Condom use problems during anal sex among men who have sex with men (MSM): findings from the Safe in the City study.

Our research aims were to: (1) assess the prevalence of two condom use problems: breakage or slippage and partial use (delayed application or early removal) among men who have sex with men (MSM) seeking services in urban US STD clinics; and (2) examine the association between these condom use problems and participant, partner and partnership characteristics. Analysis was restricted to HIV-negative MSM who reported having anal sex at least once in the preceding 3 months and who completed both the baseline and 3 month follow-up assessments. Two models were fitted using the generalized estimating equations (GEE) approach. A total of 263 MSM (median age=32 years) reported 990 partnerships. Partnerships with no condom use 422 (42.6%) were excluded. Thus, 207 MSM and 568 partnerships were included. Among condom users, 100% use was reported within 454 partnerships (79.9%) and <100% within 114 (20.1%), and 21(3.7%) reported both condom use problems, 25 (4.4%) reported only breakage, 67 (11.8%) reported only partial use, and 455 (80.1%) reported no errors. The breakage or slippage and partial use rates per condom used were 3.4% and 11.2%, respectively. A significantly higher rate of breakage or slippage occurred among non-main partnerships. Characteristics associated with increased odds for condom breakage or slippage were: lower education level (OR=2.78; CI: 1.1-7.5), non-main partner status (OR=4.1; CI: 1.5-11.7), and drunk or high during sex (OR=2.0; CI: 1.1-3.8), and for partial use: lower education level (OR=2.6; CI: 1.0-6.6), perceived partner sexually transmitted infections (STI) risk (OR=2.4; CI: 1.3-4.2), and inconsistent condom use (OR=3.7; CI: 2.0-6.6). A high percentage of MSM partnerships reported no condom use and among condom users, a sizable proportion did not use them consistently or correctly. MSM may benefit from interventions designed to increase proficiency for condom use with a particular focus on the behaviors of inconsistent and partial condom use.

Patterns of adolescent alcohol, cigarette, and marijuana use over a 6-month period.

In the current study, alcohol, cigarette, and marijuana use among adolescents (N= 794, 48.6% female) was assessed at two time points, and four patterns of use were identified: (1) abstainers: no lifetime use; (2) new users: no use at baseline but had used by the follow-up period; (3) experimenters: use prior to the baseline but no use in the period up to the follow-up; and (4) consistent users: self-report of use prior to the baseline and the follow-up. Mean levels of psychosocial variables (mastery, self-esteem, and parental social support) were compared across the four patterns of use for each substance. Only analyses including parental social support as the dependent variable were significant. Adolescents with higher levels of social support were more likely to be classified as abstainers or experimenters of alcohol than consistent users. More frequent users of cigarettes at baseline were likely to be classified as frequent users at the follow-up. The discussion focuses on the identification of the situational context of substance use for alcohol, cigarettes, and marijuana.

'Don't know' and 'didn't think of it': condom use at first intercourse by Latino adolescents.

We examined the specific reasons Latino adolescents did or did not use condoms at first intercourse and their specific reasons for their perceived risk for contracting HIV. Latino adolescents (n = 618), ages 11-19, completed a face-to-face interview that included information on demographics (sex, age, family-status (lives with both natural parents versus other family structure) and country of birth) and sexual behaviour. The respondents cited 'don't know' (25.9%), 'not available' (25.9%) and 'didn't think of it' (23.5%) as the most frequent reasons for not using condoms at first intercourse. Anyone can get it (41.8%), unknown knowledge of partner's serostatus (24.7%) and unprotected sex (23.8%) were the top three reasons for perceiving oneself as being at risk for contracting HIV. Sexually active adolescents were more likely to perceive themselves at risk for contracting HIV than adolescents that had not had sex. Males were significantly more likely to report using condoms for protection at first intercourse than females. The remaining demographic factors were not significantly related to use of condoms at first intercourse nor to perceived risk for contracting HIV.

Incentives vs outreach workers for latent tuberculosis treatment in drug users.

