Investigating the impact of condomless vaginal intercourse and lubricant use on the vaginal metabolome: a pre-post observational study

OBJECTIVE

The vaginal metabolome is a significant factor in the vaginal microenvironment, and data are emerging on its independent role in urogenital health. Condomless vaginal intercourse and personal lubricant use are common practices that may affect the vaginal metabolome. The aim of the present study is to describe the associations between condomless intercourse and lubricant use on the vaginal metabolome.

METHODS

This study used archived mid-vaginal swabs from a 10-week observational cohort of reproductive age women who self-collected samples and recorded behavioural diaries daily. Cases and controls were defined as participants who self-reported condomless vaginal intercourse with or without lubricant use, respectively. Samples were drawn prior to and following condomless vaginal intercourse. Twenty-two case participants were race/ethnicity matched to 22 control participants. Mid-vaginal swabs were subjected to 16S rRNA gene amplicon sequencing and untargeted ultrahigh performance liquid chromatography tandem mass spectroscopy metabolomics. Bayesian mixed-effects regression (unadjusted and adjusted for the vaginal microbiota) was used to evaluate differences in metabolite concentration associated with vaginal intercourse and lubricant use.

RESULTS

Both condomless penile-vaginal intercourse and lubricant use were independently associated with higher (up to 8.3-fold) concentrations of metabolites indicative of epithelial damage (eg, sarcosine) and many host-produced antioxidants. Lubricant use was significantly associated with increases in lipids related to cellular damage, host-produced sphingolipids (antimicrobials), antioxidants and salicylate, a cooling agent common to lubricants, in a study design which controls for the independent effect of intercourse. Metabolites involved in oxidative stress and salicylate were strongly correlated with several molecular bacterial vaginosis-associated bacteria.

CONCLUSIONS

This study provides important foundational data on how condomless vaginal-penile intercourse and lubricant use affect the vaginal metabolome and may affect the protective mechanisms in the vaginal microenvironment.

How did the COVID-19 pandemic affect access to condoms, chlamydia and HIV testing, and cervical cancer screening at a population level in Britain? (Natsal-COVID)

OBJECTIVES

To investigate how differential access to key interventions to reduce STIs, HIV and their sequelae changed during the COVID-19 pandemic.

METHODS

British participants (18-59 years) completed a cross-sectional web survey 1 year (March-April 2021) after the initial lockdown in Britain. Quota-based sampling and weighting resulted in a quasi-representative population sample. We compared Natsal-COVID data with Natsal-3, a household-based probability sample cross-sectional survey (16-74 years) conducted in 2010-2012. Reported unmet need for condoms because of the pandemic and uptake of chlamydia testing/HIV testing/cervical cancer screening were analysed among sexually experienced participants (18-44 years) (n=3869, Natsal-COVID; n=8551, Natsal-3). ORs adjusted for age and other potential confounders describe associations with demographic and behavioural factors.

RESULTS

In 2021, 6.9% of women and 16.2% of men reported unmet need for condoms because of the pandemic. This was more likely among participants: aged 18-24 years, of black or black British ethnicity, and reporting same-sex sex (past 5 years) or one or more new relationships (past year). Chlamydia and HIV testing were more commonly reported by younger participants, those reporting condomless sex with new sexual partners and men reporting same-sex partners; a very similar distribution to 10 years previously (Natsal-3). However, there were differences during the pandemic, including stronger associations with chlamydia testing for men reporting same-sex partners; with HIV testing for women reporting new sexual partners and with cervical screening among smokers.

CONCLUSIONS

Our study suggests differential access to key primary and secondary STI/HIV prevention interventions continued during the first year of the COVID-19 pandemic. However, there was not strong evidence that differential access has changed during the pandemic when compared with 2010-2012. While the pandemic might not have exacerbated inequalities in access to primary and secondary prevention, it is clear that large inequalities persisted, typically among those at greatest STI/HIV risk.

HIV prevalence and related risk behaviours in female seasonal farm workers in Souss Massa Draa, Morocco: results from a cross-sectional survey using cluster-based sampling

OBJECTIVES

To determine prevalence of HIV and HIV-related behaviours in female seasonal farm workers (FSFWs) in two provinces of Souss Massa Draa (SMD) region in Morocco. SMD has a higher burden of HIV compared with other parts of Morocco and is characterised by a substantial aggregation of FSFW.

METHODS

We carried out a cross-sectional HIV biobehavioural survey using cluster-based sampling of farms in the provinces Chtouka Aït Baha and Taroudant Ouled Teïma in 2014. HIV testing was done using the Determine HIV-1/2 rapid test and reactive specimens were tested using ELISA and western blot. Collected data were post hoc weighted for region-based stratification and adjusted for clustering effects using complex survey functions of SPSS (V.21).

