Neighborhood social disorganization and the acquisition of trichomoniasis among young adults in the United States

Objectives. We examined relationships between neighborhood social disorganization and trichomoniasis among young US adults.Methods. We employed multilevel logistic regression modeling with secondary data from wave III of the National Longitudinal Study of Adolescent Health (2001–2002). The dependent variable—trichomoniasis—was measured via urine testing. The measures for neighborhood social disorganization were derived from the 2000 US Census—racial and ethnic composition, concentrated poverty, and residential instability. The sample comprised 11 370 individuals across 4912 neighborhoods.Results. Trichomoniasis was more likely in neighborhoods with higher concentrations of Black residents (adjusted odds ratio [AOR] = 1.16; 95% confidence interval [CI] = 1.03, 1.30). However, this association was mediated by neighborhood concentrated poverty. Furthermore, young adults who lived in neighborhoods with higher concentrations of poverty were significantly more likely to have trichomoniasis (AOR = 1.25; 95% CI = 1.07, 1.46). Neither immigrant concentration nor residential instability was significantly associated with trichomoniasis.Conclusions. These findings strengthen the evidence that neighborhood structural conditions are associated with individual sexually transmitted infection (STI) acquisition. Research is needed to explore the mechanisms through which these conditions influence STI. In addition, STI-prevention programs that include structural interventions targeting neighborhood disadvantage are needed.Adolescents and young adults are at increased risk for sexually transmitted infections (STIs) because of a complex interplay of biological, behavioral, and developmental factors.¹ Nearly half of all STIs diagnosed in the United States annually are among adolescents and young adults^1,2 despite national priority goals aimed at reducing infection rates.³ Trichomoniasis, a common and easily curable STI,¹ is of increasing concern because the infection facilitates HIV acquisition and transmission through mucosal inflammation of the genital tract and alterations in the innate immune response. ^4-7 The infection is caused by the protozoa, Trichomonas vaginalis, and is typically transmitted via penis-to-vagina or vulva-to-vulva contact.¹ Infected persons are often asymptomatic or experience only mild symptoms,¹ which can hinder early detection and treatment and increase the risk of STIs and HIV.In the United States, the prevalence of trichomoniasis is difficult to ascertain because routine screening currently is not recommended nor is the reporting of positive results required.^1,4 According to urine assay data from the National Longitudinal Study of Adolescent Health (Add Health), the prevalence of trichomoniasis among the young adult population in 2001–2002 was approximately 2.3%.⁷ The study also found that women were at greater risk than were men (2.8% vs 1.7%) as were non-Hispanic Black (6.9%) and Latino (2.1%) youths compared with their non-Hispanic White peers (1.2%).⁷ In other studies of adult women, individual risk factors for trichomoniasis included poverty, lower education, douching, non-Hispanic Black race/ethnicity, and greater numbers of lifetime sexual partners.^8,9 Among clinic samples of adolescent women, research found trichomoniasis to be associated with older male sexual partners, casual sexual activity, marijuana use, and delinquency.¹⁰However, to date, no studies have examined the role of the broader structural context in shaping trichomoniasis risk, despite theory and previous STI research suggesting that the neighborhood environment may play a role. According to social disorganization theory,^11–14 key indicators of neighborhood structural disadvantage (i.e., racial/ethnic composition, concentrated poverty, and residential instability) influence health outcomes by weakening social ties, reducing access to institutional resources, and limiting exposure to positive role models, conventional social norms, and collective efficacy. Findings from previous research examining other STIs support the hypothesis that neighborhood contexts influence STI prevalence. For example, with respect to racial and ethnic composition, studies have found that gonorrhea rates were higher in cities and neighborhoods with greater proportions of Black residents.^15,16 Furthermore, in an analysis of Chicago neighborhoods, the incidence rates of gonorrhea and chlamydia were higher for neighborhoods in which more than 60% of the residents were Black compared with those in which more than 60% of residents were Hispanic, which suggests that segregated Hispanic ethnic enclaves may be protective of STI compared with segregated Black communities.¹⁷ Researchers hypothesize that the residential segregation of Black communities has contributed to the pervasive Black-White disparities in STI through discrimination processes, which in turn has led to greater concentration of poverty, lower male-to-female gender ratios due to the disproportionate incarceration and mortality of Black men, and closed, racially segregated sexual networks that facilitate the transmission of infection.^18–20In addition, the role of community poverty in shaping STI risk has been examined extensively and found to be positively associated with rates of chlamydia, gonorrhea, syphilis, and HIV in cross-sectional^{15,17,21–23} and longitudinal analyses.¹⁶ Other socioeconomic factors, such as unemployment^17,24 and lower educational attainment,^16,17 have also been linked to higher rates of chlamydia and gonorrhea. Research on the effects of residential instability on STI is limited, but the single study that examined these relationships found greater residential instability was associated with fewer self-reported STIs among a national sample of adolescents.²⁴ Depending on the context, perhaps residential instability could increase STI risk by disrupting social support ties and informal social control measures or reduce STI risk by dispersing closed sexual networks that facilitate infection transmission.Although the aforementioned studies have illustrated links between neighborhood social disorganization and a variety of STIs, limitations exist. First, the majority have been ecological studies, in which the outcomes were measured as community STI rates and no adjustment was made for potential confounding relationships with individual-level data.^{15–17,21–23} Consequently, inferences can be made only about the community, and individual variation in the outcome cannot be ascertained.²⁵ Second, although 1 study examined individual STI, the measure was based on self-report,²⁴ which potentially increases bias because of underreporting as well as unrecognized or undiagnosed infection. In addition, the study only focused on STI in general, which could limit our understanding of unique relationships with specific infectious organisms. Third, data sources of previous research tend to be at local or state levels,^{15–17,21–23} which limits external validity of the findings. Therefore, the purpose of our research was to examine relationships between neighborhood social disorganization and trichomoniasis among young adults in the United States. Our research builds on previous studies in 3 significant ways: (1) we examined multiple levels of analysis, which enabled us to simultaneously examine the independent relationships between individual and neighborhood variables and individual acquisition of trichomoniasis, (2) we examined a more refined measure of STI through the use of urine screening, and (3) we examined data from a large national data set—Add Health.     

Randomized clinical trial of brief risk reduction counseling for sexually transmitted infection clinic patients in Cape Town, South Africa

