Sexual risk behaviours and barriers to HIV testing among clients of female sex workers in Guatemala: a qualitative study

Few interventions have targeted clients of female sex workers in Central America, despite their potential role in HIV/STI prevention. Semi-structured interviews were conducted with 30 clients of female sex workers on attitudes towards prevention of HIV/STIs, barriers to condom use and behaviour towards HIV/STI testing and treatment in Escuintla, Guatemala. Despite high knowledge of condoms as an HIV/STI preventive measure, the decision to use them was often based on the client's social judgment of the woman's sexual conduct. Regular clients reported lower condom use. Clients' risk perception diminished with the awareness of the public HIV/STI clinic addressed to female sex workers. Most preferred private clinics to increase confidentiality and were reluctant to take the HIV test for fear of a positive result. Outreach programmes offering HIV/STI counselling and testing to clients of female sex workers could increase their test uptake and health-seeking behaviour and reduce potential transmission to the general population.     

The contextual determinants of sexually transmissible infections among street-involved youth in North America

Young people living on the urban street are at a significantly increased risk of HIV and other sexually transmitted infections (STIs). Much research examining the epidemiological basis for their heightened susceptibility has concentrated on the individual behaviours and characteristics associated with acquiring these infections. However, contextual factors, including the social, structural and environmental forces that influence sexual risk behaviour, are increasingly found to play an important role in shaping the transmission dynamics of HIV and STIs within these marginalised populations. This paper reviews research describing the individual and contextual factors that have been shown to influence street youth sexual behaviour and provides an analysis of the potential impact of such factors on HIV and STI transmission. In order to implement effective sexual health programmes for street-involved young people, innovative programmes are required that take into account the unique social and structural context of youth homelessness. Interventions to reduce the elevated prevalence and incidence of HIV and STIs among this population must explicitly target multi-level factors influencing the transmission dynamics of these diseases.     

‘It's raining stones’: stigma,violence and HIV vulnerability among men who have sex with men in Dakar,Senegal

Research in many countries has highlighted the vulnerability of men who have sex with men to HIV and other sexually transmitted infections (STIs). Yet in Africa, such men have received little attention in HIV/AIDS programming and service delivery because of the widespread denial and stigmatization of male homosexual behaviour. In Dakar, Senegal, a study conducted by researchers from Cheikh Anta Diop University, the Senegal National Council Against AIDS, and the Horizons Program elicited quantitative and qualitative data about the needs, behaviours, knowledge, and attitudes of men who have sex with men. Findings reveal that respondents have distinct identities and social roles that go beyond sexual practices, that sex with men is driven by many reasons, including love, pleasure, and economic exchange, and that respondents' lives are often characterized by stigma, violence and rejection. The data also highlight that many men are at risk of HIV because of unprotected sex with other men, a history of STI symptoms, and poor knowledge of STIs. The study underscores the need for non‐stigmatizing, sexual health information and services.     

The contextual determinants of sexually transmissible infections among street‐involved youth in North America

Young people living on the urban street are at a significantly increased risk of HIV and other sexually transmitted infections (STIs). Much research examining the epidemiological basis for their heightened susceptibility has concentrated on the individual behaviours and characteristics associated with acquiring these infections. However, contextual factors, including the social, structural and environmental forces that influence sexual risk behaviour, are increasingly found to play an important role in shaping the transmission dynamics of HIV and STIs within these marginalised populations. This paper reviews research describing the individual and contextual factors that have been shown to influence street youth sexual behaviour and provides an analysis of the potential impact of such factors on HIV and STI transmission. In order to implement effective sexual health programmes for street‐involved young people, innovative programmes are required that take into account the unique social and structural context of youth homelessness. Interventions to reduce the elevated prevalence and incidence of HIV and STIs among this population must explicitly target multi‐level factors influencing the transmission dynamics of these diseases.     

