The association between alcohol use and sexual risk behaviors among African American women across three developmental periods: a review

Adverse Childhood Experiences, Acculturation, and Risky Sexual Behaviors in Hispanic Young Adults: Findings from Project RED

While adverse childhood experiences (ACE) are well-documented predictors of maladaptive behaviors in adulthood, including risky sexual behaviors (RSB), the influence of acculturation in this association remains unknown. Although Hispanics are a rapidly growing population in the United States and are disproportionately affected by adverse sexual health outcomes, there is a paucity of research examining the interplay of ACE, acculturation, and RSB in this population. We observed the ACE-RSB association and how this relationship varies across U.S. and Hispanic acculturation levels, in a sample of Hispanic young adults (n = 715). Data for this study were from Project RED, a longitudinal study of Hispanic health. We ran regression models to test associations between ACE (0, 1-3, 4+) and several RSB (e.g., early sexual initiation (≤14 years), condomless sex, lifetime sexual partners, and alcohol/drug use before intercourse), and assessed moderation by U.S./Hispanic acculturation. Compared with those without ACE, individuals with 4 + ACE had higher odds of early sexual initiation (AOR: 2.23), alcohol/drug use before last intercourse (AOR: 2.31), and condomless sex (AOR: 1.66), as well as a higher number of lifetime sexual partners (β: 0.60). For those reporting 4 + ACE, high U.S. acculturation was protective in the association between ACE and using alcohol/drugs before intercourse. Future research implications are discussed.

Assessing the Preliminary Efficacy of a Nonrandomized, Clinic-Based HIV Risk Reduction Pilot Intervention for PrEP-Initiated, Alcohol- and Other Drug-Using Women of Color in Miami, FL

In this paper, we assessed the preliminary efficacy and acceptability of a quasi-experimental, clinic-based sexual risk reduction pilot intervention for pre-exposure prophylaxis (PrEP)-initiated, alcohol- and other drug-using women of color and explored their self-reported barriers to, and facilitators of, PrEP use. Using a mixed methods design, analyses incorporated pre- and post-intervention study assessment data from 38 women and semi-structured process evaluations using a subsample of 25. The intervention administered over an 8-week period consisted of 4 one-on-one in person educational sessions, a process evaluation, and study assessments conducted at baseline and 3 and 6 months. Post intervention, statistically significant changes in sexual risk scores were not observed; however, we found significant decreases in alcohol use (Z =  - 3.02, p = .003, η2 = .41). Process evaluation data revealed interpersonal relationships as a key motivator for PrEP initiation as well as a prominent barrier to PrEP use; these relationships rarely facilitated adherence. Overall, women found the intervention to be acceptable and reported a wide range of benefits of participation-most notably its therapeutic benefits. Findings from this study provide preliminary evidence of the potential for the Talking PrEP with Women of Color intervention to improve risky behaviors, knowledge, and attitudes related to sexual risk taking. Furthermore, findings suggest that interventions to increase PrEP uptake and adherence in at-risk women may benefit from supporting them in accurately estimating their risk for HIV and increasing their sense of social support.

Condom Use at Last Sex and Sexual Negotiation Among Young African American Women in North Carolina: Context or Personal Agency

African American women are 10.8 times more likely to be diagnosed with HIV compared with White women. This descriptive study fills a gap by examining associations among social and contextual factors and sexual communication, condom use, and safer sex negotiation among African American women. Study participants between 18 and 25 years of age and who reported recent substance use were recruited from three North Carolina counties. A risk behavior survey was administered via audio computer-assisted self-interview, and logistic regression analyses were conducted to assess associations between social and contextual variables and condom use at last sex with a main partner. Education (AOR: 2.078; 95% CI: 1.214, 3.556), sexual communication with a main partner (AOR: 1.079; 95% CI: 1.050, 1.109), and condom use relationship scale (AOR: 1.059; 95% CI: 1.023, 1.098) were positively associated with condom use at last sex, whereas living with a main partner (AOR: 0.447; 95% CI: 0.210, 0.950) and the alcohol and drug problem scale (AOR: 0.971; 95% CI: 0.944, 0.998) were negatively associated with condom use (p < 0.05). The study findings show that among young African American women at risk for HIV, contextual and personal factors may influence condom use. A socio-ecological approach combining personal empowerment, interpersonal, structural, and biobehavioral strategies is necessary in implementing holistic gender-focused HIV prevention programs.

Association of Major Disease Outbreaks With Adolescent and Youth Mental Health in Low- and Middle-Income Countries: A Systematic Scoping Review

IMPORTANCE

Adolescents and young people have been historically understudied populations, and previous studies indicate that during epidemics, these populations, especially in low- and middle-income countries (LMICs), are at high risk of developing mental disturbances.

OBJECTIVE

To identify the existing evidence regarding the association of mental health with outbreaks of the influenza A (H1N1), Zika, Ebola, and SARS-CoV-2 virus in exposed youth and adolescents in LMICs.

EVIDENCE REVIEW

Across 6 databases (Embase, Cochrane Library, PubMed, PsycINFO, Scopus, and Web of Science), the mental health outcomes of adolescents and youth (aged 10-24 years) associated with 4 major pandemic outbreaks from January 2009 to January 2021 in LMICs were reviewed. A group of 3 authors at each stage carried out the screening, selection, and quality assessment using Joanna Briggs Institute checklists. The social determinants of adolescent well-being framework was used as a guide to organizing the review.

FINDINGS

A total of 57 studies fulfilled the search criteria, 55 related to the SARS-CoV-2 (COVID-19) pandemic and 2 covered the H1N1 influenza epidemics. There were no studies associated with Zika or Ebola outbreaks that met screening criteria. The studies reported high rates of anxiety and depressive symptoms among adolescents, including posttraumatic stress disorder, general stress, and health-related anxiety. Potential risk factors associated with poor mental health outcomes included female sex; home residence in areas with strict lockdown limitations on social and physical movement; reduced physical activity; poor parental, family, or social support; previous exposure to COVID-19 infection; or being part of an already vulnerable group (eg, previous psychiatric conditions, childhood trauma, or HIV infection).