BACKGROUND: Drug users are at increased risk for latent tuberculosis infection (LTBI) and also at increased risk for noncompletion of medication regimens for treatment of LTBI or tuberculosis disease. Directly observed therapy (DOT) provided by outreach workers, the use of incentives, or both have been suggested as a means to increase adherence. OBJECTIVE: To compare the independent and combined effects of monetary incentives and outreach worker provision of DOT for LTBI treatment in a sample of active drug users. METHODS: The research design was a randomized controlled trial in a community outreach program setting. Participants consisted of a volunteer sample of 163 active injection drug and crack cocaine users placed on twice weekly DOT. Condition 1 of the interventions consisted of provision of DOT by an outreach worker at a location chosen by the participant (active outreach) and a $5 per visit incentive. Condition 2 was comprised of active outreach with no monetary incentive, and Condition 3, provision of DOT at the study community site and a $5 per visit incentive. The main outcome measures were percentage of medication taken as prescribed and completion of medication regimen. RESULTS: The percentage of prescribed medication taken was higher for those who received incentives, either with (71%) or without (68%) active outreach, compared to those who received active outreach alone (13%). Only 4% of participants assigned to Condition 2 completed treatment, compared to 53% of Condition 1 participants, and 60% of Condition 3 participants. CONCLUSIONS: Monetary incentives were clearly superior to active outreach. Active outreach in combination with monetary incentives did not increase adherence over incentives alone.

Acculturation and interrelationships between problem and health-promoting behaviors among Latino adolescents.

PURPOSE: To examine: (a) the effects of acculturation on a healthy lifestyle including problem behaviors (substance use and sex acts) and health-promoting behaviors (e.g., seat belt use, vitamin intake, hours of sleep per night) and (b) the interrelationships among problem and health-promoting behaviors among Latino adolescents. METHODS: Face-to-face interviews were conducted with Latino adolescents (n = 609) with questions covering the following areas: acculturation, sociodemographics, problem behaviors, and health-promoting behaviors. The participants ranged in age from 11 to 19 (mean = 15) years. Bivariate correlations and factor analyses were used to examine the relationship between problem and health-promoting behaviors. A combination of one-way analyses of variance (ANOVAs), Chi-square tests, and Student's t-tests were used to analyze the effects of acculturation on problem and health-promoting behaviors. RESULTS: Higher levels of acculturation were associated with an increased likelihood of exhibiting problem behaviors and a decreased likelihood of exhibiting certain health-promoting behaviors. Foreign-born Latinos were significantly less likely to engage in problem behaviors. Problem behaviors were likely to co-occur; however, the co-occurrence of health-promoting behaviors was not evident. The results also revealed the co-occurrence of problem behaviors with selected health-promoting behaviors. CONCLUSIONS: Among Latino adolescents, there seems to be evidence that problem behaviors and certain health-promoting behaviors do co-occur. To the extent that "healthy lifestyles" are conceptualized as the presence of health-promoting behaviors and the absence of problem behaviors, less acculturated Latino adolescents seem to fare better than those that are more acculturated. Interventions to promote "healthy lifestyles" among Latino adolescents should be tailored to take into consideration the effect of acculturation.

Behavioral interventions for the control of tuberculosis among adolescents.

OBJECTIVES: Activation of latent tuberculosis infection into tuberculosis disease (TB), the primary killer among infectious diseases worldwide, can be prevented with six months of anti-TB medication. A large percentage of adolescents started on medication, however, fail to complete their treatment. The authors developed and tested the effects of innovative educational strategies on infected adolescents at two health centers serving ethnically diverse populations. METHODS: The authors used a randomized experimental four-group design to assess the independent and combined effects of peer counseling and a participant-parent contingency contract intervention. RESULTS: A total of 794 adolescents were recruited into the study, for a 79% participation rate. The overall rate of treatment completion was 79.8%. Self-efficacy for medication-taking behavior at post-test correlated strongly with completion of care (R = 0.367, p = 0.002). Participants randomized to the peer counseling groups demonstrated significantly greater improvements in self-efficacy and mastery than the usual care control group. Based on the study results, continuing education seminars and workshops were implemented for TB control staff at the two health clinics and for all TB Control Division staff at the Los Angeles County Health Department. Educational materials and a training manual for enhancing completion of treatment of latent TB infection through tailored educational approaches were developed and disseminated to the clinics. CONCLUSIONS: Health education and incentives are helpful adjuncts to the completion of treatment for latent tuberculosis infection in adolescents.

