Modelling the epidemiologic impact of achieving UNAIDS fast-track 90-90-90 and 95-95-95 targets in South Africa.

UNAIDS established fast-track targets of 73% and 86% viral suppression among human immunodeficiency virus (HIV)-positive individuals by 2020 and 2030, respectively. The epidemiologic impact of achieving these goals is unknown. The HIV-Calibrated Dynamic Model, a calibrated agent-based model of HIV transmission, is used to examine scenarios of incremental improvements to the testing and antiretroviral therapy (ART) continuum in South Africa in 2015. The speed of intervention availability is explored, comparing policies for their predicted effects on incidence, prevalence and achievement of fast-track targets in 2020 and 2030. Moderate (30%) improvements in the continuum will not achieve 2020 or 2030 targets and have modest impacts on incidence and prevalence. Improving the continuum by 80% and increasing availability reduces incidence from 2.54 to 0.80 per 100 person-years (-1.73, interquartile range (IQR): -1.42, -2.13) and prevalence from 26.0 to 24.6% (-1.4 percentage points, IQR: -0.88, -1.92) from 2015 to 2030 and achieves fast track targets in 2020 and 2030. Achieving 90-90-90 in South Africa is possible with large improvements to the testing and treatment continuum. The epidemiologic impact of these improvements depends on the balance between survival and transmission benefits of ART with the potential for incidence to remain high.

Intimate partner violence perpetration, standard and gendered STI/HIV risk behaviour, and STI/HIV diagnosis among a clinic-based sample of men.

BACKGROUND: The estimated one in three women worldwide victimized by intimate partner violence (IPV) consistently demonstrate elevated STI/HIV prevalence, with their abusive male partners' risky sexual behaviours and subsequent infection increasingly implicated. To date, little empirical data exist to characterise the nature of men's sexual risk as it relates to both their violence perpetration, and STI/HIV infection. METHODS: Data from a cross-sectional survey of men ages 18-35 recruited from three community-based health clinics in an urban metropolitan area of the northeastern US (n = 1585) were analysed to estimate the prevalence of IPV perpetration and associations of such violent behaviour with both standard (eg, anal sex, injection drug use) and gendered (eg, coercive condom practices, sexual infidelity, transactional sex with a female partner) forms of sexual-risk behaviour, and self-reported STI/HIV diagnosis. RESULTS: Approximately one-third of participants (32.7%) reported perpetrating physical or sexual violence against a female intimate partner in their lifetime; one in eight (12.4%) participants self-reported a history of STI/HIV diagnosis. Men's IPV perpetration was associated with both standard and gendered STI/HIV risk behaviours, and to STI/HIV diagnosis (OR 4.85, 95% CI 3.54 to 6.66). The association of men's IPV perpetration with STI/HIV diagnosis was partially attenuated (adjusted odds ratio (AOR) 2.55, 95% CI 1.77 to 3.67) in the multivariate model, and a subset of gendered sexual-risk behaviours were found to be independently associated with STI/HIV diagnosis-for example, coercive condom practices (AOR 1.67, 95% CI 1.04 to 2.69), sexual infidelity (AOR 2.46, 95% CI 1.65 to 3.68), and transactional sex with a female partner (AOR 2.03, 95% CI 1.36 to 3.04). CONCLUSIONS: Men's perpetration of physical and sexual violence against intimate partners is common among this population. Abusive men are at increased risk for STI/HIV, with gendered forms of sexual-risk behaviour partially responsible for this association. Thus, such men likely pose an elevated infection risk to their female partners. Findings indicate the need for interwoven sexual health promotion and violence prevention efforts targeted to men; critical to such efforts may be reduction in gendered sexual-risk behaviours and modification of norms of masculinity that likely promote both sexual risk and violence.

Identification of primary HIV-1C infection in Botswana.