CONCLUSIONS AND RELEVANCE

Results of this systematic scoping review suggest that the COVID-19 pandemic and H1N1 epidemic were associated with adverse mental health among adolescents and youth from LMICs. Vulnerable youth and adolescents may be at higher risk of developing mental health-related complications, requiring more responsive interventions and further research. Geographically localized disease outbreaks such as Ebola, Zika, and H1N1 influenza are highly understudied and warrant future investigation.

Understanding Sexual Health Indicators During Adolescence: A Study to Consider Time Since Sexual Debut When Exploring Multiple Sexual Partners

Understanding risky sexual behaviors among adolescents is key in efforts devoted to reducing the health burden related to sexually transmitted infections and unintended or unplanned pregnancies. The aims of this study were to understand the association between number of lifetime sexual partners and time since sexual debut (TSSD) among adolescents and to determine whether sex modified this association. Data were drawn from the 2018-2019 COMPASS-Quebec study, a cohort study conducted in secondary schools in the province of Quebec, Canada. Of 18,467 respondents aged 14 years and older, 6991 (37.9%; mean age 15.3) reported consensual sexual intercourse and answered questions on their age at sexual initiation and number of lifetime sexual partners. Multilevel Poisson regressions with robust standard errors were estimated to adjust for covariates and produce adjusted group mean differences. The adjusted mean number of lifetime sexual partners ranged from 1.5 for those who had recently begun sexual activity (< 12 months) to 4.0 for those who had been active for > 35 months, an average rise of about 0.6 per year. Females-to-males adjusted mean differences showed that males reported more sexual partners than females at all time points, but the differences were only significant at the shorter (< 12 months) and longer (> 35 months) time spans. This study highlights the importance of taking into account TSSD when using and interpreting the number of lifetime sexual partners as risky sexual behavior among adolescents. Sex did not have a significant modifying effect on the relationship between number of lifetime sexual partners and TSSD.

Horizons and Group Motivational Enhancement Therapy: HIV Prevention for Alcohol-Using Young Black Women, a Randomized Experiment

INTRODUCTION

Black women are at disproportionately greater risk for HIV and sexually transmitted infections than women of other ethnic/racial backgrounds. Alcohol use may further elevate the risk of HIV/sexually transmitted infection acquisition and transmission.

STUDY DESIGN

A random-assignment parallel-group comparative treatment efficacy trial was conducted with random assignment to 1 of 3 conditions.

SETTING/PARTICIPANTS

The sample comprised 560 Black or African American women aged 18-24 years who reported recent unprotected vaginal or anal sex and recent alcohol use. Participants were recruited from community settings in Atlanta, Georgia, from January 2012 to February 2014.

INTERVENTION

A Group Motivational Enhancement Therapy module was designed to complement a Centers for Disease Control and Prevention-designated evidence-based intervention (Horizons) to reduce sexual risk behaviors, alcohol use, and sexually transmitted infections, with 3 comparison groups: (1) Horizons + Group Motivational Enhancement Therapy intervention, (2) Horizons + General Health Promotion intervention, and (3) enhanced standard of care.

MAIN OUTCOME MEASURES

Outcome measures included safe sex (abstinence or 100% condom use); condom nonuse; proportion of condom use during sexual episodes; incident chlamydia, gonorrhea, and trichomonas infections; and problematic alcohol use measured by Alcohol Use Disorders Identification Test score. Treatment effects were estimated using an intention-to-treat protocol‒generalized estimating equations with logistic regression for binomial outcomes and Poisson regression for count outcomes. Analyses were conducted between October 2018 and October 2019.

RESULTS

Participants assigned to Horizons + Group Motivational Enhancement Therapy had greater odds of safe sex (AOR=1.45, 95% CI=1.04, 2.02, p=0.03), greater proportion of condom use (AOR=1.68, 95% CI=1.18, 2.41, p=0.004), and lower odds of condom nonuse (AOR=0.57, 95% CI=0.38, 0.83, p=0.004). Both interventions had lower odds of problematic alcohol use (Horizons: AOR=0.57, 95% CI=0.39, 0.85, p=0.006; Horizons + Group Motivational Enhancement Therapy: AOR=0.61, 95% CI=0.41, 0.90, p=0.01).

CONCLUSIONS

Complementing an evidence-based HIV prevention intervention with Group Motivational Enhancement Therapy may increase safer sexual behaviors and concomitantly reduce alcohol use among young Black women who consume alcohol.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT01553682.

Think Inside the Box: the Heterogeneity of "in Risk" Among "at Risk" Female African American Adolescents in North Carolina

INTRODUCTION

An abundance of research investigates the health of often referred to as "at risk" or "high risk" youth from underserved communities and usually racial/ethnic minorities. These ubiquitous terms relate to poverty, violence, and unsafe behaviors (e.g., sex without condoms, alcohol, and drug use).

METHODS

This analysis distinguished the heterogeneity of risks among African American female adolescents recruited for an intervention study from underserved communities in North Carolina. Eligibility included: ages 16-19, considered or dropped out of school, never completed high school, and during the past 3 months had sex with a male partner and used drugs or alcohol. A variable was created to represent the continuum of risk comprised of history of homelessness, or trading sex, or current heavy alcohol and marijuana use. Participants fell into 0, 1, or 2-3 categories. Ordinal logistic regression estimated the odds of adverse poor outcomes by category. Linear regression estimated reduction in material and emotional support by category.

RESULTS

Of the 237 participants, 59.5%, 27.8%, and 12.7% were in 0, 1, or 2-3 categories, respectively. Relative to adolescents in 0 categories, participants in other categories were more likely to report food insecurity (OR = 3.27, 95%CI [1.8, 5.94]); past arrest (OR = 3.56 [2.08, 6.09]); run away (OR = 3.30 [1.79, 6.10]); multiple sex partners (2.97 [1.61, 5.48]); and vaginal/anal sexual abuse (OR = 3.21[1.73, 5.96]). Material and emotional support was significantly lower for participants in 2-3 risk categories.

CONCLUSIONS

Vague use of "at risk" fails to recognize the heterogeneity of experiences and needs of underserved African American youth.