Health care professional communication about STI vaccines with adolescents and parents

Vaccination of adolescents against sexually transmitted infections (STIs) is an important prevention strategy that may reduce the global burden of disease. The World Health Organization, Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices, and other national health agencies recommend the use of existing STI vaccines, and many countries have incorporated them into their routine vaccination schedule. Despite this, however, data indicate that STI vaccine uptake is suboptimal for a variety of reasons. Health care professionals (HCP) have been shown to have a strong beneficial effect on STI vaccine uptake, yet studies demonstrate that many HCPs fail to discuss or recommend them to adolescent patients. This review article focuses on HCP communication about STI vaccines with adolescents and their parents. It describes STI vaccine message content and delivery as well as the context in which HCPs formulate their messaging approach. It also examines other contextual factors that may shape communication about STI vaccines. Studies from many countries indicate that HCPs often possess misinformation about adolescents, including their sexual risk behaviors, as well as STIs, vaccine safety and efficacy, and STI vaccination recommendations. They also have misconceptions of parental barriers to STI vaccination. These may impact STI vaccine communication and have a negative influence on STI vaccine uptake. These findings highlight the critical need for improved HCP education related to adolescent health, sexuality, and STI vaccination. This may be particularly important in settings without an existing infrastructure or expertise in caring for this unique patient population.     

“Eyes that don't see,heart that doesn't feel”: Coping with sex work in intimate relationships and its implications for HIV/STI prevention

Partner communication about HIV sexual risk behaviors represents a key area of epidemiologic and social importance in terms of infection acquisition and potential for tailored interventions. Nevertheless, disclosing sexual risk behaviors often presents myriad challenges for marginalized couples who engage in stigmatized behaviors. Using qualitative data from a social epidemiology study of risk for HIV and other sexually transmitted infections (STIs) among female sex workers and their intimate, non-commercial male partners along the Mexico–U.S. border, we examined both partners' perspectives on sex work and the ways in which couples discussed associated HIV/STI risks in their relationship. Our thematic analysis of individual and joint interviews conducted in 2010 and 2011 with 44 couples suggested that broader contexts of social and economic inequalities profoundly shaped partner perspectives of sex work. Although couples accepted sex work as an economic contribution to the relationship in light of limited alternatives and drug addiction, it exacted an emotional toll on both partners. Couples employed multiple strategies to cope with sex work, including psychologically disconnecting from their situation, telling “little lies,” avoiding the topic, and to a lesser extent, superficially discussing their risks. While such strategies served to protect both partners' emotional health by upholding illusions of fidelity and avoiding potential conflict, non-disclosure of risk behaviors may exacerbate the potential for HIV/STI acquisition. Our work has direct implications for designing multi-level, couple-based health interventions.     

Control of sexually transmitted infections and prevention of HIV transmission: mending a fractured paradigm

Control of sexually transmitted infections (STIs) is feasible, leads to improved sexual and reproductive health and contributes to preventing HIV transmission. The most advanced HIV epidemics have developed under conditions of poor STI control, particularly where ulcerative STIs were prevalent. Several countries that have successfully controlled STIs have documented stabilization or reversal of their HIV epidemics.STI control is a public health outcome measured by reduced incidence and prevalence. The means to achieve this include: (i) targeting and outreach to populations at greatest risk; (ii) promoting and providing condoms and other means of prevention; (iii) effective clinical interventions; (iv) an enabling environment; and (v) reliable data.Clinical services include STI case management, screening and management of STIs in sex partners. Syndromic case management is effective for most symptomatic curable STIs and screening strategies exist to detect some asymptomatic infections. Presumptive epidemiologic treatment of sex partners and sex workers complement efforts to interrupt transmission and reduce prevalence. Clinical services alone are insufficient for control since many people with STIs do not attend clinics. Outreach and peer education have been effectively used to reach such populations.STI control requires effective interventions with core populations whose rates of partner change are high enough to sustain transmission. Effective, appropriate targeting is thus necessary and often sufficient to reduce prevalence in the general population. Such efforts are most effective when combined with structural interventions to ensure an enabling environment for prevention. Reliable surveillance and related data are critical for designing and evaluating interventions and for assessing control efforts.     