Methods for identification of primary HIV infections seem increasingly important to understand pathogenesis, and to prevent transmission, which is particularly efficient during acute infection. Most current algorithms for HIV testing are based on detection of HIV antibodies and are unable to identify early infections before seroconversion. The efficiency of prospective cohorts, which is a standard approach for identifying primary HIV-1 infection, depends on a variety of epidemiological and cultural factors including HIV incidence and stigma and, not surprisingly, varies significantly in different geographical areas. We report a voluntary counseling and testing (VCT)-based approach to identifying primary HIV-1C infection that was developed as part of a primary HIV-1 subtype C infection study in Botswana. The referral strategy was based on: (1) collaboration with VCT centers at city clinics operated by the Ministry of Health; (2) partnering with the busiest non-government VCT center; (3) educating healthcare workers and the community about primary HIV infection; and (4) pairing with diverse VCT providers, including NGOs and private-sector organizations. Acute HIV-1 infections were defined by a negative HIV-1 serology combined with a positive HIV-1 RT-PCR test. Recent HIV-1 infections were identified by detuned EIA testing according to the classic STARTH algorithm. The VCT-based referral strategy resulted in the successful identification of 57 cases of acute and early HIV infection. A referral strategy of expanded VCT with viral RNA (Ribonucleic acid) testing to a national program in Botswana may be a promising approach for identification of primary HIV infections on a countrywide level. The program should offer VCT with viral RNA testing to the general public, facilitate proper counseling and risk reduction, and allow initiation of early HAART, and may reduce new viral transmissions.

Improving comprehension for HIV vaccine trial information among adolescents at risk of HIV.

A simplified version of the HIVNET prototype HIV vaccine process was developed for adolescents at risk of HIV by:(1) reducing reading level; (2) reorganizing; (3) adding illustrations; and (4) obtaining focus group feedback. Then adolescents (N = 187) in three cities were randomly assigned to the standard or simplified version. Adolescents receiving the simplified version had significantly higher comprehension scores (80% correct vs. 72% correct), with 37% of items significantly more likely to be answered correctly. They were also significantly more likely to recall study benefits and procedures. Overall, adolescents were less willing to participate in a potential HIV vaccine trial after presentation than prior to presentation. The present study indicates that it would be feasible for adolescents to participate in a vaccine trial, as simplification of vaccine information, combined with illustrations to depict key concepts, resulted in improved scores for adolescents on the comprehension and recall test.

Impact of opportunistic diseases on chronic mortality in HIV-infected adults in Côte d'Ivoire.

OBJECTIVE: To estimate incidence rates of opportunistic diseases (ODs) and mortality for patients with and without a history of OD among HIV-infected patients in Côte d'Ivoire. METHODS: Using incidence density analysis, we estimated rates of ODs and chronic mortality by CD4 count in patients in a cotrimoxazole prophylaxis trial in Abidjan before the highly active antiretroviral therapy (HAART) era. Chronic mortality was defined as death without a history of OD or death more than 30 days after an OD diagnosis. We used Poisson's regression to examine the effect of OD history on chronic mortality after adjusting for age, gender, and current CD4 count. RESULTS: Two hundred and seventy patients (40% male, mean age 33 years, median baseline CD4 count 261 cells/microl) were followed up for a median of 9.5 months. Bacterial infections and tuberculosis were the most common severe ODs. Of 47 patients who died, 9 (19%) died within 30 days of an OD, 26 (55%) died more than 30 days after an OD, and 12 (26%) died with no OD history. The chronic mortality rate was 31.0/100 person-years for those with an OD history, and 11.1/100 person-years for those with no OD history (rate ratio (RR) 2.81, 95% confidence interval (CI): 1.43 - 5.54). Multivariate analysis revealed that OD history remained an independent predictor of mortality (RR 2.15, 95% CI: 1.07 - 4.33) after adjusting for CD4 count, age and gender. CONCLUSIONS: Before the HAART era, a history of OD was associated with increased chronic HIV mortality in Côte d'Ivoire, even after adjusting for CD4 count. These results provide further evidence supporting OD prophylaxis in HIV-infected patients.