RESULTS

Among those eligible to participate, the response rate was 92.8%. HIV prevalence was 0.9% (95% CI 0.4% to 2.4%) among 520 recruited participants. A high proportion of respondents (67.7%) had no education. Ever having sex was reported by 79.8% and among these, 12.7% ever exchanged sex for money or goods. Sixty-one per cent reported condom use at most recent commercial vaginal sex in the past 12 months. STI symptom recognition was found to be low because 62.4% and 46.8% of FSFW could not report any STI symptoms in men and women, respectively. Twenty-seven per cent of respondents had an HIV test in the past 12 months. In multivariable analysis, those with primary or higher education (adjusted OR (aOR)=2.38, 95% CI 1.33 to 4.27) and those who participated in an HIV educational session at their workplace (aOR=11.00, 95% CI 3.99 to 30.31) had higher odds of ever been tested for HIV.

CONCLUSIONS

Although we found a relatively low HIV prevalence among FSFW in SMD, HIV interventions should be intensified, in particular, in a subgroup of women who are involved in sex work.

Patterns of sexual behaviour and sexual healthcare needs among transgender individuals in Melbourne, Australia, 2011-2014

OBJECTIVE

Literature surrounding the healthcare needs of transgender individuals is limited in Australia. This study aimed to investigate the demographic characteristics, risk behaviours and HIV/STI positivity among male-to-female (MTF) and female-to-male (FTM) transgender individuals attending Melbourne Sexual Health Centre (MSHC), Australia, between 2011 and 2014.

METHOD

A retrospective cohort analysis for 133 transgender individuals was conducted based on the first visit of individuals to MSHC during the study period. Demographic characteristics, sexual behaviours and HIV/STI positivity were examined.

RESULTS

The majority of transgender individuals were single or never married (74%; n=99). Almost half of the individuals (47%; n=62) had ever engaged in sex work during their lifetime. The median number of male sexual partners (MSP) reported in the last 3 months was 1 (IQR: 1-2) and with female sexual partners (FSP) was 2 (IQR: 1-4). For those who reported having sexual partners in the previous 3 months, always using condoms with MSP was 31% (n=22), and that with FSP was 18% (n=2). HIV/STI positivity during the study period was 7% (n=8) for chlamydia, 5% (n=6) for gonorrhoea, 5% (n=5) for syphilis and 1% (n=1) for HIV. Hormone use for reassignment was reported by 63% (n=90) of individuals and reassignment surgery was reported by 27% (n=29+6=35).

CONCLUSIONS

Transgender individuals in this study were found to be a diverse group, with a history of sex work being a common feature. These findings indicate that transgender individuals' sexual healthcare needs differ substantially from those in other countries, including the US and Canada. Attention to differences in MTF and FTM transgender persons must be considered in healthcare settings in Australia.

Comparing 3-month recall to daily reporting of sexual behaviours

OBJECTIVES

This study aimed to examine discrepancies between self-report methods and methodological issues related to sexual risk taking. We examined sexual behaviour assessed via 3-month electronic recall and by daily electronic reporting among a large cohort of patients attending STI clinics.

METHODS

STI clinic attenders (N= 628) aged 15 to 60 years reported on demographic information (at baseline), penile-vaginal sex acts, condom-unprotected penile-vaginal sex and STI history using 3-month recall and daily reports. Additionally, interviewer-participant match related to race and gender, as well as study site were considered as covariates.

RESULTS

Concordance between recall and daily reports on penile-vaginal sex was moderately strong (Spearman's r (rs)=0.62; p<0.001). Comparison for reports for condom-unprotected penile-vaginal sex resulted in a correlation coefficient of 0.61 (p<0.001), also indicating moderately strong agreement between the two methods. Two generalised logit models were conducted to explain lack of strong concordance in penile-vaginal sex acts and condom-unprotected penile-vaginal sex. The odds of a female reporting higher frequency of sex in daily reports compared with recall were more than two times that of a male. Every five person increase in the number of lifetime sexual partners was associated with five times the odds of a discrepancy in reporting methods. Age was also significantly associated with unequal daily versus recall sex frequency reporting.

CONCLUSIONS

Shifting focus to methodological considerations of technological reports can help ensure better investment of resources into sexual health research due to greater understanding of the methodological properties of data collection methods.

Factors associated with consistent condom use and STIs among foreign female entertainment workers: results from a cross-sectional survey in Singapore

OBJECTIVES

We assessed the prevalence of consistent condom use and laboratory-confirmed STIs among foreign female entertainment workers (FEWs) who engaged in paid or casual sex in Singapore and the factors associated with these characteristics.

