Correlates of Double Risk of HIV Acquisition and Transmission Among Women who Inject Drugs in St. Petersburg,Russia

Russia continues to experience a growing HIV epidemic, and women account for an increasing proportion of new HIV diagnoses in the country. This study aims to provide up-to-date information on factors associated with unsafe sex and drug use behaviors among women who inject drugs in St. Petersburg, Russia. In this community-based sample of 500 women who inject drugs, 64% tested positive for HIV. Women reported the following: 21% reported injection risk, 22% reported sexual risk, and 18% reported double risk. Multivariable analyses using logistic multinomial regression showed that older age is associated with increased risk behaviors. Involvement in transactional sex is associated with injection risk [aOR = 1.59 (1.02, 2.48)] but protective against sexual risk [aOR = 0.11 (0.06, 0.19)]. Exposure to sexual violence is associated with increased injection risk [aOR = 1.78 (1.01, 3.14)] and double risk [aOR = 3.38 (1.50, 7.63)]. These findings indicate the need to address both the unsafe injection and sexual risks among women who inject drugs in Russia.     

HIV Prevalence and Risk Behaviours Among Foreign Migrant Women Residing in Cape Town,South Africa

HIV prevalence and risk behaviour among foreign migrants in South Africa has not been explored. This paper describes the effectiveness of respondent-driven sampling (RDS) to recruit foreign migrant women residing in Cape Town, reports HIV prevalence, and describes key characteristics among them. We conducted a biological and behavioural surveillance survey using RDS. After written informed consent, participants completed an audio computer assisted self-interview and provided a dried blood sample for HIV analysis. HIV prevalence was estimated to be 7 % (CI 4.9–9.5) among 935 women. HIV sero-positivity was associated with older age (p = 0.001), country of origin (p < 0.000), being unmarried (p < 0.000), having lived in South Africa for 3–5 years (p = 0.023), sexual debut at ≥15 years (p = 0.047), and having used a condom at last sex with a main partner (p = 0.007). Few women reported early sexual debut, or multiple sexual partners. RDS was successful in recruiting foreign migrant women.     

Relationship Power and Sexual Violence Among HIV-Positive Women in Rural Uganda

Gender-based power imbalances place women at significant risk for sexual violence, however, little research has examined this association among women living with HIV/AIDS. We performed a cross-sectional analysis of relationship power and sexual violence among HIV-positive women on anti-retroviral therapy in rural Uganda. Relationship power was measured using the Sexual Relationship Power Scale (SRPS), a validated measure consisting of two subscales: relationship control (RC) and decision-making dominance. We used multivariable logistic regression to test for associations between the SRPS and two dependent variables: recent forced sex and transactional sex. Higher relationship power (full SRPS) was associated with reduced odds of forced sex (AOR = 0.24; 95 % CI 0.07–0.80; p = 0.020). The association between higher relationship power and transactional sex was strong and in the expected direction, but not statistically significant (AOR = 0.47; 95 % CI 0.18–1.22; p = 0.119). Higher RC was associated with reduced odds of both forced sex (AOR = 0.18; 95 % CI 0.06–0.59; p < 0.01) and transactional sex (AOR = 0.38; 95 % CI 0.15–0.99; p = 0.048). Violence prevention interventions with HIV-positive women should consider approaches that increase women’s power in their relationships.     

HIV Testing and Intimate Partner Violence Among Non-Pregnant Women in 15 US States/Territories: Findings from Behavioral Risk Factor Surveillance System Survey Data

Intimate partner violence (IPV) has been shown to be associated with higher rates of HIV infection among women, underscoring the importance of encouraging IPV victims to receive HIV testing. However, we do not know how much HIV testing behavior is influenced by IPV victimization. The current study characterized the association between individual types of IPV and HIV testing in a large sample of non-pregnant women in 15 US states/territories. The 2005 Behavioral Risk Factor Surveillance System data were analyzed after restricting the sample to non-pregnant women. The dependent variable, whether a woman ever had an HIV test, was examined in relation to individual types of IPV victimization (threatened physical violence; attempted physical violence; completed physical violence; and unwanted sex). Associations between HIV testing and types of IPV were assessed using adjusted risk ratios (aRR) that controlled for demographics and HIV-related risk factors (intravenous drug use, sexually transmitted diseases, exchange sex, unprotected anal sex). Approximately 28.6 % of women reported ever having experienced IPV, and 52.8 % of these women reported being tested for HIV. Among women who had not experienced IPV, 32.9 % reported ever having been tested for HIV. HIV testing was associated with lifetime experience of threatened violence (aRR = 1.43; 95 % CI = 1.24?1.65), attempted violence (aRR = 1.43; 95 % CI = 1.20?1.69), completed physical violence (aRR = 1.30; 95 % CI = 1.13?1.48), and unwanted sex (aRR = 1.66; 95 % CI = 1.48?1.86). Women who experienced each type of IPV were more likely to have been ever tested for HIV compared to women with no IPV history. However, nearly half of those reporting IPV, even though at greater risk for HIV infection, had never been tested. Additional efforts are needed to address barriers to testing in this group.     

