Condom effectiveness in reducing heterosexual HIV transmission: a systematic review and meta-analysis of studies on HIV serodiscordant couples

Knowledge of Sexually Transmitted Infections and Its Association With Condom Use Self-Efficacy (CUSES) Among People Living With HIV (PLHIV) in Public Health Clinics in Selangor, Malaysia

Background Condom use self-efficacy is critical in preventing the spread of HIV among people living with HIV (PLHIV). Knowledge of sexually transmitted infections (STIs) is a crucial factor in promoting safer sexual behaviors. However, there is scarce data on its association with condom use self-efficacy, particularly among PLHIV. Objectives This study aims to determine the association between knowledge of STIs and other demographic and behavioral factors with condom use self-efficacy among PLHIV in public health clinics at Hulu Langat, Selangor. Methods A cross-sectional study involved PLHIV attending public health clinics in Selangor, Malaysia. Participants were recruited using convenience sampling. Eligibility criteria included being 18 years or older, able to read and comprehend the Malay language, and having not been diagnosed with psychiatric illness or learning difficulties that may impede their ability to answer the questionnaire. Data were collected from December 2023 to March 2024 through self-administered questionnaires assessing demographic characteristics, sexual practice, clinical factors, knowledge of STIs, and condom use self-efficacy. Multiple linear regressions were performed to identify factors associated with condom use self-efficacy. Results The mean score for condom use self-efficacy was 77.72 ± 12.88, and the mean score for knowledge of STIs was 30.87 ± 5.50. The higher STI knowledge score was associated with higher condom use self-efficacy (B = 0.73, p < 0.001). Other significant factors were higher household income (B = 9.27, p < 0.001), recent sexual activity within the last three months (B = -4.34, p < 0.001), engaging in receptive anal sex (B = 7.06, p < 0.001), and not using a condom during the last sexual intercourse (B = -4.43, p < 0.001) were associated with condom use self-efficacy. Conclusion The study confirms that good STI knowledge increases condom use self-efficacy among PLHIV, therefore highlighting the need to educate those at risk with better knowledge of STIs. It also highlights the importance of conducting interventions for those at higher risk due to lower condom use self-efficacy and exploring their barriers towards the use of condoms.

Condom use increased after a peer group intervention implemented by community volunteers in Malawi

BACKGROUND

HIV prevention remains a global priority, especially in sub-Saharan Africa. Our research team previously developed an evidence-based peer group program for HIV prevention called Mzake ndi Mzake (Friend to Friend). A community-engaged collaboration adapted the program for community ownership and implementation. Here we report whether this HIV prevention program, implemented by community volunteers, increased condom use among sexually active individuals in rural Malawi.

METHODS

Three communities sequentially rolled out the program. Effectiveness was evaluated using a stepped wedge design. Repeated surveys 11-13 months apart were conducted between 2016 and 2019. At Time 1, no community had offered the intervention. At Time 2, the first community had offered the intervention and two had not (control group). At Time 3, two communities had offered the intervention and one had not (control group). We used two condom use indicators; condom use frequency in the last 2 months (N = 771) and condom use at last sex (N = 880). The analytical sample included all sexually active persons answering that question at one or more time points. Mixed-effects cumulative logit and Generalized Estimating Equation (GEE) models were used to model the two condom indicators over time, controlling for demographic factors, UNAIDS HIV knowledge, safer sex self-efficacy and partner communication.

RESULTS

This peer group intervention implemented by trained community volunteers increased both condom use indicators at Times 2 and 3. In the final adjusted models with non-significant factors removed, condom use in the last two months increased for the intervention group vs. control group [Time 2: Adjusted Odds Ratio (AOR) = 1.59 (1.15, 2.21); Time 3: AOR 2.01 (1.23, 3.30)]. Similarly, condom use at last sex increased for the intervention group vs. control group [Time 2: AOR = 1.48 (1.08, 2.03); Time 3: AOR 1.81 (1.13, 2.90)]. Other significant predictors of greater condom use were also described. Although the intervention increased UNAIDS HIV knowledge, knowledge did not predict condom use.

CONCLUSIONS

In this community-engaged implementation study, an evidence-based peer group program for HIV prevention increased condom use when delivered by trained community volunteers. Community ownership and program delivery by trained volunteers offer an innovative and cost-effective strategy to address ongoing HIV prevention needs without overburdening healthcare systems in sub-Saharan Africa.

TRIAL REGISTRATION

Clinical Trials.gov NCT02765659 Registered May 6, 2016.

Safe sex negotiation and HIV risk reduction among women: A cross-sectional analysis of Burkina Faso 2021 Demographic and Health Survey

Women are biologically more susceptible to the Human Immunodeficiency Virus (HIV) and other sexually transmitted Infections (STIs) because receptive sex is riskier than insertive. Despite condom use being the staple preventive method for HIV infection (over 80% efficacy), in Sub-Saharan African countries like Burkina Faso, a high burden of HIV and the unmet need for condom use coexist. Moreover, even though women in SSA are disproportionately HIV positive, they are reportedly less capable of negotiating condom use for HIV risk reduction. Thus, using the Health Believe Model (HBM), this study explored the factors that influence condom use among women within the context of HIV prevention, with a key interest in condom use negotiation. Using the women's dataset of the 2021 Burkina Faso Demographic and Health Survey and applying logistic regression models, this study examined the factors associated with condom use for HIV risk reduction. Women who had confidence to negotiate condom use with their partners (OR = 1.57, P<0.001, 95%CI: 1.29, 1.91), those with secondary education (OR = 1.38, P<0.05, 95%CI: 1.07 1.77), from richest households (OR = 1.64, P<0.05, 95%CI: 1.08, 2.47), the employed (OR = 1.23, P<0.05, 95%CI: 1.02, 1.49), women with knowledge of sexually transmitted infections (OR = 1.58, P<0.001, 95%CI: 1.26, 1.97), those who have ever been tested for HIV (OR = 1.85, P<0.001, 95%CI: 1.52 2.24), as well as those who knew that a healthy-looking person can have HIV (OR = 2.64, P<0.001, 95%CI: 2.15, 3.24) were all significantly more likely to practice condom use for HIV risk reduction. Also, religion and geographical location of participants significantly predicted condom use for HIV risk reduction in the study context. The ability to negotiate condom use, knowledge of HIV and STIs, the socioeconomic status of women, as well as their geographical location, influence their practice of safer sex for HIV risk reduction in Burkina Faso.

Prevalence, Trends and Correlates of HIV, Syphilis and HCV Infection Among Chinese Local and Cross-border Migrant Female Sex Workers in the Sino-Vietnam Border Area of Guangxi, 2016-2021

Female sex workers (FSWs) are considered a high-risk group for sexually transmitted infections (STIs). However, limited data exist on the prevalence and trends of HIV, syphilis and HCV among FSWs in the Sino-Vietnam border area. To determine the prevalence, trends and correlates of STIs among Chinese local FSWs (CL-FSWs) and cross-border migrant FSWs (CM-FSWs), we conducted consecutive cross-sectional surveys from 2016 to 2021, recruiting 7747 CL-FSWs and 932 CM-FSWs. The overall HIV, syphilis and HCV prevalence declined from 1.0%, 8.8% and 1.7% to 0.1%, 0.9% and 0.3%, respectively. There was no significant downward trend in the overall HIV and syphilis prevalence. However, HCV prevalence showed a decreasing trend among CL-FSWs. CM-FSWs had higher HIV prevalence (2.5% vs. 0.6%). Similarities and differences in STIs-related factors existed between CM-FSWs and CL-FSWs. For instance, receiving HIV-related services in the last year reduced the risk of HIV infection (for CM-FSWs: aOR = 0.234, 95% CI: 0.055-0.993; for CL-FSWs: aOR = 0.182, 95% CI: 0.058-0.567). Serving male clients at least 50 years old increased the risk of syphilis infection (for CM-FSWs: aOR = 4.277, 95% CI: 1.535-11.917; for CL-FSWs: aOR = 1.404, 95% CI: 1.087-1.815). Moreover, CM-FSWs with past-year STIs history had a higher risk of HIV (aOR = 34.976, 95% CI: 5.338-229.176) and HCV infection (aOR = 17.649, 95% CI: 1.846-168.846), both of which were associated with multiple factors in CL-FSWs. It is therefore necessary to develop effective, accessible, high-quality and targeted interventions for CM-FSWs and CL-FSWs.

Social cognition, personality and social-political correlates of health behaviors: Application of an integrated theoretical model

OBJECTIVE

Dispositional, intra-personal constructs such as personality traits and generalized beliefs are consistently related to health behaviors, but relatively few studies have tested the theory-based mechanisms by which these constructs relate to health behaviors and compared them across behavior type. In the current study we tested an integrated theoretical model in which belief-based social cognition constructs (attitudes, subjective norms, perceived behavioral control) were proposed to mediate effects of personality traits (conscientiousness, extroversion) and socio-political beliefs (political beliefs, locus of control, free will beliefs) on participation in three health-related behaviors: physical activity, COVID-19 vaccination, and sugar-sweetened beverage restriction.