METHODS

A cross-sectional survey, using time-location sampling, was conducted on 220 FEWs (115 Vietnamese and 105 Thai) in 2015. For multivariable analysis, we used a mixed-effects Poisson regression model with backward stepwise approach to account for clustering by venue and to obtain the adjusted prevalence ratios (aPRs) of factors associated with consistent condom use and STI positivity, respectively.

RESULTS

Consistent condom use with paid or casual partners in the past month was 39.6% and 36.2% for vaginal and oral sex, respectively. The prevalence of STI (cervical chlamydia, cervical gonorrhoea or pharyngeal gonorrhoea) positivity was 13.6%. In multivariable analysis, consistent condom use for both vaginal and oral sex increased with high self-perceived risk of getting STI/HIV (vaginal: aPR 2.09; 95% CI 1.26 to 3.46; oral: aPR 2.41; 95% CI 1.23 to 4.69) and condom negotiation (vaginal: aPR 3.74; 95% CI 2.07 to 6.75; oral: aPR 2.81; 95% CI 1.51 to 5.26). STI positivity decreased with consistent condom use for vaginal sex (aPR 0.22; 95% CI 0.07 to 0.75) and increased with number of sexual partners (aPR 1.43; 95% CI 1.07 to 1.92).

CONCLUSION

In addition to advocating for policy decisions to provide a safer work environment, behavioural interventions on condom negotiation skills and condom use and biomedical interventions on STI/HIV testing and treatment interventions are needed among the FEWs in Singapore.

TRIAL REGISTRATION NUMBER

NCT02780986; pre-results.

Sexual behaviour of backpackers who visit Koh Tao and Koh Phangan, Thailand: a cross-sectional study

OBJECTIVES

To measure the proportion of backpackers engaging in unprotected sex while travelling in Thailand and to identify predictors of unsafe sexual behaviour.

METHODS

A cross-sectional study using an anonymous questionnaire was performed. English-speaking backpackers, excluding US and Thai citizens, were recruited while travelling through the piers of Koh Tao and Koh Phangan between 25 January and 13 March 2013.

RESULTS

61.5% (1238/2013) respondents were travelling without a long-term sexual partner, of whom 39.1% (29.4% females; 51.9% males) reported intercourse with a new partner. 36.8% of these reported inconsistent/no condom use. Inconsistent condom use was independently associated with age <25 years, UK (vs Canadian) nationality and not bringing condoms from home. Backpackers who brought condoms from home were more likely to have sex with a new partner. Male gender and longer trip length increased the likelihood of new partner acquisition and overall risk of unsafe sex but were not associated with inconsistent condom use. New partners were most commonly backpackers from other countries. Men were more likely than women to have sex with a local person.

CONCLUSIONS

Backpackers visiting Thailand frequently report unsafe sex. Partner demographics demonstrate a mechanism of international sexually transmitted infection (STI) transfer. In an era of growing antibiotic resistance and continuing HIV transmission, targeting unsafe sex in backpackers has the potential to reduce STI incidence internationally. These data highlight the need for innovative public health intervention. To focus such measures, future research may elucidate why certain groups are at higher risk.

Factors associated with consistent condom use among internally displaced women in Leogane, Haiti: results from a cross-sectional tablet-based survey

OBJECTIVES

Scant research has examined factors associated with condom use among internally displaced women in postdisaster settings, such as in postearthquake Haiti. The study objective was to examine social ecological factors associated with consistent condom use among internally displaced women in postearthquake Haiti.

METHODS

A cross-sectional survey was conducted in 2012 with a peer-driven recruitment sample of internally displaced women in Leogane, Haiti. Peer health workers administered tablet-based structured interviews to a convenience sample of 175 internally displaced women.

RESULTS

The 128 participants who reported being sexually active in the last 4 weeks were included in the analyses. Two-thirds (65.2%) reported consistent condom use in the last month. In multivariate logistic regression analyses controlled for age and income, participants that reported sex work, depression, higher number of sex partners and shorter relationship duration had lower odds of consistent condom use in the past month. Participants who reported no experiences of intimate partner violence, lower self-rated health, higher sexual relationship power and more meals per day, had a higher likelihood of reporting consistent condom use.

CONCLUSIONS

This research provides the first assessment of contextual factors associated with consistent condom use among women displaced from a natural disaster such as Haiti's 2010 earthquake. Findings demonstrate the importance of social ecological approaches to understand intrapersonal (eg, sex work and depression), interpersonal (eg, relationship power, intimate partner violence and relationship duration) and structural (eg, food insecurity) factors associated with internally displaced women's condom use. Results can inform future sexual health research and interventions in international disaster contexts.

TRIAL REGISTRATION NUMBER

NCT01492829, pre-results.