Sexual Minority Status and Violence Among HIV Infected and At-Risk Women

IMPORTANCE

Sexual minority women with and at-risk for human immunodeficiency virus (HIV) may face increased risks of violence.

OBJECTIVE

To understand the relationship between sexual minority status and violence; and how high-risk sex and substance use mediate that relationship among women with and at-risk for HIV.

DESIGN & PARTICIPANTS

Longitudinal study of 1,235 HIV infected and 508 uninfected women of the Women's Interagency HIV Study (WIHS) cohort, from New York City, NY, Chicago, IL, Washington D.C., and San Francisco, CA, 1994–2012.

MAIN MEASURES

Primary exposures are sexual identity (heterosexual, bisexual, lesbian/gay) and sexual behavior (male, female, or male & female partners). Primary outcomes are sexual abuse, intimate partner violence (IPV) and physical violence; high-risk sex and substance use were examined as mediators.

KEY RESULTS

Bisexual women were at increased odds for sexual abuse [aOR 1.56 (1.00, 2.44)], IPV [aOR 1.50 (1.08, 2.09)], and physical violence [aOR 1.77 (1.33, 2.37)] compared to heterosexual women. In a separate analysis, women who reported sex with men and women (WSMW) had increased odds for sexual abuse [aOR 1.65 (0.99, 2.77], IPV [aOR 1.50 (1.09, 2.06)] and physical violence [aOR 2.24 (1.69, 2.98)] compared to women having sex only with men (WSM). Using indirect effects, multiple sex partners, cocaine and marijuana were significant mediators for most forms of abuse. Transactional sex was only a mediator for bisexual women. Women who reported sex only with women (WSW) had lower odds of sexual abuse [aOR 0.23 (0.06, 0.89)] and physical violence [aOR 0.42 (0.21, 0.85)] compared to WSM.

CONCLUSIONS

Women who identify as bisexual or report both male and female sex partners are most vulnerable to violence; multiple recent sex partners, transactional sex and some types of substance use mediate this relationship. Acknowledging sexual identity and behavior, while addressing substance use and high-risk sex in clinical and psychosocial settings, may help reduce violence exposure among women with and at-risk for HIV.     

Motherhood and HIV Risk Among Female Sex Workers in Andhra Pradesh, India: The Need to Consider Women’s Life Contexts

This study examines whether the challenges of motherhood among female sex workers (FSW) are linked with vulnerability to sexual risk factors for HIV. FSW at least 18 years of age (n = 850) were recruited through respondent driven sampling for a survey on HIV risk in the Rajahmundry area of Andhra Pradesh, India. Logistic regression models adjusted for demographic characteristics were used to assess the relation between reported caretaking challenges and sexual risk indicators for HIV. In adjusted logistic regression models, FSW who reported three or more children in their household or current child health concerns were significantly less likely to report consistent condom use (adjusted odds ratios (AORs) range: 0.5–0.6) and more likely to take more money for sex without a condom (both AORs: 2.5). Women who reported current child health concerns were also more likely to report an STI symptom in the past 6 months (AOR = 1.6; 95 % confidence interval: 1.1–2.3). Findings suggest that challenging responsibilities related to caretaking of children are associated with heightened vulnerability to HIV risk among FSW. Such findings add to the cumulating evidence urging for the implementation of HIV prevention interventions that consider the multiple challenges across various domains of women’s lives.     

HIV Risk Behaviors Among Black/African American and Hispanic/Latina Female Partners of Men Who Have Sex With Men and Women

We examined the frequencies of HIV-related risk factors among women reporting and not reporting sex with a man who has sex with men and women (MSMW). We used data from 15,625 visits of Black and Hispanic/Latina females, ages 15–64 years, to Los Angeles County HIV testing sites (2007–2008). The following risk factors were associated with reporting an MSMW partner: number of sex partners, use of party drugs, anal sex, and sexual partners with other risk factors. Overall, females who reported an MSMW partner differed little in their likelihood of testing HIV positive (0.93%) compared to those who did not (0.58%, p value = 0.19). Among females reporting one male sex partner, having an MSMW partner was strongly associated with HIV (2.8 vs. 0.63%, p = 0.03). Interventions targeting women who report other risky behaviors may reach many who have been with MSMW. Women with one partner are an important focus of such efforts.     

