-efficacy) and class membership after adjusting for substance use severity, overdose, depression, binge drinking, intimate partner violence, structural factors, and sociodemographic characteristics. Models were sex-stratified to include FWID and PWID.

RESULTS

A 3-class model best fit the data and consisted of low, medium, and high-risk classes. GSEM found that greater injection self-efficacy was associated with a lower likelihood of membership in the high-risk class for PWID and FWID. For MWID, greater length of the relationship was associated with a lower likelihood of membership in the medium-risk class. Greater relationship communication was associated with increased risk of membership in the high-risk latent class for MWID.

CONCLUSIONS

Future research must investigate if increasing risk reduction and safe sex self-efficacy could reduce drug and sexual risk behaviors and HIV transmission among PWID and their intimate partners. Interventions are needed that reduce power inequities within relationships as a method of increasing self-efficacy, particularly among women.

Managing the risk of intimacy: accounts of disclosure and responsiveness among people with HIV and intimate partners of people with HIV

It is well known that concerns about sexual risk tend to decline among people in intimate relationships where there is established commitment and trust. In the context of relationships at increased risk for HIV transmission, interactions involving disclosure and partner responsiveness are key to maintaining intimacy and physical safety. This paper explores concepts of risk and sexual intimacy articulated by a community sample of 30 people living with HIV and their intimate relationship partners. Data revealed the shifts in intimate relationship dynamics upon the disclosure of an HIV diagnosis, the importance of intimacy in the context of managing one or both partners' HIV care and responses to new advances in HIV prophylaxis. Findings suggest that participants' experiences of self-disclosure and partner responsiveness most often resulted in an increased sense of protectiveness from and for partners. This suggests that health-promoting messaging should be adapted to be more relevant to intimate couple communication and mutual support.

Love moderates the relationship between partner type and condom use among women engaging in transactional vaginal sex

Background Relationship characteristics and day-to-day variation in affective state have been associated with HIV risk behaviour. However, no research has assessed the impact of these factors on event-level condom use among women engaging in transactional sex.

METHODS

Twenty-six women engaging in transactional sex were enrolled in a prospective study of their sexual health. They completed diaries about multi-level predictors of condom use during vaginal sex twice, daily.

RESULTS

Over 4 weeks, 18 participants reported 87 paid/traded vaginal intercourse events. Of these, 51.7% were condom protected. The majority of paid/traded events (81.5%) occurred with a non-romantic partner. After controlling for partner type, feeling in love on a given day was associated with higher odds of condom use during paid/traded sexual events, while having sex on the weekend and at night were associated with lower odds of condom use (all P≤0.05). There was a significant interaction between being in love and using condoms during transactional sex (P<0.01). In paid/traded sexual events with romantic partners, the frequency of condom use was 71.4% (5/7) when women did not report love and 40% (4/10) when love was reported. In sexual events with non-romantic partners, the frequency of condom use was 43.8% (14/32) when women did not report love and 59.5% (22/37) when love was reported.

CONCLUSIONS

Women were less likely to report protected sex with romantic partners and more likely to report protected sex with non-romantic partners when they are in love. Interventions focusing on the link between day-to-day variation in affective state on condom use may help women with risk management across partner types.

Preventing syndemic Zika virus, HIV/STIs and unintended pregnancy: dual method use and consistent condom use among Brazilian women in marital and civil unions

Syndemic Zika virus, HIV and unintended pregnancy call for an urgent understanding of dual method (condoms with another modern non-barrier contraceptive) and consistent condom use. Multinomial and logistic regression analysis using data from the Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher (PNDS), a nationally representative household survey of reproductive-aged women in Brazil, identified the socio-demographic, fertility and relationship context correlates of exclusive non-barrier contraception, dual method use and condom use consistency. Among women in marital and civil unions, half reported dual protection (30% condoms, 20% dual methods). In adjusted models, condom use was associated with older age and living in the northern region of Brazil or in urban areas, whereas dual method use (versus condom use) was associated with younger age, living in the southern region of Brazil, living in non-urban areas and relationship age homogamy. Among condom users, consistent condom use was associated with reporting Afro-religion or other religion, not wanting (more) children and using condoms only (versus dual methods). Findings highlight that integrated STI prevention and family planning services should target young married/in union women, couples not wanting (more) children and heterogamous relationships to increase dual method use and consistent condom use.