Sexual practices,identities and health among women who have sex with women in Lesotho – a mixed-methods study

Despite the high prevalence of HIV and STIs among women in Africa and the growing literature on HIV and STIs among women who have sex with women, research on the sexual health of women who have sex with women in Africa is scant. This study used mixed methods to describe sexual identity, practices and health among women who have sex with women in Lesotho. Most respondents (48%) described themselves as lesbian, 29% as bisexual and 23% as heterosexual. Almost half (45%) had disclosed their same-sex attraction to family, but only 25% had done so with healthcare workers. A total of 8% reported having HIV. Self-reported HIV was associated with having three or more male partners, having male and female partners at the same time and having a history of STIs. Gender norms, the criminalisation of homosexuality, varied knowledge of, and access to, safer-sex strategies, and mixed experiences of HIV/STI testing and sexual healthcare provided social and structural contexts for HIV- and STI-related vulnerability.     

A global research synthesis of HIV and STI biobehavioural risks in female-to-male transgender adults

ABSTRACT

There is a growing interest in HIV infection and sexually transmitted infection (STI) disease burden and risk among transgender people globally; however, the majority of work has been conducted with male-to-female transgender populations. This research synthesis comprehensively reviews HIV and STI research in female-to-male (FTM) transgender adults. A paucity of research exists about HIV and STIs in FTMs. Only 25 peer-reviewed papers (18 quantitative, 7 qualitative) and 11 ‘grey literature’ reports were identified, most in the US or Canada, that include data identifying HIV and STI risks in FTMs (five with fully laboratory-confirmed HIV and/or STIs, and five with partial laboratory confirmation). Little is known about the sexual and drug use risk behaviours contributing to HIV and STIs in FTMs. Future directions are suggested, including the need for routine surveillance and monitoring of HIV and STIs globally by transgender identity, more standardised sexual risk assessment measures, targeted data collection in lower- and middle-income countries, and explicit consideration of the rationale for inclusion/exclusion of FTMs in category-based prevention approaches with MSM and transgender people. Implications for research, policy, programming, and interventions are discussed, including the need to address diverse sexual identities, attractions, and behaviours and engage local FTM communities.     

Prevalence and Correlates of HIV and Sexually Transmitted Infections among Female Sex Workers and Their Non-commercial Male Partners in Two Mexico-USA Border Cities

Female sex workers (FSWs) acquire HIV and other sexually transmitted infections (STIs) through unprotected sex with commercial and non-commercial (intimate) male partners. Little research has focused on FSWs'' intimate relationships, within which condom use is rare. We sought to determine the prevalence and correlates of HIV/STIs within FSWs'' intimate relationships in Northern Mexico. From 2010 to 2011, we conducted a cross-sectional survey of FSWs and their non-commercial male partners in Tijuana and Ciudad Juárez, Mexico. Eligible FSWs and their verified male partners were aged ≥18 years; FSWs reported lifetime use of heroin, cocaine, crack, or methamphetamine and recently exchanged sex (past month). Participants completed baseline questionnaires and testing for HIV, chlamydia, gonorrhea, and syphilis. We determined the prevalence and correlates of individuals'' HIV/STI positivity using bivariate probit regression. Among 212 couples (n = 424), prevalence of HIV was 2.6 % (n = 11). Forty-two (9.9 %) tested positive for any HIV/STIs, which was more prevalent among women than men (12.7 % vs. 7.1 %, p < 0.05). FSWs with regular sex work clients were less likely to test positive for HIV/STIs than those without regular clients. Similarly, male partners of FSWs who had regular clients were 9 % less likely to have HIV/STIs. Higher sexual decision-making power was protective against HIV/STIs for women. Men who recently used methamphetamine or reported perpetrating any conflict within steady relationships were more likely to test positive for HIV/STIs. Within FSWs'' intimate relationships in two Mexican-US border cities, nearly one in ten partners tested positive for HIV/STIs. Couple-based prevention interventions should recognize how intimate relationship factors and social contexts influence HIV/STI vulnerability.     