Economic Resources and HIV Preventive Behaviors Among School-Enrolled Young Women in Rural South Africa (HPTN 068)

Individual economic resources may have greater influence on school-enrolled young women’s sexual decision-making than household wealth measures. However, few studies have investigated the effects of personal income, employment, and other financial assets on young women’s sexual behaviors. Using baseline data from the HIV Prevention Trials Network (HPTN) 068 study, we examined the association of ever having sex and adopting sexually-protective practices with individual-level economic resources among school-enrolled women, aged 13–20 years (n = 2533). Age-adjusted results showed that among all women employment was associated with ever having sex (OR 1.56, 95 % CI 1.28–1.90). Among sexually-experienced women, paid work was associated with changes in partner selection practices (OR 2.38, 95 % CI 1.58–3.58) and periodic sexual abstinence to avoid HIV (OR 1.71, 95 % CI 1.07–2.75). Having money to spend on oneself was associated with reducing the number of sexual partners (OR 1.94, 95 % CI 1.08–3.46), discussing HIV testing (OR 2.15, 95 % CI 1.13–4.06), and discussing condom use (OR 1.99, 95 % CI 1.04–3.80). Having a bank account was associated with condom use (OR 1.49, 95 % CI 1.01–2.19). Economic hardship was positively associated with ever having sex, but not with sexually-protective behaviors. Maximizing women’s individual economic resources may complement future prevention initiatives.     

Food Insecurity is Associated with Poor HIV Outcomes Among Women in the United States

Women in the general population experience more food insecurity than men. Few studies have examined food insecurity’s impact on HIV treatment outcomes among women. We examined the association between food insecurity and HIV outcomes in a multi-site sample of HIV-infected women in the United States (n = 1154). Two-fifths (40%) of participants reported food insecurity. In an adjusted multivariable Tobit regression model, food insecurity was associated with 2.08 times higher viral load (95% confidence interval (CI): 1.04, 4.15) and lower CD4+ counts (? 42.10, CI: ? 81.16, ? 3.03). Integration of food insecurity alleviation into HIV programs may improve HIV outcomes in women.     

Correlates of Unprotected Vaginal or Anal Intercourse with Women Among Substance-Using Men Who Have Sex with Men

The role men who have sex with men and women (MSMW) play in heterosexual HIV transmission is not well understood. We analyzed baseline data from Project MIX, a behavioral intervention study of substance-using men who have sex with men (MSM), and identified correlates of unprotected vaginal intercourse, anal intercourse, or both with women (UVAI). Approximately 10 % (n = 194) of the men reported vaginal sex, anal sex, or both with a woman; of these substance-using MSMW, 66 % (129) reported UVAI. Among substance-using MSMW, multivariate analyses found unemployment relative to full/part-time employment (OR = 2.28; 95 % CI 1.01, 5.17), having a primary female partner relative to no primary female partner (OR = 3.44; CI 1.4, 8.46), and higher levels of treatment optimism (OR = 1.73; 95 % CI 1.18, 2.54) increased odds of UVAI. Strong feelings of connection to a same-race gay community (OR = 0.71; 95 % CI 0.56, 0.91) and Viagra use (OR = 0.31; 95 % CI 0.10, 0.95) decreased odds of UVAI. This work suggests that although the proportion of substance-using MSM who also have sex with women is low, these men engage in unprotected sex with women, particularly with primary female partners. This work highlights the need for further research with the substance using MSMW population to inform HIV prevention interventions specifically for MSMW.     

Gender Differences in Heterosexual Anal Sex Practices Among Women and Men in Substance Abuse Treatment

Heterosexual anal intercourse (HAI) is an understudied risk behavior among women and men in substance abuse treatment. Rates of HAI for women (n = 441) and men (n = 539) were identified for any, main and casual partners. More men (32.8 %) than women (27.1 %) reported engaging in HAI in the previous 90 days. These rates are higher than those reported for both men (6.0–15.9 %) and women (3.5–13.0 %) ages 25–59 in the National Survey of Sexual Health and Behavior. Men were significantly more likely to report HAI with their casual partners (34.1 %) than women (16.7 %). In a logistic regression model generated to identify associations between HAI and variables previously shown to be related to high risk sexual behavior, being younger, bisexual, and White were significantly associated with HAI. For men, having more sex partners was also a significant correlate. HAI is a logical target for increased focus in HIV prevention interventions.     