Expanding Couples-Based HIV Testing and Counseling in the United States: Findings from a Nationwide, Online Survey of Partnered Adults

Couples-based HIV testing and counseling (CHTC) is currently available only for gay male couples in the United States, but other types of couples could benefit from this service. Our cross-sectional, online study collected data from 536 partnered adults to assess interest in using CHTC and associated factors. Adjusted odds ratios were calculated with ordinal logistic regression to analyze factors associated with greater interest in using CHTC. Most participants were female, White, non-Hispanic, and/or students who were dating exclusively and sexually active. Participant interest in using CHTC varied. Greater interest was associated with identifying as bisexual or questioning (adjusted odds ratio [aOR] 2.53, p < .05); having a sexual agreement (aOR 6.82, p < .001); and inconsistent or no condom use for anal sex (aOR 0.31, p < .05). These findings lend support for additional research about how best to extend and offer CHTC to a wider variety of couples.

Girls cannot be trusted: young men's perspectives on contraceptive decision making and sexual relationships in Bolgatanga, Ghana

BACKGROUND

There is extensive research on African girls sexual experiences, but much less is known about boys thoughts and actions. There is a need to understand the male perspective in order to develop sexuality education programmes that address the high rates of teenage pregnancy and sexually transmitted infections in sub-Saharan Africa.

METHODS

For this qualitative, phenomenological study we spoke to 20 boys from Bolgatanga, Ghana and explored their sexual decision making, using semi-structured interviews designed to highlight psychosocial and environmental factors. Content analysis was used to construct categories and later the themes.

RESULTS

Boys often had negative perceptions about sexual relationships. They believed that girls could not be trusted and mostly embarked on sexual relationships for material gain. The boys reported engaging in multiple sexual partnerships to secure their masculine status; however, they expected girls to be 'faithful'. We found that accurate knowledge of safe sex was lacking, boys were under peer pressure to conform to beliefs about masculinity and communication about sex mainly took place within peer groups.

CONCLUSIONS

There is a need to emphasise condom use in established relationships. There should also be more discussion of issues surrounding fidelity and gender equality, as part of sexuality programmes aimed at boys in Ghana and in similar cultures.

Meta-analyses of HIV prevention interventions targeting improved partner communication: effects on partner communication and condom use frequency outcomes

Behavioral HIV prevention interventions designed to improve safer-sex communication skills with sexual partners may enhance engagement in protective behaviors and reduce HIV/STI risk. The current meta-analyses examined the efficacy of individual-based (i.e., not couples-based) HIV prevention interventions with a partner communication skills building component to increase frequency of: (a) safer-sex communication and (b) condom use with sexual partners among HIV at-risk groups (e.g., heterosexual African American females). Studies were retrieved from online bibliographic databases, a database of effective behavioral HIV prevention interventions, and an existing review of effective interventions. Eight manuscripts (k = 10 intervention vs. control comparisons) met inclusion criteria. Results indicated that compared to control conditions, at post-intervention follow-up, participants who were exposed to individual-based HIV prevention interventions with safer-sex communication skills training components had safer sex discussions with partners more frequently [d_random = 0.35 ± 0.10, p < .001, 95% CI (0.16, 0.55)], and used condoms more frequently [d_random = 0.39 ± 0.07, p < .001, 95% CI (0.25, 0.54)]. Including partner communication skills training in individual-based HIV prevention interventions may increase the frequency of both partner communication and condom use among the at-risk populations represented in the meta-analyses.

Prevalence of hepatitis C infection and its associated factors in healthy adults without identifiable route of transmission

While hepatitis C virus (HCV) infection is long known to be associated with parenteral exposure, the specific route of transmission is not identified in a proportion of infected patients. Taking blood donors as the surrogate of healthy adults in the community in Hong Kong, we identified 91 HCV-infected donors (≤0.02% positive rate) in 2014-2016, of whom 46 were recruited in a mixed-method study to examine their transmission routes. A majority (75%) of the recruited donors were HCV RNA positive, with the predominant subtypes being 1b and 6a. From the results of the structured self-administered questionnaire and in-depth interviews, only 14 (30%) recruited donors could be traced to past history of contaminated blood transfusion (n = 9) or injection drug use (n = 5). Case-control analyses with 3 different control groups were performed to examine factors associated with HCV infection in multivariable analyses. High-risk sexual behaviour, body piercing, intramuscular injection and vaccine inoculation abroad, having lived abroad for >3 months were significantly associated with HCV in donors with otherwise nonidentifiable source of infection. While the specific route of transmission cannot be established for each person, associations with multiple parenteral exposures outside Hong Kong were observed. The World Health Organization has advocated for the global elimination of HCV by 2030. With a high proportion of HCV-infected persons who are unaware of their infections, HCV elimination could be hard to achieve.