METHODS

Proposed integrated model effects were tested in a five-week prospective correlational study. Finnish residents completed measures of personality, socio-political, and social cognition constructs with respect to physical activity participation (N = 557), COVID-19 vaccination uptake (N = 1,115), and sugar-sweetened beverage restriction (N = 558) and self-reported their behavior at follow-up.

RESULTS

Structural equation models revealed direct effects of intention on behavior, and of social-cognition constructs on intention, across all behaviors. We also found indirect effects of political beliefs on behavior mediated by social cognition constructs and intentions for COVID-19 vaccination and sugar-sweetened beverage restriction behaviors, indirect effects of conscientiousness on behavior mediated by social cognition constructs and intentions for physical activity and sugar-sweetened beverage restriction behaviors, and indirect effects of health locus of control on behavior mediated by social cognition constructs and intentions for physical activity behavior. Finally, we found a negative total effect of populist beliefs on behavior for COVID-19 vaccination behavior.

CONCLUSION

Findings contribute to an evidence base for the effects of dispositional and social cognition constructs of health behaviors, point to a possible mechanism by which these generalized constructs relate to health behavior, and outline how the pattern of effects varies across the different behaviors.

The rules of mature sex: Sexual scripts and the global challenge of rising STIs

Sexual health continues to be a socially complex problem globally with rising rates of sexually transmitted infections (STIs) despite extensive government and health marketing initiatives. In particular, STIs are rising at a greater rate in mature consumers than any other age group with the main reason cited as lack of condom use. The rules around condom use are based on sexual scripts or internalised guidelines and thus a key step in developing social marketing initiatives to increase condom use and address this global challenge is identifying the sexual scripts that motivate and inhibit condom use by mature consumers. Using sexual script theory, this research involves interviews with 24 mature single heterosexual Australian consumers to identify the sexual scripts that can be leveraged in health marketing to address the grand challenge of increasing mature consumer participation in protective sexual health behaviours.

Cross-Cultural Adaptation and Psychometric Evaluation of Condom Use Self-Efficacy Scale in Chilean College Students

Background and Purpose: Limited culturally relevant condom self-efficacy measures have been adapted for use with Chilean college students. This study aims to culturally adapt and measure the psychometric properties of the Condom Use Self-Efficacy Scale (CUSES) by use in college students in Chile. Methods: This cross-sectional study was carried out in six stages: (a) authorization from original authors, (b) translation, (c) back translation, (d) analysis of equivalences, (e) content analysis, and (f) exploratory factor analysis and reliability assessment. Results: Of the 460 college students who completed the Chilean CUSES (Ch-CUSES), 73.9% were women and 99% were single with a mean age of 20.5. Total scale Cronbach's alpha was 0.845, and factor analysis demonstrated six dimensions with 59.1% of the total variance. The factor loading scores of 21 items ranged between 0.515 and 0.921. Conclusions: Ch-CUSES shows good psychometric properties for assessing self-efficacy for condom use in Chilean college students.

HIV infection

The AIDS epidemic has been a global public health issue for more than 40 years and has resulted in ~40 million deaths. AIDS is caused by the retrovirus, HIV-1, which is transmitted via body fluids and secretions. After infection, the virus invades host cells by attaching to CD4 receptors and thereafter one of two major chemokine coreceptors, CCR5 or CXCR4, destroying the host cell, most often a T lymphocyte, as it replicates. If unchecked this can lead to an immune-deficient state and demise over a period of ~2-10 years. The discovery and global roll-out of rapid diagnostics and effective antiretroviral therapy led to a large reduction in mortality and morbidity and to an expanding group of individuals requiring lifelong viral suppressive therapy. Viral suppression eliminates sexual transmission of the virus and greatly improves health outcomes. HIV infection, although still stigmatized, is now a chronic and manageable condition. Ultimate epidemic control will require prevention and treatment to be made available, affordable and accessible for all. Furthermore, the focus should be heavily oriented towards long-term well-being, care for multimorbidity and good quality of life. Intense research efforts continue for therapeutic and/or preventive vaccines, novel immunotherapies and a cure.

The Essential Need for Trust When Transmission Risk Cannot Be Eliminated in HIV-Remission Trials

Analytic treatment interruption (ATI) is scientifically necessary in HIV-remission ("cure") studies to test the effects of new interventions. However, stopping antiretroviral treatment poses risks to research participants and their sexual partners. Ethical debate about whether and how to conduct such studies has largely centered on designing risk-mitigation strategies and identifying the responsibilities of research stakeholders. In this paper, we argue that because the possibility of HIV transmission from research participants to partners during ATI cannot practicably be eliminated-that is, it is ineliminable-the successful conduct of such trials ultimately depends on relationships of trust and trustworthiness. We describe our experiences with conducting and studying HIV-remission trials with ATI in Thailand to examine the strengths, complexities, and limitations of the risk-mitigation and responsibility approaches and to explore ways in which the building of trust-and trustworthiness-may help enhance the scientific, practical, and ethical dimensions of these trials.

[Trends in the incidence of the human immunodeficiency (HIV) virus in Chile, by age and gender 2010-2017]

OBJETIVE

To determine the trends in the incidence of contagion by the HIV in Chile, according to age and gender, for the period 2010-2017.

METHODS

Analysis from the database of confirmed HIV positive diagnosis cases. HIV incidence rates were made from HIV-confirmed cases adjusted for year, age, and sex, with population denominators from the INE. A general and specific trend analysis was performed using regression equations.

RESULTS

There is a trend to increase in HIV incidence rates in the study period. 36.48% of the reported cases correspond to the male sex between 20-29 years, group with the highest incidence in the period. The estimated regression equations effectively increase more steadily in the male and young population.

CONCLUSIONS

There are deficit informative and educational factors in HIV prevention in the Chilean population. Despite the strong progression of new cases, the diagnostic gap of people living with HIV who are unaware of their health remains to be consolidated. Gaps were identified between recommendations, public policies and the Chilean results obtained.

Awareness and Willingness to use Condoms and Preexposure Prophylaxis among Gay, Bisexual, and Other Cisgendered Men who Have sex with men in Slum Communities in Ghana. BSGH-004

Introduction: Research has begun to examine human immunodeficiency virus (HIV) prevention strategies within the Ghanaian context. Still, little is known about specific populations such as gay, bisexual, and other cisgender men who have sex with men (GBMSM) living in slum communities. We studied HIV prevention strategies such as condoms and preexposure prophylaxis (PrEP) in slum communities and the awareness and willingness to use these choices among GBMSM. This qualitative study examines HIV prevention strategies, specifically examining PrEP and condom use behaviors among GBMSM in Ghana. Methods: We conducted in-depth face-to-face interviews among 12 GBMSM from slums in Accra and Kumasi cities in Ghana. Data were analyzed through a summative content analysis with multiple reviewers to develop codes. Data were collected from participants in January 2022. Results: We found the fear and perceived risk of infection were motivators for consistent condom use, especially during anal sex. GBMSM living with HIV receiving antiretroviral therapy were more inclined to use condoms. We found motivations for using PrEP were influenced by the type of sexual activity and a history of negative HIV status. Also, the barriers to PrEP for GBMSM included limited access to healthcare facilities and the distance to these facilities. Conclusions: To improve condom and PrEP access and uptake, we recommend addressing structural barriers by increasing the number of health facilities and implementing targeted interventions to address the lack of information on HIV awareness and prevention. Involving peer educators may also effectively promote HIV prevention strategies, especially in communities with limited access to healthcare such as slums. Overcoming these access constraints could significantly enhance awareness and prevention of HIV, leading to improved health outcomes for GBMSM living in slum communities.

Recent HIV Infection: Diagnosis and Public Health Implications

The early period of infection with human immunodeficiency virus (HIV) has been associated with higher infectiousness and, consequently, with more transmission events. Over the last 30 years, assays have been developed that can detect viral and immune biomarkers during the first months of HIV infection. Some of them depend on the functional properties of antibodies including their changing titers or the increasing strength of binding with antigens over time. There have been efforts to estimate HIV incidence using antibody-based assays that detect recent HIV infection along with other laboratory and clinical information. Moreover, some interventions are based on the identification of people who were recently infected by HIV. This review summarizes the evolution of efforts to develop assays for the detection of recent HIV infection and to use these assays for the cross-sectional estimation of HIV incidence or for prevention purposes.

Consistent condom utilization and associated factors among HIV positive clients attending ART clinic at Pawi general hospital, North West Ethiopia

Background

Human immunodeficiency virus (HIV) affects a highly significant number of people and is responsible for the deaths of many people in sub-Saharan African countries alone. The best prevention method for this virus is through consistent condom utilization which can help to prevent drug-resistant HIV infection and acquisition of new infection. Therefore, this study aimed to assess consistent condom utilization and associated factors among HIV-positive individuals attending an antiretroviral therapy clinic at Pawi general hospital, North West Ethiopia in 2020.