Province of residence and active syphilis infection among Zambian men and women: new evidence from population-based data.

This study examined the risk factors for active syphilis infection in a subset of nationally-representative population-based survey of Zambian men and women. Syphilis prevalence was 6.5% for women = 2107) and 7.4% for men (N = 1745). In the multivariate model, province was a strong risk factor for active syphilis infection, with Copperbelt, Eastern, Luapula, Lusaka, North-Western and Western Provinces presenting significantly higher risk for women, and Copperbelt, Eastern and Lusaka Provinces presenting significantly higher risk for men compared to the Northern Province. In addition to province, age, education, age at first intercourse, marital status, history of genital sore or discharge, and having ever paid for sex were independent predictors of syphilis infection. Given the ongoing HIV-1 epidemic in Zambia, more aggressive diagnosis and treatment of active syphilis infections, particularly in high-risk provinces, are important strategies to reduce reproductive morbidity and curb HIV-1 transmission.

Social and behavioural determinants of consistent condom use among hotel and bar workers in Northern Tanzania.

Bar and hotel workers (n=519) in Moshi, Tanzania were interviewed to obtain information about potential predictors of condom use. Samples were collected for the diagnosis of sexually transmitted diseases (STDs), including HIV. Consistent condom use was defined as always using condoms with sexual partners in the past five years. Overall consistent condom use in this population was 14.1%. In multivariate analyses, consistent condom use was inversely associated with low condom self-efficacy (adjusted odds ratio [AOR], 0.20; 95% confidence interval (CI), 0.06-0.71), low condom knowledge (AOR, 0.11; CI, 0.01-0.80), and having more than three children (AOR, 0.23; 95% CI, 0.09-0.54). Other significant predictors included perceived condom acceptability and using condoms when last exchanged sex for money or gift. These results indicate that increased specific condom knowledge, improved self-efficacy, and reduced social stigma could be effective strategies in the promotion of condom use in this population.

Impact of protease inhibitor-containing combination antiretroviral therapies on height and weight growth in HIV-infected children.

OBJECTIVE: To examine beneficial or detrimental effects of protease inhibitor (PI)-containing antiretroviral regimens on height and weight growth in children with human immunodeficiency virus (HIV) infection. METHODS: A prospective cohort study was conducted of 906 HIV-infected children, from pediatric research clinics in the United States, who were between 3 months and 18 years of age and who had height and weight assessed in 1995 (before introduction of PIs in this population) and at least once more through 1999. Changes in age- and gender-adjusted height and weight growth associated with PI use were assessed. RESULTS: Compared with a healthy reference population, children were more affected in height (mean z score: -0.90 [18th percentile]) than in weight (mean z score: -0.42 [34th percentile]) at baseline (1995). Two thirds of children received at least 1 PI during 1996 to 1999. In the multivariate mixed effects regression models adjusted for baseline log(10) CD4 cell count, baseline age, gender, and race/ethnicity, the use of PIs was associated with per-year gains of 0.13 z scores in height and 0.05 z scores in weight relative to the expected growth with non-PI-containing regimens (eg, after 1 year of PI use, a representative 6-year-old boy in our study would be approximately 0.7 cm taller and 0.1 kg heavier than if he had not received PIs). No significant differential effects of PIs on height or weight growth according to specific agents or children's sociodemographic or clinical characteristics were found. CONCLUSIONS: Although the use of PI-containing regimens was not associated with growth retardation, it was associated with only small annual increments in height and weight growth in HIV-infected children.

Incidence of primary opportunistic infections in two human immunodeficiency virus-infected French clinical cohorts.