Objectives. We examined the effects of a brief counseling intervention designed to reduce HIV risk behaviors and sexually transmitted infections (STIs) among patients receiving STI services in Cape Town, South Africa.Methods. After randomization to either a 60-minute risk reduction counseling session or a 20-minute HIV–STI educational session, patients completed computerized sexual behavior assessments. More than 85% of the participants were retained at the 12-month follow-up.Results. There were 24% fewer incident STIs and significant reductions in unprotected vaginal and anal intercourse among participants who received risk reduction counseling relative to members of the control condition. Moderator analyses showed shorter lived outcomes for heavy alcohol drinkers than for lighter drinkers. The results were not moderated by gender.Conclusions. Brief single-session HIV prevention counseling delivered to STI clinic patients has the potential to reduce HIV infections. Counseling should be enhanced for heavier drinkers, and sustained outcomes will require relapse prevention techniques. Disseminating effective, brief, and feasible behavioral interventions to those at highest risk for HIV infection should remain a public health priority.Although South Africa has less than 1% of the world''s population, it accounts for nearly 10% of the global burden of AIDS. It is estimated that currently 5.5 million South Africans (12.3% of the country''s total population of 44.8 million) are infected with HIV.¹ A number of different factors probably account for the high incidence of HIV in South Africa, including sexual mixing patterns, social migration, high rates of alcohol abuse, sexual coercion in relationships characterized by gender power imbalances, and delayed rollout of HIV prevention programs.^2–5Perhaps most critical in driving HIV infections are other co-occurring sexually transmitted infections (STIs), which increase susceptibility to HIV by degrading naturally protective mucosal immunological mechanisms, migrating vulnerable cells to the genital tract, and affording HIV a portal of entry into the bloodstream. STIs also facilitate transmission of the virus from HIV-infected partners by increasing their HIV infectiousness.⁶ As a result of these factors, in combination with high HIV prevalence rates, South Africans who contract STIs are among the highest-risk populations for HIV infection in the world.²Although behavioral interventions have been shown to be effective in reducing sexual risks among STI clinic patients,⁷ several of these interventions have relied on multiple group sessions that have proven difficult to implement.^8,9 In response to the urgent need for effective, feasible, and affordable interventions designed to prevent HIV among STI clinic patients, researchers have developed brief single-session HIV risk reduction counseling interventions intended for use in both resource-rich^10–13 and resource-poor STI clinics.¹⁴ When performed in conjunction with HIV testing, brief prevention counseling has shown promise in reducing sexual risk behaviors and decreasing STIs.^15,16Brief risk reduction counseling has also demonstrated promising outcomes when delivered outside of HIV testing. For example, Crosby et al.¹⁷ examined a single-session personalized counseling intervention for men receiving STI clinic services in the United States. The intervention led to increases in condom use, reductions in unprotected sex, reductions in sexual partners, and 38% fewer new STI diagnoses relative to a standard of care control group. Overall, single-session sexual risk reduction counseling can be as effective as interventions that require multiple sessions and consume far greater resources.^7,18The brief risk reduction counseling intervention reported here is grounded in cognitive–behavioral theories of health behavior change and is designed for use with all STI patients, including those who refuse HIV testing. We previously tested this intervention in a small trial conducted in Cape Town, South Africa. We observed a 63% reduction in unprotected vaginal and anal intercourse over a 6-month follow-up period, compared with the 30% reduction observed in an HIV education control condition.¹⁹ In addition, condom use among participants increased from 65% to 88%. The overall findings were promising and suggested that a brief single-session counseling intervention may be effective in reducing the risk of HIV and other STIs in South Africa.We report the outcomes of a randomized clinical trial designed to test the effects of a brief single-session risk reduction counseling session intended for use in resource-poor STI clinics. We hypothesized that brief theory-based risk reduction counseling sessions would reduce unprotected vaginal and anal intercourse and prevent STIs during 12 months of observation. We also examined potential moderators of the intervention effects. We included participant gender as a factor in the analyses because there are differences in STI risks between men and women, especially given the gender dynamics in sexual relationships and that men ultimately control the use of condoms. We also tested alcohol use and use of other drugs as moderators of risk reduction outcomes because they are known cofactors for HIV transmission risk behaviors in South Africa.^20,21     

Behavioral Changes Associated With Testing HIV-Positive Among Sexually Transmitted Infection Clinic Patients In Cape Town, South Africa

Objectives. We sought to examine behavioral risks and behavior changes associated with testing HIV-positive among sexually transmitted infection (STI) patients, in order to inform HIV- and STI-prevention interventions.Methods. We performed a cohort study of 29 STI patients who seroconverted from HIV-negative to HIV-positive during 1 year of observation and 77 STI patients who persistently tested HIV-negative. Computerized behavioral interviews were collected at baseline and at 1 year, and STI clinic charts were abstracted over the same 1-year period.Results. The STI patients who reported genital bleeding during sexual activity at baseline were significantly more likely to test HIV-positive. Reductions in number of sexual partners and rates of unprotected intercourse occurred for all STI clinic patients regardless of whether they tested HIV-positive.Conclusions. Although risk reductions occurred, 5% of HIV-negative STI clinic patients subsequently tested HIV-positive over 1 year. Behavioral risk-reduction interventions are urgently needed for male and female STI clinic patients.People who are newly diagnosed with HIV infection are a critical population for prevention interventions, particularly individuals with co-occurring sexually transmitted infections (STIs). Although HIV is transmissible at any time during the course of HIV disease, infectiousness is greatest just after HIV seroconversion and during episodes of co-occurring STIs.¹ Research in the United States, Europe, and Australia shows that a significant minority of newly diagnosed HIV-positive persons continues to engage in HIV-transmission risk practices immediately after learning their HIV status.² In one study of recently seroconverted men who have sex with men, Colfax et al.³ found that HIV transmission risk behaviors persisted for a substantial number of infected men. Most concerning was the continued practice of unprotected anal intercourse with HIV-negative or unknown-HIV-status partners. Case–control and prospective cohort studies report that men who seroconvert for HIV are distinguishable from men who remain HIV-negative by their use of psychoactive drugs, sensation-seeking personality characteristics, and intentional risk taking.^4–6Although the majority of HIV infections occur in southern Africa, there is little research available on the behavioral characteristics of people who seroconvert for HIV in this region. One study of Kenyan commercial sex workers showed that women who seroconverted for HIV demonstrated significant reductions in risk practices, with further risk behaviors diminishing over advancing HIV disease.⁷ The HIV epidemic in southern Africa is amplified by co-occurring STIs for several reasons. HIV transmission is facilitated by other STIs degrading naturally protective mucosal and epithelial barriers, creating a portal of entry to the bloodstream and increased access to HIV-susceptible cells. Studies of STI clinic patients show that the median time to HIV seroconversion is 1.5 years from initial STI clinic visit, and that substance use and sexual partners with STIs are major contributing factors to HIV seroconversion.⁸ Sexually transmitted infection clinic patients who seroconvert are at considerable risk for transmitting the virus to others because they are likely to be highly infectious.⁹ A meta-analysis of factors that influence per-act HIV-transmission risks showed that a history of ulcerative STI in either couple member increases the risk for HIV transmission more than 5-fold.¹⁰ Importantly, it is estimated that infectivity in the early stages of HIV infection is 9 times greater than during asymptomatic stages.¹⁰ Therefore, people diagnosed with an STI who also contract HIV represent a critical population for prevention interventions.The purpose of our study was to examine the behavioral characteristics of STI clinic patients who seroconvert for HIV. We were particularly interested in identifying behavioral risk factors as well as subsequent behavior changes among STI clinic patients who test HIV-positive following an STI infection. To achieve these goals we conducted risk behavior assessments in a cohort of STI clinic patients who had tested HIV-negative and then subsequently tested HIV-positive compared with their persistently HIV-negative counterparts.     

Pregnancy as a Window of Opportunity for HIV Prevention: Effects of an HIV Intervention Delivered Within Prenatal Care

Objectives. We sought to determine whether an HIV prevention program bundled with group prenatal care reduced sexually transmitted infection (STI) incidence, repeat pregnancy, sexual risk behavior, and psychosocial risks.Methods. We conducted a randomized controlled trial at 2 prenatal clinics. We assigned pregnant women aged 14 to 25 years (N = 1047) to individual care, attention-matched group care, and group care with an integrated HIV component. We conducted structured interviews at baseline (second trimester), third trimester, and 6 and 12 months postpartum.Results. Mean age of participants was 20.4 years; 80% were African American. According to intent-to-treat analyses, women assigned to the HIV-prevention group intervention were significantly less likely to have repeat pregnancy at 6 months postpartum than individual-care and attention-matched controls; they demonstrated increased condom use and decreased unprotected sexual intercourse compared with individual-care and attention-matched controls. Subanalyses showed that being in the HIV-prevention group reduced STI incidence among the subgroup of adolescents.Conclusion. HIV prevention integrated with prenatal care resulted in reduced biological, behavioral, and psychosocial risks for HIV.Young pregnant women are at high risk for HIV and sexually transmitted infections (STIs).¹ In a systematic review of sexual risk behavior among pregnant or mothering adolescents, 19% to 39% had an STI during pregnancy, and 14% to 39% had an STI 6 to 10 months postpartum. Furthermore, young pregnant women were 5 times less likely to use condoms compared with nulliparous women.²Despite the risks of STI and HIV infection among women of reproductive age, few HIV interventions have specifically targeted pregnant women. The Children''s Health and Responsible Mothering project (Project CHARM), a school-based intervention of pregnant and mothering adolescents, found increases in condom-use intentions, but no difference in number of unprotected acts of sexual intercourse compared with a general health promotion control group.³ Another study found that pregnant women given a 4-session HIV intervention had moderate increases in knowledge and safer sexual behaviors that were sustained 6 months after the intervention.⁴Although few studies of HIV and STI interventions have targeted pregnant women, some have focused on women attending primary care clinics.^5–8 Interventions for STI clinic patients documented significant declines in STI incidence.^8,9 However, most HIV interventions are limited because they do not integrate HIV prevention with the provision of other services,^10,11 and are not theory based.^12–14Pregnancy offers a unique opportunity for intervention as it is a time when women engage in high-risk behaviors, make behavioral changes, and have frequent contact with health care professionals.^15–18 Finally, interventions integrated with existing care systems (e.g., prenatal care) can be sustained because care is reimbursable by insurance.¹⁹The bundling of HIV prevention with existing systems can increase the accessibility of HIV prevention by providing opportunities to reach individuals who may not have the motivation or time to attend stand-alone HIV prevention sessions.¹⁹ HIV and STI prevention programs have been successfully integrated in care settings such as psychiatric, drug treatment, and palliative medicine.^20–22 We developed an HIV intervention that was integrated with a model of prenatal care.CenteringPregnancy group prenatal care^23,24 has been shown to reduce preterm birth and increase prenatal care satisfaction.^23,25 We created a modified program, CenteringPregnancy Plus, by integrating HIV prevention with the group prenatal care model. The purpose of this study was to evaluate the effects of this integrated HIV prevention program on biological outcomes (STI, repeat pregnancy), sexual risk behaviors (condom use, unprotected sexual intercourse), and psychosocial variables (communication, perceived risk, self-efficacy).     