Methods

An institutional based cross-sectional study was conducted among 419 HIV-positive individuals who have follow-up in the Pawi general hospital antiretroviral therapy clinics, from January to February 2020. The study subjects were reached using a systematic sampling technique and data were collected using a pretested and structured questionnaire. Data entry and analysis were performed using epi-data version 3.1 and SPSS version 23 respectively. Binary and multivariable analyses with a 95% confidence level were performed. In the final model, variables with P < 0.05 were considered statistically significant.

Results

A total of 419 antiretroviral therapy study participants were participated in the study with a response rate of 100%. In this finding, the consistent condom utilization rate was 49.2% [95% CI: 42.2–56.5%]. After controlling for possible confounding factors, the results showed that place of residence [AOR = 2.16, 95% CI: 1.05, 4.45], marital status [AOR = 0.19, 95%CI: 0.05, 0.67], number of partners [AOR = 0.19, 95% CI: 0.07, 0.55] and level of education [AOR = 5.33, 95% CI: 1.57, 18.08] were associated factors of consistent condom utilization.

Conclusion

Consistent condom utilization among HIV-positive clients attending antiretroviral therapy clinics at Pawi general hospital was low. Residence, marital status, level of education and number of partners were significantly associated factors of consistent condom use. Health education program and counseling services should be started to increase knowledge about way of transmission and appropriate use of condoms, increase self-efficacy towards condom use and reduction in the number of sexual partners.

Effects of Condom Use on Human Immunodeficiency Virus Transmission Among Adolescent Sexual Minority Males in the United States: A Mixed Epidemiology and Epidemic Modeling Study

BACKGROUND

We examined condom use patterns and potential population-level effects of a hypothetical condom intervention on human immunodeficiency virus (HIV) transmission among adolescent sexual minority males (ASMM).

METHODS

Using 3 data sets: national Youth Risk Behavior Survey 2015 to 2017 (YRBS-National), local YRBS data from 8 jurisdictions with sex of partner questions from 2011 to 2017 (YRBS-Trends), and American Men's Internet Survey (AMIS) 2014 to 2017, we assessed associations of condom use with year, age, and race/ethnicity among sexually active ASMM. Using a stochastic agent-based network epidemic model, structured and parameterized based on the above analyses, we calculated the percent of HIV infections averted over 10 years among ASMM ages 13 to 18 years by an intervention that increased condom use by 37% for 5 years and was delivered to 62% of ASMM at age 14 years.

RESULTS

In YRBS, 51.8% (95% confidence interval [CI], 41.3-62.3%) and 37.9% (95% CI, 32.7-42.3%) reported condom use at last sexual intercourse in national and trend data sets, respectively. In AMIS, 47.3% (95% CI, 44.6-49.9%) reported condom use at last anal sex with a male partner. Temporal trends were not observed in any data set (P > 0.1). Condom use varied significantly by age in YRBS-National (P < 0.0001) and YRBS-Trends (P = 0.032) with 13- to 15-year-olds reporting the lowest use in both; age differences were not significant in AMIS (P = 0.919). Our hypothetical intervention averted a mean of 9.0% (95% simulation interval, -5.4% to 21.2%) of infections among ASMM.

CONCLUSIONS

Condom use among ASMM is low and appears to have remained stable during 2011 to 2017. Modeling suggests that condom use increases, consistent with previous interventions, have potential to avert 1 in 11 new HIV infections among ASMM.

Risk Estimation of Sexual Transmission of Zika Virus-United States, 2016-2017

BACKGROUND

Zika virus (ZIKV) can be transmitted sexually but the risk of sexual transmission remains unknown. Most evidence of sexual transmission is from partners of infected travelers returning from areas with ZIKV circulation.

METHODS

We used data from the US national arboviral disease surveillance system on travel- and sexually acquired ZIKV disease cases during 2016-2017 to develop individual-level simulations for estimating risk of male-to-female, male-to-male, and female-to-male sexual transmission of ZIKV via vaginal and/or anal intercourse. We specified parametric distributions to characterize individual-level variability of parameters for ZIKV persistence and sexual behaviors.

RESULTS

Using ZIKV RNA persistence in semen/vaginal fluids to approximate infectiousness duration, male-to-male transmission had the highest estimated probability (1.3% [95% confidence interval, CI, .4%-6.0%] per anal sex act), followed by male-to-female and female-to-male transmission (0.4% [95% CI, .3%-.6%] per vaginal/anal sex act and 0.1% [95% CI, 0%-.8%] per vaginal sex act, respectively). Models using viral isolation in semen vs RNA detection to approximate infectiousness duration predicted greater risk of sexual transmission.

CONCLUSIONS

While likely insufficient to maintain sustained transmission, the estimated risk of ZIKV transmission through unprotected sex is not trivial and is especially important for pregnant women, as ZIKV infection can cause severe congenital disorders.

Cervical cancer prevention and control in women living with human immunodeficiency virus

Despite being highly preventable, cervical cancer is the fourth most common cancer and cause of cancer death in women globally. In low-income countries, cervical cancer is often the leading cause of cancer-related morbidity and mortality. Women living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome are at a particularly high risk of cervical cancer because of an impaired immune response to human papillomavirus, the obligate cause of virtually all cervical cancers. Globally, approximately 1 in 20 cervical cancers is attributable to HIV; in sub-Saharan Africa, approximately 1 in 5 cervical cancers is due to HIV. Here, the authors provide a critical appraisal of the evidence to date on the impact of HIV disease on cervical cancer risk, describe key methodologic issues, and frame the key outstanding research questions, especially as they apply to ongoing global efforts for prevention and control of cervical cancer. Expanded efforts to integrate HIV care with cervical cancer prevention and control, and vice versa, could assist the global effort to eliminate cervical cancer as a public health problem.

Prevalence of Consistent Condom Use and Associated Factors among Serodiscordant Couples in Ethiopia, 2020: A Mixed-Method Study

BACKGROUND

Heterosexual transmission within serodiscordant relationships is the core source of new HIV infections. Although consistent condom use can significantly reduce HIV transmission risk among serodiscordant couples, it has not been extensively studied in Ethiopia. Consequently, the current study looked at the proportion of serodiscordant couples in Ethiopia who used condoms consistently and the factors associated with that.

METHODS

A cross-sectional was conducted from October 2019 to June 2020. For the quantitative findings to be more robust and reliable, a qualitative design was incorporated. An interviewer-administered questionnaire was used to collect the data. Qualitative data were collected using gender-matched four focus group discussions. Multivariable logistic regression was conducted to identify factors associated with consistent condom use. The statistical significance of the variables was declared at a P value of less than 0.05.

RESULTS

This study confirmed that the proportion of consistent condom use was 58.4% [95% CI: 53.1-63.1%]. After controlling for all other variables, unmarried partners, adjusted odds ratio (AOR) = 0.44 [95% CI: 0.229-0.877] and students and employees, AOR = 0.33 [95% CI: 0.130-0.846] and AOR = 0.39 [95% CI: 0.165-0.939], respectively, were less likely consistently use condoms, whereas couples living together, AOR = 1.86 [95% CI: 1.197-2.195], receiving counseling about condom use, AOR = 1.90 [95% CI: 1.182-3.076], and having more knowledge about HIV, AOR = 1.61 [95% CI: 1.031-2.525] were more likely to use condoms consistently.

CONCLUSION

Despite its importance, the proportion of consistent condom use among serodiscordant couples was significantly low. To improve condom use consistently, planners, policymakers, and health care practitioners should consider the factors listed above when making decisions. There should be an increased focus on student and employee intervention as well.

Using mobile health technologies to test the association of cocaine use with sexual desire and risky sexual behaviors among people with and without HIV who use illicit stimulants

BACKGROUND

Cocaine use is broadly associated with risky sexual behavior potentially through elevated sexual desire. Understanding the within-person effects of cocaine on sexual desire and risky sexual behavior and the modification of HIV infection may inform primary and secondary HIV interventions.

METHODS

We conducted a mobile health (mHealth) study in a community sample of males and females with (n = 28) and without (n = 32) HIV who use illicit stimulant drugs. Participants completed ecological momentary assessments (EMAs) and daily diaries over 28 days. Mixed effects models were employed to examine the within-person association of cocaine use with sexual desire and risky sexual behavior.

RESULTS

Participants completed 3505 EMA responses, with 36 % involving recent cocaine use, including powder and/or crack cocaine. They completed 1427 daily diary responses, with cocaine use reported on 49 % of these days and sexual behavior on 21 % of these days. Sexual desire was highest in the first hour since cocaine use and gradually decreased with time. Sexual desire was lowest when participants had not used any cocaine in the past 6 h, and it correlated positively with the amount of use. Participants were more likely to have risky sexual behavior on days they used cocaine. These associations were similar for participants with and without HIV.

CONCLUSION

This study demonstrates the dynamic and proximal effects of cocaine use on sexual desire and risky sexual behavior. Our findings support the development of HIV prevention interventions that utilize mHealth technology to reduce sexual risk behavior among persons who use stimulant drugs.

Sexually Transmitted Infections Treatment Guidelines, 2021

These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11-14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.

