Sexual orientation, use of drugs and risk perception among HIV-positive men in Sao Paulo, Brazil.

The aim of this cross-sectional study, carried out among 250 HIV-positive (HIV+) men who have sex with women, was to describe their risk perception before learning of their HIV+ status and their sexual and drug use behaviour. Of the 250 men, 62.0% were heterosexuals and 38.0% where bisexuals. They most often reported becoming infected through unprotected sex (24.5%) and injecting drug use (11.0%). They were usually tested because they became ill (42.2%). Condom use with women in all episodes of sexual intercourse before HIV+ diagnosis was reported by 22.6% of heterosexuals and 34.7% of bisexuals (P < 0.05). With respect to drug use, 58.0% reported the use of drugs at some period in their lifetime. A higher proportion of individuals who had used drugs perceived themselves at risk (P < 0.05). Findings showed that most HIV+ men who have sex with women, regardless of sexual orientation or injecting drug use, did not use condoms and did not perceive themselves at risk before learning of their HIV+ status, and only undergo testing due to illness. The implications for heterosexual transmission of HIV are discussed.

Health sector reform and equity - learning from evidence?

Presents specific policy recommendations, based on the findings. Implementing most of these recommendations would require modifications to the design of the national health systems as well as additional resources targeted towards reducing inequities. Document in PDF format, required Acrobat Reader.

Managed competition for the poor or poorly managed competition? Lessons from the Colombian health reform experience.

BACKGROUND: In 1993, Colombia enacted and subsequently implemented a radical reform in its system of providing health care for the poor, moving in a short time from a traditional model of providing health services in public hospitals to a managed competition model in which the government buys health insurance for the poor. This study examines and attempts to draw lessons from the early experience with this reform. METHODS: Information was gathered from document reviews and interviews with key actors at both the national and local levels. Other quantitative data, such as data from existing national surveys and financial operating data, were also used as available. RESULTS: The new system made important achievements in its first few years, including the enrollment of 7 million Colombians (about half of the targeted population) in health insurance plans and improving access to care. Nevertheless, there were substantial problems with the lack of managerial infrastructure and flow of information needed for the new system to function properly. Because of these difficulties, substantial resources were wasted, and insurance coverage did not always result in true access to health care. CONCLUSIONS: Other countries contemplating similar reforms should educate health administrators and the public, and establish solid administrative capacity in advance of implementation. In Colombia, many initial problems still need to be overcome while maintaining and extending the programme's important accomplishments.

Rejecting family practice: why medical students switch to other specialties.

BACKGROUND AND OBJECTIVES: Medical schools have been encouraged to increase the number of primary care graduates. This study determined the proportion of medical students who change specialty preference during the clinical years and explored how ultimate choice is affected by perceptions of medical specialties acquired during this period. METHODS: A survey was mailed to 397 graduating medical students at the University of California, San Francisco (UCSF) after the National Resident Matching Program Match and before graduation in 1996, 1997, and 1998. RESULTS: The response rate was 81% (320/397). Of 41 respondents who reported that family practice had been their first specialty choice prior to beginning clinical rotations, only 15 (37%) eventually matched in family practice. Comparable numbers for internal medicine and pediatrics were 50% and 69%. Students rejecting family practice were more likely than their colleagues rejecting other specialties to cite insufficient prestige, low intellectual content, and concern about mastering too broad a content area as reasons. CONCLUSIONS: At UCSF, family practice retains fewer interested students than other primary care specialties. To reverse this trend, schools such as UCSF need to raise the prestige of family practice and counter concerns about its intellectual content being impossible to master.

Risk perception and counselling among HIV-positive women in São Paulo, Brazil.

This study of HIV-positive women at a clinic for HIV/AIDS in São Paulo examined their risk perception for HIV before they had learned of their diagnosis and their experiences with pre- and post-test counselling. A sample of 148 women was interviewed regarding demographics, HIV risk factors and risk perception, pre- and post-test counselling, and sexual and reproductive conduct. The majority (77%) had been infected by their partners--37% by an injecting drug user partner. More than half (53%) did not perceive themselves at risk before learning of their HIV status and, of 68 who had perceived themselves at risk, 29% did so only after their partners became ill. The majority (64%) did not receive any kind of pre-test counselling. Post-test counselling was reported by 83% but 14% reported being mishandled by a physician in the process. Findings suggest the importance of prevention efforts to reduce women's barriers to learning about HIV status and the necessity of improving the quality of pre- and post-test counselling.