Association of Depressive Symptoms and Substance Use With Risky Sexual Behavior and Sexually Transmitted Infections Among African American Female Adolescents Seeking Sexual Health Care

Objectives. We examined how depression and substance use interacted to predict risky sexual behavior and sexually transmitted infections (STIs) among African American female adolescents.Methods. We measured depressive symptoms, substance use, sexual behavior, and STIs in 701 African American female adolescents, aged 14 to 20 years, at baseline and at 6-month intervals for 36 months in Atlanta, Georgia (2005–2007). We used generalized estimating equation models to examine effects over the 36-month follow-up period.Results. At baseline, more than 40% of adolescents reported significant depressive symptoms; 64% also reported substance use in the 90 days before assessment. Depression was associated with recently incarcerated partner involvement, sexual sensation seeking, unprotected sex, and prevalent STIs (all P < .001). In addition, adolescents with depressive symptoms who reported any substance use (i.e., marijuana, alcohol, Ecstasy) were more likely to report incarcerated partner involvement, sexual sensation seeking, unprotected sex, and have an incident STI over the 36-month follow-up (all P < .05).Conclusions. African American female adolescents who reported depressive symptoms and substance use were more likely to engage in risky behavior and acquire incident STIs. This population might benefit from future prevention efforts targeting the intersection of depression and substance use.Although self-exploration and identity seeking are healthy aspects of adolescence, certain adverse behaviors, such as substance use and risky sexual behavior, have also been associated with adolescence. HIV, other sexually transmitted infections (STIs), and adolescent pregnancy are significant contributors to female adolescents’ morbidity and mortality in the United States.1 Adolescents aged 15 to 24 years account for approximately 50% of new STI cases each year,2 and it is estimated that 24.1% of adolescent girls aged 14 to 19 years have 1 of 5 commonly reported STIs (herpes simplex virus, trichomonaisis, chlamydia, gonorrhea, and human papilloma virus).3 Minority adolescents are disproportionately at higher risk for HIV and other STIs relative to their White counterparts.4 For example, African American adolescents account for 65% of HIV diagnoses among individuals aged 13 to 24 years.5 Among African American female adolescents aged 14 to 19 years, a national study found that 44% had at least 1 STI.3 Because African American female adolescents are at heightened risk for engaging in risky sexual behavior and STI acquisition, it is important to gain a better understanding of factors that may be associated with these risks. Two such factors are depressive symptoms and substance use or abuse.6–15In a national survey, 4.3% of youths, aged 12 to 17 years, reported current depression, and girls, regardless of age, were more likely to report depression than boys (6.7% vs 4.0%).16 In addition, 1 study found that among adolescents in mental health treatment, girls were more likely to use condoms inconsistently and were more than 9 times likely to contract an STI than were boys.17 The National Longitudinal Study of Adolescent Health found that 19.7% of African American female adolescents reported recent and chronic depressive symptoms compared with 13% among White female adolescents.18 Other studies found rates of depressive symptoms ranging from 40% to 55% among African American female adolescents.6,7,19 Previous research among African American female adolescents reported that depressive symptoms were associated with inconsistent condom use,6,10,12 multiple sexual partners,7,9,10 risky male sexual partners,6 sexual contact while high on alcohol or drugs,6,7,9,11 low frequency of sexual communication,6,7 fear of communication about condoms,6,7 self-reported previous or current STI,7,8,10 and biologically confirmed STIs.6With regards to substance use, a national survey revealed that among African American female 9th to 12th graders, 31.3% reported current alcohol use (vs 35.7% for White and 39.7% for Hispanic), 11.5% reported 5 or more drinks in a sitting (vs 21.1% for White and 22.6% for Hispanic), 27.1% reported current marijuana use (vs 18% for White and 27.4% for Hispanic), and 2.1% reported ever using Ecstasy (vs 4.6% for White and 10.1% for Hispanic).20 Another study found that approximately 27% of African American female adolescents reported having 3 or more drinks in a sitting.13 Substance use often co-occurred with sexual risk behaviors,20 placing adolescents at increased risk for less condom use. Among young African American women, substance use was associated with inconsistent condom use,13,15 sexual sensation seeking,13 multiple sexual partners,13,15 risky sexual partners,15 having sexual intercourse while high on alcohol or drugs,13 and STIs.13–15Previous studies established the relationship between depression, substance use, and risky sexual behavior, and although limited, some studies examined the longitudinal effects of depressive symptoms and substance use on sexual risk-taking among African American female adolescents.7,11–13,15 However, to our knowledge, there is scant research available on the interaction of depressive symptoms and substance use to longitudinally predict sexual risk-taking and STIs among this population. A previous study found that substance use mediated the relationship between depression and substance use, but this effect was only significant for male adolescents and not for female adolescents.8 In addition, this previous study sample included adolescents from multiple ethnicities; thus, the findings might not be applicable to African American adolescents.Because of the impact of these 2 factors on sexual risk-taking, combined with increased HIV/STI vulnerability among African American female adolescents, we aimed to expand upon the existing literature on depression, substance use, and risky sexual behavior in African American female adolescents. To advance the current knowledge and inform HIV/STI prevention efforts among this group, we examined the longitudinal effects of depression and substance use on risky sexual behavior and STI contraction, as well as the interaction between these 2 factors among a clinic-based sample of African American female adolescents over an extended period (36-month follow-up).     

Sexual Orientation Disparities in Sexually Transmitted Infection Risk Behaviors and Risk Determinants Among Sexually Active Adolescent Males: Results From a School-Based Sample