BACKGROUND: Clinical guidelines for the prevention of opportunistic infections in human immunodeficiency virus (HIV)-infected individuals have been developed on the basis of natural history data collected in the USA. The objective of this study was to estimate the incidence of primary opportunistic infections in HIV-infected individuals in geographically distinct cohorts in France. METHODS: We conducted our study on 2664 HIV-infected patients from the Tourcoing AIDS Reference Centre and the hospital-based information system of the Groupe d'Epidémiologie Clinique du SIDA en Aquitaine enrolled from January 1987 to September 1995 and followed through December 1995. We estimated: (1) CD4-adjusted incidence rates of seven primary opportunistic infections in the absence of prophylaxis for that specific infection or any antiretroviral drugs other than zidovudine; and (2) CD4 lymphocyte count decline. RESULTS: The highest incidence rates for all opportunistic infections studied occurred in patients with CD4 counts < 200/microl. With CD4 counts < 50/microl, the most common opportunistic infections were toxoplasmic encephalitis (12.6 per 100 person-years) and Pneumocystis carinii pneumonia (11.4 per 100 person-years). Mycobacterium tuberculosis was the least common opportunistic infection (< 5.0/100 person-years). Even with CD4 counts > 300/microl, cases of Pneumocystis carinii pneumonia and toxoplasmic encephalitis were reported. The mean CD4 lymphocyte decline per month was 4.6 cells/microl. There was a significant association between HIV risk behaviour and the incidence of cytomegalovirus infection, between calendar year and the incidence of Pneumocystis carinii pneumonia, toxoplasmic encephalitis and Candida esophagitis, and between geographical area and the incidence of Pneumocystis carinii pneumonia and cytomegalovirus infection. CONCLUSIONS: Geographical differences exist in the incidence of HIV-related opportunistic infections. These results can be used to define local priorities for prophylaxis of opportunistic infections.

Homozygous and heterozygous CCR5-Delta32 genotypes are associated with resistance to HIV infection.

OBJECTIVE: To investigate evidence for resistance to HIV-1 infection associated with the heterozygous genotype CCR5-+/Delta32 and with the homozygous genotype CCR5-Delta32/Delta32, which results in a nonfunctional CCR5 receptor. DESIGN: Cohort study of initially HIV-seronegative high-risk individuals from eight different cities. Enrollment data were analyzed to investigate the association of demographic factors and risk behaviors with CCR5 genotypes on the assumption that increased genotype prevalence among persons with histories of longer or more intensive exposure to HIV would indicate HIV resistance associated with that genotype. Longitudinal data were analyzed to investigate the association of HIV seroincidence with CCR5 genotypes. The cohort of 2996 individuals included 1892 men who have sex with men (MSM), 474 male injection drug users (IDUs), 347 women at heterosexual risk, and 283 female IDUs. MEASUREMENTS: CCR5 genotype, HIV serostatus, demographic factors, and risk behaviors during the 6 months before enrollment, followed by measurement of HIV seroincidence during the subsequent 18 months (for men) and 24 months (for women). RESULTS: Forty (1.3%) subjects were homozygous CCR5-Delta32/Delta32 and 387 (12.9%) were heterozygous CCR5-+/Delta32. All but 1 CCR5-Delta32/Delta32 individuals and 51 CCR5-+/Delta32 individuals were Caucasian. Among 1531 Caucasian MSM, CCR5-+/Delta32 individuals were present more frequently (22.3%) among those reporting unprotected receptive anal intercourse than among those not reporting this risk (15.9%) (p =.002), suggesting a selective advantage of the heterozygous genotype. CCR5-+/Delta32 individuals also had a significantly reduced relative risk of HIV seroconversion adjusted for unprotected receptive anal intercourse compared with CCR5-/+ individuals (relative risk = 0.30, 95% confidence interval [CI]: 0.08-0.97). CCR5-Delta32/Delta32 prevalence among Caucasian MSM was significantly associated with age among subjects recruited from high HIV seroprevalence cities (New York City and San Francisco) (odds ratio [OR] for each decade increase in age = 2.57, CI: 1.56-4.21) but not among those recruited from lower HIV prevalence sites (Boston, Chicago, Philadelphia, Seattle, and Providence/Pawtucket, Rhode Island) (OR = 1.20, CI: 0.75-1.89). CONCLUSIONS: Cross-sectional and longitudinal analyses indicated that among high-risk HIV seronegative MSM, CCR5-+/Delta32 and CCR5-Delta32/Delta32 are associated with protection against HIV infection. These findings imply that strategies aimed at reducing susceptibility to HIV infection by blocking CCR5 receptor sites need not seek blockage of all receptor sites to achieve an imperfect but substantial degree of protection.