Integrating Individual and Contextual Factors to Explain Disparities in HIV/STI Among Heterosexual African American Youth: A Contemporary Literature Review and Social Ecological Model

Heterosexual African American youth face substantial disparities in sexual health consequences such as HIV and STI. Based on the social ecological framework, the current paper provides a comprehensive, narrative review of the past 14 years of literature examining HIV/STI risk, including risky sexual behavior, among heterosexual African American youth and a conceptual model of risk among this population. The review found that individual psychological and biological factors are insufficient to explain the sexual health disparities faced by this group; instead, structural disadvantage, interpersonal risk, and community dysfunction contribute to the disparity in HIV/STI outcomes directly and indirectly through individual psychological factors. The conceptual model presented suggests that for African American youth, (1) HIV/STI risk commonly begins at the structural level and trickles down to the community, social, and individual levels, (2) risk works in a positive feedback system such that downstream effects compound the influence of structural risks, and (3) contextual and individual risk factors must be considered within the advanced stage of the epidemic facing this population. Despite advanced HIV and STI epidemics among heterosexual African American youth, multisystemic interventions that target structural risk factors and their downstream effects are posited to reduce the disparity among this high-risk population.

Age-related associations between substance use and sexual risk behavior among high-risk young African American women in the South

BACKGROUND

We assessed age-related associations between substance use and sexual risk behavior using data from three HIV prevention trials that enrolled young African American women.

METHODS

We used integrative data analysis to pool data from 1862 individuals aged 16-25 years. We used time-varying effect models to examine associations between substance use (alcoholic drinks per month, recent marijuana use, cigarettes smoked per day) and sexual risk behaviors (monthly frequency of vaginal sex, multiple sex partners, condomless sex), adjusting for the fixed effect of trial.

RESULTS

In models that included all three substances, cigarette smoking was not associated with any outcome. Alcohol quantity was associated with greater frequency of sex at all ages, an increased likelihood of having multiple sex partners from about age 17-24 years, and an increased likelihood of condomless sex after about age 18.5 years. Associations between alcohol quantity and sex frequency were relatively stable; associations with having multiple sex partners and condomless sex increased beginning at about age 22 years. Marijuana use was associated with greater sex frequency at approximate ages 16.5-24 years and an increased likelihood of having multiple sex partners at ages 18-24 years. Associations with sex frequency were relatively stable; associations with having multiple sex partners increased from about age 18 and peaked at about age 23 years.

CONCLUSIONS

We observed developmentally-dependent relationships between both alcohol and marijuana and sexual risk behavior. The findings underscore the need to address substance-related sexual risk among young African American women and may inform optimal timing of intervention.

Sexual health of young people with perinatal HIV and HIV negative young people in England

As adolescents with perinatal HIV (PHIV) survive into adulthood, gaining insight into sexual behaviour and risk-taking is important. Between 2013–2015, 296 PHIV aged 13–21 years and 96 HIV negative affected adolescents (13–23 years) were recruited to the Adolescents and Adults Living with Perinatal HIV (AALPHI) cohort in England. Sexual health data were collected through computer-assisted self-interview questionnaires. Quality of life and household deprivation were also measured. T-tests compared means, and χ² proportions; logistic regression examined predictors of ever having sex. 120(41%) PHIV and 31(32%) HIV- young people were male, 254(86%) and 70(73%) were black, median age 16 [IQR 15,18] and 16 [14,18] years respectively. 77(26%) PHIV had a previous AIDS diagnosis. 93(32%) PHIV and 38(40%) HIV- had ever had sex; median number of partners was 3 [1,6] and 4 [1,6] respectively. 54 (41%) of 131 young people who were sexually active reported not always using condoms, including 32% (30/93) of PHIV. In multivariable analysis, older age, male sex, worse deprivation score, worse quality of life, and alcohol and/or drugs were associated with ever having sex, but not HIV status. 12/30 PHIV reporting unprotected sex had at least one HIV viral load ≥200c/ml in the previous 12 months. Age at first sex and number of sexual partners were similar among PHIV and HIV-, and comparable to normative data. In conclusion, small numbers of PHIV reported condomless sex with a detectable viral load, which could result in HIV transmission, indicating the need for targeted sexual health and ART adherence interventions for young people with perinatal HIV.

mHealth versus face-to-face: study protocol for a randomized trial to test a gender-focused intervention for young African American women at risk for HIV in North Carolina

Background

Disparities in the prevalence of HIV persist in the southern United States, and young African American women have a disproportionate burden of HIV as compared with young women of other racial/ethnic backgrounds. As a result, engaging young African American women in the HIV care continuum through HIV testing is imperative. This study is designed to reach this key population at risk for HIV. The study seeks to test the efficacy of two formats of a gender-focused, evidence-based, HIV-risk reduction intervention—the Young Women’s CoOp (YWC)—relative to HIV counseling and testing (HCT) among young African American women between the ages of 18 and 25 who use substances and have not recently been tested for HIV.

Methods

Using a seek-and-test framework, this three-arm cross-over randomized trial is being conducted in three county health departments in North Carolina. Each county is assigned to one of three study arms in each cycle: in-person (face-to-face) YWC, mobile Health (mHealth) YWC, or HCT. At study enrollment, participants complete a risk behavior survey via audio computer-assisted self-interview, and drug, alcohol, and pregnancy screening tests, and are then referred to HIV, gonorrhea, and chlamydia testing through their respective health departments. Participants in either of the YWC arms are asked to return approximately 1 week later to either begin the first of two in-person individual intervention sessions or to pick up the mHealth intervention preloaded on a tablet after a brief introduction to using the app. Participants in all arms are asked to return for a 6-month follow-up and 12-month follow-up, and repeat the survey and biological testing from baseline.

Discussion

The findings from this study will demonstrate which delivery format (mHealth or face-to-face) is efficacious in reducing substance use and sexual risk behaviors. If found to be efficacious, the intervention has potential for wider dissemination and reach.

Trial registration

ClinicalTrials.gov: NCT02965014. Registered November 16, 2016.