Objectives. We examined disparities in risk determinants and risk behaviors for sexually transmitted infections (STIs) between gay-identified, bisexual-identified, and heterosexual-identified young men who have sex with men (YMSM) and heterosexual-identified young men who have sex with women (YMSW) using a school-based sample of US sexually active adolescent males.Methods. We analyzed a pooled data set of Youth Risk Behavior Surveys from 2005 and 2007 that included information on sexual orientation identity, sexual behaviors, and multiple STI risk factors.Results. Bisexual-identified adolescents were more likely to report multiple STI risk behaviors (number of sex partners, concurrent sex partners, and age of sexual debut) compared with heterosexual YMSW as well as heterosexual YMSM and gay-identified respondents. Gay, bisexual, and heterosexual YMSM were significantly more likely to report forced sex compared with heterosexual YMSW.Conclusions. Our results provide evidence that sexual health disparities emerge early in the life course and vary by both sexual orientation identity and sexual behaviors. In particular, they show that bisexual-identified adolescent males exhibit a unique risk profile that warrants targeted sexual health interventions.Several studies have documented an elevated risk of acquiring sexually transmitted infections (STIs), including HIV/AIDS, among young men who have sex with men (YMSM).1 In recent years, HIV/AIDS infection rates have actually increased among this population.2,3 To develop more effective and targeted STI prevention programs, researchers have suggested using multiple measures of sexual minority status when examining disparities in STI risk by sexual orientation.4–8 Existing research on sexual health disparities among adolescents often uses community-based samples that rarely yield large enough sample sizes to examine multiple sexual minority statuses in any given study.6,9 This gap in the literature is particularly problematic given the documented incongruence between sexual orientation identity and sexual behaviors among sexual minority adolescents.10–12 Thus, although studies have demonstrated that both YMSM1,13–15 and bisexual- and gay-identified male adolescent16,17 are more likely to report a variety of STI risk factors, to our knowledge, no studies to date have used both indicators of sexual orientation identity and sexual behaviors to examine disparities in STI risk factors among adolescents.Elevated rates of STI among sexual minority adolescent males are due to a variety of factors, including social conditions, sexual networks, and, in particular, the excess biological risk associated with anal sex.1,18 Elevated STI risk, however, has also been attributed to sexual orientation disparities in a variety of risk behaviors, including earlier age of sexual debut, more sex partners,14,17,19 higher rates of substance use during sex,15 and lower rates of condom use.13,20 These disparities have been documented through use of sexual behaviors1,13–15 or sexual orientation identity16,17 to capture sexual minority status. As a result, STI risk interventions based on studies that use sexual orientation identity alone may not reach adolescents who engage in same-sex behavior but identify as heterosexual.1 Alternatively, focusing exclusively on sexual behavior obscures potentially important differences across social identities, which are critical for understanding and eliminating disparities in STIs.5 Studies that use either sexual orientation identity or behavior are therefore likely to capture different populations and provide an incomplete portrait of STI risk among sexual minority adolescents.21To develop appropriate STI intervention strategies, it is also critical to understand what factors might lead to risk-taking behaviors among sexual minority populations. Studies have shown that sexual minority adolescent males are more likely to report multiple sources of victimization, including forced sex16,22 and intimate partner violence (IPV),23–25 compared with their sexual nonminority peers. Forced sex may directly expose young men to STIs, but it also may have long-lasting implications for the development of sexual self-efficacy, safe sex communication skills, and normative attitudes surrounding sexual risk behaviors.26,27 IPV has been identified as a significant barrier to effective communication about safer sex behaviors and is linked to elevated STI risk among adolescents.28 Similar to the literature on STI risk behaviors, existing studies on forced sex and IPV among sexual minorities rely on single indicators of sexual orientation—either sexual orientation identity16,23 or the sex of sex partners.25 Given the stigma associated with gay or bisexual identity, sexual minority–identified respondents may be more likely to be targeted for victimization than YMSM who identify as heterosexual.Understanding which aspects of sexual minority status (e.g., sexual orientation identity, sex of sex partners) are related to STI risk factors during adolescence is critical for developing targeted prevention efforts to curb rising STI infection rates. New evidence suggests that STI risk varies by both sexual orientation identity and behaviors among young adult men.4 It is unclear whether similar patterns in STI risk behaviors and risk behavior determinants emerge during adolescence. Using a school-based sample of adolescent males, we aimed to determine whether sexual risk behaviors, including age of sexual debut, number of sex partners, concurrent sex partners, condom use, and drug and alcohol during sex, as well 2 indicators of risk behavior determinants (forced sex and IPV) vary at the intersection of sexual orientation identity and sexual behaviors.     

Risk Assessment and Screening for Sexually Transmitted Infections, HIV, and Hepatitis Virus Among Long-Distance Truck Drivers in New Mexico, 2004�C2006

Objectives. We examined sexually transmitted infection (STI), HIV, and hepatitis virus prevalence and risk behaviors among truck drivers.Methods. We asked participants about their risk behaviors, and we screened them for STIs, HIV, and hepatitis infections. We used logistic regression to identify factors associated with outcomes.Results. Of the 652 enrolled participants, 21% reported sex with sex workers or casual partners in the prior year. Driving solo (odds ratio [OR] = 15.04; 95% confidence interval [CI] = 1.92, 117.53; P = .01), history of injection drug use (IDU; OR = 2.69; 95% CI = 1.19, 6.12; P = .02), and history of an STI (OR = 2.47; 95% CI = 1.19, 5.09; P = .01) were independently associated with high-risk sexual behaviors. Fourteen percent of participants reported drug use in the previous year, and 11% reported having ever injected drugs. Participants tested positive as follows: 54 for HCV antibodies (8.5%), 66 for hepatitis B anticore (anti-HBc) antibodies (10.4%), 8 for chlamydia (1.3%), 1 for gonorrhea (0.2%), 1 for syphilis (0.2%), and 1 for HIV (0.2%). History of injecting drugs (OR = 26.91; 95% CI = 11.61, 62.39; P < .01) and history of anti-HBc antibodies (OR = 7.89; 95% CI = 3.16, 19.68; P < .01) were associated with HCV infection.Conclusions. Our results suggest a need for hepatitis C screening and STI risk-reduction interventions in this population.Studies in Africa, Southeast Asia, Eastern Europe, and South America have linked long-distance truck drivers and commercial sex workers with the dissemination of sexually transmitted infections (STIs), including human immunodeficiency virus (HIV) infection.^1–15 Evidence suggests that the spread of HIV throughout central Africa was facilitated by truck traffic along the Kinshasa-Mombasa highway.^1,2 High rates of STIs and HIV have been observed among long-distance truck drivers in India and Bangladesh, where truck drivers are implicated in the spread of STIs and HIV into rural areas and areas surrounding international border crossings.^7–11 Results from studies in Eastern Europe suggest risky behavior and increased syphilis rates among truck drivers.^12,13 Additionally, studies among truck drivers in Brazil show low levels of perceived risk of infection despite high rates of syphilis and high levels of risky behaviors, e.g., unprotected sex with multiple partners, including commercial sex workers, and high levels of drug use.^14,15Little is known about the roles that long-distance truck drivers and sex workers at truck stops might play in spreading STIs or HIV in the United States. An ecological study in North Carolina examining reported syphilis cases during an outbreak found that the counties along interstate highways had higher syphilis rates than other counties in the state.¹⁶ The authors theorized that truck drivers and sex workers might have played a role in this finding, but there were no data to support this. A 1995 ethnographic study in Florida examining STI risk behaviors of truck drivers found low levels of perceived STI or HIV risk but high levels of risky behaviors.¹⁷ However, no laboratory studies were conducted; therefore, there are no data estimating the prevalence of STIs among long-distance truck drivers in the United States.To examine the environments in which STIs, HIV, and hepatitis virus are transmitted, and to assess the prevalence of STIs, HIV infection, and hepatitis virus infection and risk behaviors among truck drivers, we conducted a risk assessment and screening for STIs, HIV, and hepatitis among truck drivers traveling through New Mexico.     

The effect of widowhood on mortality by the causes of death of both spouses

Objectives. We investigated the effect of spousal bereavement on mortality to document cause-specific bereavement effects by the causes of death of both the predecedent spouse and the bereaved partner.Methods. We obtained data from a nationally representative cohort of 373 189 elderly married couples in the United States who were followed from 1993 to 2002. We used competing risk and Cox models in our analyses.Results. For both men and women, the death of a predecedent spouse from almost all causes, including various cancers, infections, and cardiovascular diseases, increased the all-cause mortality of the bereaved partner to varying degrees. Moreover, the death of a predecedent spouse from any cause increased the survivor''s cause-specific mortality for almost all causes, including cancers, infections, and cardiovascular diseases, to varying degrees.Conclusions. The effect of widowhood on mortality varies substantially by the causes of death of both spouses, suggesting that the widowhood effect is not restricted to one aspect of human biology. Future research should examine the specific mechanisms of the widowhood effect and identify opportunities for health interventions.The increased likelihood for a recently widowed person to die—often called the “widowhood effect”—is one of the best documented examples of the effect of social relations on health.¹ The widowhood effect has been found among men and women of all ages throughout the world.^2–5 Recent longitudinal studies put the excess mortality of widowhood (compared with marriage) among the elderly between 30% and 90% in the first 3 months and around 15% in the months thereafter.^1,6–8 These estimates are comparable across various statistical methodologies, including multivariate models that statistically control for a wide range of confounding factors,^1,6,8,9 prompting increasing confidence in a causal basis of the widowhood effect.^6,8,10,11Most previous studies on the widowhood effect, however, have focused on overall (i.e., all-cause) mortality. By comparison, much less is known about the link between widowhood and specific causes of death. Cause specificity in the widowhood effect can be traced in 2 ways: by the cause of death of the predecedent spouse and by the cause of death of the bereaved partner. Research on either dimension of cause specificity is scarce, particularly research that accounts for the cause of death of the predecedent spouse. This is regrettable as cause specificity of the widowhood effect may help illuminate the specific mechanisms by which the death of a spouse increases the mortality of the survivor and may thus help identify opportunities for health interventions.Previous work in this area, often using a narrow list of disease categories, has yielded mixed results. For example, whereas several large studies have found that spousal bereavement is associated with increased death from cancer,^12–14 several other studies^4,7,15–19—including the only 2 longitudinal studies that consider multiple causes of death in the United States^4,7—found evidence that was not statistically significant or was inconsistent for increased cancer mortality after widowhood, after adjusting for covariates.To address this deficit in knowledge, our study investigated variation in the widowhood effect by the causes of death of both spouses using a detailed list of causes of death from a large, longitudinal, and nationally representative sample of elderly married couples. Specifically, we analyzed 2 questions. First, does the death of a predecedent spouse (from any cause) affect the bereaved partner''s risk of dying from certain causes more than it affects his or her risk of dying from certain other causes? Second, does the bereaved partner''s all-cause mortality depend on the specific cause of death of the predecedent spouse? We analyzed these questions separately for men and women and offer interpretations linking our results to the possible mechanisms underlying the relationship between widowhood and mortality.     