Do Associations Between Pleasure Ratings and Condom Use During Penile-Vaginal Intercourse Vary by Relationship Type?: A Study of Canadian University Students

Research suggests the relationship between pleasure and condom use during penile-vaginal intercourse (PVI) is associated with relationship status. This online study examined pleasure ratings and condom use at last PVI, stratifying by partner type, among a national sample of Canadian university students. Participants were 715 undergraduates (60.7% women, 39.3% men) who reported on their most recent sexual experience. Condom use decreased with level of relationship commitment, whereas ratings of pleasure increased. Overall, participants were more likely to rate their most recent PVI as Very pleasurable when condoms were not used compared to when condoms were used. However, when stratified by partner type, these differences largely disappeared. For women, with one exception, there were no differences in pleasure between PVI with and without condoms across most partner-type categories. Women in committed dating relationships were more likely to report their last PVI as very pleasurable if condoms were not used than women in these same relationships who had used condoms. Across relationship categories, men who did and did not use condoms did not differ in terms of their pleasure ratings. The results of this study suggest relationship context should be taken into account when assessing condom use experiences.

The Context of Sexual Decisions and Intrapersonal and Interpersonal Factors Related to Sexual Initiation Among Female Military-Dependent Youth

Despite the sizable population of military-dependent youth (MDY) in the United States and the military stressors they experience (e.g., relocations, parental deployment), little is known about MDY's sexual behavior, especially about the perceived role that military stressors play in their sexual decisions, such as the decision to initiate sex. We conducted 25 semistructured, in-depth interviews with sexually experienced female MDY aged 15 to 19 years to (a) describe MDY's general perceptions of military life and (b) identify intrapersonal and interpersonal characteristics related to MDY's sexual initiation, including the perceived impact of military stressors. We analyzed life history grids and transcripts to identify common and unique themes across participants' experiences. Most participants reported having positive experiences related to military life, and most did not believe that military stressors influenced their decision to initiate sex. Common intrapersonal and interpersonal characteristics related to sexual initiation were having an older first sexual partner, being in a dating relationship, receiving sexual health education prior to their first sexual experience, and discussing sex with a parent prior to their first sexual experience. These intrapersonal and interpersonal characteristics should be considered when developing sexual health programs for MDY, which should focus on building supportive peer and parental relationships.

Agency as a mediator in the pathway from transactional sex to HIV among pregnant women in Swaziland: a multigroup path analysis

Introduction: Transactional sex is a structural driver of HIV for women and girls in sub-Saharan Africa. In transactional relationships, sexual and economic obligations intertwine and may have positive and negative effects on women’s financial standing and social status. We conducted a clinic-based survey with pregnant women in Swaziland using a locally validated transactional sex scale to measure the association between subjective social status, transactional sex, and HIV status, and to assess whether this association differed according to a woman’s agency within her relationship.

Methods: We recruited a convenience sample of 406 pregnant women at one rural and one urban public antenatal clinic in Swaziland and administered a behavioural survey that was linked to participant HIV status using clinic records. We then conducted a multigroup path analysis to test three hypotheses: (1) that more engagement in transactional sex is associated with decreased condom use and increased subjective social status; (2) that subjective social status mediates the relationship between transactional sex and HIV status; and (3) that these relationships are different across groups according to whether or not a woman reported any indicator of constrained agency within her relationship.

Results: The amount and value of material goods received from a sexual partner was significantly and positively associated with higher subjective social status among all participants. As the amount of material goods received from a partner increased, women who reported no indicators of constrained agency were less likely to use condoms. Conversely, there was no relationship between transactional sex and condom use among women who reported any indicator of constrained relationship agency. Among women who reported any indicator of constrained agency, HIV was significantly associated with lower subjective social status.