Reducing AIDS risk among port workers in Santos, Brazil.

OBJECTIVES: This study examined the impact of worksite-based AIDS prevention program among port workers in Santos, Brazil, on sexual risk behavior for HIV infection. METHODS: Male port workers (n = 226) were followed in a 3-wave prospective cohort study. A multifaceted intervention costing US $90,000 for 20,000 workers was conducted between waves 2 and 3. RESULTS: Heterosexual risk behavior showed no decline between waves 1 and 2 (before the intervention) but decreased substantially between waves 2 and 3 (after the intervention). This decrease resulted from both a decrease in nonprimary partners and an increase in condom use. CONCLUSIONS: This worksite-based AIDS program produced marked behavior change at modest cost.

AIDS and condoms in Brasilia: a telephone survey.

A telephone survey was conducted to measure AIDS knowledge, media usage and condom attitudes and behaviors among 500 adults aged 18 to 49 in Brasilia, as well as to evaluate the feasibility of the telephone survey method in a developing country. The response rate was 91.6%. Respondents had good knowledge about correct modes of HIV transmission and prevention but also believed HIV was transmitted through blood donation, public toilets, swimming pools, and mosquito bites. TV and newspapers were the most important sources of information on health matters and AIDS, though health workers were considered the most credible sources of such information. Only 19% of sexual encounters in the 4 weeks prior to the survey included condoms. Single and younger respondents and those with more positive attitudes used condoms more frequently. More work is needed to identify appropriate messages to motivate people to use condoms. Telephone surveys regarding AIDS and sexual attitudes and behaviors are feasible in Brasilia, a planned community with universal telephone coverage.

PIP: This study examines the knowledge, attitudes, and behavior of AIDS and condom use in Brazil. Data were obtained during March-April 1994 from 500 completed telephone interviews among a sample of adults 18-49 years old living in the Plano Piloto sector of Brasilia, Brazil. The survey was conducted about 2 months after a national television and radio campaign on AIDS prevention, use of condoms, and avoidance of sharing syringes or needles. The questionnaire was based on questions from the Global Program on AIDS protocol. 99% of the sample reported that AIDS was one of the most important health problems facing Brazil today. The other health problems mentioned were cancer, famine, and cholera. 27% did not consider themselves at risk of AIDS. 2% considered themselves at great risk. The rest believed they had a small to moderate risk. 93% were aware that people with AIDS might appear healthy looking. 95% indicated sexual contact as a mode of transmission. 34% reported condom use as a means of avoiding AIDS transmission. 19% reported sexual abstinence as a preventive measure. 15% reported that people should inform others of their AIDS status as a way to avoid transmitting AIDS. 41% knew someone with AIDS. Less educated respondents held more inaccurate beliefs about the general means of transmission, but there were no educational differences about safe activities involving specific contact with persons infected with AIDS. Most misinformation pertained to public toilets, blood donations, use of swimming pools, and mosquito bites. 89% believed in a high risk at dental clinics used by AIDS patients. 72% were regular television users. Television and newspapers were the most important sources of information on AIDS and health. Only 19% used condoms in sexual activity occurring in the prior 4 weeks. Psychosocial factors were more important than demographic factors in predicting condom use.

A research agenda for AIDS prevention in the developing world.

BACKGROUND: In the developing world, HIV is spreading in many epidemiologic patterns, ranging from slow spread in limited segments of the population to exponential growth to mature epidemics. These differences are superimposed on widely varying cultures and patterns of behavior, creating unique challenges for prevention in each setting. Local prevention research is continually necessary to respond appropriately and effectively to local prevention needs and to best use scarce resources. THE RESEARCH AGENDA: We propose a research agenda for AIDS prevention in the developing world, consisting of three main components: epidemiologic and behavioral surveillance; enhancing local understanding of HIV risk behavior; and testing interventions. We review examples of each. This 'bottom-up' research is contrasted with 'top-down' research conducted in the developing world by scientists from developed countries to answer questions of general interest. RESULTS: The articles published in this volume exemplify the scope and importance of AIDS prevention research in the developing world. They also show what can be accomplished through international collaboration directed towards meeting local needs.