School-Based Condom Education and Its Relations With Diagnoses of and Testing for Sexually Transmitted Infections Among Men in the United States

An intense social and political debate continues in the United States regarding sexuality education. Included in the debate are those who favor comprehensive approaches, those who favor abstinence-only approaches, and those who favor no sexuality education. In this study, we showed that men who received school-based condom education were less likely to have been diagnosed with sexually transmitted infections (STIs) and were more likely to ever have been tested for sexually transmitted infections than were men without such education. School-based condom education is associated with less, rather than more, STI risk.Despite rising rates of sexually transmitted infections (STIs) and unintended pregnancy, school-based sexuality education remains controversial in the United States relative to other industrialized nations.^1,2 Large, national studies have shown that most parents in the United States favor sexuality education approaches in schools that provide scientifically and medically accurate information on sexual health issues, including condom use; still, a minority of opponents have claimed that discussing condom use in and of itself will increase risky sexual behaviors.³ Several studies have documented the long-term positive effects of school-based sexuality education programs on STI-related knowledge, attitudes, and preventive behaviors.^4–7 However, potential relations between school-based condom education (i.e., specifically being taught how to use a condom in a school setting) and sexual health outcomes, including STI diagnoses, are not well understood. Therefore, the present study assessed associations between school-based condom education and one''s likelihood of being tested for and diagnosed with an STI among a large sample of sexually active men in the United States.     

Integrated behavioral intervention to improve HIV/AIDS treatment adherence and reduce HIV transmission

Objectives. We conducted a randomized clinical trial to test an integrated behavioral intervention designed to enhance using HIV treatment as prevention by improving medication adherence, reducing risks for other sexually transmitted infections, and minimizing risk compensation beliefs.Methods. Individuals living with HIV/AIDS (n = 436) participated in a randomized clinical trial testing an intensive behavioral intervention aimed at reducing HIV transmission risks compared with an attention control condition. We used unannounced pill counts to monitor antiretroviral therapy adherence and computerized interviews to measure risk behaviors.Results. The integrated transmission risk reduction intervention demonstrated increased antiretroviral therapy adherence and less unprotected intercourse with nonseroconcordant partners at 3- and 6-month follow-ups as well as fewer new sexually transmitted infections diagnosed over the 9-month follow-up period (adjusted odds ratio = 3.0; P < .05; 95% confidence interval = 1.01, 9.04). The integrated intervention also reduced behavioral risk compensation beliefs.Conclusions. A theory-based integrated behavioral intervention can improve HIV treatment adherence and reduce HIV transmission risks. HIV treatment as prevention should be bundled with behavioral interventions to maximize effectiveness.Antiretroviral therapy (ART) improves the health and increases the longevity of people infected with HIV.¹ Growing evidence indicates that ART can also reduce HIV infectiousness, raising the possibility of using HIV treatment as prevention.^2–3 Mathematical models suggest that HIV testing with immediate treatment may have a substantial preventative effect in high HIV prevalence populations.^4–6 The potential preventative benefits of treating HIV infection are shifting prevention policies. Most notably, the Swiss Federal AIDS Commission has stated that repeated undetectable HIV RNA (viral load) tests can render individuals noninfectious.^7–9 Although biologically and epidemiologically plausible,^10,11 using HIV treatment as prevention will fail when medication adherence is poor and when there are co-occurring sexually transmitted infections (STIs).Most ART regimens demonstrate suppressive effects in the genital tract that are similar to those in blood plasma,¹² and the genital tract suffers similar detrimental ramifications of ART nonadherence.¹³ The most forgiving ART regimens require at least 85% adherence to suppress HIV replication, avoid treatment-resistant variants of the virus, and reduce infectiousness.^14–16 Evidence also shows that individuals who experience difficulty adhering to ART engage in higher-risk sexual behaviors.¹⁷ Even under optimal adherence, persons with undetectable peripheral blood viral loads will be highly infectious in their genital secretions when they have co-occurring STIs.¹⁸Co-occurring STIs are prevalent among people living with HIV/AIDS^19,20 and cause HIV shedding in genital fluids.²¹ Individuals who are coinfected with HIV and other STIs are therefore far more infectious than their blood plasma viral load indicates. The poor concordance between blood plasma and semen HIV RNA is at least in part the result of inflammatory processes caused by co-occurring STIs.²² The interplay between treatment, viral load, and sexual transmission is further complicated by risk compensation; individuals who believe they are less infectious take fewer precautions against infecting partners.^23–26To succeed, the use of HIV treatment as prevention, or so-called test and treat strategies, will require a comprehensive approach that encompasses adherence support, sexual risk reduction, and the amelioration of risk compensation.²⁷ HIV transmission risk reduction interventions for people infected with HIV have thus far focused exclusively on reducing unprotected sex with non-HIV–positive partners.²⁸ Similarly, ART adherence interventions have not directly addressed HIV transmission risks. One example of an intervention that addressed treatment adherence and transmission risk reduction was the Healthy Living Project.^29–30 In a multisite trial, the Healthy Living Project targeted mental health, treatment adherence, and risk behaviors in separate intervention modules delivered several weeks apart. The investigators of the Healthy Living Project examined the 3 modules independently in separate analyses. The Healthy Living Project medication module demonstrated significant increased treatment adherence,²⁸ and the prevention module resulted in significant reductions in HIV transmission risk behaviors.²⁹ Unfortunately, the Healthy Living Project did not test the synergistic effects of the adherence and risk reduction modules. We are not aware of any unified behavioral intervention that has attempted to simultaneously reduce HIV infectiousness by improving treatment adherence and reducing HIV exposures. We sought to fill this gap by testing an integrated adherence and risk-reduction intervention designed for use in conjunction with HIV treatment as prevention.The aim of this clinical trial was to test the effects of a theory-based integrated behavioral intervention for reducing HIV transmission risks in individuals living with HIV/AIDS. Our primary hypothesis was that an integrated intervention approach would improve treatment adherence and reduce risk behaviors relative to a matched-contact control intervention. The secondary hypothesis was that the integrated intervention would reduce risk compensation beliefs concerning undetectable HIV RNA.     