The Magnetic Couples Study: protocol for a mixed methods prospective cohort study of HIV-serodifferent heterosexual couples' perspectives and use of pre-exposure prophylaxis (PrEP)

INTRODUCTION

HIV transmission within serodifferent heterosexual couples plays a key role in sustaining the global HIV pandemic. In the USA, transmission within established mixed-status couples accounts for up to half of all new HIV infections among heterosexuals. Oral HIV pre-exposure prophylaxis (PrEP) is a highly effective prevention method, although underutilised among serodifferent couples. Moreover, there is a dearth of research on US HIV-serodifferent couples' perspectives and use of PrEP, alone or in combination with other prevention methods. In this paper, we describe the study protocol for the Magnetic Couples Study, designed to fill critical knowledge gaps regarding HIV-serodifferent heterosexual couples' perspectives, experiences and utilisation of PrEP.

METHODS AND ANALYSIS

The Magnetic Couples Study is a mixed methods prospective cohort study designed to describe temporal patterns and identify determinants at multiple levels (individual, couple, HCF) of PrEP outcomes along the care continuum (PrEP awareness, linkage, uptake, retention and medication adherence) among HIV-serodifferent heterosexual couples residing in New York City. The study will also examine clinical management of PrEP, side effects and changes in sexual-related and substance use-related behaviour. A prospective cohort of 230 mixed-status couples already on oral PrEP was recruited, with quarterly assessments over 18 months; in addition, a cross-sectional sample of 150 mixed-status couples not currently on PrEP was recruited. In-depth semistructured qualitative interviews were conducted with a subsample of 25 couples. Actor-partner interdependence modelling using multilevel analysis will be employed for the analysis of longitudinal dyadic data. Framework analysis will be used to analyse qualitative data. A parallel convergent design will be used for mixed methods integration.

ETHICS AND DISSEMINATION

The study was approved by the University of Rochester Institutional Review Board (RSRB00052766). Study findings will be disseminated to community members and providers and to researchers and policy makers.

Progress toward HIV elimination goals: trends in and projections of annual HIV testing and condom use in Africa

OBJECTIVES

To estimate trends in and projections of annual HIV testing and condom use at last higher-risk sex and to calculate the probability of reaching key United Nations Programme on AIDS (UNAIDS)'s target.

DESIGN

We included 114 nationally-representative datasets in 38 African countries from Demographic and Health Surveys and Multiple Indicator Cluster Surveys with 1 456 224 sexually active adults age 15-49 from 2003 to 2018.

METHODS

We applied Bayesian mixed effect models to estimate the coverage of annual HIV testing and condom use at last higher-risk sex for every country and year to 2030 and the probability of reaching UNAIDS testing and condom use targets of 95% coverage by 2030.

RESULTS

Seven countries saw downward trends in annual HIV testing and four saw decreases in condom use at higher-risk sex, whereas most countries have upward trends in both indicators. The highest coverage of testing in 2030 is predicted in Swaziland with 92.6% (95% credible interval: 74.5-98.1%), Uganda with 90.5% (72.2-97.2%), and Lesotho with 90.5% (69.4%-97.6%). Meanwhile, Swaziland, Lesotho, and Namibia will have the highest proportion of condom use in 2030 at 85.0% (57.8-96.1%), 75.6% (42.3-93.6%), and 75.5% (42.4-93.2%). The probabilities of reaching targets were very low for both HIV testing (0-28.5%) and condom use (0-12.1%).

CONCLUSIONS

We observed limited progress on annual HIV testing and condom use at last higher-risk sex in Africa and little prospect of reaching global targets for HIV/AIDS elimination. Although some funding agencies are considering withdrawal from supporting Africa, more attention to funding and expanding testing and treatment is needed in this region.

Antiretroviral drug exposure in urethral and glans surface sampling of the penis

BACKGROUND

HIV exposure to penile tissues provides a risk of acquisition among men, yet studies evaluating penile antiretroviral (ARV) drug distribution have been lacking. We measured ARVs on urethral and glans surface swabs collected following a dose of tenofovir alafenamide, emtricitabine, elvitegravir, darunavir and cobicistat.

METHODS

Thirty-five HIV-negative male participants provided urethral swabs, glans swabs, rectal swabs, blood and urine up to 96 h following a single dose of tenofovir alafenamide/emtricitabine/elvitegravir/cobicistat and darunavir. ARVs were measured by liquid chromatography-mass spectrometry with a lower limit of detection (LOD) of 1 ng/swab for swabs and 10 ng/mL for plasma and urine. Concentrations are reported as median and range.

RESULTS

Urethral swab emtricitabine and darunavir concentrations peaked at 4 h for emtricitabine (36 ng/swab; 3-307 ng/swab) and 8 h for darunavir (25 ng/swab; 2-52 ng/swab). Glans swab emtricitabine and darunavir concentrations peaked 24 h after dosing (emtricitabine 14 ng/swab, <LOD-328 ng/swab; darunavir 6 ng/swab, <LOD-149 ng/swab). Estimated peak urethral secretion emtricitabine and darunavir concentrations are between 10 and 20 μg/mL, similar to rectal secretions, 4-fold greater than in plasma, but 2-fold lower than in urine. Tenofovir and elvitegravir were detected on less than 20% of urethral or glans swabs collected within 24 h of dosing.

CONCLUSIONS

We document ARV dosing in the urethra and on the glans surface with high drug concentrations noted for emtricitabine and darunavir and lower tenofovir and elvitegravir concentrations. Data suggest a potential protective role of urethral emtricitabine or darunavir against penile HIV acquisition.

Quantifying the Evolving Contribution of HIV Interventions and Key Populations to the HIV Epidemic in Yaoundé, Cameroon

BACKGROUND

Key populations (KP) including men who have sex with men (MSM), female sex workers (FSW), and their clients are disproportionately affected by HIV in Sub-Saharan Africa. We estimated the evolving impact of past interventions and contribution of unmet HIV prevention/treatment needs of key populations and lower-risk groups to HIV transmission.

SETTING

Yaoundé, Cameroon.

METHODS

We parametrized and fitted a deterministic HIV transmission model to Yaoundé-specific demographic, behavioral, HIV, and intervention coverage data in a Bayesian framework. We estimated the fraction of incident HIV infections averted by condoms and antiretroviral therapy (ART) and the fraction of all infections over 10-year periods directly and indirectly attributable to sex within and between each risk group.

RESULTS

Condom use and ART together may have averted 43% (95% uncertainty interval: 31-54) of incident infections over 1980-2018 and 72% (66-79) over 2009-2018. Most onward transmissions over 2009-2018 stemmed from sex between lower-risk individuals [47% (32-61)], clients [37% (23-51)], and MSM [35% (20-54)] with all their partners. The contribution of commercial sex decreased from 25% (8-49) over 1989-1998 to 8% (3-22) over 2009-2018, due to higher intervention coverage among FSW.

CONCLUSION

Condom use and recent ART scale-up mitigated the HIV epidemic in Yaoundé and changed the contribution of different partnerships to onward transmission over time. Findings highlight the importance of prioritizing HIV prevention and treatment for MSM and clients of FSW whose unmet needs now contribute most to onward transmission, while maintaining services that successfully reduced transmissions in the context of commercial sex.

Drug Injection-Related and Sexual Behavior Changes in Drug Injecting Networks after the Transmission Reduction Intervention Project (TRIP): A Social Network-Based Study in Athens, Greece

The Transmission Reduction Intervention Project (TRIP) was a network-based, enhanced contact tracing approach, targeting recently HIV-infected people who inject drugs (PWID) in Athens, Greece (2013–2015). This analysis examines behavioral changes of participants in TRIP and their determinants between baseline and follow-up visits to the program. All participants of TRIP were tested for HIV and interviewed using a questionnaire with items on drug injection-related and sexual behaviors. Multivariable logistic regression models were used to examine potential relationships between participants’ behaviors and sociodemographic or other characteristics. The analysis included 292 participants. At follow-up, the percentage of participants who injected drugs decreased [92.5%, n = 270 versus 72.3%, n = 211 (p < 0.001)], and more participants adopted safer behaviors. Employment, age, and gender were significantly associated with some behavioral changes. For instance, unemployed participants were half as likely as the employed to stop drug injection [adjusted odds ratio (aOR): 0.475, 95% confidence interval (CI): 0.228, 0.988]. Increasing age was associated with lower probability of sharing syringes at follow-up (aOR: 0.936, 95%CI: 0.887, 0.988). Finally, females were less likely than males to improve their behavior related to sharing cookers, filters, or rinse water (aOR: 0.273, 95% CI: 0.100, 0.745). In conclusion, adoption of safer behaviors was observed following TRIP implementation. Future prevention programs should focus on younger PWID and especially females. Social efforts to support employment of PWID are also important.

Actions taken by female sex workers (FSWs) after condom failure in semi urban Blantyre, Malawi

Background

Little is known about actions taken by female sex workers (FSWs) after male condom failure during male–female sexual intercourse. The objective of this study was to investigate the actions taken by FSWs after condom failure among FSWs in semi-urban, Blantyre in Malawi.