HIV/STI risk by migrant status among workers in an urban high-end entertainment centre in Eastern China

Large-scale internal migration in China may be an important mechanism for the spread of HIV/sexually transmitted infections (STIs) because of the risk behaviours of migrants. We conducted a self-administered survey among 724 employees of a high-end entertainment centre in Kunshan, Jiangsu Province, China. Using logistic regression, we examined the association of hometown of origin (Kunshan city, elsewhere in Jiangsu Province, or another province in China) and consecutive years living in Kunshan with measures of HIV/STI risk behaviour. We found that increased time living in Kunshan was associated with lower odds of using condoms as contraception [odds ratio (OR) = 0.78, 95% confidence interval (CI): 0.64-0.95] and consistent condom use with a casual partner (OR = 0.66, 95% CI: 0.47-0.93), after controlling for gender, marital status age and income. The odds of having had an STI were significantly lower for Kunshan natives than those originally from outside provinces (OR = 0.25, 95% CI: 0.07-0.96), but increasing years living in Kunshan was not related to lower risk for an STI. Our findings do not support the hypothesis that migrants living far from home participate in higher risk behaviour than locals. Findings suggest that adaptation to local culture over time may increase HIV/STI risk behaviours, a troublesome finding.     

Barriers to sexually transmitted infection testing in New Zealand: a qualitative study

Objective: To investigate the barriers that prevent or delay people seeking a sexually transmitted infection (STI) test. Methods: Qualitative in‐depth interviews were conducted with 24 university students, who are a group prone to behaviours putting them at risk of STIs, to understand the factors that had prevented or delayed them from going for an STI test in the past. Resulting data were thematically analysed employing a qualitative content analysis method, and a final set of themes identified. Results: There were three main types of barrier to STI testing. These were: personal (underestimating risk, perceiving STIs as not serious, fear of invasive procedure, self‐consciousness in genital examination and being too busy); structural (financial cost of test and clinician attributes and attitude); and social (concern of being stigmatised). Conclusions and implications for public health: These data will help health providers and policy‐makers provide services that minimise barriers and develop effective strategies for improving STI testing rates. The results of this study suggest a holistic approach to encouraging testing is required, which includes addressing personal beliefs, working with healthcare providers to minimise structural barriers and developing initiatives to change social views about STIs.     

Sexual activity and risk-taking in later life

The primary study objective was to identify the prevalence of sexual activity and sexual risk-taking behaviour among a sample of older community-based adults. Secondary objectives included gathering data about past experiences of consultations regarding sexual health issues with general practitioners (GPs) and at genitourinary medicine (GUM) clinics, and exploring participants' STI and HIV/AIDS-related information needs. Individuals over the age of 50 were identified from four electoral wards within Sheffield, UK by means of a postal screen based on the electoral register. Respondents self completed a short postal questionnaire. Three hundred and nineteen individuals aged over 50 years selected at random from the general population responded. Approximately 80% of respondents were currently sexually active and 7% engaged in behaviours that may place them at risk of contracting a sexually transmitted infection (STI). Risk takers were typically male, aged between 50 and 60 years and married. Being male was also related to reporting current or past sexual health concerns. In total, of 75 respondents reporting such concerns, two thirds had discussed these concerns with their GP or attended a GUM clinic. Levels of satisfaction with such consultations were generally high, but declined with increasing age. Overall, most participants felt they had not received very much information about STIs and HIV, and about one quarter reported that they would like to receive more information on these topics. These data have implications for all health and social care professionals who work with older people and indicate a potential need for education to help professionals meet the sexual health needs of their older patients/clients. Further implications for sexual health promotion and the need for additional research in this field are also discussed.     