Substance use among men who have sex with men: comparison with a national household survey.

OBJECTIVE: Compare substance use among men who have sex with men (MSM) at high risk for HIV infection to a nationally representative sample of heterosexual men. METHODS: Compare data from surveys of 3,212 MSM recruited for participation in a Vaccine Preparedness Study (VPS) with an age-standardized group of 2481 single, urban-dwelling men from the 1995 National Household Survey on Drug Abuse (NHSDA). RESULTS: Except for alcohol, relative risk (RR [95% confidence interval (CI)]) for use of any substance was higher in the VPS than the National Household Survey on Drug Abuse (NHSDA) (3.64 [3.01-4.42]). Drugs with the highest relative risks were "poppers" (21.6 [15.2-30.8]), sedatives (6.98 [2.46-19.8]), hallucinogens (6.14 [4.61-8.17]), tranquilizers (4.99 [2.96-8.42]), and stimulants (4.47 [3.58-5.58]). RR was higher for weekly use of poppers (33.5 [12.5-89.6]), stimulants (2.75 [1.79-4.22]), marijuana (2.37 [1.93-2.92]), and cocaine (2.24 [1.32-3.79]); and for daily use of marijuana (1.49 [1.08-2.05]). CONCLUSIONS: Participants in the VPS used more substances than a group of age-standardized, single, urban-dwelling men from the NHSDA. In view of previous data showing that substance use can be associated with unprotected sex, assessing substance use among MSM at high risk for HIV infection is an important component of risk reduction efforts.

Are US populations appropriate for trials of human immunodeficiency virus vaccine? The HIVNET Vaccine Preparedness Study.

Questions exist about whether testing of preventive human immunodeficiency virus (HIV)-1 vaccines, which will require rapid recruitment and retention of cohorts with high HIV-1 seroincidence, is feasible in the United States. A prospective cohort study was conducted in 1995-1997 among 4,892 persons at high risk for HIV infection in nine US cities. At 18 months, with an 88% retention rate, 90 incident HIV-1 infections were observed (1.31/100 person-years (PY), 95% confidence interval (CI): 1.06, 1.61). HIV-1 seroincidence rates varied significantly by baseline eligibility criteria--1.55/100 PY among men who had sex with men, 0.38/100 PY among male intravenous drug users, 1.24/100 PY among female intravenous drug users, and 1.13/100 PY among women at heterosexual risk-and by enrollment site, from 0.48/100 PY to 2.18/100 PY. HIV-1 incidence was highest among those men who had sex with men who reported unprotected anal intercourse (2.01/100 PY, 95% CI: 1.54, 2.63), participants who were definitely willing to enroll in an HIV vaccine trial (1.96/100 PY, 95% CI: 1.41, 2.73), and women who used crack cocaine (1.62/100 PY, 95% CI: 0.92, 2.85). Therefore, cohorts with HIV-1 seroincidence rates appropriate for HIV-1 vaccine trials can be recruited, enrolled, and retained.

The cost effectiveness of combination antiretroviral therapy for HIV disease.