Methods

A cross sectional, qualitative study was conducted among FSWs in Blantyre, Malawi between May and July 2019. Snowballing technique was used to recruit study participants in four purposively selected study sites. Focus group discussions and in-depth interviews were conducted by trained research assistants among 40 FSWs. Data were analyzed using thematic content analysis.

Results

Study participants reported having taken different actions after condom failure. Out of 18 FSWs who experienced condom failure, 10 reported to have stopped sex immediately and changed the condom and then resumed afterwards. They reported to have douched, urinated, and/or squatted to prevent pregnancy, sexually transmitted infections (STIs) and HIV acquisition. Five study participants reported to have asked for extra pay from the client; 10 FSWs didn’t seek medical care. They thought the actions taken were enough for HIV and pregnancy prevention. Out of the 18 FSWs, only 3 stopped sexual intercourse completely and sought medical care which included post-exposure prophylaxis for HIV, STI treatment, and emergency contraceptives. Another 3 reported that they did not stop the sexual intercourse but only squatted and/or douched after sexual intercourse. The remaining 2 FSWs reported not to have stopped sexual intercourse and no any other actions were taken after the condom failure.

Conclusion

We report some inadequate behaviors among FSWs after condom failure. Health programs should develop interventions and support the performance of safer sex and actions after condom failure among FSWs to prevent STIs including HIV, and unplanned pregnancies. Interpersonal, structural and policy factors hindering FSWs’ access to perform effective interventions need to be addressed.

Facilitators and barriers to condom use among Filipinos: A systematic review of literature

Background: Between 2010 and 2018, the Philippines had a 203% increase in new human immunodeficiency virus (HIV) infections. The use of condoms is an effective and practical means to prevent HIV transmission. The purpose of this study was to identify facilitators and barriers to condom use among Filipinos guided by the Ecological Model of Health Promotion.

Methods: A systematic review of literature using electronic databases was performed using the following keywords: "condom," "Filipinos," and "Philippines." To be included in this review, papers should be (1) research studies, (2) studies that examined condom use, and (3) studies that sampled Filipinos residing in the Philippines. The final sample comprised of 27 articles.

Results: Multiple and interrelated factors at the individual and social environment levels influence condom use among different groups of Filipinos. Majority of these factors originated at the intrapersonal level. Some of the facilitators to condom use were knowledge on HIV, higher perceived HIV risk, peer support, positive manager attitude, health provider engagement, and city ordinances. In contrast, some of the barriers to condom use were discomfort and displeasure on condom use, low parental communication, lack of sex education, social stigma, and the high price of condoms.

Conclusion: A collaborative, culturally-sensitive, and population-specific approach is essential to develop and implement acceptable, sustainable, and successful condom use interventions.

Durable protection against repeated penile exposures to simian-human immunodeficiency virus by broadly neutralizing antibodies

Penile acquisition of HIV accounts for most infections among men globally. Nevertheless, candidate HIV interventions for men advance to clinical trials without preclinical efficacy data, due primarily to a paucity of relevant animal models of penile HIV infection. Using our recently developed macaque model, we show that a single subcutaneous administration of broadly neutralizing antibody (bNAb) 10-1074 conferred durable protection against repeated penile exposures to simian-human immunodeficiency virus (SHIV_SF162P3). Macaques co-administered bNAbs 10-1074 and 3BNC117, or 3BNC117 alone, also exhibited significant protection against repeated vaginal SHIV_AD8-EO exposures. Regression modeling estimated that individual plasma bNAb concentrations of 5 μg ml^-1 correlated with ≥99.9% relative reduction in SHIV infection probability via penile (10-1074) or vaginal (10-1074 or 3BNC117) challenge routes. These results demonstrate that comparably large reductions in penile and vaginal SHIV infection risk among macaques were achieved at clinically relevant plasma bNAb concentrations and inform dose selection for the development of bNAbs as long-acting pre-exposure prophylaxis candidates for use by men and women.

Integrating HIV pre-exposure prophylaxis and harm reduction among men who have sex with men and transgender women to address intersecting harms associated with stimulant use: a modelling study

INTRODUCTION

Among men who have sex with men (MSM) and transgender women (TW), stimulant use is high and has been associated with an increased risk of HIV infection, suicide and cardiovascular disease (CVD) mortality. We used epidemic modelling to investigate these intersecting health harms among MSM/TW in Lima, Peru and assess whether they could be mitigated by prioritizing HIV pre-exposure prophylaxis (PrEP) and harm reduction interventions among MSM/TW who use stimulants.

METHODS

We adapted a dynamic model of HIV transmission among MSM/TW in Lima to incorporate stimulant use and increased HIV risk, suicide and CVD mortality. Among 6% to 24% of MSM/TW using stimulants (mostly cocaine), we modelled an increased risk of unprotected anal sex (RR = 1.35 [95%CI: 1.17 to 1.57]) obtained from local data, and increased risk of suicide (SMR = 6.26 [95%CI: 2.84 to 13.80]) and CVD (SMR = 1.83 [95%CI: 0.39 to 8.57]) mortality associated with cocaine use based on a global systematic review. We estimated the proportion of health harms occurring among MSM/TW who use stimulants in the next year (01-2020/01-2021). We also investigated the 10-year impact (01-2020/01-2030) of: (1) PrEP prioritization for stimulant-using MSM/TW compared to random allocation, and (2) integrating PrEP with a theoretical intervention halving stimulant-associated risk.

RESULTS

MSM/TW in Lima will experience high HIV incidence, suicide mortality and CVD mortality (1.6/100 py, and 0.018/100 py, 0.13/100 py respectively) in 2020. Despite stimulant using MSM/TW comprising an estimated 9.5% (95%CI: 7.8 to 11.5) of all MSM/TW, in the next year, 11% 95%CI (i.e. 2.5% to 97.5% percentile) 10% to 13%) of new HIV infections, 39% (95%CI: 18% to 60%) of suicides and 15% (95%CI: 3% to 44%) of CVD deaths could occur among this group. Scaling up PrEP among all stimulant using MSM/TW could prevent 19% (95%CI: 11% to 31%) more HIV infections over 10 years compared to random allocation. Integrating PrEP and an intervention to halve stimulant-associated risks could reduce new HIV infections by 20% (95%CI: 10% to 37%), suicide deaths by 14% (95%CI: 5% to 27%) and CVD deaths by 3% (95%CI: 0% to 16%) over a decade.

CONCLUSIONS

MSM/TW who use stimulants experience a disproportionate burden of health harms. Prioritizing PrEP based on stimulant use, in addition to sexual behaviour/gender identity criteria, could increase its impact. Integrated substance use, harm reduction, mental health and HIV care among MSM/TW is needed.

"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.

Errors in Condom Use in the Setting of HIV Transmission: A Systematic Review

Background:

The efficacy of condom use in declining HIV transmission may be compromised by their incorrect usage. Much focus has been paid on the regularity of condom usage but consumer mistakes and challenges must be considered. Breakage, slipping, leakage, incomplete use and other problems during the sexual event may compromise the protective role of the condom.

Objective:

To evaluate through a systematic review of published data, the type, and incidence of error and problems in condom use, and their possible role in reducing the preventive action of condoms.

Methods:

A systematic literature search for peer-reviewed articles published between January 2000 and January 2019, issued in English in peer-reviewed journals, and reporting the occurrence of condom errors/problems among HIV high-risk populations.

Results:

Twenty studies representing nine countries met the inclusion criteria. The most predominant mistakes associated with condom use included condom breakage, slippage, delayed condom application, early removal, issues related to erection loss and difficulties with fit and feel were reported, failure to squeeze out air, use of expired condoms, reuse of condom, and wearing the condom outside out were other issues noticed.

Conclusions:

Condom use problems and mistakes are prevalent across the globe. Educational efforts are needed to empower HIV the at-risk population with confidence and knowledge to improve correct condom use and increase preventive activity

Responding to global stimulant use: challenges and opportunities

We did a global review to synthesise data on the prevalence, harms, and interventions for stimulant use, focusing specifically on the use of cocaine and amphetamines. Modelling estimated the effect of cocaine and amphetamine use on mortality, suicidality, and blood borne virus incidence. The estimated global prevalence of cocaine use was 0·4% and amphetamine use was 0·7%, with dependence affecting 16% of people who used cocaine and 11% of those who used amphetamine. Stimulant use was associated with elevated mortality, increased incidence of HIV and hepatitis C infection, poor mental health (suicidality, psychosis, depression, and violence), and increased risk of cardiovascular events. No effective pharmacotherapies are available that reduce stimulant use, and the available psychosocial interventions (except for contingency management) had a weak overall effect. Generic approaches can address mental health and blood borne virus infection risk if better tailored to mitigate the harms associated with stimulant use. Substantial and sustained investment is needed to develop more effective interventions to reduce stimulant use.

Critical evaluation of arguments opposing male circumcision: A systematic review

OBJECTIVE

To systematically evaluate evidence against male circumcision (MC).

METHODS

We searched PubMed, Google Scholar, EMBASE and Cochrane databases.