Client-perpetrated and husband-perpetrated violence among female sex workers in Andhra Pradesh, India: HIV/STI risk across personal and work contexts

Objectives

This study examines violence experienced in work and personal contexts and relation to HIV risk factors in these contexts among female sex workers (FSW) in Andhra Pradesh, India.

Methods

FSW at least 18 years of age (n=2335) were recruited through three rounds of respondent-driven sampling between 2006 and 2010 for a survey on HIV risk. Using crude and adjusted logistic regression models, any sexual/physical violence (last 6 months) perpetrated by clients and husbands were separately assessed in association with accepting more money for sex without a condom (last 30 days), consistent condom use with clients and husbands (last 30 days), and sexually transmitted infection (STI) symptoms (last 6 months).

Results

The mean age among participants was 32, 22% reported being currently married, and 22% and 21% reported physical/sexual violence by clients and husbands, respectively. In adjusted logistic regression models, FSW who experienced client violence were more likely to report accepting more money for unprotected sex trades (adjusted OR (AOR)=1.7; 95% CI 1.4 to 2.2), less likely to report consistent condom use with clients (AOR=0.6; 95% CI 0.5 to 0.7) and more likely to report STI symptoms (AOR=3.5; 95% CI 2.6 to 4.6). Women who reported husband violence were more likely to report accepting more money for unprotected sex trades (AOR=2.1; 95% CI 1.2 to 3.7), less likely to report consistent condom use with clients (AOR=0.5; 95% CI 0.3 to 0.8) and more likely to report STI symptoms (AOR=2.6; 95% CI 1.6 to 4.1).

Conclusions

Among FSW, experiences of violence in work and personal contexts are associated with sexual HIV risk behaviours with clients as well as STI symptoms.

Sexual abstinence and other behaviours immediately following a new STI diagnosis among STI clinic patients: Findings from the Safe in the City trial

BACKGROUND

Few studies have assessed patients' sexual behaviours during the period immediately following a new diagnosis of a curable sexually transmitted infection (STI).

METHODS

Data were analysed from a behavioural study nested within the Safe in the City trial, which evaluated a video-based STI/HIV prevention intervention in three urban STI clinics. We studied 450 patients who reported having received a new STI diagnosis, or STI treatment, 3 months earlier. Participants reported on whether they seriously considered, attempted and succeeded in adopting seven sex-related behaviours in the interval following the diagnostic visit. We used multivariable logistic regression to identify, among men, correlates of two behaviours related to immediately reducing reinfection risk and preventing further STI transmission: sexual abstinence until participants were adequately treated and abstinence until their partners were tested for STIs.

RESULTS

Most participants reported successfully abstaining from sex until they were adequately treated for their baseline infection (89%-90%) and from sex with potentially exposed partners until their partners were tested for HIV and other STIs (66%-70%). Among men who intended to be abstinent until they were adequately treated, those who did not discuss the risks with a partner who was possibly exposed were more likely not to be abstinent (OR, 3.7; 95% CI 1.5 to 9.0) than those who had this discussion. Similarly, among men who intended to abstain from sex with any potentially exposed partner until the partner was tested for HIV and other STIs, those who reported not discussing the risks of infecting each other with HIV/STIs were more likely to be sexually active during this period (OR, 3.5; 95% CI 1.6 to 8.1) than were those who reported this communication.

CONCLUSIONS

Improved partner communication could facilitate an important role in the adoption of protective behaviours in the interval immediately after receiving a new STI diagnosis.

TRIAL REGISTRATION NUMBER

NCT00137670.

Cervicitis aetiology and case definition: a study in Australian women attending sexually transmitted infection clinics

OBJECTIVES

Studies examining cervicitis aetiology and prevalence lack comparability due to varying criteria for cervicitis. We aimed to outline cervicitis associations and suggest a best case definition.

METHODS

A cross-sectional study of 558 women at three sexually transmitted infection clinics in Sydney, Australia, 2006-2010, examined pathogen and behavioural associations of cervicitis using three cervicitis definitions: 'microscopy' (>30 pmnl/hpf (polymorphonuclear leucocytes per high-powered field on cervical Gram stain)), 'cervical discharge' (yellow and/or mucopurulent cervical discharge) or 'micro+cervical discharge' (combined 'microscopy' and 'cervical discharge').