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

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

Alcohol and HIV Risk Among Russian Women of Childbearing Age

Russia has one of the fastest rising rates of HIV among women in the world. This study sought to identify key factors in HIV transmission among women in Russia. Data were collected as part of a larger clinical trial to prevent alcohol-exposed pregnancies (AEP). Women at risk for an AEP were recruited at women's clinics; 708 women, aged 18-44 (M = 29.04 years), completed HIV risk surveys. Structural Equation Modeling was used to test the relationships between alcohol use and sex behavior constructs with HIV/STI risk. While the model indicated that multiple factors are involved in women's HIV/STI risk, the independent alcohol use variable explains 20 % of the variance in women's HIV/STI risk. The findings suggest that alcohol use directly and indirectly predicts HIV/STI risk among women, and its effect is mediated by alcohol use before sex.

The relationship between different dimensions of alcohol use and the burden of disease-an update

BACKGROUND AND AIMS

Alcohol use is a major contributor to injuries, mortality and the burden of disease. This review updates knowledge on risk relations between dimensions of alcohol use and health outcomes to be used in global and national Comparative Risk Assessments (CRAs).

METHODS

Systematic review of reviews and meta-analyses on alcohol consumption and health outcomes attributable to alcohol use. For dimensions of exposure: volume of alcohol use, blood alcohol concentration and patterns of drinking, in particular heavy drinking occasions were studied. For liver cirrhosis, quality of alcohol was additionally considered. For all outcomes (mortality and/or morbidity): cause of death and disease/injury categories based on International Classification of Diseases (ICD) codes used in global CRAs; harm to others.

RESULTS

In total, 255 reviews and meta-analyses were identified. Alcohol use was found to be linked causally to many disease and injury categories, with more than 40 ICD-10 three-digit categories being fully attributable to alcohol. Most partially attributable disease categories showed monotonic relationships with volume of alcohol use: the more alcohol consumed, the higher the risk of disease or death. Exceptions were ischaemic diseases and diabetes, with curvilinear relationships, and with beneficial effects of light to moderate drinking in people without heavy irregular drinking occasions. Biological pathways suggest an impact of heavy drinking occasions on additional diseases; however, the lack of medical epidemiological studies measuring this dimension of alcohol use precluded an in-depth analysis. For injuries, except suicide, blood alcohol concentration was the most important dimension of alcohol use. Alcohol use caused marked harm to others, which has not yet been researched sufficiently.

CONCLUSIONS

Research since 2010 confirms the importance of alcohol use as a risk factor for disease and injuries; for some health outcomes, more than one dimension of use needs to be considered. Epidemiological studies should include measurement of heavy drinking occasions in line with biological knowledge.

The relationship between different dimensions of alcohol use and the burden of disease-an update

BACKGROUND AND AIMS

Alcohol use is a major contributor to injuries, mortality and the burden of disease. This review updates knowledge on risk relations between dimensions of alcohol use and health outcomes to be used in global and national Comparative Risk Assessments (CRAs).

METHODS

Systematic review of reviews and meta-analyses on alcohol consumption and health outcomes attributable to alcohol use. For dimensions of exposure: volume of alcohol use, blood alcohol concentration and patterns of drinking, in particular heavy drinking occasions were studied. For liver cirrhosis, quality of alcohol was additionally considered. For all outcomes (mortality and/or morbidity): cause of death and disease/injury categories based on International Classification of Diseases (ICD) codes used in global CRAs; harm to others.

RESULTS

In total, 255 reviews and meta-analyses were identified. Alcohol use was found to be linked causally to many disease and injury categories, with more than 40 ICD-10 three-digit categories being fully attributable to alcohol. Most partially attributable disease categories showed monotonic relationships with volume of alcohol use: the more alcohol consumed, the higher the risk of disease or death. Exceptions were ischaemic diseases and diabetes, with curvilinear relationships, and with beneficial effects of light to moderate drinking in people without heavy irregular drinking occasions. Biological pathways suggest an impact of heavy drinking occasions on additional diseases; however, the lack of medical epidemiological studies measuring this dimension of alcohol use precluded an in-depth analysis. For injuries, except suicide, blood alcohol concentration was the most important dimension of alcohol use. Alcohol use caused marked harm to others, which has not yet been researched sufficiently.

CONCLUSIONS

Research since 2010 confirms the importance of alcohol use as a risk factor for disease and injuries; for some health outcomes, more than one dimension of use needs to be considered. Epidemiological studies should include measurement of heavy drinking occasions in line with biological knowledge.

Does alcohol use have a causal effect on HIV incidence and disease progression? A review of the literature and a modeling strategy for quantifying the effect

In the first part of this review, the nature of the associations between alcohol use and HIV/AIDS is discussed. Alcohol use has been found to be strongly associated with incidence and progression of HIV/AIDS, but the extent to which this association is causal has traditionally remained in question. Experiments where alcohol use has been manipulated as the independent variable have since helped establish a causal effect of alcohol use on the intention to engage in condomless sex. As the intention to engage in condomless sex is a surrogate measure of actual condom use behavior, which itself is linked to HIV incidence and re-infection, the causal chain has been corroborated. Moreover, there are biological pathways between alcohol use and the course of HIV/AIDS, only in part being mediated by adherence to antiretroviral medication. In the second part of the contribution, we provide suggestions on the quantification of the link between alcohol use and HIV incidence, using risk relations derived from experimental data. The biological links between alcohol use and course of HIV/AIDS are difficult to quantify given the current state of knowledge, except for an operationalization for the link via adherence to medication based on meta-analyses. The suggested quantifications are exemplified for South Africa.