BACKGROUND: Combination antiretroviral therapy with a combination of three or more drugs has become the standard of care for patients with human immunodeficiency virus (HIV) infection in the United States. We estimated the clinical benefits and cost effectiveness of three-drug antiretroviral regimens. METHODS: We developed a mathematical simulation model of HIV disease, using the CD4 cell count and HIV RNA level as predictors of the progression of disease. Outcome measures included life expectancy, life expectancy adjusted for the quality of life, lifetime direct medical costs, and cost effectiveness in dollars per quality-adjusted year of life gained. Clinical data were derived from major clinical trials, including the AIDS Clinical Trials Group 320 Study. Data on costs were based on the national AIDS Cost and Services Utilization Survey, with drug costs obtained from the Red Book. RESULTS: For patients similar to those in the AIDS Clinical Trials Group 320 Study (mean CD4 cell count, 87 per cubic millimeter), life expectancy adjusted for the quality of life increased from 1.53 to 2.91 years, and per-person lifetime costs increased from $45,460 to $77,300 with three-drug therapy as compared with no therapy. The incremental cost per quality-adjusted year of life gained, as compared with no therapy, was $23,000. On the basis of additional data from other major studies, the cost-effectiveness ratio for three-drug therapy ranged from $13,000 to $23,000 per quality-adjusted year of life gained. The initial CD4 cell count and drug costs were the most important determinants of costs, clinical benefits, and cost effectiveness. CONCLUSIONS: Treatment of HIV infection with a combination of three antiretroviral drugs is a cost-effective use of resources.

Effect of combination therapy including protease inhibitors on mortality among children and adolescents infected with HIV-1.

BACKGROUND: Combination therapy including protease inhibitors has been shown to be effective in treating adults infected with human immunodeficiency virus type 1 (HIV-1), but there are only limited data regarding the treatment of children and adolescents. METHODS: A cohort of 1028 HIV-1-infected children and adolescents, from birth through 20 years of age, who were enrolled in research clinics in the United States before 1996 was followed prospectively through 1999. We used proportional-hazards regression models to estimate the effect on mortality of combination therapy including protease inhibitors. RESULTS: Seven percent of the subjects were receiving combination therapy including protease inhibitors in 1996; by 1999, 73 percent were receiving such therapy. In univariate analyses, a higher base-line percentage of lymphocytes that were CD4-positive, a higher weight for age, a higher height for age, black race, Hispanic ethnic background, younger age, and perinatally acquired infection were associated with a longer median time to the initiation of this type of therapy (P<0.001). After adjustment for covariates, the differences among racial and ethnic groups in the time to initiation were not statistically significant. Mortality declined from 5.3 percent in 1996 to 2.1 percent in 1997, 0.9 percent in 1998, and 0.7 percent in 1999 (P for trend <0.001). There were reductions in mortality in all subgroups defined according to age, sex, percentage of CD4+ lymphocytes, educational level of the parent or guardian, and race or ethnic background. In adjusted analyses, the initiation of combination therapy including protease inhibitors was independently associated with reduced mortality (hazard ratio for death, 0.33; 95 percent confidence interval, 0.19 to 0.58; P<0.001). CONCLUSIONS: The use of combination therapy including protease inhibitors has markedly reduced mortality among children and adolescents infected with HIV-1.

Randomized controlled trial of audio computer-assisted self-interviewing: utility and acceptability in longitudinal studies. HIVNET Vaccine Preparedness Study Protocol Team.

Recent studies have reported on the utility of audio computer-assisted self-interviewing (ACASI) in surveys of human immunodeficiency virus (HIV) risk behaviors that involve a single assessment. This paper reports the results of a test of ACASI within a longitudinal study of HIV risk behavior and infection. Study participants (gay men (n = 1,974) and injection drug users (n = 903)) were randomly assigned to either ACASI or interviewer-administered assessment at their second follow-up visit 12 months after baseline. Significantly more of the sexually active gay men assessed via ACASI reported having sexual partners who were HIV antibody positive (odds ratio = 1.36, 95% confidence interval: 1.08, 1.72), and a higher proportion reported unprotected receptive anal intercourse. Among injection drug users (IDUs), our hypothesis was partially supported. Significantly more IDUs assessed via ACASI reported using a needle after another person without cleaning it (odds ratio = 2.40, 95% confidence interval: 1.34, 4.30). ACASI-assessed IDUs reported similar rates of needle sharing and needle exchange use but a lower frequency of injection. Participants reported few problems using ACASI, and it was well accepted among members of both risk groups. Sixty percent of the participants felt that the ACASI elicited more honest responses than did interviewer-administered questionnaires. Together, these data are consistent with prior research findings and suggest that ACASI can enhance the quality of behavioral assessment and provide an acceptable method for collecting self-reports of HIV risk behavior in longitudinal studies and clinical trials of prevention interventions.