Does measured behavior reflect STD risk? An analysis of data from a randomized controlled behavioral intervention study. Project RESPECT Study Group.

BACKGROUND: Many studies measure sex behavior to determine the efficacy of sexually transmitted disease (STD)/HIV prevention interventions. GOAL: To determine how well measured behavior reflects STD incidence. STUDY DESIGN: Data from a trial (Project RESPECT) were analyzed to compare behavior and incidence of STD (gonorrhea, chlamydia, syphilis, HIV) during two 6-month intervals. RESULTS: A total of 2879 persons had 5062 six-monthly STD exams and interviews; 8.9% had a new STD in 6 months. Incidence was associated with demographic factors but only slightly associated with number of partners and number of unprotected sex acts with occasional partners. Many behaviors had paradoxical associations with STD incidence. After combining behavior variables to compare persons with highest and lowest risk behaviors, the STD incidence ratio was only 1.7. CONCLUSION: Behavioral interventions have prevented STD. We found people tend to have safe sex with risky partners and risky sex with safe partners. Therefore, it is difficult to extrapolate the disease prevention efficacy of an intervention from a measured effect on behavior alone.

Structure of outcome beliefs in condom use. The Project RESPECT Study Group.

To study the structure of beliefs about condom use outcomes, the authors derived and tested 4 psychosocial hypothetical models: (a) a 2-factor model of the personal and social outcomes of condom use; (b) a 2-factor model of the pros and cons of the behavior; (c) a 3-factor model (i.e., physical, self-evaluative, and social) of outcome expectancies; and (d) a thematic 4-factor model of the protection, self-concept, pleasure, and interaction implications of the behavior. All 4 models were studied with a confirmatory factor analysis approach in a multisite study of 4,638 participants, and the thematic solution was consistently the most plausible. Self-concept and pleasure were most strongly associated with attitudes toward using condoms, intentions to use condoms, and actual condom use, whereas protection and interaction generally had little influence.

Stage of change versus an integrated psychosocial theory as a basis for developing effective behaviour change interventions. The Project RESPECT Study Group.

According to the Stages of Change (SOC) model, behavioural change involves a process of movement from precontemplation (no intention to change), to contemplation (some intention to change, but no behaviour), to preparation (intention to change and early inconsistent behavioural attempts to change), to action (consistent behavioural performance for less than six months) and finally, to maintenance (consistent behavioural performance for six months or more). Moreover, it is argued that cognitive (e.g. attitude change) and action oriented (e.g. changing self-efficacy) strategies are differentially effective at different stages. In contrast, most other behavioural prediction and change models suggest that both cognitive and action oriented approaches are necessary to move people from precontemplation to contemplation (i.e. to develop intentions). This paper tests this and other differences between these two theoretical approaches. Among other findings, our data indicate that a combination of cognitive and action strategies may be the most effective way to target individuals who have no intention to change their behaviour.

Monetary versus nonmonetary incentives for TB skin test reading among drug users.

BACKGROUND: In a prior study, we reported that monetary incentives were effective in increasing return for tuberculosis (TB) skin test reading. The purpose of this study was to compare the effects of monetary versus nonmonetary incentives and a theory-based educational intervention on return for TB skin test reading in a sample of newly recruited active injection and crack cocaine users, and to determine the prevalence of TB infection in this sample. METHODS: Active injection drug and/or crack cocaine users (n = 1,078), recruited using street outreach techniques, were skin tested for TB. They were randomly assigned to 1 of 5 experimental treatment conditions: $10 cash, grocery store coupons, bus tokens/fast-food coupons, motivational education, or usual encouragement to return. Nonmonetary incentives had a $10 value, and all incentives were provided at return for skin test reading. RESULTS: Ninety-five percent of those who received $10 returned for skin test reading compared to 86% of those who received grocery store coupons and 83% of those who received either bus tokens or fast-food coupons. In contrast, only 47% of those who received the educational session and only 49% of those who received usual encouragement returned for skin test reading. The prevalence of a positive tuberculin test was 21%, and was similar for crack cocaine and injection drug users. CONCLUSIONS: Nonmonetary and monetary incentives dramatically increased the return rate for TB skin test reading among drug users who are at high risk of TB infection. Nonmonetary incentives were somewhat less effective than monetary incentives.

Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. Project RESPECT Study Group.

CONTEXT: The efficacy of counseling to prevent infection with the human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs) has not been definitively shown. OBJECTIVE: To compare the effects of 2 interactive HIV/STD counseling interventions with didactic prevention messages typical of current practice. DESIGN: Multicenter randomized controlled trial (Project RESPECT), with participants assigned to 1 of 3 individual face-to-face interventions. SETTING: Five public STD clinics (Baltimore, Md; Denver, Colo; Long Beach, Calif; Newark, NJ; and San Francisco, Calif) between July 1993 and September 1996. PARTICIPANTS: A total of 5758 heterosexual, HIV-negative patients aged 14 years or older who came for STD examinations. INTERVENTIONS: Arm 1 received enhanced counseling, 4 interactive theory-based sessions. Arm 2 received brief counseling, 2 interactive risk-reduction sessions. Arms 3 and 4 each received 2 brief didactic messages typical of current care. Arms 1, 2, and 3 were actively followed up after enrollment with questionnaires at 3, 6, 9, and 12 months and STD tests at 6 and 12 months. An intent-to-treat analysis was used to compare interventions. MAIN OUTCOME MEASURES: Self-reported condom use and new diagnoses of STDs (gonorrhea, chlamydia, syphilis, HIV) defined by laboratory tests. RESULTS: At the 3- and 6-month follow-up visits, self-reported 100% condom use was higher (P<.05) in both the enhanced counseling and brief counseling arms compared with participants in the didactic messages arm. Through the 6-month interval, 30% fewer participants had new STDs in both the enhanced counseling (7.2%; P= .002) and brief counseling (7.3%; P= .005) arms compared with those in the didactic messages arm (10.4%). Through the 12-month study, 20% fewer participants in each counseling intervention had new STDs compared with those in the didactic messages arm (P = .008). Consistently at each of the 5 study sites, STD incidence was lower in the counseling intervention arms than in the didactic messages intervention arm. Reduction of STD was similar for men and women and greater for adolescents and persons with an STD diagnosed at enrollment. CONCLUSIONS: Short counseling interventions using personalized risk reduction plans can increase condom use and prevent new STDs. Effective counseling can be conducted even in busy public clinics.

Tuberculosis screening and compliance with return for skin test reading among active drug users.

OBJECTIVES: This study assessed the independent and combined effects of different levels of monetary incentives and a theory-based educational intervention on return for tuberculosis (TB) skin test reading in a sample of active injection drug and crack cocaine users. Prevalence of TB infection in this sample was also determined. METHODS: Active or recent drug users (n = 1004), recruited via street outreach techniques, were skin tested for TB. They were randomly assigned to 1 of 2 levels of monetary incentive ($5 and $10) provided at return for skin test reading, alone or in combination with a brief motivational education session. RESULTS: More than 90% of those who received $10 returned for skin test reading, in comparison with 85% of those who received $5 and 33% of those who received no monetary incentive. The education session had no impact on return for skin test reading. The prevalence of a positive tuberculin test was 18.3%. CONCLUSIONS: Monetary incentives dramatically increase the return rate for TB skin test reading among drug users who are at high risk of TB infection.

Screening for chlamydial cervicitis in a sexually active university population.

Enzyme-linked immunoabsorbent assays to detect chlamydial cervicitis were performed on samples from 1,320 sexually active university women. Seventy-five (prevalence 5.7 percent) had positive tests. Demographic, history, symptom, and physical examination variables were insufficient to predict infection accurately. We conclude that screening during routine visits with this population is cost-effective.

A patient education program to improve adherence rates with antituberculosis drug regimens.