Religiosity, spirituality, and HIV risk behaviors among African American women from four rural counties in the southeastern U.S

In a cross-sectional survey of 1,013 African American women from rural Alabama and North Carolina, we examined the relationship of (1) organizational religiosity (i.e., religious service attendance), (2) non-organizational religiosity (e.g., reading religious materials), and (3) spirituality with these outcomes: women's reports of their sexual behaviors and perceptions of their partners' risk characteristics. Women with high non-organizational religiosity, compared with low, had fewer sex partners in the past 12 months (adjusted prevalence ratio (aPR): 0.58, 95% confidence interval (CI): 0.42, 0.80) and were less likely to have concurrent partnerships (aPR: 0.47, 95% CI: 0.30, 0.73). Similar results were observed for spirituality, and protective but weaker associations were observed for organizational religiosity. Weak associations were observed between organizational religiosity, non-organizational religiosity, and spirituality with partners' risk characteristics. Further exploration of how religiosity and spirituality are associated with protective sexual behaviors is needed to promote safe sex for African American women.

Alcohol and marijuana use in pathways of risk for sexually transmitted infection in white and black adolescent females

BACKGROUND

Some types of sexually transmitted infection (STI) have higher prevalence in females than males, and among black, relative to white, females. Identifying mechanisms of STI risk is critical to effective intervention. The authors tested a model in which alcohol and marijuana use serve as mediating factors in the associations between depression and conduct problems with sexual risk behavior (SRB) and STI in adolescent females.

METHODS

The Pittsburgh Girls Study is a longitudinal observational study of females who have been followed annually to track the course of mental and physical health conditions. The 3 oldest cohorts (N = 1750; 56.8% black, 43.2% white) provided self-reports of substance use, depression and conduct problems, SRB, and STI at ages 16-18. A path model tested alcohol and marijuana use at age 17 as mechanisms that mediate the associations of depression and conduct problems at age 16 with SRB and STI at age 18.

RESULTS

Race was involved in 2 risk pathways. In one pathway, white females reported greater alcohol use, which was associated with greater SRB. In another pathway, black females reported earlier sexual onset, which was associated with subsequent SRB. Public assistance use was independently associated with early sexual onset and STI. SRB, but not substance use, mediated the association of depression and conduct problems with STI.

CONCLUSIONS

Differences by race in pathways of risk for SRB and STI, involving, for example, alcohol use and early sexual onset, were identified for young white and black females, respectively. Depression and conduct problems may signal risk for SRB and STI in young females, and warrant attention to improve health outcomes.

Alcohol misuse, risky sexual behaviors, and HIV or syphilis infections among Chinese men who have sex with men

BACKGROUND

Few studies have employed standardized alcohol misuse measures to assess relationships with sexual risk and HIV/syphilis infections among Chinese men who have sex with men (MSM).

METHODS

We conducted a cross-sectional study among MSM in Beijing during 2013-2014. An interviewer-administered survey was conducted to collect data on sociodemographics, high-risk behaviors, and alcohol use/misuse patterns (hazardous/binge drinking and risk of alcohol dependence) in the past 3 months using Alcohol Use Disorder Identification Test-Consumption (AUDIT-C). We defined AUDIT-C score ≥4 as recent hazardous drinkers, and drinking ≥6 standard drinks on one occasion as recent binge drinkers.

RESULTS

Of 3588 participants, 14.4% reported hazardous drinking, 16.8% reported binge drinking. Hazardous and binge drinking are both associated with these factors (p<0.05): older age, being migrants, living longer in Beijing, township/village origin, being employed, higher income, self-perceived low/no HIV risk, and sex-finding via non-Internet venues. Hazardous (vs non-hazardous) or binge (vs. non-binge) drinkers were more likely to use illicit drugs, use alcohol before sex, have multiple partnerships, pay for sex, and have condomless insertive anal intercourse. MSM who reported binge (AOR, 1.34, 95% CI, 1.02-1.77) or hazardous (AOR, 1.36, 95% CI, 1.02-1.82) drinking were more likely to be HIV-infected. MSM at high risk of current alcohol dependence (AUDIT-C ≥8) were more likely to be HIV- (AOR, 2.37, 95% CI, 1.39-4.04) or syphilis-infected (AOR, 1.96, 95% CI, 1.01-3.86).

CONCLUSIONS

Recent alcohol misuse was associated with increased sexual and HIV/syphilis risks among Chinese MSM, emphasizing the needs of implementing alcohol risk reduction programs in this population.

Individual and Partner-Level Factors Associated with Condom Non-Use Among African American STI Clinic Attendees in the Deep South: An Event-Level Analysis

The US HIV/AIDS epidemic is concentrated in the Deep South, yet factors contributing to HIV transmission are not fully understood. We examined relationships between substance use, sexual partnership characteristics, and condom non-use in an African American sample of STI clinic attendees in Jackson, Mississippi. We assessed condom non-use at last intercourse with up to three recent sexual partners reported by participants between January and June 2011. Participant- and partner-level correlates of condom non-use were examined using generalized estimating equations. The 1295 participants reported 2880 intercourse events, of which 1490 (51.7 %) involved condom non-use. Older age, lower educational attainment, reporting financial or material dependence on a sex partner, sex with a primary partner, and higher frequency of sex were associated with increased odds of condomless sex. HIV prevention efforts in the South should address underlying socioeconomic disparities and structural determinants that result in partner dependency and sexual risk behavior.

Maryland Alcohol Sales Tax and Sexually Transmitted Infections: A Natural Experiment

INTRODUCTION

Sexually transmitted infections are common causes of morbidity and mortality, including infertility and certain types of cancer. Alcohol tax increases may decrease sexually transmitted infection rates overall and differentially across population subgroups by decreasing alcohol consumption in general and prior to sex, thus decreasing sexual risk taking and sexually transmitted infection acquisition. This study investigated the effects of a Maryland increase in alcohol beverage sales tax on statewide gonorrhea and chlamydia rates overall and within age, gender, and race/ethnicity subpopulations.

METHODS

This study used an interrupted time series design, including multiple cross-state comparisons, to examine the effects of the 2011 alcohol tax increase in Maryland on chlamydia and gonorrhea cases reported to the U.S. National Notifiable Disease Surveillance System for January 2003 to December 2012 (N=120 repeated monthly observations, analyzed in 2015). Effects were assessed with Box-Jenkins autoregressive moving average models with structural parameters.