Feasibility of chemoprophylaxis studies in high risk HIV-seronegative populations.

Administration of antiretroviral medications-recommended to prevent HIV infection after occupational exposure-has not been evaluated for safety or efficacy following nonoccupational exposure. HIV-seronegative persons at increased risk for HIV exposure completed a self-administered questionnaire assessing their willingness to join studies of this approach. Of 4,572 respondents, 60% were willing to join a study of a "morning-after" pill; dosing three times a day and mild side effects reduced willingness to 30%. Men who have sex with men (MSM) who reported unprotected anal intercourse in the prior 6 months were significantly more likely to be willing to join a morning-after study than MSM who did not (p = 0.006). MSM favored a preventive HIV vaccine over oral chemoprophylaxis; other populations preferred oral chemoprophylaxis. Interest in studies declined as the hypothetical regimen became more demanding. Studies must emphasize the unknown efficacy of this approach, given increased interest among MSM at greater risk of exposure.

Acceptability of formulations and application methods for vaginal microbicides among drug-involved women: results of product trials in three cities.

BACKGROUND AND OBJECTIVES: Female-controlled methods of HIV prevention, such as vaginal microbicides, are urgently needed, particularly among drug-involved women. Acceptability research is critical to product development. GOAL: To assess the acceptability of forms and application methods for future microbicides. DESIGN: Eighty-four drug-involved women were introduced in groups to three lubricant products, asked to try each for 3 weeks, and scheduled for individual follow-up interviews. RESULTS: Participants and their partners felt positive about the products, and expressed willingness to use microbicides if they were shown to be effective against HIV. Women agreed on product characteristics that influenced their reactions (e.g. ease of insertion, degree of "messiness"), but often disagreed on whether their reactions to these characteristics were positive or negative. CONCLUSION: Development of acceptable and effective HIV-prevention products depends on understanding the interaction between characteristics of the products and the characteristics and perceptions of women. Levels of sexual risk and acceptability factors based on drug-use patterns, race and ethnicity, culture, age, and types and attitudes of male partners suggest that a "one size fits all" approach will not win broad acceptance among drug-involved women.

Drug-involved women as potential users of vaginal microbicides for HIV and STD prevention: a three-city survey.

We wished to obtain potential users' perspectives on vaginal microbicides from a population of women at high risk for HIV. We conducted a face-to-face survey of convenience samples (total n = 743) of drug-using women and female sexual partners of male injection drug users in Bridgeport, Connecticut, Providence, Rhode Island, and San Juan, Puerto Rico. Ninety percent of respondents said that they would be very likely to use microbicides with paying partners and 78% with primary partners (p = 0.001). High hypothetical likelihood of use was expressed even after several potential product characteristics (e.g., causes minor vaginal irritation or burning) were rated as unacceptable. Latinas had significantly higher predicted likelihood of use with primary (p = 0. 001) and paying partners (p = 0.018) than blacks and whites. Eighty percent of respondents preferred products that enhance sexual pleasure by providing additional lubrication or "wetness." More than 80% of respondents said that they would want their primary partners to know of their microbicide use, and 42% (p = 0.001) said that they would want their paying partners to know. Women's concern about a paying partner's violent response to suggested use of risk reduction measures was inversely related to predicted likelihood of microbicide use (p = 0.045). Microbicides should be assessed in the context of the potential users' actual relationships and cultures. Achieving broad acceptability among drug-involved women will require a range of products.