RESULTS

Database searches retrieved 297 publications for inclusion. Bibliographies of these yielded 101 more. After evaluation we found: Claims that MC carries high risk were contradicted by low frequency of adverse events that were virtually all minor and easily treated with complete resolution. Claims that MC causes psychological harm were contradicted by studies finding no such harm. Claims that MC impairs sexual function and pleasure were contradicted by high-quality studies finding no adverse effect. Claims disputing the medical benefits of MC were contradicted by a large body of high-quality evidence indicating protection against a wide range of infections, dermatological conditions, and genital cancers in males and the female sexual partners of men. Risk-benefit analyses reported that benefits exceed risks by 100-200 to 1. To maximize benefits and minimize risks, the evidence supported early infant MC rather than arguments that the procedure should be delayed until males are old enough to decide for themselves. Claims that MC of minors is unethical were contradicted by balanced evaluations of ethical issues supporting the rights of children to be provided with low-risk, high-benefit interventions such as MC for better health. Expert evaluations of case-law supported the legality of MC of minors. Other data demonstrated that early infant MC is cost-saving to health systems.

CONCLUSIONS

Arguments opposing MC are supported mostly by low-quality evidence and opinion, and are contradicted by strong scientific evidence.

Global patterns of opioid use and dependence: harms to populations, interventions, and future action

We summarise the evidence for medicinal uses of opioids, harms related to the extramedical use of, and dependence on, these drugs, and a wide range of interventions used to address these harms. The Global Burden of Diseases, Injuries, and Risk Factors Study estimated that in 2017, 40·5 million people were dependent on opioids (95% uncertainty interval 34·3-47·9 million) and 109 500 people (105 800-113 600) died from opioid overdose. Opioid agonist treatment (OAT) can be highly effective in reducing illicit opioid use and improving multiple health and social outcomes-eg, by reducing overall mortality and key causes of death, including overdose, suicide, HIV, hepatitis C virus, and other injuries. Mathematical modelling suggests that scaling up the use of OAT and retaining people in treatment, including in prison, could avert a median of 7·7% of deaths in Kentucky, 10·7% in Kiev, and 25·9% in Tehran over 20 years (compared with no OAT), with the greater effects in Tehran and Kiev being due to reductions in HIV mortality, given the higher prevalence of HIV among people who inject drugs in those settings. Other interventions have varied evidence for effectiveness and patient acceptability, and typically affect a narrower set of outcomes than OAT does. Other effective interventions focus on preventing harm related to opioids. Despite strong evidence for the effectiveness of a range of interventions to improve the health and wellbeing of people who are dependent on opioids, coverage is low, even in high-income countries. Treatment quality might be less than desirable, and considerable harm might be caused to individuals, society, and the economy by the criminalisation of extramedical opioid use and dependence. Alternative policy frameworks are recommended that adopt an approach based on human rights and public health, do not make drug use a criminal behaviour, and seek to reduce drug-related harm at the population level.

Knowledge, Normative Beliefs and Attitudes Related to Recent HIV Infection among People who Inject Drugs in Athens, Greece

BACKGROUND

Despite great improvements in prevention over the last years, much has to be done to reduce new human immunodeficiency virus (HIV) infections. Substantial evidence shows that the six-month period of recent HIV infection contributes disproportionately to HIV transmission.

OBJECTIVE

This study aims to investigate knowledge, normative beliefs, and attitudes of people who inject drugs (PWID) regarding recent HIV infection.

METHODS

People who inject drugs in Athens, Greece were recruited in the fifth round of a respondent- driven sampling program (ARISTOTLE). The participants were tested for HIV and answered a structured questionnaire, which also included items on knowledge, normative beliefs, and attitudes regarding recent infection to address needs of the social network-based Transmission Reduction Intervention Project. The multivariable analyses included logistic regression models, which produced odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

In total, 1,407 people (mean age: 36.3 ± 7.9 years old; males: 81.9%) took part in the fifth round of ARISTOTLE. Of these, 61.5% knew that HIV-infected people who are not on treatment are more likely to transmit HIV during the first six months of their infection and 58.4% reported that people in their network would react positively towards a recently HIV-infected person. People who inject drugs who were knowledgeable of recent HIV infection were more likely to disagree with statements such as that one should avoid all contact with a person recently infected by HIV (adjusted OR: 1.510, 95% CI: 1.090, 2.091) or more likely to agree with statements such as that an HIV+ person is much less likely to transmit HIV when h/she is on combination antiretroviral treatment (adjusted OR: 2.083, 95% CI: 1.231, 3.523).

CONCLUSION

A considerable proportion of PWID in Athens, Greece, were aware of the high HIV transmission risk of recent HIV infection, although improvement is needed for some population segments. People who inject drugs who were knowledgeable of the role of recent HIV infection were more likely to have normative beliefs and attitudes that favor behaviors that could help rather than harm or stigmatize people who have recently been infected with HIV. Interventions that are based on the role of recent HIV infection in HIV transmission could be important to HIV prevention.

Social capital, migration stress, depression and sexual risk behaviors among rural-to-urban migrants in China: a moderated mediation modeling analysis

Background: Few studies have examined the complex relationship of migration stress and depression with sexual risk behaviors among migrants. The relationship between migration stress and sexual risk behaviors may be mediated by depression, and the mediation process may be modified by social capital. The study aims to investigate this moderated mediation mechanism among rural-to-urban migrants. Methods: Data were collected from rural-to-urban migrants in China. Migration stress, depression, and social capital were measured with validated scales and used as predictor, mediator and moderator, respectively, to predict the likelihood of having sex with risk partners. Mediation and moderated mediation models were used to analyze the data. Results: Depression significantly mediated the migration stress-sex with risk partner relationship for males (the indirect effect [95%CI] = 0.36 [0.08, 0.66]); the mediation effect was not significant for females (0.31 [-0.82, 0.16]). Among males, social capital significantly moderated the depression-sex with risk partner relation with moderation effect -0.12 [-0.21, -0.04], -0.21 [-0.41, -0.01] and -0.17 [-0.30, -0.05] for total, bonding and bridging capital respectively. Conclusion: Social capital may weaken the association between migration stress and sexual risk behavior by buffering the depression-sexual risk behaviors association for males. Additional research is needed to examine this issue among females.

Effectiveness of a Couple-Based HIV and Sexually Transmitted Infection Prevention Intervention for Men in Community Supervision Programs and Their Female Sexual Partners: A Randomized Clinical Trial

IMPORTANCE

In the United States, the prevalence rates of HIV and sexually transmitted infections (STIs) are higher among individuals in community supervision programs (CSPs) than in the general population. However, to date, no couple-based HIV or STI prevention interventions have been implemented for the large number of men in CSPs.

OBJECTIVE

To determine the effectiveness of a 5-session couple-based prevention intervention, compared with a 1-session counseling, testing, and referral (CTR) program, in reducing HIV and STIs as well as condomless intercourse among men in CSPs and their female sexual partners.

DESIGN, SETTING, AND PARTICIPANTS

A randomized clinical trial was conducted from July 11, 2013 (first recruitment), through May 17, 2016 (last randomization). Participants were drug-involved men mandated to a CSP and their female sexual partners (n = 230 couples or 460 individuals). Participants were recruited from various CSP sites in New York, New York, and randomized into either the PACT (Protect and Connect) intervention condition or the HIV CTR control condition (n = 115 couples or 230 individuals in each arm). Analysis of behavioral outcomes used an intent-to-treat approach. Statistical analyses were conducted from November 1, 2017, through June 1, 2018.

MAIN OUTCOMES AND MEASURES

Self-reported data on sexual behaviors in the past 90 days were used to assess behavioral outcomes at all time points. Biomarkers were collected at baseline and 12 months, and behavioral outcomes were collected at baseline and 3, 6, and 12 months.

RESULTS

A total of 230 couples (460 individuals) were included. The mean (SD) age of participants was 35.0 (12.8) years, and most participants (341 [74.1%]) self-identified as black or African American race/ethnicity. Of the 18 new cases of STIs identified at the 12-month assessment, 10 came from the PACT arm and 8 from the HIV CTR control arm. Compared with the control participants, PACT participants had 33% fewer acts of condomless vaginal and/or anal intercourse with their main partner (incidence rate ratio [IRR], 0.67; 95% CI, 0.45-0.99; P = .04), 70% fewer acts with other partners (IRR, 0.30; 95% CI, 0.12-0.74; P = .009), and 40% fewer acts with all sexual partners (IRR, 0.60; 95% CI, 0.42-0.85; P = .005) over the entire follow-up period. In addition, PACT participants were less likely to report being under the influence of drugs or alcohol the last time they had vaginal and/or anal intercourse with their study partners (odds ratio, 0.55; 95% CI, 0.31-0.96; P = .04) and had 26% fewer sexual partners in the past 90 days (IRR, 0.74; 95% CI, 0.61-0.88; P = .001). At 12 months, HIV and STI incidence did not differ significantly between the 2 arms.

CONCLUSIONS AND RELEVANCE

The PACT intervention appeared to reduce risky sexual behaviors, such as condomless intercourse; this finding suggests that a couple-based HIV and STI prevention intervention program may curb the burgeoning HIV epidemic in CSPs.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01690494.