What role does transactional sex play in the HIV/STI and reproductive health risk behaviour among high-tier entertainment centre workers in China?

China's rapid economic growth over the last three decades has led to increased population wealth and the proliferation of entertainment centres where people can conduct business, relax and meet new people. Little is known about the sexual risk behaviours of employees at high-tier entertainment centres. This paper addresses this gap in knowledge by comparing HIV risk perception and sexual and reproductive health behaviours among female and male employees at three high-tier entertainment centres in two cities in China, comparing those who report a history of transactional sex to those who do not. In both cities, participants who reported a history of transactional sex were more likely than those without a history of transactional sex to report multiple sexual partnerships, more lifetime sexual partners, a history of sexually transmitted infections (STIs), having anal sex and/or recent abortions, and were more likely to perceive themselves to be at risk for STIs/HIV. However, risk behaviour was also high among those with no history of transactional sex. These findings highlight the need for targeted sexual and reproductive health initiatives for employees in these work settings.     

Sexually active older Australian's knowledge of sexually transmitted infections and safer sexual practices

Objective: Rates of sexually transmitted infections (STIs) are rising among older Australians. We conducted a large survey of older people's knowledge of STIs and safer sexual practices. Methods: A total of 2,137 Australians aged 60 years and older completed the survey, which included 15 questions assessing knowledge of STIs and safer sexual practices. We examined both levels of knowledge and factors associated with an overall knowledge score. Results: In total, 1,652 respondents reported having sex in the past five years and answered all knowledge questions. This group had good general knowledge but poorer knowledge in areas such as the protection offered by condoms and potential transmission modes for specific STIs. Women had better knowledge than men. Men in their 60s, men with higher education levels, and men who thought they were at risk of STIs reported better knowledge than other men. Knowledge was also better among men and women who had been tested for STIs or reported ‘other’ sources of knowledge on STIs. Conclusions: Many older Australians lack knowledge of STIs and safer sexual practices. Implications for public health: To reverse current trends toward increasing STI diagnoses in this population, policies and education campaigns aimed at improving knowledge levels may need to be considered.     

Knowledge, attitudes and behaviours of health care workers towards clients of sexual health services in Fiji

A cross-sectional survey was conducted to identify the attitudes and behaviours of health care workers (HCWs) in health care settings (HCS) in Fiji involving 369 participants. Self-rated knowledge of HIV and sexually transmissible infections (STIs) varied depending on whether the HCS was divisional or sub-divisional, and varied between the various national divisions. HCWs with experience in HIV, reproductive health and antenatal clinics had higher self-rated HIV knowledge. A high proportion had a fear of catching HIV from HIV-positive clients. This study found high levels of negative attitudes towards clients from vulnerable groups with regards to the transmission and spread of HIV. Study participants also reported observing differential treatment by their colleagues if a client was known to have or was suspected of having HIV. There is a need for further HIV education of HCWs, with training focussed on occupational risk, and on reducing stigma and discrimination of those living with or vulnerable to HIV in Fiji.     

Infecciones de transmisión sexual en hombres internos en prisión: riesgo de desarrollo de nuevas infecciones

ObjectiveTo measure incidence and main risk factors related to sexually transmitted infections (STIs) in Daroca Prison (Zaragoza, Spain).MethodA retrospective cohort study (2005-2013) to measure the incidence of STI and a cross-sectional study to measure risk factors.ResultsOf the 203 inmates, 79 developed an STI, 37 had a previous STI, 55.2% lacked knowledge on STI prevention, and 28.9% showed behaviours unfavourable for STI prevention. The incidence rate was 6.5 STIs per 1,000 inmates-year. The most frequent STIs were hepatitis B (39.7%), Ureaplasma urealyticum (19.1%), herpes simplex (16.2%) and HIV (8.8%). The risk (hazard ratio, HR) of acquiring a new STI was significantly higher in inmates with a history of previous STI (HR = 2.61; 95%CI: 1.01 to 6.69), and was at the limit of significance for non-preventive behaviour (HR = 2.10; 95%CI: 0.98 to 4.53), but not in knowledge related to STIs (HR = 1.33; 95%CI: 0.58 to 3.07).ConclusionThe most important risk factors in prison are behaviours related to STIs and previous history of STIs. Other factors are being a repeat offender, injecting drug use, or being in a methadone programme. Health personnel and peer education can facilitate prevention and control.     