Social support, exposure to violence and transphobia, and correlates of depression among male-to-female transgender women with a history of sex work

Objectives. We determined racial/ethnic differences in social support and exposure to violence and transphobia, and explored correlates of depression among male-to-female transgender women with a history of sex work (THSW).Methods. A total of 573 THSW who worked or resided in San Francisco or Oakland, California, were recruited through street outreach and referrals and completed individual interviews using a structured questionnaire.Results. More than half of Latina and White participants were depressed on the basis of Center For Epidemiologic Studies Depression Scale scores. About three quarters of White participants reported ever having suicidal ideation, of whom 64% reported suicide attempts. Half of the participants reported being physically assaulted, and 38% reported being raped or sexually assaulted before age 18 years. White and African American participants reported transphobia experiences more frequently than did others. Social support, transphobia, suicidal ideation, and levels of income and education were significantly and independently correlated with depression.Conclusions. For THSW, psychological vulnerability must be addressed in counseling, support groups, and health promotion programs specifically tailored to race/ethnicity.The term “transgender” has been used as an umbrella term, capturing people who do not conform with a binary male–female gender category.¹ In this study, we use the term “transgender women” or “male-to-female transgender women” to describe individuals who were born biologically male but self-identify as women and desire to live as women.² Although transgender persons or those who identify their gender other than male or female have been historically reported in many cultures around the world, their social roles, status, and acceptance have varied across time and place.³ In the United States, as part of the gay rights movement in the 1970s, a transgender civil rights movement emerged to advocate for transgender people''s equal rights and to eradicate discrimination and harassment in their daily lives.⁴ However, transphobia—institutional, societal, and individual-level discrimination against transgender persons—is still pervasive in the United States and elsewhere. It often takes the form of laws, regulations, violence (physical, sexual, and verbal), harassment, prejudices, and negative attitudes directed against transgender persons.^5–7Studies have reported that transgender persons lack access to gender-sensitive health care^6,8,9 and often experience transphobia in health care and treatment.^5,9 Transgender persons are frequently exposed to violence, sexual assault, and harassment in everyday life, mainly because of transphobia.^5–7,9–11 Physical and sexual assaults and violence, and verbal and nonphysical harassment, derive from various perpetrators (e.g., strangers, acquaintances, partners, family members, and police officers). Transgender persons suffer from assaults, rape, and harassment at an early age, and these experiences persist throughout life.¹ A number of studies have examined violence and harassment against sexual minorities, although these have mainly focused on gay men.^12–15 A limited literature has described the prevalence of violence, transphobia, and health disparities among transgender persons.^7–9Psychological indicators such as depression and suicidal ideation and attempts have been reported among transgender persons.^{5,6,10,16–18} Transgender women of color, such as African Americans, Latinas, and Asians/Pacific Islanders (APIs), are at high risk for adverse health outcomes because of racial/ethnic minority status and gender identity,⁶ as well as for depression through exposure to transphobia.¹⁹ Although transgender persons have reported relatively high rates of using basic health care services,²⁰gender-appropriate mental health services are needed,⁵ particularly among African Americans.²¹ A lack of social support, specifically from the biological family, is commonly reported among transgender persons and is associated with discomfort and lack of security and safety in public settings.²² Sparse research exists on social support among transgender persons, although such support could ameliorate adverse psychological consequences associated with transphobia and also mitigate racial discrimination for transgender persons of color.Because of relatively high rates of unemployment, lack of career training and education, and discrimination in employment, many transgender women engage in sex work for survival.^23,24 Sex work is linked to high-risk situations, including substance abuse, unsafe sex, and sexual and physical abuse.²⁵ Physical abuse, social isolation, and the social stigma associated with sex work exacerbate transgender women''s vulnerability to mental illness and HIV risk.^5,17 High HIV seroprevalence rates among transgender women have been reported,^5,20,26–28 particularly among racial/ethnic minorities,⁵ substance users,²⁷ and sex workers.^{20,24,25,29–31} Transgender women of color face multiple adversities, such as racial and gender discrimination; transphobia; economic challenges including unemployment, substance abuse, HIV and other sexually transmitted infections; and mental illness. However, few studies have investigated racial/ethnic differences in psychological status among transgender women of color in relation to social support and exposure to transphobia.To develop culturally appropriate and transgender specific mental health promotion programs, we describe the prevalence of violence, transphobia, and social support in relation to racial/ethnic background among transgender women with a history of sex work (THSW). We also investigated the role of social support and exposure to transphobia on participants’ levels of depression.     

Social gradients in oral health in older adults: findings from the English longitudinal survey of aging

Objectives. We examined prospective associations between socioeconomic position (SEP) markers and oral health outcomes in a national sample of older adults in England.Methods. Data were from the English Longitudinal Survey of Aging, a national cohort study of community-dwelling people aged 50 years and older. SEP markers (education, occupation, household income, household wealth, subjective social status, and childhood SEP) and sociodemographic confounders (age, gender, and marital status) were from wave 1. We collected 3 self-reported oral health outcomes at wave 3: having natural teeth (dentate vs edentate), self-rated oral health, and oral impacts on daily life. Using multivariate logistic regression models, we estimated associations between each SEP indicator and each oral health outcome, adjusted for confounders.Results. Irrespective of SEP marker, there were inverse graded associations between SEP and edentulousness, with proportionately more edentate participants at each lower SEP level. Lower SEP was also associated with worse self-rated oral health and oral impacts among dentate, but not among edentate, participants.Conclusions. There are consistent and clear social gradients in the oral health of older adults in England, with disparities evident throughout the SEP hierarchy.The inverse linear relationship between socioeconomic position (SEP) and health is well established.^1–4 The uneven distribution of health across socioeconomic strata has been observed in both industrialized and less developed countries and for most common diseases and causes of death.^1,5–8 In most cases, the association between SEP and health is characterized by a linear graded pattern, with people in each lower SEP category having successively worse levels of health and dying earlier than those that are better off, a characteristic known as the social gradient in health.⁹Although there is clear and consistent evidence about the existence of the social gradient in working-age adults,^10,11 studies in older adults are less consistent, with some showing attenuation of the gradient^12,13 and others reporting that it persisted^14,15 or even increased¹⁶ in magnitude.Oral health is particularly important at older ages with tooth loss shown to be independently associated with disability and mortality.^17–20 Oral health status in older people is also an important determinant of nutritional status.²¹Socioeconomic disparities in oral health have been consistently demonstrated for various indicators, mostly clinical and disease related^22–31 but also subjective measures of oral health and quality of life.^30,32–38 Some of these studies have explicitly assessed the existence of an oral health gradient,^{23,25–31,34–37} but almost all were carried out on adolescents and adults, with very few focusing on older people.^33,36 These few relevant studies are cross-sectional and inconclusive and have used a limited number of SEP indicators (typically, education and occupational class), thereby hindering any comprehensive analysis on the relationship between SEP and oral health.We addressed the gap in the literature about the existence of an oral health gradient at older ages by examining the prospective associations between a wide range of SEP indicators (education, occupation, household income, household wealth, subjective social status [SSS], and childhood SEP) and various oral health outcomes (presence of natural teeth, self-rated oral health, and oral impacts) in a national sample of older adults from the English Longitudinal Survey of Aging (ELSA). We explored whether there are any significant socioeconomic inequalities in oral health among older people in England and, if so, whether these take the form of a gradient.     

Health status, neighborhood socioeconomic context, and premature mortality in the United States: The National Institutes of Health-AARP Diet and Health Study