Does Male Circumcision Reduce Women's Risk of Sexually Transmitted Infections, Cervical Cancer, and Associated Conditions?

Background: Male circumcision (MC) is proven to substantially reduce men's risk of a number of sexually transmitted infections (STIs). We conducted a detailed systematic review of the scientific literature to determine the relationship between MC and risk of STIs and associated conditions in women. Methods: Database searches by "circumcision women" and "circumcision female" identified 68 relevant articles for inclusion. Examination of bibliographies of these yielded 14 further publications. Each was rated for quality using a conventional rating system. Results: Evaluation of the data from the studies retrieved showed that MC is associated with a reduced risk in women of being infected by oncogenic human papillomavirus (HPV) genotypes and of contracting cervical cancer. Data from randomized controlled trials and other studies has confirmed that partner MC reduces women's risk not only of oncogenic HPV, but as well Trichomonas vaginalis, bacterial vaginosis and possibly genital ulcer disease. For herpes simplex virus type 2, Chlamydia trachomatis, Treponema pallidum, human immunodeficiency virus and candidiasis, the evidence is mixed. Male partner MC did not reduce risk of gonorrhea, Mycoplasma genitalium, dysuria or vaginal discharge in women. Conclusion: MC reduces risk of oncogenic HPV genotypes, cervical cancer, T. vaginalis, bacterial vaginosis and possibly genital ulcer disease in women. The reduction in risk of these STIs and cervical cancer adds to the data supporting global efforts to deploy MC as a health-promoting and life-saving public health measure and supplements other STI prevention strategies.

Effectiveness of female condom in preventing HIV and sexually transmitted infections: a systematic review protocol

INTRODUCTION

The HIV pandemic continues to evolve with young women being the most vulnerable group to acquire infection. The presence of sexually transmitted infections (STIs) further enhances HIV susceptibility and also leads to long-term complications such as infertility and cervical cancer. The female condom is a self-initiated method for STI and HIV prevention but there are controversies on its effects. We aim to assess the effectiveness, safety and acceptability of the use of female condoms for prevention of STI and HIV acquisition among women.

METHODS AND ANALYSIS

We will search Cochrane Central Register of Controlled Trials, PubMed, EMBASE, Scopus, WHO International Clinical Trials Registry and reference lists of relevant publications for potentially eligible studies. We will screen search outputs, select eligible studies, extract data and assess risk of bias in duplicate; resolving discrepancies through discussion and consensus or arbitration. We will combine data from clinically homogenous studies in a fixed effect meta-analysis and assess the certainty of the evidence using the method for Grading of Recommendations Assessment, Development and Evaluation. We registered the planned systematic review with the International Prospective Register of Systematic Reviews (PROSPERO) in March 2018 and will finalise the search strategy in August 2018; conduct the searches and select eligible studies between August and October 2018; and collect data, conduct statistical analyses and prepare and submit the manuscript for consideration by a peer-reviewed journal between November 2018 and April 2019.

ETHICS AND DISSEMINATION

We will use publicly available data; hence no formal ethical approval is required for this review. We will disseminate the findings of this review through conference presentations and publication in an open-access peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42018090710.

Diagnostics as Prevention - A Rapid Testing-Based Strategy of Sex Workers against Sexual HIV Exposure

Introduction

German sex workers have illegally established a prevention strategy, which consists of testing potential sexual partners with human immunodeficiency virus (HIV)-specific rapid diagnostic tests (RDTs) prior to engaging in unprotected sexual intercourse eventually performed in case of a negative test result. Based on a recently established modeling approach, the effectiveness of this strategy regarding the risk of HIV exposure was compared with protection provided by condom use.

Methods

Based on a literature search, the following assumptions were used for the calculations: an averaged 80% exposure risk reduction with a condom used during sexual intercourse, usage of a well-characterized 4th-generation HIV RDT, and a 10 day post-infection period without any measurable viral load in peripheral blood followed by a sero-conversion period of about 3 weeks with 12.3% test sensitivity (antigen-specific) and only afterwards 97.3% (antibody-specific) test sensitivity.

Results

In most constellations, the HIV exposure risk in case of RDT-based prevention was lower than with condom use. Conclusions: The RDT-based HIV exposure prevention as established by sex workers is effective in most situations. A notable weakness of the strategy is the RDTs' poor sensitivity in spite of a high transmission risk during the seroconversion stage.

HIV prevention strategies and risk of infection: a model-based analysis

Risk populations for HIV infections tend to neglect condom use, making alternative preventive approaches necessary. Accordingly, we modelled the risk of sexual HIV transmission for condom use vs. use of rapid diagnostic test (RDT) systems with subsequent exclusion of potential sexual partners with a correctly or falsely positive test from unprotected sex with and without the use of HIV pre-exposure prophylaxis (PrEP) in a bio-statistical approach. We combined a previously described model of transmission risk for HIV-exposed individuals with a newly suggested model of risk of HIV exposure for sexually active HIV-negative individuals. The model was adapted for several stages of infection and different strategies of HIV infection prevention.HIV prevention with RDTs can reduce the transmission risk by up to 97% compared with having sex without any prevention and up to 80% compared with condom use. Nevertheless, RDT-based prevention strategies demonstrate a lack of protection in several stages of infection; in particular, RNA-based RDT systems may fail under treatment. RDT-based pre-screening of potential sex partners prior to unprotected sexual contacts substantially reduces HIV transmission risk. Combination of different prevention strategies is advisable for high-risk groups.

Pre-exposure prophylaxis (PrEP) in an era of stalled HIV prevention: Can it change the game?

Pre-exposure prophylaxis (PrEP) for HIV prevention has evolved significantly over the years where clinical trials have now demonstrated the efficacy of oral PrEP, and the field is scaling-up implementation. The WHO and UNAIDS have made PrEP implementation a priority for populations at highest risk, and several countries have developed guidelines and national plans accordingly, largely based on evidence generated by demonstration projects. PrEP presents the opportunity to change the face of HIV prevention by offering a new option for protection against HIV and disrupting current HIV prevention systems. Nevertheless, as with all new technologies, both practical and social requirements for implementation must be taken into account if there is to be sustained and widespread adoption, which will also apply to forthcoming prevention technologies. Defining and building success for PrEP within the scope of scale-up requires careful consideration. This review summarises where the PrEP field is today, lessons learned from the past, the philosophy and practicalities of how successful programming may be defined, and provides perspectives of costs and affordability. We argue that a successful PrEP programme is about effective intervention integration and ultimately keeping people HIV negative.

Inconsistent Condom Use Among Male University Students in Northern Thailand

University students are at increased risk of HIV infection, but little is known about the determinants of inconsistent condom use among them. The study aims to assess the association of sociodemographic, individual, dyadic, and social factors with inconsistent condom use among male university students. Of 1091 participants, 67.0% had sexual intercourse, though 64.4% had inconsistent condom use. It was found that "did not use a condom at first sexual intercourse" (adjusted odds ratio [AOR] 6.1; CI, 3.7-10.1), "history of STIs" (AOR, 2.1; CI, 1.0-4.2), low "self-efficacy" (AOR, 2.4; CI, 1.3-4.7), "perception that condom use reduces pleasure" (AOR, 1.4; CI, 1.0-2.1), and "high subjective norm" (AOR, 1.9; CI, 1.3-2.8) were associated with increased odds of inconsistent condom use. Condom use should be promoted from the onset of sexual activity to establish a habit of safe sex practices and for improvement in self-efficacy of condom use. Emphasis must be laid on pleasure-enhancing benefits of condom use and changing social norms.

Condomless sex and HIV transmission among serodifferent couples: current evidence and recommendations

Human immunodeficiency virus (HIV) infection remains a global pandemic. The primary driver of HIV incidence is sexual transmission between serodifferent individuals. Condoms, when used consistently and correctly, are effective at preventing sexually transmitted HIV infections and are considered an integral component of a comprehensive approach to HIV prevention. However, the demonstrated effectiveness of antiretroviral therapy (ART) to prevent HIV transmission, known as treatment as prevention and of pre-exposure prophylaxis, have raised an intriguing dilemma on the necessity and additive preventive benefit of condom use among individuals in serodifferent relationships utilizing these prevention strategies. Recent published evidence, although of limited follow-up duration, has shown no linked HIV transmissions with condomless sex among serodifferent couples where the infected partner was on ART and virologically suppressed. This paper will review the evidence surrounding HIV transmission risk among serodifferent couples with and without the use of condoms and will highlight factors that increase or attenuate this risk. It will also address the important benefits that condomless sex offers couples. This paper aims to provide a template for providers to have personalized discussions with their patients, particularly those with an HIV-positive sexual partner, around their individual risk of HIV transmission and the role of condom use.

Effectiveness of community-based condom distribution interventions to prevent HIV in the United States: A systematic review and meta-analysis

BACKGROUND

Despite significant public health implications, the extent to which community-based condom distribution interventions (CDI) prevent HIV infection in the United States is not well understood.