PIP: In the developing world, HIV is spreading in many different epidemiologic patterns. The spread may be slow among a few population groups, exponential, or at the level of a mature epidemic. HIV is spreading across a wide range of cultures and behavior patterns. A need therefore exists to tailor prevention measures to conditions and needs at local levels. Research at the local level is needed to guide the development and implementation of appropriate HIV prevention programs. The authors propose a research agenda for AIDS prevention in the developing world which consists of the following central components: epidemiologic and behavioral surveillance, improving the local understanding of HIV risk behavior, and testing interventions. Examples of each component are reviewed. In addition, bottom-up research is contrasted with top-down research conducted in the developing world by scientists from developed countries.

Evaluating an AIDS sexual risk reduction program for young adults in public night schools in São Paulo, Brazil.

OBJECTIVES: To describe sexual risk for HIV infection among adult night school students in São Paulo, Brazil, and to evaluate the effect of an HIV/AIDS prevention workshop to reduce sexual risk. SUBJECTS AND METHODS: A longitudinal study was conducted among four demographically similar public night schools in the inner city of São Paulo. Schools were randomized into intervention and control conditions. Of 394 young adults who took part in the baseline survey, 304 (77%) completed a postintervention questionnaire. INTERVENTIONS: In a workshop consisting of four sessions of 3 h each, the students discussed AIDS symbolism, the impact of AIDS on their lives, risk perception, the way in which sexual norms shape knowledge and attitudes, AIDS-related knowledge, reproduction and sexual pleasure, and condom use negotiation. We fostered community-building through AIDS training courses for teachers in the schools, peer support programs and public events. RESULTS: At baseline, 87% had been sexually active at some time and 76% had had sex in the past 6 months. Among those who reported vaginal intercourse and/or anal intercourse, condom use was low. The workshops were positively process-evaluated and supported by the community, the students, their teachers and their parents. We obtained statistically significant effects from the workshops for females only, who reported improved communication with partners about sex and AIDS and less unprotected sex with non-monogamous partners after the intervention. CONCLUSION: These data show that the sexual risk of HIV infection can be lowered when Brazilian disenfranchized communities support AIDS prevention workshops. Even more impressive results may be achieved if the need to address socioeconomic obstacles and gendered sexual roles is emphasized through further long-term community development programs.

Truck drivers in Brazil: prevalence of HIV and other sexually transmitted diseases, risk behavior and potential for spread of infection.

OBJECTIVES: To determine the prevalence of HIV and syphilis and related risk behavior in a sample of truck drivers in Santos, Brazil. SUBJECTS AND METHODS: A cross-sectional study was performed of 300 male truck drivers recruited in the port of Santos, Brazil, including a face-to-face interview and blood sampling for HIV and syphilis serology. RESULTS: Of 300 subjects, 4 (1.3%) were positive for HIV, 25 (8.3%) for syphilis by the Venereal Disease Research Laboratory (VDRL) test and 38 (13%) were positive for syphilis by the fluorescent treponemal antibody (absorbed) test (FTA-Abs). Seventy-one per cent had been employed as truck drivers for more than 10 years and 93% lived outside of Santos. Most participants were married (72%); 40% reported having more than one sex partner; 21% reported sex with commercial sex workers; 14% reported sex with girls that they met on the road; 16% had sex with other men's wives; and 3.3% reported sex with men during the past year. The use of rebite, an oral stimulant, was reported by 43% and was associated with being FTA-Abs-positive (P = 0.04). Being HIV-positive was associated with having sex with friends (P = 0.04), partners usually considered 'safe' by truck drivers. Being syphilis-positive (VDRL) was significantly associated with sex with partners also considered as 'safe', namely primary sex partners, steady partners and other men's wives. DISCUSSION: This is the first study to determine HIV and syphilis seroprevalence among truck drivers in South America. Findings confirm that this group has a high potential risk for HIV infection and other sexually transmitted diseases, and thus currently presents an opportunity for prevention.

Risk behavior and HIV seroprevalence among injecting drug users in Rio de Janeiro, Brazil.