HIV Risk Reduction in Rural African American Women Who Use Cocaine

ABSTRACT

Research has demonstrated associations between cocaine use and sexually transmitted infections (STIs), including Human Immunodeficiency Virus (HIV). More research has been conducted among the sub-population of women, with less focus on rural African American women. Investigation of the social context that influences rural African American women's behavior that places them at risk for STI/HIV has received limited attention. The results of one component of the comprehensive study presented here focused on perceived STI/HIV risk reduction strategies of U.S. southern rural African American women who used cocaine. This ethnographic study of 30 rural African American women using cocaine was conducted over four years. Respondents described HIV risk reduction strategies and their motives for using them. Condoms were used more with casual partners (80%) than primary partners (16%) and with partners who were less known, less trusted, young, or physically or sexually “dirty.” Condoms were also used to prevent pregnancy (60%) more than to prevent STI/HIV (40%). HIV testing patterns varied, as did the motives for seeking testing. The sexual behavior of the women in this study exposed them to increased risk of STI/HIV. Although many perceived that they were using sexual risk reduction strategies, these strategies were not scientifically sound risk reduction strategies. Consequently, their exposure to STI/HIV continued as they used ineffective strategies both in assessing partner risk and in implementing risk reduction behaviors.     

Sexual behaviour and related knowledge among a representative sample of secondary school students between 1997 and 2008

Objective: This paper reports on the sexual health knowledge and risk behaviours of year 10 and 12 students between 1997 and 2008. Method: Data were from nationally representative cross‐sectional stratified cluster samples of year 10 and 12 students in the Australian secondary school system collected at three intervals — 1997, 2002 and 2008. A number of methods were used to analyse students' sexual health knowledge and behavioural data over time. Results: Student knowledge of HIV/AIDS has stabilised since the 2002 survey and remains high. Between 1997 and 2008 there has been an increase in student knowledge with respect to STIs and hepatitis. Although the proportion of students reporting ever having had sexual intercourse has increased over time, the increases between 2002 and 2008 were not significant. There has been a significant increase in the number of sexual partnerships reported by students over a year, particularly for those in year 12. Conclusion: Student knowledge of HIV/AIDS remains high and there has been some improvement in STI and hepatitis knowledge, although knowledge in these domains is still moderate. Sexually active students were more likely to report having sex with multiple partners compared to previous surveys. Consistency of condom use has not increased since 1997. Implications: Although consistent condom use remains moderately high, it is of some concern that condom use has not increased since 1997 despite related increases in sexual activity among adolescents who have experienced sexual intercourse and increased rates of STIs among this group.     

Health students’ knowledge of sexually transmitted infections and risky behaviors before participation to the health promotion program

ObjectivesWe aimed to evaluate knowledge of health students (HS) enrolled in a health promotion program about sexually transmitted infections (STIs) and the frequency of risky behaviors.MethodsHS answered two anonymous questionnaires, a mandatory one about knowledge of STIs and STI prevention and an optional one about behaviors.ResultsTwo-hundred and sixteen HS answered the first questionnaire and 183 answered the second one. Eighty-three percent of HS had a good knowledge of HIV transmission, but half of them were aware of pre-exposure and post-exposure prophylaxes for HIV. The role of HPV infection in genital warts and anal cancer was respectively known by 33 (15.3%) and 10 (4.6%) HS. Thirty-six HS (19.7%) reported having unprotected sex in the previous 12 months.ConclusionFrench HS had a poor knowledge of STIs and STI prevention, and risky behaviors. It is necessary to provide good training on STIs to HS.