Predicting HIV Transmission Risk among HIV-Infected Patients Seen in Clinical Settings

We assessed risk of transmission among 4,016 HIV-infected patients in primary care, including men who have sex with men (MSM, n = 2,109), women (n = 1,104) and men who had sex with women (MSW, n = 803) in clinics in 15 cities across the U.S. A transmission risk act, assessed by computer assisted interviews, was defined as unprotected vaginal or anal sex with a partner who was HIV-uninfected or of unknown HIV status. MSM were more than twice as likely to report transmission risk acts than MSW (Odds Ratio [OR] = 2.35; 95% Confidence Interval [CI] = 1.84, 3.00; P ≤ .001). Women were also more likely to report transmission risk acts than MSW (OR = 1.56; 95% CI = 1.19, 2.05; P ≤ .001). Stimulant use was associated with transmission risk in all three groups (P ≤ .05). MSM were more likely to use methamphetamines (8% versus 2% and 3% respectively), while MSW (17%) and women (12%, compared to 11% for MSM) were more likely to use cocaine. Clinical settings offer opportunities for preventing HIV transmission, particularly if interventions are tailored to sub-populations of HIV-infected patients.     

Associations of HIV Testing,Sexual Risk and Access to Prevention Among Female Sex Workers in the Dominican Republic

The Caribbean region has one of the highest proportions of HIV in the general female population attributable to sex work. In 2008 (n = 1256) and 2012 (n = 1525) in the Dominican Republic, HIV biological and behavioral surveys were conducted among female sex workers (FSW) in four provinces using respondent driven sampling. Participants were ≥15 years who engaged in intercourse in exchange for money in the past 6 months and living/working in the study province. There were no statistically significant changes in HIV and other infections prevalence from 2008 to 2012, despite ongoing risky sexual practices. HIV testing and receiving results was low in all provinces. FSW in 2012 were more likely to receive HIV testing and results if they participated in HIV related information and education and had regular checkups at health centers. Further investigation is needed to understand barriers to HIV testing and access to prevention services.     

Alcohol and HIV Risk Among Russian Women of Childbearing Age

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

The Relationship Between Risk Perception and Frequency of HIV Testing Among Men Who Have Sex with Men and Transgender Women,Lima, Peru

HIV infections in Peru are concentrated among men who have sex with men (MSM) and transgender women (TW). HIV testing rates among them remain low, delaying entrance into care. We assessed the prevalence of frequent HIV testing (at least every 6 months) and associated factors among 310 MSM and TW who attend sexual health clinics in Lima, Peru, and who reported that they were HIV seronegative or unaware of their status. Only 39% of participants tested frequently, and 22% had never tested; 29% reported that they were at low or no risk for acquiring HIV. Reporting low or no risk for acquiring HIV was associated with frequent testing (adjusted prevalence ratio [aPR] = 1.53, 95% CI 1.13–2.08); those reporting unprotected anal sex were less likely to test frequently (aPR = 0.66, 95% CI 0.50–0.87). HIV prevalence was 12% and did not vary by risk perception categories. This at-risk population tests infrequently and may not understand the risk of having unprotected sex.     

The WHOMEN’s Scale (Women’s HAART Optimism Monitoring and EvaluatioN Scale v.1) and the Association with Fertility Intentions and Sexual Behaviours Among HIV-Positive Women in Uganda

The objective of this study was to develop a reliable HAART optimism scale among HIV-positive women in Uganda and to test the scale’s validity against measures of fertility intentions, sexual activity, and unprotected sexual intercourse. We used cross-sectional survey data of 540 women (18–50 years) attending Mbarara University’s HIV clinic in Uganda. Women were asked how much they agreed or disagreed with 23 statements about HAART. Data were subjected to a principal components and factor analyses. Subsequently, we tested the association between the scale and fertility intentions and sexual behaviour using Wilcoxon rank sum test. Factor analysis yielded three factors, one of which was an eight-item HAART optimism scale with moderately high internal consistency (α = 0.70). Women who reported that they intended to have (more) children had significantly higher HAART optimism scores (median = 13.5 [IQR: 12–16]) than women who did not intend to have (more) children (median = 10.5 [IQR: 8–12]; P < 0.0001). Similarly, women who were sexually active and who reported practicing unprotected sexual intercourse had significantly higher HAART optimism scores than women who were sexually abstinent or who practiced protected sexual intercourse. Our reliable and valid scale, termed the Women’s HAART Optimism Monitoring and EvaluatioN scale (WHOMEN’s scale), may be valuable to broader studies investigating the role of HAART optimism on reproductive intentions and sexual behaviours of HIV-positive women in high HIV prevalence settings.     