OBJECTIVE: To characterize HIV seroprevalence and risk behavior among injecting drug users (IDUs) in Rio de Janeiro, Brazil, between 1990 and 1996. DESIGN: We report data from three separate cross-sectional samples of IDUs in Rio de Janeiro: the World Health Organization (WHO) sample (n = 479), the Proviva sample (n = 138) and the Brasil sample (n = 110). These data provide the most comprehensive view available, to date, of this understudied population in Rio. METHODS: Demographic characteristics, HIV/AIDS risk behavior and HIV seroprevalence were compared across the three samples and combined analyses were performed to determine the factors associated with injecting risk behavior, sexual risk behavior and HIV seropositivity. RESULTS: The overall HIV seroprevalence among IDUs was 25%. Two encouraging findings of the present analysis were the lower levels of needle-sharing among participants recruited in the latest years (1995-1996) and the lower HIV seroprevalence in the Proviva sample composed mainly of less educated, poorer IDUs living in deprived neighborhoods. No trends toward safer behavior were found for sexual risk, younger age being the principal factor associated with high risk. CONCLUSIONS: Levels of needle-sharing and sexual risk among IDUs in Rio remain high, demonstrating the urgent need to increase the limited preventive measures undertaken so far. Seroprevalence levels for HIV remain significantly lower in the most deprived sample, arguing for the fundamental importance of prompt and effective prevention strategies to keep infection rates from rising among the poorest and largest strata of Rio's IDUs.

HIV risk behavioral surveillance in Bangkok, Thailand: sexual behavior trends among eight population groups.

OBJECTIVE: To assess trends in HIV risk behaviors over a 3-year period in eight population groups in Bangkok, Thailand. DESIGN AND SUBJECTS: Using a repeated cross-sectional survey design with a structured questionnaire, we collected five sets of self-reported sexual behavior data related to HIV risk from the following subject groups at the same sampling sites during 1993-1996: direct and indirect female sex workers, male attenders of sexually transmitted disease (STD) clinics, female attenders of antenatal care clinics, male and female vocational students, and male and female factory workers. RESULTS: Reported patronage of commercial sex by the three male groups declined by an overall average of 48% over the 3-year period. Other non-regular sexual partnerships declined among male STD clinic attenders and vocational students. Condom use during most recent sexual intercourse between sex workers and clients peaked at high levels (>90%) in the early data waves, while among indirect sex workers and their clients, consistent condom usage increased from 56% to 89%. Low condom use persisted among sex workers and their non-paying sex partners. Single women reported low levels of sexual activity and condom use with no signs of an increase. Similarly, married women from antenatal clinics reported low condom use with their husbands, with no change throughout the period of the study. CONCLUSIONS: HIV risk behavioral surveillance is a useful way of determining whether behavior change has occurred in specific population groups. The results here confirm and add to a growing set of evidence of risk behavior reduction in Thailand. The behavioral changes did not occur uniformly but varied depending on the sexual dyad and the population group under study. Behavioral surveillance should be promoted and its methodologies strengthened in attempts to understand the local dynamics of HIV epidemics.

Condom use with casual partners by men in Kampala, Uganda.

OBJECTIVE: To estimate the prevalence and correlates of condom use with casual sex partners by men in urban Uganda and to identify barriers to condom use that are amenable to intervention. DESIGN: Cross-sectional, door-to-door survey of men residing in a poor area of Kampala, Uganda. SUBJECTS AND METHODS: A multistage, probability sample was approximated by recruiting participants within randomly selected neighborhoods. A total of 301 men between the ages of 18 and 45 years answered questions about condom knowledge, attitudes, beliefs and practices. The respondents also provided demographic and HIV risk-related information. RESULTS: Condom use was higher than previously found in studies in Uganda: 46% of men reported using a condom at the last casual sexual encounter; 31% reported always using condoms with casual partners. In multivariate analysis, independent correlates of condom use included higher condom self-efficacy (4-item scale, odds ratio 1.3 per scale point), lower embarrassment around condoms (3-item scale, odds ratio 0.44 per scale point), knowing where to buy a condom (odds ratio 3.9), knowing how to use a condom (8-item scale, odds ratio 1.4 per scale point), and increasing number of casual sex partners (odds ratio 1.4 per partner). CONCLUSIONS: These data suggest that condom use may be further increased in this population by conducting demonstrations of condom use skills, preparing individuals to anticipate circumstances that make using condoms difficult and using a variety of outlets to dispense condoms.