RESULTS

Chlamydia trachomatis (CT), Mycoplasma genitalium (MG), Trichomonas vaginalis (TV) and Neisseria gonorrhoeae (NG) had the strongest associations with cervicitis definitions 'micro+cervical discharge': CT adjusted prevalence ratio (APR)=2.13 (95% CI 1.38 to 3.30) p=0.0006, MG APR=2.21 (1.33 to 3.69) p=0.002, TV APR=2.37 (1.44 to 3.90) p=0.0007 NG PR=4.42 (3.79 to 5.15) p<0.0001 and 'cervical discharge': CT APR=1.90 (1.25 to 2.89) p=0.003, MG APR=1.93 (1.17 to 3.19) p=0.011, TV APR=2.02 (1.24 to 3.31) p=0.005 NG PR=3.88 (3.36 to 4.48) p<0.0001. Condom use for vaginal sex 'always/sometimes' reduced cervicitis risk: ('micro+cervical discharge') APR=0.69 (0.51 to 0.93) p=0.016. Combined population attributable risk % (PAR%) of these four pathogens was only 18.0% with a protective PAR% of condoms of 25.7%. Exposures not associated with cervicitis included bacterial vaginosis, Mycoplasma hominis, Ureaplasma urealyticum, herpes simplex virus 1&2, cytomegalovirus, Candida, age, smoking and hormonal contraception.

CONCLUSIONS

Cervicitis was associated with CT, MG, TV and NG with combined PAR% of these pathogens only 18% in this setting, suggesting other factors are involved. Condoms significantly reduced cervicitis risk. Cervicitis definitions with best clinical utility and pathogen prediction were 'cervical discharge' and 'micro+cervical discharge'.

Condom deserts: geographical disparities in condom availability and their relationship with rates of sexually transmitted infections

BACKGROUND

Identifying predictors that contribute to geographical disparities in sexually transmitted infections (STIs) is necessary. This study assesses the spatial relationship between condom availability to locations of STIs in order to better understand these geographical disparities.

OBJECTIVES

We conducted a condom availability audit among potential condom-selling establishments. New gonorrhoea and chlamydia cases in 2011 (n=6034) and HIV infection cases from 2006 to 2011 (n=565) were collected by census tract in St Louis, Missouri. 829 potential condom-selling establishments participated in the condom availability audit in St Louis City; 242 of which sold condoms.

RESULTS

A negative linear relationship exists between condom vendors and cases of gonorrhoea and chlamydia, after adjusting for concentrated disadvantage and free condom locations. Higher concentrated disadvantage, higher proportions of convenience vendors and free locations were associated with higher rates of HIV.

CONCLUSIONS

This study was conducted to provide evidence that lack of condom availability is associated with STI rates, and likely is an integral component to influencing the subjective norms surrounding condom use and STI rates. Condom distribution interventions may be addressing availability needs and social norms, yet are more likely to be effective when placed in locations with the highest STI rates.

Differences in risk behaviours and HIV/STI prevalence between low-fee and medium-fee female sex workers in three provinces in China

OBJECTIVES

To better understand risk behaviours and factors associated with low-fee female sex workers (FSW) and support HIV/sexually transmitted infections (STI) epidemic control among this key population in China.

METHODS

A cross-sectional study using convenience sampling to recruit 1487 eligible low-fee and medium-fee FSW was conducted in 2012 in three provinces. The participants were interviewed using a structured questionnaire and tested for HIV-1, herpes simplex virus (HSV)-2 and syphilis antibody. Log-binomial modelling was used to estimate prevalence ratios (PR) and examine factors associated with low-fee sex work.

RESULTS

Prevalence of HIV-1, syphilis and HSV-2 antibody positive were 0.5%, 4.8% and 27.8%, respectively. Low-fee FSW were more likely to have HSV-2 infection (adjusted prevalence ratio (APR)=1.3, 95% CI 1.1 to 1.7), but not more likely to have HIV-1 and syphilis infection compared with medium-fee FSW. Compared with medium-fee FSW, low-fee FSW were more likely to be ≥35 years of age (APR=2.1, 95% CI 1.3 to 3.6), engage in sex work ≥6 days/per week (APR=1.7, 95% CI 1.2 to 2.6), have ≥3 clients per day (APR=2.2, 95% CI 1.5 to 3.3), have clients decide condom use (APR=1.6, 95% CI 1.1 to 2.3), fail to persuade clients to use condoms (APR=1.6, 95% CI 1.1 to 2.6), express willingness to have unprotected sex in return for receipt of a higher fee (APR=1.8, 95% CI 1.2 to 2.8), have had genital symptoms in the past year (APR=1.4, 95% CI 1.1 to 1.8) and have migrated from another city.

CONCLUSIONS

Low-fee FSW in China have unique risks for acquiring HIV/STI, in part due to greater economic pressures. Tailored interventions targeting low-fee FSW and incorporating their prevailing perception of HIV/STI risks and condom use negotiation challenges that they face are urgently needed.

A longitudinal daily diary analysis of condom use during bleeding-associated vaginal sex among adolescent females

OBJECTIVE

Sex during bleeding is a risk factor for sexually transmitted infection (STI) and other bloodborne viruses, including HIV. We examined daily predictors of adolescent women's male condom use during bleeding-associated vaginal sex.