Conclusions: Relationship agency likely plays a key role in determining which mechanisms create HIV risk for women in transactional relationships. Interventions to mitigate these risks must address social forces that penalize women who engage in sexual relationships as well as structural drivers of gendered economic disparity that reduce women’s agency within their sexual and romantic relationships.

Factors Associated With Condom Use Among Sexually Active US Adults, National Survey of Family Growth, 2006-2010 and 2011-2013

BACKGROUND

Condom-less sex can increase the risk of acquiring or transmitting HIV.

AIM

To characterize the prevalence of condom use at the most recent sex act and identify factors associated with use of a condom at the most recent sex act in adults in the United States.

METHODS

Data from the cross-sectional National Survey of Family Growth from cycles 2006 through 2010 and 2011 through 2013 were analyzed for sexually active men and women 18 to 44 years old who reported having sex (vaginal, anal, or oral) with an opposite-sex partner in the past 12 months. HIV-related sexual risk behaviors (SRBs) in the past 12 months included sex with at least four opposite-sex partners; exchanging sex for money or drugs; sex with an injection drug user; sex with an HIV-positive person; sex with a man who previously had sex with a man (women only); sex with a man (men only); or sex with a partner who had sex with other partners.

OUTCOMES

The outcome for this analysis was condom use at the most recent anal or vaginal sex act.

RESULTS

Overall prevalence of condom use was 24.8%; only 33.8% of adults with at least one SRB reported the use of a condom. Only 46.4% of unmarried or single men (vs 14.7% married or cohabitating men) and 32.3% unmarried or single women (vs 14.1% married or cohabitating women) with SRBs reported using a condom at the most recent sexual encounter and were less likely to use a condom at the most recent sexual encounter compared with those who did not report SRBs. We did not find a significant relation between using a condom and SRBs in married or cohabitating men and women.

STRENGTHS AND LIMITATIONS

Our analysis adds to the literature on how condom use varies by marital status. We measured the use of condoms at the most recent sexual act, which might not reflect an individual's previous behavior of condom use. Nonetheless, condom use at the most recent sexual act has been documented in previous studies as a valid proxy of condom use over time.

CONCLUSION

Continued efforts are needed to promote condom use in heterosexual adults in the United States, particularly those at high risk for HIV, namely individuals engaging in anal sexual acts and with multiple sex partners. Nasrullah M, Oraka E, Chavez PR, et al. Factors Associated With Condom Use Among Sexually Active US Adults, National Survey of Family Growth, 2006-2010 and 2011-2013. J Sex Med 2017;14:541-550.

Sexual Risk and Protective Behaviors Among Reproductive-Aged Women in the United States

BACKGROUND

In 2014, women represented 19% of HIV diagnoses in the United States. Of these, 78% were among black women and Latinas. Sexual risk behaviors-for example concurrent sex partnerships, nonmonogamous sex partners, and inconsistent condom use-are associated with increased HIV transmission and prevalence; these behaviors have been understudied, collectively, in women.

METHODS

To examine HIV-related sexual risk behaviors among sexually active women aged 18-44 years by race/ethnicity and over time, we used data from the 2006-2008, 2008-2010, and 2011-2013 cycles of the National Survey of Family Growth. We estimated weighted percentages and performed logistic regression to measure adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) for associations between selected behaviors and sociodemographic covariates.

RESULTS

Among 13,588 women, 1.1% reported concurrent sex partnerships, 10.3% reported male partners whom they perceived were nonmonogamous, and 21.1% reported using a condom at either last vaginal or anal sex. Black women (aPR = 1.52; CI = 1.36-1.71) and Latinas (aPR = 1.29; CI = 1.14-1.47) were more likely to report condom use at either last vaginal or anal sex compared with white women. However, black women were also more likely to report concurrent opposite-sex partnerships (aPR = 2.44; CI = 1.57-3.78) and perceived nonmonogamous sex partners (aPR = 1.33; CI = 1.14-1.56) compared with white women.

CONCLUSIONS

Improved HIV behavioral risk-reduction strategies are needed for women. Black women could benefit from interventions that address partnership concurrency. For black women and Latinas, who are more likely to use condoms, further examination of broader social and structural factors as contributors to racial/ethnic gaps are warranted and vital for understanding and decreasing HIV-related disparities.