METHODS

We systematically reviewed research evidence applying Cochrane Collaboration methods. We used a comprehensive search strategy to search multiple bibliographic databases for relevant randomized controlled trials (RCTs) and non-RCTs published from 1986-2017. We focused on CDI that made condoms widely available or accessible in community settings. Eligible outcomes were HIV infection (primary), sexually transmitted infections, condom use, and multiple sexual partnership. Two reviewers independently screened citations to assess their eligibility, extracted study data, and assessed risk of bias. We calculated risk ratios (RR) with 95% confidence intervals (CI) and pooled them using random-effects models. We assessed evidence quality using GRADE.

RESULTS

We reviewed 5,110 unique records. Nine studies (including one RCT) met eligibility criteria. Studies were conducted in 10 US states between 1989 and 2011. All studies were at high risk of bias. Interventions were categorized into three groups: "Ongoing" (unlimited access to condoms), "Ongoing-plus" (unlimited access to condoms, with co-interventions), and "Coupon-based" (coupons redeemed for condoms). No studies reported incident HIV. Ongoing CDI (four non-RCTs) modestly reduced condomless sex (RR 0.88, 95% CI 0.78 to 0.99). Ongoing-plus CDI (two non-RCTs) significantly reduced multiple sexual partnership (RR 0.37, 95% CI 0.16 to 0.87). Of two coupon-based studies, one (non-RCT) showed reduction in condomless sex in female participants (Odds Ratio 0.67, 95% CI 0.47 to 0.96), while the other one (RCT) showed no effect on STI incidence (RR 0.91, 95% CI 0.63 to 1.31). Evidence quality was "very low" for all outcomes.

CONCLUSIONS

CDI may reduce some risky sexual behaviors, but the evidence for any reduction is limited and of low-quality. Lack of biological outcomes precludes assessing the link between CDI and HIV incidence.

Examination of HIV infection through heterosexual contact with partners who are known to be HIV infected in the United States

: Using data from the National HIV Surveillance System, we examined HIV infections diagnosed between 2010 and 2015 attributed to heterosexual contact with partners previously known to be HIV infected. More than four in 10 HIV infections among heterosexual males and five in 10 HIV infections among heterosexual women were attributed to this group. Findings may inform the prioritization of prevention and care efforts and resource allocation modeling for reducing new HIV infection among discordant partnerships.

'When it comes to HIV, that's when you find out the genuinity of that love': The experience of disclosing a HIV+ status to an intimate partner

Despite a medical discourse of the 'normalisation' of HIV, it remains a highly stigmatising condition and makes the issue of disclosing one's HIV status particularly complex. This article reports on the experience of 18 people living with HIV in the United Kingdom of disclosing their HIV+ status in arguably their most important relationship, their intimate partnership. Five main themes arose: disclosure as the battlefield, preparing psychologically to disclose, disclosure as a test of the partner's love, disclosure as an opportunity for the partner to know them more deeply and the renegotiation of the relationship narrative.

Risky Business: condom failures as experienced by female sex workers in Mombasa, Kenya

Limited research exists about condom failure as experienced by female sex workers. We conducted a qualitative study to examine how female sex workers in Mombasa, Kenya contextualise and explain the occurrence of condom failure. In-depth, semi-structured interviews were conducted with thirty female sex workers to ascertain their condom failure experiences. We qualitatively analysed interview transcripts to determine how the women mitigate risk and cope with condom failure. Condom failure was not uncommon, but women mitigated the risk by learning about correct use, and by supplying and applying condoms themselves. Many female sex workers felt that men intentionally rupture condoms. Few women were aware of or felt empowered to prevent HIV, STIs, and pregnancy after condom failure. Interventions to equip female sex workers with strategies for minimising the risk of HIV, STIs, and pregnancy in the aftermath of a condom failure should be investigated.

Cost-Effectiveness of the 'One4All' HIV Linkage Intervention in Guangxi Zhuang Autonomous Region, China

BACKGROUND

In Guangxi Zhuang Autonomous Region, China, an estimated 80% of newly-identified antiretroviral therapy (ART)-eligible patients are not engaged in ART. Delayed ART uptake ultimately translates into high rates of HIV morbidity, mortality, and transmission. To enhance HIV testing receipt and subsequent treatment uptake in Guangxi, the Chinese Center for Disease Control and Prevention (CDC) executed a cluster-randomized trial to assess the effectiveness and cost-effectiveness of a streamlined HIV testing algorithm (the One4All intervention) in 12 county-level hospitals.

OBJECTIVE

To determine the incremental cost-effectiveness of the One4All intervention delivered at county hospitals in Guangxi, China, compared to the current standard of care (SOC).

PERSPECTIVE

Health System.

TIME HORIZON

1-, 5-and 25-years.

METHODS

We adapted a dynamic, compartmental HIV transmission model to simulate HIV transmission and progression in Guangxi, China and identify the economic impact and health benefits of implementing the One4All intervention in all Guangxi hospitals. The One4All intervention algorithm entails rapid point-of-care HIV screening, CD4 and viral load testing of individuals presenting for HIV screening, with same-day results and linkage to counselling. We populated the model with data from the One4All trial (CTN-0056), China CDC HIV registry and published reports. Model outcomes were HIV incidence, mortality, costs, quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER) of the One4All intervention compared to SOC.

RESULTS

The One4All testing intervention was more costly than SOC (CNY 2,182 vs. CNY 846), but facilitated earlier ART access, resulting in delayed disease progression and mortality. Over a 25-year time horizon, we estimated that introducing One4All in Guangxi would result in 802 averted HIV cases and 1629 averted deaths at an ICER of CNY 11,678 per QALY gained. Sensitivity analysis revealed that One4All remained cost-effective at even minimal levels of effectiveness. Results were robust to changes to a range of parameters characterizing the HIV epidemic over time.

CONCLUSIONS

The One4All HIV testing strategy was highly cost-effective by WHO standards, and should be prioritized for widespread implementation in Guangxi, China. Integrating the intervention within a broader combination prevention strategy would enhance the public health response to HIV/AIDS in Guangxi.

Male condom use, multiple sexual partners and HIV: a prospective case-control study in Kinshasa (DRC)

In the Democratic Republic of Congo no previous studies have assessed the factors associated with different patterns of condom use and with multiple sexual partners, and the association between condom use simultaneously taking into account multiple sexual partnerships, and HIV infection. We carried out a prospective case-control study. From December 2010 until June 2012, 1630 participants aged 15-49 getting HIV Voluntary Counseling and Testing in a hospital in Kinshasa were selected. Cases were new HIV diagnosis and controls were HIV-negative participants detected along the study period. We recruited 274 cases and 1340 controls that were interviewed about HIV-related knowledge, attitudes and behaviours. Among cases there was a high prevalence of multiple lifetime and concurrent sexual partnerships (89.8% and 20.4%, respectively) and most cases never used condoms with only 1.5% using them consistently. Condom use and multiple partnerships were associated with male, single and high-educated participants. An association was found between multiple lifetime partners and 'any condom use' (OR = 2.99; 95%CI: 2.14-4.19) but not with consistent use. Both having two or more multiple concurrent sexual partners or not using condoms were variables similarly and highly associated to HIV risk. The association found between having two or more concurrent sexual partners and HIV was slightly higher (OR = 3.58, 95%CI:2.31-5.56) than the association found between never condom use and HIV (OR = 3.38, 95%CI:1.15-9.93). We found a high prevalence of multiple lifetime sexual partners and an extremely high prevalence of inconsistent condom use, both strongly associated with HIV seropositivity. Local programmes would benefit from comprehensive interventions targeting all behavioural and sociocultural determinants.

Overview of HIV molecular epidemiology among people who inject drugs in Europe and Asia

HIV strains continuously evolve, tend to recombine, and new circulating variants are being discovered. Novel strains complicate efforts to develop a vaccine against HIV and may exhibit higher transmission efficiency and virulence, and elevated resistance to antiretroviral agents. The United Nations Joint Programme on HIV/AIDS (UNAIDS) set an ambitious goal to end HIV as a public health threat by 2030 through comprehensive strategies that include epidemiological input as the first step of the process. In this context, molecular epidemiology becomes invaluable as it captures trends in HIV evolution rates that shape epidemiological pictures across several geographical areas. This review briefly summarizes the molecular epidemiology of HIV among people who inject drugs (PWID) in Europe and Asia. Following high transmission rates of subtype G and CRF14_BG among PWID in Portugal and Spain, two European countries, Greece and Romania, experienced recent HIV outbreaks in PWID that consisted of multiple transmission clusters including subtypes B, A, F1, and recombinants CRF14_BG and CRF35_AD. The latter was first identified in Afghanistan. Russia, Ukraine, and other Former Soviet Union (FSU) states are still facing the devastating effects of epidemics in PWID produced by A_FSU (also known as IDU-A), B_FSU (known as IDU-B), and CRF03_AB. In Asia, CRF01_AE and subtype B (Western B and Thai B) travelled from PWID in Thailand to neighboring countries. Recombination hotspots in South China, Northern Myanmar, and Malaysia have been generating several intersubtype and inter-CRF recombinants (e.g. CRF07_BC, CRF08_BC, CRF33_01B etc.), increasing the complexity of HIV molecular patterns.