METHODS

Adolescent females (N=387; 14-17 years) were recruited from primary care clinics for a longitudinal cohort study of STIs and sexual behaviour. Data were daily partner-specific sexual diaries; generalised estimating equation logistic regression assessed the likelihood of condom use during bleeding-associated vaginal sex.

RESULTS

Less than 30% of bleeding-associated vaginal sex events were condom protected. Condom use during these events was less likely with younger age, higher partner support, higher partner negativity or past week bleeding-associated sex with a given partner; condom use was more likely with high individual mood and past week condom use during bleeding-associated vaginal sex with a given partner.

CONCLUSIONS

Low condom rates during bleeding-associated vaginal sex can increase STI and bloodborne virus risk. Providers should consider integrating partner-specific and behavioural factors when they deliver sexual health messages to young women.

Do young women engage in greater sexual risk behaviour with biological fathers of their children?

OBJECTIVES

Qualitative research suggests that young women's relationships with the biological fathers of their children (BFRs), known colloquially as 'baby daddy' relationships, enable risk for pregnancy and STI/HIV. Our study compared partner characteristics and sexual risk within dyads based on BFR, among a sample of young women in Baltimore, Maryland, USA.

METHODS

We conducted secondary analysis of survey data collected in 2011-2013 from heterosexually experienced youth ages 15-24 in Baltimore, Maryland, USA. Analyses are limited to women with at least one recent (past 6 months) sex partner (n=171 participants, reporting on 271 relationships). Using generalised estimating equations with logit function for correlated binary responses, we evaluate associations of BFR with partner characteristics, sexual risk behaviour and contraceptive non-use.

RESULTS

At least one BFR partner was reported by 25.2%. Male partners in BFRs were more likely to have been incarcerated or arrested. BFRs were more often characterised by women as 'main' versus 'casual' partners (adjusted OR (AOR) 3.92, 95% CI 1.19 to 12.9). In adjusted analyses, BFR was associated with condom non-use for vaginal (AOR 12.3, 95% CI 3.92 to 38.7) and anal (AOR 3.32, 95% CI 1.34 to 8.22) intercourse. While BFR was associated with contraceptive non-use (AOR 2.21, 95% CI 1.01 to 4.84), this association attenuated to non-significance after adjusting for partnership type (AOR 2.06, 95% CI 0.91 to 4.67).

CONCLUSIONS

While few differences in BFR partner characteristics emerged, significantly greater risk for unprotected intercourse was identified within BFR relationships. Findings suggest that the relationship context of a shared child heightens sexual risk for the young women most affected by STI.

"First, I… then, we…": exploring the sequence of sexual acts and safety strategies reported during a sexual encounter using a modified timeline followback method

OBJECTIVES

Assessments of sexual safety often rely on questions about the occurrence of condom use within a designated timeline, assuming that penile-vaginal intercourse (PVI) occurred once at the conclusion of the event. An investigation of all sexual acts and safety strategies that occur during a single event may present a more nuanced picture of sexual risk.

METHODS

Behaviourally, bisexual women (N=45) were recruited due to the potential diversity of their sexual behaviour and safety strategies. A modified timeline follow-back method, the SEQUENCE Calendar, was designed to capture information about the participants' most recent sexual event with a male partner, including the order of each sexual act during the sexual event. Interviews took between 1 and 3 h. These acts were compiled into narratives and the behavioural sequences were reviewed and coded.

RESULTS

Participants reported an average of 7.9 (SD=4.3) sexual acts. Over a third (35.9%, N=14) of the participants who reported PVI indicated engaging in genital contact after PVI and over 15% (N=6) of these participants reporting PVI at two different time points, separated by sexual behaviour. Additional potential for infection outside of condom use and PVI was also identified.

CONCLUSIONS

Sexual interactions are comprised of multiple acts that occur in a variety of permutations. Understanding the complexity of people's sexual encounters has potential to inform the ways we measure condom use and consider sexual safety.

Malawi faith communities responding to HIV/AIDS: preliminary findings of a knowledge translation and Participatory-Action Research (PAR) project

This paper reports on the preliminary findings (year one) of a four-year intervention and Participatory-Action Research (PAR) project in Malawi. Project goals are to enhance the response capacity and effectiveness of Faith Community (FC) leaders to the problem of HIV/AIDS. Ethnographic interviews with FC leaders were conducted. Intercultural training sessions and theological events were also held using a participatory method called conceptual events. Preliminary results indicate a commitment on the part of faith community leaders to enter into a dialogue with other sectors and faith traditions in addressing the common, critical concern of HIV/AIDS. All FC leaders share a common feeling that they are a small moral voice in this fight against HIV/AIDS, drowned out by a 'big voice' promoting condom use by donors and government. FC leaders are expected to present themselves as having an authoritative voice with respect to protecting the soul, but at the same time are sincerely searching for ways to speak about HIV/AIDS in more practical ways. Condoms become a metaphor for resistance. For example, FC leaders wish to know how the message of condom promotion (a behavioural and technical argument) might be grafted onto what they would posit as a moral message of care, prevention and support. This challenge is made even more complex by the quiet assumption to incorporate the truths of African traditional religion (ATR) in the construction of an ecumenical theology of faith, hope and compassion.