Unique and Shared Relationship Benefits of Consensually Non-Monogamous and Monogamous Relationships

Abstract. The increased media and public curiosity on the topic of consensual non-monogamy (CNM) presents an interesting case, given that these types of relationships are highly stigmatized. In the present review piece, we first situate common themes of benefits that people believe are afforded to them by their CNM relationships within the current state of the literature to provide insight into unique and shared (with monogamy) relationship benefits. This approach helps uncover relationship benefits and theoretical advances for research on CNM by highlighting some of the key features of CNM relationships that people find rewarding, including need fulfillment, variety of activities, and personal growth and development. Second, we discuss common misconceptions about CNM and stigma toward CNM. Finally, we conclude with future directions and recommendations for scholars interested in pursuing research on CNM.

Condom Use as a Function of Number of Coital Events in New Relationships

STUDY OBJECTIVE

To assess condom use as a function of number of coital events in newly formed sexual relationships.

METHODS

Participants who reported at least one new partner during the 12-week study interval (n = 115; ages 18-29 years; 48% women; 90% African American) completed weekly sexually transmitted infections testing and 3 times daily electronic diary collection assessing individual and partner-specific affect, daily activities, sexual behavior, and condom use. We analyzed event-level condom use percentage and participant-level behavior response effects. generalized additive mixed models were used to estimate condom use probability accounting for within-partner and within-participant correlations via random effects.

RESULTS

The average condom use probability at the first coital event in new relationships was 55% for men and 36% for women. Analyses showed that smooth shapes of estimated condom use probabilities were similar for both sexes and were fitted using generalized additive mixed models. Relatively higher condom use percentage was followed by a sharp decline during the first 9 coital events decreasing to 16% for men and 8% for women. More rapid decline in condom use among women was highly associated with higher levels of relationship and sexual satisfaction.

CONCLUSIONS

The likelihood of condom use declines sharply for both men and women after the early accrual experience with a partner. Relationship and sexual satisfaction also influence declines in condom use, especially among women.

Dual protection to address the global syndemic of HIV and unintended pregnancy in Brazil

BACKGROUND

Syndemic HIV and unintended pregnancy is prevalent in Brazil, where 79% of female HIV cases occur in women of reproductive age and 55% of all pregnancies are unintended. Although increasing condom use to prevent HIV may decrease non-barrier contraception and increase unintended pregnancy, few studies focus on dual protection or dual methods (condoms with another modern contraceptive).

AIM

To describe the correlates of dual method use and consistent condom use in women of reproductive age in Brazil.

METHOD

Data are from the 2006 Pesquisa Nacional de Demografia e Saúde da Mulher e da Criança, a decennial nationally representative household survey of women of reproductive age in Brazil. Multivariate logistic regression models identify the socio-demographic, sexual debut, fertility and relationship factors associated with dual method use and consistent condom use.

RESULTS

Two-thirds of contracepting women in Brazil used dual protection (40% exclusive condoms, 27% dual methods). Consistent condom use in the past year occurred among 61% of exclusive condom users and 27% of dual method users. Dual methods (vs exclusive condoms) was associated with some high school education [relative risk ratio (RRR)=1.69, p<0.05], living in the Southern region (RRR=1.59, p<0.01), and number of children (RRR=1.22, p<0.01), net of other factors. Consistent condom use was associated with condom use at sexual debut [adjusted odds ratio (AOR)=1.84, p<0.001], wants no (more) children (AOR=1.86, p<0.001), single/separated relationship status (AOR=2.77/2.45, p<0.001) and using exclusive condoms (vs dual methods: AOR=0.19, p<0.001).

CONCLUSIONS

Findings highlight that targeting and delivering integrated HIV and family planning services should focus on completed/large families. single/separated individuals, and promoting dual protection at sexual debut.

Sex Partner Type, Drug Use and Condom Use Self-Efficacy Among African Americans from Disadvantaged Neighborhoods: Are Associations with Consistent Condom Use Moderated by Gender?

Gender inequalities in sexual behavior are explored from the perspective of the theory of gender and power. This study focused on the effect of sex partner type (steady versus casual), drug use, and condom use self-efficacy regarding consistent condom use (CCU) among a community-based sample of adults. The sample included 1,357 African American men and women (M age 37.0, SD 13.1 years; 44% women, 66% men) from 61 disadvantaged census block groups in Atlanta, GA as part of a study of individual and neighborhood characteristics and HIV risk-taking. Having a steady partner decreased the odds of CCU, while higher condom use self-efficacy increased the odds of CCU. Among non-drug users, having a drug-using partner was associated with decreased odds of condom use for women only. Women with drug-using partners, especially a steady partner, were least likely to report CCU. Therefore, interventions intended to empower CCU among women need to expand beyond acknowledging the reduced control that women who use drugs demonstrate to also consider those who have drug-using sexual partners.