Objectives. We examined whether the risk of premature mortality associated with living in socioeconomically deprived neighborhoods varies according to the health status of individuals.Methods. Community-dwelling adults (n = 566 402; age = 50–71 years) in 6 US states and 2 metropolitan areas participated in the ongoing prospective National Institutes of Health–AARP Diet and Health Study, which began in 1995. We used baseline data for 565 679 participants on health behaviors, self-rated health status, and medical history, collected by mailed questionnaires. Participants were linked to 2000 census data for an index of census tract socioeconomic deprivation. The main outcome was all-cause mortality ascertained through 2006.Results. In adjusted survival analyses of persons in good-to-excellent health at baseline, risk of mortality increased with increasing levels of census tract socioeconomic deprivation. Neighborhood socioeconomic mortality disparities among persons in fair-to-poor health were not statistically significant after adjustment for demographic characteristics, educational achievement, lifestyle, and medical conditions.Conclusions. Neighborhood socioeconomic inequalities lead to large disparities in risk of premature mortality among healthy US adults but not among those in poor health.Research dating back to at least the 1920s has shown that the United States has experienced persistent and widening socioeconomic disparities in premature mortality over time.^1–5 However, it has been unclear whether socioeconomic inequalities affect the longevity of persons in good and poor health equally. Socioeconomic status (SES) and health status are interrelated,^6–8 and both are strong independent predictors of mortality.⁹ Low SES is associated with greater risk of ill health and premature death,^{1–5,8,10–13} partly attributable to disproportionately high prevalence of unhealthful lifestyle practices^10,14,15 and physical and mental health conditions.^13,16 Correspondingly, risk of premature mortality is higher in poor than in more affluent areas.^16,17 Although the association between neighborhood poverty and mortality is independent of individual-level SES,^17,18 aggregation of low-SES populations in poor areas may contribute to variations in health outcomes across neighborhoods. Conversely, economic hardships resulting from ill health may lead persons in poor physical or mental health to move to poor neighborhoods.¹⁹ This interrelatedness may create spurious associations between neighborhood poverty and mortality.Although previous studies have found that the risk of premature death associated with poor health status varies according to individuals'' SES,^20,21 no published studies have examined whether the relative risks for premature mortality associated with living in neighborhoods with higher levels of socioeconomic deprivation vary by health status of individuals. Clarifying these relationships will inform social and public health policies and programs that aim to mitigate the health consequences of neighborhood poverty.^22,23We used data from a large prospective study to examine whether the risk of premature mortality associated with neighborhood socioeconomic context differs according to health status at baseline and remains after adjustment for person-level risk factors for mortality, such as SES, lifestyle practices, and chronic medical illnesses.     

Correlates of incarceration among young methamphetamine users in Chiang Mai, Thailand

Objectives. We examined correlates of incarceration among young methamphetamine users in Chiang Mai, Thailand in 2005 to 2006.Methods. We conducted a cross-sectional study among 1189 young methamphetamine users. Participants were surveyed about their recent drug use, sexual behaviors, and incarceration. Biological samples were obtained to test for sexually transmitted and viral infections.Results. Twenty-two percent of participants reported ever having been incarcerated. In multivariate analysis, risk behaviors including frequent public drunkenness, starting to use illicit drugs at an early age, involvement in the drug economy, tattooing, injecting drugs, and unprotected sex were correlated with a history of incarceration. HIV, HCV, and herpes simplex virus type 2 (HSV-2) infection were also correlated with incarceration.Conclusions. Incarcerated methamphetamine users are engaging in behaviors and being exposed to environments that put them at increased risk of infection and harmful practices. Alternatives to incarceration need to be explored for youths.Over the past decade, methamphetamine use has increased exponentially and reached epidemic proportions, particularly in North America¹ and Southeast Asia.² The methamphetamine epidemic has been concentrated among adolescents and young adults and has significant public health implications² because methamphetamine use has been associated with high-risk behaviors including multiple sexual partners, contractual sex, polydrug use, and aggression.^3,4Thailand has experienced a steadily increasing methamphetamine epidemic since 1996.⁵ By 2003, an estimated 3 500 000 Thais had ever used methamphetamines.⁶ In 1996, Thailand criminalized methamphetamines, treating the trafficking, possession, and use of methamphetamines with the same severity as heroin-related offenses.⁷ In 2003 the government began a “war on drugs” in an attempt to control the epidemic.^8,9 In combination, these events led to a doubling in the number of incarcerated individuals between 1996 and 2004.^7,10 In 2005, 64% of Thai inmates were drug offenders,¹¹ and in 2006, 75% of drug-related arrests and charges were related to methamphetamines.¹² Treatment for methamphetamine use is limited. Institutional management of methamphetamine users includes the use of rehabilitation centers, military-style boot camps, compulsory drug treatment centers, and prisons.¹¹A history of incarceration has been associated with negative health outcomes, including sexually transmitted infections (STIs) and blood-borne viruses, particularly syphilis,¹³ herpes,¹⁴ HIV,^10,15,16 hepatitis b (HBV),^17,18 and HCV.^18–21 The prevalence of these pathogens has been found to be much higher in prisons than in the general population.^22–26 Although these infections may be a result of a high-risk lifestyle leading to incarceration, it is also clear that the prison system exposes individuals to environments and behaviors that increase their risk of acquiring these infections, such as tattooing,^{10,18,21,27–29} unprotected sex as a result of limited condom availability,²⁷ and using shared needles to inject drugs.^27,30,31With so many young methamphetamine users entering the judicial system, it is important to understand the characteristics of this group so that appropriate public health interventions can be designed. Young methamphetamine users need to be diverted away from the judicial system to decrease high-risk behaviors that may impact their own well-being and that of the community.As part of a randomized controlled trial to reduce the risks associated with methamphetamine use among youths in Chiang Mai, Thailand, we investigated behavioral and viral correlates of incarceration among a sample of 1189 young adults aged 18 to 25 years.     

Risks of Recreational Exposure to Waterborne Pathogens Among Persons With HIV/AIDS in Baltimore, Maryland

Objectives. We assessed the prevalence of recreational activities in the waterways of Baltimore, MD, and the risk of exposure to Cryptosporidium among persons with HIV/AIDS.Methods. We studied patients at the Johns Hopkins Moore Outpatient AIDS Clinic. We conducted oral interviews with a convenience sample of 157 HIV/AIDS patients to ascertain the sites used for recreational water contact within Baltimore waters and assess risk behaviors.Results. Approximately 48% of respondents reported participating in recreational water activities (fishing, crabbing, boating, and swimming). Men and women were almost equally likely to engage in recreational water activities (53.3% versus 51.3%). Approximately 67% (105 of 157) ate their own catch or that of friends or family members, and a majority (61%, or 46 of 75) of respondents who reported recreational water contact reported consumption of their own catch.Conclusions. Baltimoreans with HIV/AIDS are engaging in recreational water activities in urban waters that may expose them to waterborne pathogens and recreational water illnesses. Susceptible persons, such as patients with HIV/AIDS, should be cautioned regarding potential microbial risks from recreational water contact with surface waters.Persons with HIV/AIDS are at high risk for increased morbidity and mortality associated with a range of opportunistic infections, some of which are caused by Cryptosporidium. Cryptosporidium species are of particular public health and medical importance because they are prevalent in surface waters of the United States,^1–7 are efficiently transmitted via water,⁸ and can be consumed in foods contaminated by fecal matter.^9–11 Exposures to Cryptosporidium are common in the US population,¹² and past studies have demonstrated that Cryptosporidium infections significantly contribute to illness and mortality in persons with HIV/AIDS.^13–15 In the 1980s, Cryptosporidium was identified as a major opportunistic pathogen.^16–21 Infection continues to be frequently diagnosed in persons with HIV/AIDS.^22–27 Before the advent of highly active antiretroviral therapy, Cryptosporidium was a relatively common opportunistic infection even in developed countries.^28,29Cryptosporidiosis manifests as an acute gastroenteritis, accompanied by cramps, anorexia, vomiting, abdominal pains, fever, and chills²⁹ and by histological presentation of gastrointestinal mucosal injury.^30,31 Persons with AIDS who become infected with this parasite are at increased risk of developing chronic and often life-threatening diarrhea, biliary tract diseases, pancreatitis, colitis, and chronic asymptomatic infection and recurrence. These developments are especially likely in those who are severely immunosuppressed (CD4 counts < 150 cells/mL).^29,32–35 Infection is diagnosed by the presence of oocysts in unpreserved or preserved stools.³⁶ Histological and ultrastructural examination of biopsy material for different Cryptosporidium life stages, detection of Cryptosporidium DNA and antigens, and identification of species through molecular techniques can also aid in diagnosis.^36–38Cryptosporidium species are enteric protozoan organisms and are prevalent in US watersheds, especially in urban waters.^1,6,39 These parasites have natural hosts in domestic and wild animals such as cattle (especially newborn calves), horses, fish, and birds.^5,40–42 These parasites cause cryptosporidiosis by infecting and damaging the cells of the small intestine and other organs.^13,41 For persons with HIV/AIDS, increased risk for infection by Cryptosporidium has been related to sexual practices such as engaging in sexual intercourse within the past 2 years, having multiple partners during that time, and engaging in anal intercourse.⁴³ Use of spas and saunas has also been identified as a risk factor.⁴³In the United States, Cryptosporidium is the most commonly identified pathogen in cases of recreationally acquired gastroenteritis⁴⁴; the majority of those affected are children. Increased risk of cryptosporidiosis in persons with HIV/AIDS has been associated with swimming.^45,46 US residents make an estimated 360 million annual visits to recreational water venues such as swimming pools, spas, and lakes; swimming is the second most popular physical activity in the country and the most popular among children.⁴⁷Recreational swimming, even in highly chlorinated water, carries a high risk of exposure to enteric pathogens, including Cryptosporidium, Norovirus, Shigella, Escherichia coli, and Giardia.⁴⁸ Cryptosporidiosis and some other enteric illnesses are seasonal, with spikes in occurrence in the summer months from contact with recreational water venues.⁴⁹ Extreme precipitation⁵⁰ and high ambient temperatures⁵¹ can also affect patterns of disease outbreaks. Because not all infections with Cryptosporidium lead to apparent illness or symptoms, infected persons may unknowingly transmit these pathogens to others, such as household members and other recreationists.^12,52 Cryptosporidiosis from swimming, wading, and splashing is prevalent in the United States.^44,46,53,54Risks from the presence of pathogens in waterways include (1) waterborne gastroenteritis and other recreational water illnesses in anglers and other recreationists^44,55–59; (2) transmission of pathogens to humans from caught seafood acting as fomites, or surface carriers⁶⁰; (3) food-borne gastroenteritis from consumption of raw or improperly cooked fish and shellfish^61,62; and (4) hand-to-mouth transmission of pathogens while eating, drinking, or smoking during activities such as fishing and crabbing.⁷Recreational water activities in the Baltimore, Maryland, area take place in Jones Falls and Baltimore Harbor. These and other waterways are used for angling, crabbing, swimming, kayaking, and boating (including paddle boating).^7,63 In addition, Baltimore-area residents often catch and consume fish and crabs from the Baltimore Harbor and local waterways, many of which are already highly contaminated by persistent chemicals such as mercury and polychlorinated biphenyls.⁶⁴ These activities are known to increase risks of exposure to waterborne pathogens through direct contact with contaminated waters or through contact with or handling and consumption of caught seafood (fish, crabs, oysters).^7,65,66To investigate the potential contribution of recreational water contact to Cryptosporidium exposures among persons with HIV/AIDS, we carried out a cross-sectional study at the Johns Hopkins Moore Outpatient AIDS Clinic. The Baltimore metropolitan area has a high prevalence rate of HIV/AIDS among both men and women,⁶⁷ and its population makes intensive recreational use of a contaminated watershed. In addition, laboratory experiments have indicated that crabs can become superficially contaminated by Cryptosporidium and transfer the pathogen to hands.⁶⁸ Local anglers are at risk from Cryptosporidium on wild-caught fish.⁷Our objective was to address the risks of exposure to Cryptosporidium for an urban subpopulation, persons with HIV/AIDS, as a result of recreational contact with Baltimore waterways. We also assessed the patterns and locations of recreational water activities in Baltimore waters.     