Habitual condom use across partner type and sexual position among younger gay and bisexual men: findings from New Zealand HIV behavioural surveillance 2006-2011

Objectives

Our objectives were to investigate demographic and behavioural factors associated with condom use and to examine how habitual condom use was across partner types and sexual positions among younger men who have sex with men (YMSM), aged 16–29, surveyed in New Zealand.

Methods

We analysed the 2006–2011 national HIV behavioural surveillance data from YMSM who reported anal intercourse in four scenarios of partner type and sexual position: casual insertive, casual receptive, regular insertive and regular receptive. For each, respondents’ condom use was classified as frequent (always/almost always) or otherwise, with associated factors identified with multivariate mixed-effect logistic regression. Habitual condom use across scenarios was examined using a latent variable technique that estimated the intraclass correlation coefficient (ICC).

Results

Frequent condom use was reported for 63.6% of 5153 scenarios reported from 2412 YMSM. Frequent use increased from boyfriend to fuckbuddy to casual partners. Infrequent use was associated with online recruitment, Pacific ethnicity, less education, HIV positivity, sex with women, having ≥20 sexual partners versus 1 and reporting insertive and receptive sexual positions. Frequent condom use was associated with having two to five sexual partners versus one and shorter regular partnerships. The ICC=0.865 indicated highly habitual patterns of use; habitual infrequent condom use was most prevalent with regular partners (53.3%) and habitual frequent condom use was most prevalent with casual partners (70.2%) and for either sexual position (50.5% and 49.1%).

Conclusions

Habitual condom use among YMSM highlights the value of early, engaging and sustained condom promotion. Public health should provide better and more compelling condom education, training and promotion for YMSM.

Associations between rushed condom application and condom use errors and problems

OBJECTIVE

To determine whether any of four condom use errors/problems occurred more frequently when condom application was 'rushed' among a clinic-based sample from three US states.

METHODS

A convenience sample (n=512) completed daily electronic assessments including questions about condom use being rushed and also assessed condom breakage, slippage, leakage and incomplete use.

RESULTS

Of 8856 events, 6.5% (n=574) occurred when application was rushed. When events involved rushed condom application, the estimated odds of breakage and slippage were almost doubled (estimated OR (EOR)=1.90 and EOR=1.86). Rushed application increased the odds of not using condoms throughout sex (EOR=1.33) and nearly tripled the odds of leakage (EOR=2.96). With one exception, all tests for interactions between gender and rushed application and between age and rushed application were not significant (p values>0.10).

CONCLUSIONS

This event-level analysis suggests that women and men who perceive that condom application was rushed are more likely to experience errors/problems during the sexual event that substantially compromise the protective value of condoms against disease and pregnancy. Educational efforts emphasising the need to allow ample time for condom application may benefit this population.

Reliance on condoms for contraceptive protection among HIV care and treatment clients: a mixed methods study on contraceptive choice and motivation within a generalised epidemic

Objectives

To (i) describe the contraceptive practices of HIV care and treatment (HCTx) clients in Manzini, Swaziland, including their unmet needs for family planning (FP), and compare these with population-level estimates; and (ii) qualitatively explore the causal factors influencing contraceptive choice and use.

Methods

Mixed quantitative and qualitative methods were used. A cross-sectional survey conducted among HCTx clients (N=611) investigated FP and condom use patterns. Using descriptive statistics, findings were compared with population-level estimates derived from Swaziland Demographic and Health Survey data, weighted for clustering. In-depth interviews were conducted with HCTx providers (n=16) and clients (n=22) and analysed thematically.

Results

64% of HCTx clients reported current contraceptive use; most relied on condoms alone, few practiced dual method use. Rates of condom use for FP among female HCTx clients (77%, 95% CI 71% to 82%) were higher than population-level estimates in the study region (50% HIV-positive, 95% CI 43% to 57%; 37% HIV-negative, 95% CI 31% to 43%); rates of unmet FP needs were similar when condom use consistency was accounted for (32% HCTx, 95% CI 26% to 37%; vs 35% HIV-positive, 95% CI 28% to 43%; 29% HIV-negative, 95% CI 24% to 35%). Qualitative analysis identified motivational factors influencing FP choice: fears of reinfection; a programmatic focus on condoms for people living with HIV; changing sexual behaviours before and after antiretroviral therapy (ART) initiation; failure to disclose to partners; and contraceptive side effect fears.