Correlates of condom failure in a sexually active cohort of men who have sex with men.

Condom failure (slippage or breakage) has been shown to be associated with HIV seroconversion among men who have sex with men (MSM), but predictors of failure have been poorly elucidated. Of 2592 HIV-seronegative MSM participants in the HIV Network for Prevention Trials (HIVNET) multisite Vaccine Preparedness Study who reported condom use for anal sex in the 6 months before enrollment, condom failure was reported by 16.6%, with failure rates of 2.1/100 episodes of condom usage (2.5 failures/100 episodes for receptive anal sex and 1.9/100 episodes for insertive anal sex). In separate multivariate models evaluating predictors of condom failure reported by the insertive and receptive partners, more frequent condom use was associated with a decreased per-condom failure rate and amphetamine and heavy alcohol use with increased rates in both models. Being employed, having private medical insurance, and using lubricants for >80% of anal sex acts were significantly associated with decreased failure rates in the insertive model. Safer sex counseling should particularly target men of lower socioeconomic status, promote proper and consistent use of condoms with appropriate lubricants, and address the impact of drug use, especially amphetamines and alcohol, on condom failure.

PIP: Although the extent of condom use during anal intercourse has increased considerably among men who have sex with men (MSM) in response to the HIV/AIDS pandemic, condom failure through both slippage and breakage limits the effectiveness of such method use. Condom failure is associated with HIV seroconversion among MSM. 16.6% of the 2592 HIV-seronegative MSM participants in the HIV Network for Prevention Trials (HIVNET) multi-site Vaccine Preparedness Study who reported condom use for anal sex in the 6 months before enrollment reported condom failure. The overall failure rate was 2.1/100 episodes of condom use, with 2.5 failures/100 episodes for receptive anal sex and 1.9/100 episodes for insertive anal sex. Almost half of the men were aged 30 years or younger, 25% were non-White, 60.6% attended college, and 85.7% were employed either part- or full-time. Multivariate analysis of reported failures found more frequent condom use to be associated with a decreased per condom failure rate, and amphetamine and heavy alcohol use with increased rates in both models. Being employed, having private medical insurance, and using lubricants for more than 80% of anal sex acts were significantly associated with decreased failure rates in the insertive model. These findings suggest that safer sex counseling should therefore target men of lower socioeconomic status, promote the proper and consistent use of condoms with appropriate lubricants, and address the impact of drug use upon condom failure.

Non-injection substance use correlates with risky sex among men having sex with men: data from HIVNET.

Associations between substance use and sexual behavior were examined among 3220 seronegative men who have sex with men (MSM) in a HIV vaccine preparedness study. Relationships between current and past substance use and current sexual risk were evaluated using crude odds ratios and logistic regression to adjust for confounding variables. Heroin and injection drug use were uncommon (< 2%). Substances most often used were alcohol (89%), marijuana (49%), nitrite inhalants (29%), amphetamines or similarly acting stimulants (21%), cocaine 14% and hallucinogens (14%). Increased adjusted odds for unprotected sex were significantly associated with current heavy alcohol use (OR 1.66; CI 1.18, 2.33), past alcohol problems (OR 1.25; CI 1.05, 1.48), and current drug use (OR 1.26; CI 1.08, 1.48). When associations with specific drugs and nitrite inhalants were examined separately, current use of cocaine and other stimulants (OR 1.25; CI 1.01, 1.55), hallucinogens (OR 1.40; CI 1.10, 1.77), and nitrite inhalants (some (OR 1.61; CI 1.35, 1.92); heavy (OR 2.18; CI 1.48, 3.20)), were independently associated with unprotected sex. Those with past drug use or past heavy alcohol use but not currently using demonstrated no increase in sexual risk, suggesting an important role for substance-focused interventions in risk reduction efforts among MSM.