RESULTS

After the alcohol-specific sales tax increase, gonorrhea rates decreased 24% (95% CI=11%, 37%), resulting in 1,600 fewer statewide gonorrhea cases annually. Cohen's d indicated a substantial effect of the tax increase on gonorrhea rates (range across control group models, -1.25 to -1.42). The study did not find evidence of an effect on chlamydia or differential effects across age, race/ethnicity, or gender subgroups.

CONCLUSIONS

Results strengthen the evidence from prior studies of alcohol taxes influencing gonorrhea rates and extend health prevention effects from alcohol excise to sales taxes. Alcohol tax increases may be an efficient strategy for reducing sexually transmitted infections.

Demographic Predictors of Event-Level Associations between Alcohol Consumption and Sexual Behavior

Alcohol consumption is associated with sexual behavior and outcomes, though research indicates a variety of moderating factors, including demographic characteristics. To better target interventions aimed at alcohol-related sexual risk behavior, our analyses simultaneously examine demographic predictors of both day- and event-level associations between alcohol consumption and sexual behavior in a sample of young adults (N = 301) who are sexually active and consume alcohol. Young adults (aged 18-29) recruited using time-space sampling and incentivized snowball sampling completed a survey and a timeline follow-back calendar reporting alcohol consumption and sexual behavior in the past 30 days. On a given day, a greater number of drinks consumed was associated with higher likelihood of sex occurring, particularly for women and single participants. During a given sexual event, number of drinks consumed was not associated with condom use, nor did any demographic predictors predict that association. Findings highlight associations between alcohol and sexual behavior, though not between alcohol and sexual risk behavior, highlighting the need for additional research exploring the complex role of alcohol in sexual risk behavior and the need to develop prevention efforts to minimize the role of alcohol in the initiation of sexual encounters.

Alcohol Use Problems and Sexual Risk Among Young Adult African American Mothers

Studies have documented high levels of alcohol use and sexual risk among young mothers. We examined parenting satisfaction and self-efficacy in relation to alcohol use problems and sexual risk among 346 young African American women enrolled in an HIV prevention trial, 41 % (n = 141) of whom were mothers. Among mothers, greater parenting satisfaction was associated with a reduced likelihood of problematic alcohol use, having multiple sex partners, and testing positive for Trichomonas vaginalis. Relative to non-parenting women, mothers reported lower condom use. Compared to non-parenting women, mothers with the highest parenting satisfaction reported fewer alcohol use problems; mothers with the lowest parenting satisfaction reported lower condom use and were more likely to have multiple partners and test positive for T. vaginalis. Parenting self-efficacy was not associated with the outcomes examined. Future research investigating relationships between parenting satisfaction, alcohol use and sexual risk may be useful for improving multiple maternal health outcomes.

Association Between Cumulative Psychosocial Risk and Cervical Human Papillomavirus Infection Among Female Adolescents in a Free Vaccination Program

OBJECTIVE

This study investigated the association of cervical human papillomavirus (HPV) infection with cumulative psychosocial risk reflecting family disadvantage, psychological distress, and unhealthy lifestyle.

METHODS

The sample (N = 745) comprised sexually active female adolescent patients (12-19 yr), primarily ethnic minorities, enrolled in a free HPV vaccination program. Subjects completed questionnaires and provided cervical swabs for HPV DNA testing. Unweighted and weighted principal component analyses for categorical data were used to derive multisystemic psychosocial risk indices using 9 indicators: low socioeconomic status, lack of adult involvement, not attending high school/college, history of treatment for depression/anxiety, antisocial/delinquent behavior, number of recent sexual partners, use of alcohol, use of drugs, and dependency risk for alcohol/drugs. The association between cervical HPV (any type, high-risk types, vaccine types) assayed by polymerase chain reaction and self-reported number of psychosocial risk indicators was estimated using multivariable logistic regression.

RESULTS

Subjects had a median of 3 psychosocial risk indicators. Multiple logistic regression analyses showed associations with unweighted and weighted number of psychosocial indicators for HPV any type (adjusted odds ratio [aOR] = 1.1; 95% confidence interval [CI], 1.0-1.2), with the strongest associations between weighted drug/alcohol use, drug/alcohol dependency risk, and antisocial/delinquent behavior and detection of HPV vaccine types (aOR = 1.5; 95% CI, 1.1-2.0) independent of number of recent sexual partners and vaccine dose (0-3).

CONCLUSION

Increased HPV infections including HPV vaccine types were associated with greater number of psychosocial risk indicators even after controlling for demographics, sexual behavior, history of chlamydia, and vaccine dose.

Associations Between a Dopamine D4 Receptor Gene, Alcohol Use, and Sexual Behaviors among Female Adolescent African Americans

Adolescent African-American females are disproportionately impacted by HIV, thus there is a clear need to understand factors associated with increased HIV-risk behaviors among this vulnerable population. We sought to explore the association between a dopamine D4 receptor gene (DRD4), a genetic marker associated with natural variations in rewarding behaviors, and self-reported alcohol-use and sexual risk-behaviors, while controlling for other known correlates of risk-taking such as impulsivity, sensation seeking, and peer norms among a group of high-risk African American female adolescents to evaluate whether this biological factor enhances our understanding of patterns of risk in this vulnerable group.

The Relationship between Alcohol Outlets, HIV Risk Behavior, and HSV-2 Infection among South African Young Women: A Cross-Sectional Study

Background

Alcohol consumption has a disinhibiting effect that may make sexual risk behaviors and disease transmission more likely. The characteristics of alcohol-serving outlets (e.g. music, dim lights, lack of condoms) may further encourage risky sexual activity. We hypothesize that frequenting alcohol outlets will be associated with HIV risk.

Methods

In a sample of 2,533 school-attending young women in rural South Africa, we performed a cross-sectional analysis to examine the association between frequency of alcohol outlet visits in the last six months and four outcomes related to HIV risk: number of sex partners in the last three months, unprotected sex acts in the last three months, transactional sex with most recent partner, and HSV-2 infection. We also tested for interaction by alcohol consumption.