Place and Sexual Partnership Transition Among Young American Indian and Alaska Native Women

Multiple challenges expose American Indian and Alaska Native (AIAN) women to high-risk sexual partnerships and increased risk for HIV/STI. Using a unique sample of sexually-active young AIAN women (n = 129), we examined characteristics of last three partners and whether transitional partnerships were associated with different risk profiles, including where partners met, lived, and had sex. Respondents were more likely to have met their previous or current secondary partner (P2) at a friend’s or family setting (versus work or social setting) (AOR = 3.92; 95 % CI 1.31, 11.70). Condom use was less likely when meeting a partner at friend’s or family settings (AOR = 0.17; 95 % CI 0.05, 0.59). Sexual intercourse with P2 (compared to P1) usually took place in “riskier” settings such as a car, bar, or outside (AOR = 4.15; 95 % CI 1.59, 10.68). Perceived “safe” places, e.g., friend’s or family’s house, were identified with risky behaviors; thus, homogeneous messaging campaigns may promote a false sense of safety.     

Food Insecurity Increases HIV Risk Among Young Sex Workers in Metro Vancouver,Canada

This research aimed to determine the effect of food insecurity on sexual HIV risk with clients among youth sex workers (YSWs) <30 years in Metro Vancouver, Canada. Data were drawn from a prospective community cohort of sex workers (2010–2013). We examined the independent relationship between YSWs’ food insecurity and being pressured into sex without a condom by clients (“client condom refusal”). Of 220 YSWs, 34.5 % (n = 76) reported client condom refusal over the 3.5-year study period and 76.4 % (n = 168) reported any food insecurity. Adjusting for other HIV risk pathways, food insecurity retained an independent effect on client condom refusal (AOR 2.08, 95 % CI 1.23–3.51), suggesting that food insecurity is significantly associated with HIV risk among YSWs. This study indicates a critical relationship between food insecurity and HIV risk, and demonstrates YSWs’ particular vulnerability. Public policies for food assistance as a harm reduction measure may be key to addressing this disparity.     

Different Dimensions of HIV-Related Stigma May Have Opposite Effects on HIV Testing: Evidence Among Young Men and Women in South Africa

Although HIV-related stigma in general is known to deter HIV-testing, the extent to which different dimensions of stigma independently influence testing behaviour is poorly understood. We used data on young black men (n = 553) and women (n = 674) from the 2009 Cape Area Panel Study to examine the independent effects of stigmatising attitudes, perceived stigma and observed enacted stigma on HIV-testing. Multivariate logistic regression models showed that stigma had a strong relationship with HIV-testing among women, but not men. Women who held stigmatising attitudes were more likely to have been tested (OR 3, p < 0.01), while perceived stigma (OR 0.61, p < 0.1) and observed enacted stigma (OR 0.42, p < 0.01) reduced the odds significantly of women having had an HIV test. Our findings highlight that different dimensions of stigma may have opposite effects on HIV testing, and point towards the need for interventions that limit the impact of enacted and perceived stigma on HIV-testing among women.     

HIV Status Communication with Sex Partners and Associated Factors Among High-Risk MSM and Transgender Women in Lima,Peru

Men who have sex with men (MSM) and transgender women (TW) are key populations in the HIV epidemic. HIV status communication between sex partners can inform decisions regarding sexual behavior. MSM and TW were asked about HIV status communication with sex partners at baseline, 9- and 18-months. GEE models assessed associations with HIV status communication at baseline using prevalence ratios (PRs) and longitudinally using odds ratios (ORs). At baseline, those who had previously had an HIV test, disclosed their HIV status to 42 % of their sex partners. HIV status communication was associated with knowing their sex partner’s HIV status at baseline (aPR 5.20) and longitudinally (aOR 1.86). HIV positivity at baseline was negatively associated with HIV status communication during follow-up (aOR 0.55). All reported aPRs and aORs have p < 0.05. Interventions promoting HIV status communication and more frequent HIV testing should be explored as current efforts are insufficient.