The Efficacy of HIV/STI Behavioral Interventions for African American Females in the United States: A Meta-Analysis

Objectives. We evaluated the efficacy of HIV behavioral interventions for African American females in the United States, and we identified factors associated with intervention efficacy.Methods. We conducted a comprehensive literature review covering studies published from January 1988 to June 2007, which yielded 37 relevant studies. Data were analyzed using mixed-effects models and meta-regression.Results. Overall, behavioral interventions had a significant impact on reductions in HIV-risk sex behaviors (odds ratio [OR] = 0.63; 95% confidence interval [CI] = 0.54, 0.75; n = 11 239; Cochrane Q₃₂ = 84.73; P < .001) and sexually transmitted infections (STIs; OR = 0.81; 95% CI = 0.67, 0.98; n = 8760; Cochrane Q₁₆ = 22.77; P = .12). Greater intervention efficacy was observed in studies that specifically targeted African American females used gender- or culture-specific materials, used female deliverers, addressed empowerment issues, provided skills training in condom use and negotiation of safer sex, and used role-playing to teach negotiation skills.Conclusions. Behavioral interventions are efficacious at preventing HIV and STIs among African American females. More research is needed to examine the potential contribution of prevention strategies that attend to community-level and structural-level factors affecting HIV infection and transmission in this population.The HIV epidemic continues to disproportionately affect African American females in the United States. Although African Americans represent only 12% of the US female population,¹ African American women and adolescents accounted for 64% of all HIV cases among women at the end of 2006.² Sexual intercourse with high-risk men was the source of HIV infection in 75% of African American females living with HIV/AIDS in 2006.²Various factors place African American females at high risk for HIV transmission. The highest rates of sexually transmitted infection (STI) are found among African Americans.² Physical changes caused by STIs can serve as entry points for HIV and can increase one''s chance of acquiring HIV.^3,4 Women are generally at greater risk of acquiring HIV and other STIs than are men because the female genital tract is more prone to injury and infection resulting from high-risk heterosexual contact.⁵In addition to biological factors, relational, cultural, and socioeconomic factors also increase African American females vulnerability to HIV. Several studies suggest that some African American females perceive that they lack control over condom use because they have insufficient power in their relationships,^6–8 which may be partly exacerbated by the low ratio of men to women in African American communities.⁹ Additionally, poverty may place African American females at increased risk for HIV/STIs because of the power imbalance created by their financial dependency on men.^9,10 The need for gender-specific interventions to address empowerment is evident in light of the high HIV prevalence among African American females. HIV interventions may also need to be sensitive to African American culture to increase the relevance of the content and its subsequent effectiveness among African American females.Numerous interventions targeting high-risk sex behaviors among African American females have been evaluated in recent years. Although previously published meta-analyses have evaluated the efficacy of HIV behavioral interventions for women,^11,12 Black and Hispanic STI clinic patients,¹³ and African American heterosexuals,¹⁴ the empirical findings specifically for African American females have not been examined as a whole. In this meta-analysis, we located and described available behavioral interventions for African American females, assessed the overall efficacy of these behavioral interventions, and identified factors associated with intervention efficacy for this high-risk population. Our review expands the scope of previously published meta-analyses^11–14 by including more recently published studies; directly testing whether intervention components that were culture-specific, gender-specific, empowerment-focused, and skills-training–focused were associated with intervention efficacy; and identifying research gaps with regard to HIV prevention among African American females in the United States.     

The Role of Young Adults’ Pleasure Attitudes in Shaping Condom Use

Condoms can help young adults protect themselves from sexually transmitted infections and unintended pregnancy. We examined young people’s attitudes about whether condoms reduced pleasure and how these attitudes shape condom practices. We used a nationally representative sample of 2328 heterosexually active, unmarried 15- to 24-year-old young adults to document multivariate associations with condom nonuse at the last sexual episode. For both young men and women, pleasure-related attitudes were more strongly associated with lack of condom use than all sociodemographic or sexual history factors. Research and interventions should consistently assess and address young people’s attitudes about how condoms affect pleasure.Because of their unique ability to prevent both pregnancy and sexually transmitted infections (STIs), male condoms are a vital public health tool. For decades, researchers have worked to understand and promote young adults’ consistent condom use. Although 15- to 24-year-old young adults represent only 25% of the sexually experienced population in the United States, they account for 53% of all unintended pregnancies1 and nearly half of all new STI cases.2Many studies document the sociodemographic and sexual history factors most associated with young adults’ condom use,3–5 including age, education, and number of sexual partners.6 Research also explores psychosocial factors such as self-esteem7,8 and condom self-efficacy,9 as well as gender inequality that may render condom use especially difficult for young women.10 Relatively little research explores young people’s attitudes about condoms and sexual pleasure.Burgeoning research among samples of “older” adults11,12 and college students13,14 has suggested that attitudes about how condoms affected sexual pleasure might influence condom use practices, although this work has primarily focused on men.15,16 One exploratory mixed-gender study documented that both adult women and men who reported that condoms undermine arousal and enjoyment were least likely to use them.17 However, fewer studies have explored such pleasure attitudes among adolescents and young adults, especially among young women,18 and no nationally representative studies of this topic exist for any age group. We addressed these limitations using a nationally representative sample of young adult women and men to assess how attitudes about condoms and sexual pleasure might be related to condom practices.