Results

Visiting alcohol outlets was associated with having more sex partners [adjusted odds ratio (aOR), one versus zero partners (95% confidence interval (CI)): 1.51 (1.21, 1.88)], more unprotected sex acts [aOR, one versus zero acts (95% CI): 2.28 (1.52, 3.42)], higher levels of transactional sex [aOR (95% CI): 1.63 (1.03, 2.59)], and HSV-2 infection [aOR (95% CI): 1.30 (0.88, 1.91)]. In combination with exposure to alcohol consumption, visits to alcohol outlets were more strongly associated with all four outcomes than with either risk factor alone. Statistical evidence of interaction between alcohol outlet visits and alcohol consumption was observed for all outcomes except transactional sex.

Conclusions

Frequenting alcohol outlets was associated with increased sexual risk in rural South African young women, especially when they consumed alcohol. Sexual health interventions targeted at alcohol outlets may effectively reach adolescents at high risk for sexually transmitted infections like HIV and HSV-2.

Trial Registration

HIV Prevention Trials Network HPTN 068

Relationship between community-level alcohol outlet accessibility and individual-level herpes simplex virus type 2 infection among young women in South Africa

BACKGROUND

Exposure to alcohol outlets may influence sexual health outcomes at the individual and community levels. Visiting alcohol outlets facilitates alcohol consumption and exposes patrons to a risky environment and network of potential partners, whereas the presence of alcohol outlets in the community may shift social acceptance of riskier behavior. We hypothesize that living in communities with more alcohol outlets is associated with increased sexual risk.

METHODS

We performed a cross-sectional analysis in a sample of 2174 South African schoolgirls (ages 13-21 years) living across 24 villages in the rural Agincourt subdistrict, underpinned by long-term health and sociodemographic surveillance. To examine the association between number of alcohol outlets in village of residence and individual-level prevalent herpes simplex virus type 2 (HSV-2) infection, we used generalized estimating equations with logit links, adjusting for individual- and village-level covariates.

RESULTS

The median number of alcohol outlets per village was 3 (range, 0-7). Herpes simplex virus type 2 prevalence increased from villages with no outlets (1.4% [95% confidence interval, 0.2-12.1]), to villages with 1 to 4 outlets (4.5% [3.7-5.5]), and to villages with more than 4 outlets (6.3% [5.6, 7.1]). An increase of 1 alcohol outlet per village was associated with an 11% increase in the odds of HSV-2 infection (adjusted odds ratio [95% confidence interval], 1.11 [0.98-1.25]).

CONCLUSIONS

Living in villages with more alcohol outlets was associated with increased prevalence of HSV-2 infection in young women. Structural interventions and sexual health screenings targeting villages with extensive alcohol outlet environments could help prevent the spread of sexually transmitted infections.

Risky Sexual Behavior and Substance Use among Adolescents: A Meta-analysis

This study presents the results of a meta-analysis of the association between substance use and risky sexual behavior among adolescents. 87 studies fit the inclusion criteria, containing a total of 104 independent effect sizes that incorporated more than 120,000 participants. The overall effect size for the relationship between substance use and risky sexual behavior was in the small to moderate range (r = .22, CI = .18, .26). Further analyses indicated that the effect sizes did not substantially vary across the type of substance use, but did substantially vary across the type of risky sexual behavior being assessed. Specifically, mean effect sizes were smallest for studies examining unprotected sex (r = .15, CI = .10, .20), followed by studies examining number of sexual partners (r = .25, CI = .21, .30), those examining composite measures of risky sexual behavior (r = .38, CI = .27, .48), and those examining sex with an intravenous drug user (r = .53, CI = .45, .60). Furthermore, our results revealed that the relationship between drug use and risky sexual behavior is moderated by several variables, including sex, ethnicity, sexuality, age, sample type, and level of measurement. Implications and future directions are discussed.

Sex-Related Alcohol Expectancies Among African American Women Attending an Urban STI Clinic

African American women are disproportionately affected by human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and sexually transmitted infections (STIs). Alcohol use is a significant risk factor for HIV/STI acquisition. Sex-related alcohol expectancies (SRAEs) may partially account for alcohol-related risky sexual behaviors. Using qualitative interviews we explored the link between alcohol use and risky sex among 20 African American women attending an STI clinic who had consumed four or more alcoholic drinks per drinking day (binge drinking) and/or reported vaginal or anal sex while under the influence of alcohol. Four SRAEs emerged, which we named drink for sexual desire, drink for sexual power, drink for sexual excuse, and drink for anal sex. While the desire SRAE has been documented, this study identified three additional SRAEs not currently assessed by expectancy questionnaires. These SRAEs may contribute to high-risk sex when under the influence of alcohol and suggests the importance of developing integrated alcohol-sexual risk reduction interventions for high-risk women.

Receptivity to and recall of alcohol brand appearances in U.S. popular music and alcohol-related behaviors

BACKGROUND

The average U.S. adolescent is exposed to about 2.5 hours of popular music and 8 mentions of alcohol brands every day. Alcohol brand mentions may function as advertising whether or not they are sanctioned by the alcohol industry. Our study aimed to determine associations between adolescents' involvement with music containing alcohol brand mentions and alcohol-related behaviors.

METHODS

In 2010 to 2011, we conducted a random-digit-dial survey using national U.S. land line and cell phone frames. Through screening interviews, we identified 6,466 eligible households with subjects between 15 and 23 years of age, of whom 3,422 (53%) completed the telephone survey. Of these, 2,541 opted to participate in a subsequent web-based component. Independent variables included a composite score indicating owning and liking popular songs with alcohol brand mentions and correct recall of alcohol brands in songs. Outcome measures included ever having consumed a complete drink, ever bingeing, bingeing at least monthly, and having experienced problems from alcohol use.

RESULTS

Among the 2,541 participants, compared with those in the lowest tertile on the receptivity scale, those in the highest tertile had higher odds of having had a complete drink (OR = 3.4; 95% CI = 2.2, 5.2) after adjusting for age, sex, race/ethnicity, socioeconomic status, sensation seeking, friend alcohol use, and parent alcohol use. Compared with those who did not identify at least 1 alcohol brand correctly, those who did had over twice the odds of having had a complete drink (OR = 2.1; 95% CI = 1.2, 3.8) after adjusting for all covariates. Results were also significant for the outcome of ever bingeing, but not for bingeing at least monthly or having had problems due to drinking.