Correlates of Risky Heterosexual Behaviors Among Women Who Use Methamphetamine

Women who use methamphetamine are at heightened risk of engaging in sexual behaviors that increase their odds of contracting HIV or sexually transmitted infections (STIs). However, little is known regarding correlates of such behaviors within this population. In a community-based sample of women who use methamphetamine ( N = 322), we examined participant characteristics (i.e., demographics, drug- and sex-related behaviors, and mental health characteristics) associated with three operationalizations of risky heterosexual behaviors in the past 6 months (i.e., number of male partners, condomless sex with male partners, and both multiple male partners and condomless sex). Analyses revealed important distinctions in the correlates of risky heterosexual behaviors as a function of outcome. Results suggest that HIV and STI prevention strategies should consider characteristics associated with differing risky heterosexual behaviors. In addition, differences in correlates of these behaviors suggest a need for standardization in measurement and evaluation of sexual risk in research and practice with women who use methamphetamine.

The Causal Effects of Relational Security and Insecurity on Condom Use Attitudes and Acquisition Behavior

Research on attachment and condom use has been limited to correlational studies of self-report measures, yielding inconsistent results. Here, we examined the causal effects of attachment priming on self-reported condom use attitudes and an observational measure of condom acquisition behavior. In three experiments, participants were exposed to one of three attachment primes (security, anxiety, or avoidance) or a control prime. For Study 1, participants in the security and anxiety conditions preferred condom non-use to a greater extent, compared to participants in the avoidance condition. This effect was replicated in Study 2, and was mediated by perceptions of sexual health threat. In Study 3, the effect of security priming on condom acquisition behavior was eliminated through the use of a framing manipulation, though the effect of primed attachment on condom use attitudes was not significant. A meta-analysis, however, revealed that the predicted effects of attachment priming were consistent across the three studies, supporting the role of attachment in evaluations of condom use. Priming attachment security or anxiety leads participants to perceive their sexual partners as less of a sexual health threat, resulting in a devaluation of condom use. Primed security also reduced condom acquisition behavior, though this negative effect eliminated by framing condoms as protecting a partner's sexual health. Overall, these studies suggest that relational factors, such as attachment, require greater consideration when studying sexual health and designing interventions.

Barriers to Condom Use: Results for Men and Women Enrolled in HIV Risk Reduction Trials in Outpatient Drug Treatment

HIV transmission often occurs through heterosexual high-risk sex. Even in the era of HIV combination prevention, promoting condom use, and understanding condom barriers, remain priorities, especially among substance-dependent individuals. Men and women (N=729) in outpatient drug treatment participated in a five-session gender-specific risk reduction group or one-session HIV Education group. Condom barriers (Motivation, Partner-related, Access/Availability, Sexual experience) were assessed at baseline and 6-month follow-up. Completing either intervention was associated with fewer motivation and partner-related barriers. Among women, reductions in motivation and sexual experience barriers were associated with less sexual risk with primary partners. Condom barriers are important to gender-specific HIV prevention; given limited resources, brief interventions maximizing active components are needed.

The Role of Relationship Type, Risk Perception, and Condom Use in Middle Socioeconomic Status Black Women's HIV-prevention Strategies

This research analyzes qualitative focus group and interview data from the Sister Circle Study- a pilot study that explored HIV risk among middle SES Black women ages 25- 45 in North Carolina. Findings reveal that gendered relationship dynamics, perceptions of a sex ratio imbalance, and levels of trust in relationships may reduce some women's ability to negotiate monogamy and condom use with their male partners. The research suggests that higher socioeconomic status does not fully buffer some middle SES Black women from HIV risk and highlights the role interpersonal and structural factors play in shaping HIV risk for this group.