Conclusions

Fears of reinfection prevailed over consideration of pregnancy risk. Given current evidence on reinfection, HCTx services must move beyond a narrow focus on condom promotion, particularly for those in seroconcordant relationships, and consider diverse strategies to meet reproductive needs.

Prevalence, correlates and trends in seroadaptive behaviours among men who have sex with men from serial cross-sectional surveillance in San Francisco, 2004-2011

OBJECTIVES

We sought to assess the prevalence and correlates of seroadaptive behaviours (i.e., sexual history incorporating some unprotected anal intercourse (UAI)) and conventional risk reduction behaviours (i.e., consistent condom use or no anal intercourse) among men who have sex with men (MSM) in San Francisco in 2011. We compared the prevalence of seroadaptive behaviours between serial cross-sectional surveys from 2004, 2008 and 2011.

METHODS

We analysed data from the 2011 wave of the National HIV Behavioral Surveillance system in San Francisco. We categorised men's self-reported sexual behaviour history in the past 6 months into a schema of seroadaptive behaviours and conventional risk reduction behaviours. We compared the prevalence of behaviour categories by self-reported HIV serostatus, HIV testing history, awareness of pre-exposure HIV prophylaxis (PrEP) and diagnosis of a sexually transmitted infection (STI).

RESULTS

Seroadaptive behaviours remained common in San Francisco MSM, with a 2011 prevalence of 46.6%, up from 35.9% in 2004. Consistent condom use or no anal intercourse was more common than seroadaptive behaviours in HIV-negative MSM, men who had not heard of PrEP and men without an STI diagnosis. Seroadaptive behaviours increased from 2004 to 2011.

CONCLUSIONS

HIV seroadaptive behaviours remain common in San Francisco MSM, have increased in the last decade and are practiced differently by MSM with different sexual health knowledge and outcomes. Public health researchers and officials should continue to document the prevalence, intentionality, efficacy and safety of seroadaptive behaviours among diverse communities of MSM.

Location-based HIV behavioural surveillance among MSM in Auckland, New Zealand 2002-2011: condom use stable and more HIV testing

OBJECTIVES

Over the last decade, annual HIV diagnoses among men who have sex with men (MSM) in New Zealand increased, then stabilised in 2006 and have not increased further. The aim was to examine trends in behaviours in order to better understand this pattern and inform community-based prevention.

METHODS

From 2002 to 2011, we conducted five repeat cross-sectional behavioural surveillance surveys among MSM at community locations in Auckland (fair day, gay bars, sex-on-site venues; n=6091). Participation was anonymous and self-completed. Recruitment methods were consistent at each round.

RESULTS

Overall, the samples became more ethnically diverse and less gay community attached over time. Condom use during anal intercourse was stable across three partnering contexts (casual, current regular fuckbuddy, current regular boyfriend), with a drop among casual contacts in 2011 only. In the 6 months prior to surveys, there was a gradual decline over time in the proportion reporting >20 male partners, an increase in acquiring partners from the internet and increases in engagement in anal intercourse in some partnering contexts. HIV testing in the 12 months prior to surveys rose from 35.1% in 2002 to 50.4% in 2011, mostly from 2008.

CONCLUSIONS

This first indepth examination of trends in HIV-related behaviours among five consecutive large and diverse samples of MSM in New Zealand does not suggest condom use is declining. However, subtle changes in sexual networks and partnering may be altering the epidemic determinants in this population and increasing exposure.

Condoms for prisoners: no evidence that they increase sex in prison, but they increase safe sex

Objectives

To determine if the provision of condoms to prisoners in two Australian state prison systems with different policies affects sexual behaviour. In New South Wales’ (NSW) prisons, condoms are freely distributed, while in Queensland prisons none are distributed.

Methods

We used a computer-assisted telephone interview to survey randomly selected prisoners in both states about their sexual behaviour in prison.

Results

Two thousand and eighteen male prisoners participated. The proportion of prisoners reporting anal sex in prison was equally low in NSW (3.3%) and Queensland (3.6%; p=0.8). A much higher proportion of prisoners who engaged in anal sex in NSW (56.8%) than Queensland (3.1%; p<0.0001) reported they had used a condom if they had had anal sex in prison. Sexual coercion was equally rare in both prison systems.

Conclusions

We found no evidence that condom provision to prisoners increased consensual or non-consensual sexual activity in prison. If available, condoms were much more likely to be used during anal sex. Condoms should be made available to prisoners as a basic human right.