The design, logic, and results of a two-year health education study directed at improving rates of patient adherence to antituberculosis medical regimens are presented. An incentive scheme to reward positive health behaviors plus targeted educational counseling sessions was implemented in a randomized clinical controlled trial. The 205 subjects who participated in the study are categorized according to patients with active tuberculosis (n = 88) or preventive patients with no evidence of active disease (n = 117). Patients in each of these groups were randomly assigned to a special intervention (SI) group or a usual care (UC) control group and were followed monthly throughout their treatment program. While SI patients with active tuberculosis demonstrated higher levels of appointment-keeping behavior and mean percent of medication taken compared to UC patients, no statistically significant differences between the two groups were found. Preventive therapy patients assigned to the SI group, however, were significantly more likely than UC patients to remain in care during their 12-month regimen (64% vs 47%; p = .003). Furthermore, SI patients had significantly higher levels of adherence to their medical regimen compared to UC patients (68% vs 38%; p less than .001). These results demonstrate the positive effects of a structured health education program on the improvement of continuity of care and adherence behavior among patients with tuberculosis.

Evaluation of a tuberculosis screening and prophylaxis program for international students.

In many parts of the world, tuberculosis (TB) is still a major cause of morbidity and mortality. Because of the high rate of worldwide TB infection, the University of California, Los Angeles (UCLA), requires nonimmigrant foreign students to have a tuberculin skin test before completing registration for classes. Out of 589 students tested, 57.6% were positive (n = 339) at the level of 5 mm induration or greater. All positive reactors with no contraindications to isoniazid (INH) were urged to take INH chemoprophylaxis (n = 290). Several strategies designed to improve compliance were used with all students. In addition, some students attended a lecture and discussion prior to initiation of therapy. Completion rates were low for all students, including those who attended the lecture-discussion session. Implications of the results for future screening activities are discussed.

Comparison of direct immunofluorescent staining and an enzyme-linked immunoabsorbent assay for identifying Chlamydia trachomatis in cervical and urethral specimens.

A direct fluorescent antibody (DFA) stain (MicroTrak, Syva) and an enzyme-linked immunoabsorbent assay (Chlamydiazyme, Abbott) were used to detect chlamydial infection in 179 cervical specimens and 56 specimens obtained from the female urethra. Chlamydiazyme, when compared with the DFA technique, revealed a high degree of correlation in these specimens (22 and 21 positive cervical specimens, respectively, and 7 each positive urethral specimens). Since both techniques are readily available, inexpensive and easy to perform, they should become valuable tools in the objective assessment of women at risk of this common and important sexually transmitted disease.

Enzyme-linked immunoabsorbent assays in the detection of Chlamydia trachomatis: how valid are they?

Two enzyme-linked immunoabsorbent assays (Chlamydiazyme, Abbott Laboratories, North Chicago, IL, and IDEIA, Boots-CellTech Diagnostics Inc., East Hanover, NJ) specific for the detection of Chlamydia trachomatis antigen were used to assess 451 cervical specimens. All specimens obtained from the subjects were also simultaneously cultured for Chlamydia. Both assays identified 90.9% (20/22) of the culture positive cases. Chlamydiazyme identified two and IDEIA three additional specimens as positive. Of these additional positive tests, one of two Chlamydiazyme and three of three IDEIA specimens were confirmed as positive by the direct fluorescent antibody technique (MicroTrak, Syva Co., Palo Alto, CA). Given the inexpense, availability, ease of performance, high sensitivity (91%), and specificity (99%) of these tests, both should become valuable tools to objectively assess women at risk for this common sexually transmitted disease.

Evaluation of a tobacco and alcohol abuse prevention curriculum for adolescents.

This study examined the effectiveness of a tobacco and alcohol prevention program that was delivered to sixth and seventh grade students by minimally trained classroom teachers. The program focused on (a) teaching students to identify and resist peer influences, (b) information about short- and long-term consequences of tobacco and alcohol use, (c) the correction of normative expectations, and (d) the establishment of conservative intentions regarding tobacco and alcohol use. Two cohorts of students were pretested, and subsequent to delivery of the program, they were tracked longitudinally. The first cohort was followed for four years, the second was followed for three years. Results indicate that the program reduced the onset and prevalence of tobacco use but not alcohol use. The effects for tobacco were differentially related to the school district in which the program was delivered, the sex of student, and ethnicity, suggesting that prevention program content is only one variable that may affect the effectiveness of prevention interventions.