Black Women with Multiple Sex Partners: The Role of Sexual Agency

Motivations of low-income substance using heterosexual Black women in New York City for having multiple sexual partners are explored in this paper. Analysis of in-depth interviews with 50 study participants demonstrates that their relationships consisted of those who had: (1) a main sex partner and a secondary sex partner; or (2) two or more "casual" partners. Individual-level motivations for extra relational sex fell into four dominant themes: sexual pleasure, partner infidelity, sex exchange and past main partners. Using a Black feminist framework, we describe how participants displayed considerable autonomy by actively forming and withdrawing from sexual relationships with men. However, women described low rates of condom use with main partners and inconsistent use of condoms with more casual sexual partners. This contradiction becomes an important area for sexual health interventions. Women who had sexual relations with only one current mate in the past two years were recruited as a monogamous comparison group.

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

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

The role of dyad-level factors in shaping sexual and drug-related HIV/STI risks among sex workers with intimate partners

BACKGROUND

Despite high HIV burden among sex workers (SWs) globally, and relatively high prevalence of client condom use, research on potential HIV/STI risk pathways of intimate partnerships is limited. This study investigated partner/dyad-level factors associated with inconsistent condom use among SWs with intimate partners in Vancouver, Canada.

METHODS

Baseline data (2010-2013) were drawn from a community-based prospective cohort of women SWs. Multivariable generalized estimating equations logistic regression examined dyad-level factors associated with inconsistent condom use (<100% in last six months) with up to three male intimate partners per SW. Adjusted odds ratios and 95% confidence intervals were reported (AOR[95%CI]).

RESULTS

Overall, 369 SWs reported having at least one intimate partner, with 70.1% reporting inconsistent condom use. Median length of partnerships was 1.8 years, with longer duration linked to inconsistent condom use. In multivariable analysis, dyad factors significantly associated with increased odds of inconsistent condom use included: having a cohabiting (5.43[2.53-11.66]) or non-cohabiting intimate partner (2.15[1.11-4.19]) (versus casual partner), providing drugs (3.04[1.47-6.30]) or financial support to an intimate partner (2.46[1.05-5.74]), physical intimate partner violence (2.20[1.17-4.12]), and an intimate partner providing physical safety (2.08[1.11-3.91]); non-injection drug use was associated with a 68% reduced odds (0.32[0.17-0.60]).

CONCLUSIONS

Our study highlights the complex role of dyad-level factors in shaping sexual and drug-related HIV/STI risk pathways for SWs from intimate partners. Couple and gender-focused interventions efforts are needed to reduce HIV/STI risks to SWs through intimate partnerships. This research supports further calls for integrated violence and HIV prevention within broader sexual/reproductive health efforts for SWs.

Sex Work, Heroin Injection, and HIV Risk in Tijuana: A Love Story

The relationships between female sex workers and their non-commercial male partners are typically viewed as sites of HIV risk rather than meaningful unions. This ethnographic case study presents a nuanced portrayal of the relationship between Cindy and Beto, a female sex worker who injects drugs and her intimate, non-commercial partner who live in Tijuana, Mexico. Based on ethnographic research in Tijuana and our long term involvement in a public health study, we suggest that emotions play a central role in sex workers' relationships and contribute in complex ways to each partner's health. We conceptualize Cindy and Beto's relationship as a "dangerous safe haven" in which HIV risk behaviors such as unprotected sex and syringe sharing convey notions of love and trust and help sustain emotional unity amidst broader uncertainties, but nevertheless carry very real health risks. Further attention to how emotions shape vulnerable couples' health remains a task for anthropology.

Female Condom Use and Adoption Among Men and Women in a General Low-Income Urban U.S. Population

HIV prevention is increasingly focused on antiretroviral treatment of infected or uninfected persons. However, barrier methods like male condoms (MC) and female condoms (FC) remain necessary to achieve broad reductions in HIV and other sexually transmitted infections (STI). Evidence grows suggesting that removal of basic obstacles could result in greater FC use and reduced unprotected sex in the general population. We conducted four annual cross-sectional surveys (2009-2012) of urban residents (N = 1614) in low-income neighborhoods of a northeastern U.S. city where prevalence of HIV and other STIs is high. Findings indicate slow FC uptake but also heterosexual men's willingness to use them. Factors associated with men's and women's FC use included positive FC attitudes, network exposure, and peer influences and norms. These results suggest that men can be supporters of FC, and reinforce the need for targeted efforts to increase FC use in both men and women for HIV/STI prevention.