CONCLUSIONS

In a national sample of U.S. adolescents and young adults, there were independent associations between involvement with popular music containing alcohol brand mentions and both having ever had a complete drink and having ever binged on alcohol.

Heterogeneous population effects of an alcohol excise tax increase on sexually transmitted infections morbidity

BACKGROUND AND AIMS

Alcohol taxes reduce population-level excessive alcohol use and alcohol-related morbidity and mortality, yet little is known about the distribution of the effects of alcohol taxation across race/ethnicity and age subgroups. We examined the race/ethnicity- and age group-specific effects of an excise alcohol tax increase on a common and routinely collected alcohol-related morbidity indicator, sexually transmitted infections.

METHODS

We used an interrupted time series design to examine the effect of a 2009 alcohol tax increase in Illinois, USA on new cases of two common sexually transmitted infections (chlamydia and gonorrhea) reported to the US National Notifiable Disease Surveillance System from January 2003 to December 2011 (n = 108 repeated monthly observations). We estimated the effects of the tax increase on infection rates in the general population and within specific race/ethnicity and age subgroups using mixed models accounting for temporal trends and median income.

RESULTS

Following the Illinois alcohol tax increase, state-wide rates of gonorrhea decreased 21% [95% confidence Interval (CI) = -25.7, -16.7] and chlamydia decreased 11% [95% CI = -17.8, -4.4], resulting in an estimated 3506 fewer gonorrhea infections and 5844 fewer chlamydia infections annually. The null hypothesis of homogenous effects by race/ethnicity and age was rejected (P < 0.0001). Significant reductions were observed among non-Hispanic blacks: gonorrhea rates decreased 25.6% (95% CI = -30.0, -21.0) and chlamydia rates decreased 14.7% (95% CI = -20.9, -8.0). Among non-Hispanics, point estimates suggest decreases were highest among 25-29-year-olds.

CONCLUSIONS

Increased alcohol taxes appear to reduce sexually transmitted infections, especially among subpopulations with high disease burdens, such as non-Hispanic blacks.

Optimizing the scientific yield from a randomized controlled trial (RCT): evaluating two behavioral interventions and assessment reactivity with a single trial

Randomized controlled trials (RCTs) remain the gold standard for evaluating intervention efficacy but are often costly. To optimize their scientific yield, RCTs can be designed to investigate multiple research questions. This paper describes an RCT that used a modified Solomon four-group design to simultaneously evaluate two, theoretically-guided, health promotion interventions as well as assessment reactivity. Recruited participants (N = 1010; 56% male; 69% African American) were randomly assigned to one of four conditions formed by crossing two intervention conditions (i.e., general health promotion vs. sexual risk reduction intervention) with two assessment conditions (i.e., general health vs. sexual health survey). After completing their assigned baseline assessment, participants received the assigned intervention, and returned for follow-ups at 3, 6, 9, and 12 months. In this report, we summarize baseline data, which show high levels of sexual risk behavior; alcohol, marijuana, and tobacco use; and fast food consumption. Sexual risk behaviors and substance use were correlated. Participants reported high satisfaction with both interventions but ratings for the sexual risk reduction intervention were higher. Planned follow-up sessions, and subsequent analyses, will assess changes in health behaviors including sexual risk behaviors. This study design demonstrates one way to optimize the scientific yield of an RCT.

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

Background

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

Methods

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

Results

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

Conclusions

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

Access to HIV prevention services among gender based violence survivors in Tanzania

INTRODUCTION

Currently, Tanzania's HIV prevalence is 5.7%. Gender inequality and Gender Based Violence (GBV) are among factors fuelling the spread of HIV in Tanzania. This study was conducted to assess universal access to HIV prevention services among GBV survivors in Iringa and Dar-es-Salaam where HIV prevalence is as high as 14.7% and 9% respectively compared to a national average of 5.7%.

METHODS

In 2010, a mixed methods study using triangulation model was conducted in Iringa and Dar-es-Salaam regions to represent rural and urban settings respectively. Questionnaires were administered to 283 randomly selected survivors and 37 health providers while 28 in-depth interviews and 16 focus group discussions were conducted among various stakeholders. Quantitative data was analyzed in SPSS by comparing descriptive statistics while qualitative data was analyzed using thematic framework approach.

RESULTS

Counseling and testing was the most common type of HIV prevention services received by GBV survivors (29%). Obstacles for HIV prevention among GBV survivors included: stigma, male dominance culture and fear of marital separation. Bribery in service delivery points, lack of confidentiality, inadequate GBV knowledge among health providers, and fear of being involved in legal matters were mentioned to be additional obstacles to service accessibility by survivors. Reported consequences of GBV included: psychological problems, physical trauma, chronic illness, HIV infection.

CONCLUSION

GBV related stigma and cultural norms are obstacles to HIV services accessibility. Initiation of friendly health services, integration of GBV into HIV services and community based interventions addressing GBV related stigma and cultural norms are recommended.

Preconception and contraceptive care for women living with HIV

Women living with HIV have fertility desires and intentions that are similar to those of uninfected women, and with advances in treatment most women can realistically plan to have and raise children to adulthood. Although HIV may have adverse effects on fertility, recent studies suggest that antiretroviral therapy may increase or restore fertility. Data indicate the increasing numbers of women living with HIV who are becoming pregnant, and that many pregnancies are unintended and contraception is underutilized, reflecting an unmet need for preconception care (PCC). In addition to the PCC appropriate for all women of reproductive age, women living with HIV require comprehensive, specialized care that addresses their unique needs. The goals of PCC for women living with HIV are to prevent unintended pregnancy, optimize maternal health prior to pregnancy, improve maternal and fetal outcomes in pregnancy, prevent perinatal HIV transmission, and prevent HIV transmission to an HIV-uninfected sexual partner when trying to conceive. This paper discusses the rationale for preconception counseling and care in the setting of HIV and reviews current literature relevant to the content and considerations in providing PCC for women living with HIV, with a primary focus on well-resourced settings.