Impact of integrating HIV and TB care and treatment in a regional tuberculosis hospital in rural Guatemala.

Resource-limited settings have made slow progress in integrating TB and HIV care for co-infected patients. We examined the impact of integrated TB/HIV care on clinical and survival outcomes in rural western Guatemala. Prospective data from 254 newly diagnosed TB/HIV patients (99 enrolled in the pre-integrated program from August 2005 to July 2006, and 155 enrolled in the integrated program from February 2008 to January 2009) showed no significant baseline differences between clients in the two periods. They were principally male (65.5 %), Mayan (71 %), median age 33 years, and CD4 count averaged 111 cells/mm³. TB/HIV co-infected patients were more likely to receive antiretroviral therapy in the integrated program than in the pre-integrated program (72 vs. 22 %, respectively) and had lower mortality (HR 0.22, 95 % CI 0.14­0.33). This study shows how using a TB setting as the entry point for integrated TB/HIV care can improve health outcomes for HIV-positive patients in rural Guatemala.

Demographic and health surveys indicate limited impact of condoms and HIV testing in four African countries.

Condom promotion and HIV testing for the general population have been major components of HIV prevention efforts in sub-Saharan Africa's high prevalence HIV epidemics, although little evidence documents their public health impact. Recent enhancements to the large, population-based demographic and health surveys (DHS) and AIDS information surveys (AIS) allow use of these data to assess the population-wide impact of these strategies. We analysed the latest DHS and AIS data from four sub-Saharan African countries with high prevalence, heterosexually transmitted HIV epidemics (Côte d'Ivoire, Swaziland, Tanzania and Zambia; N = 48 298) to answer two questions: 1) Are men and women who use condoms less likely to be HIV-infected than those who do not?; and 2) Are men and women who report knowing their HIV status more likely to use condoms than those who do not? Consistent condom use was associated with lower HIV infection rates for Swazi men but with higher HIV infection rates for women in Tanzania and Zambia; it made no significant difference in the other five sex/country subgroups analysed. Inconsistent condom use was not significantly associated with HIV status in any subgroup. Knowing one's HIV status was consistently associated with higher rates of condom use only among married people who were HIV-positive, even though condom use in this group remained relatively low. Effects of knowing one's HIV status among other subgroups varied. These results suggest that condoms have had little population-wide impact for HIV/AIDS prevention in these four countries. HIV testing appears to be associated with increased condom use mainly among people in stable partnerships who test positive. HIV testing and condom promotion may be more effective when targeted to specific groups where there is evidence of benefit rather than to general populations.

Prevention messages and AIDS risk behavior in Kampala, Uganda.

Uganda was one of the first countries to substantially reduce HIV rates through behavior change, but these gains have not continued in recent years. Little is known about what messages Ugandans are currently hearing about AIDS prevention, what they themselves believe to be important prevention strategies, and how these beliefs are associated with behavior. We interviewed men and women aged between 20 and 39 in two poor peri-urban areas of Kampala, using a random sample, cross-sectional household survey design. Respondents provided detailed reports of sexual behavior over the past six months, the main prevention message they are currently hearing about AIDS, and their own ranking of the importance of prevention strategies. Condom use was the main AIDS prevention message that respondents reported hearing, followed by getting tested. These were also what respondents themselves considered most important, followed closely by faithfulness. Abstinence was the lowest ranked strategy, but a higher ranking for this prevention strategy was the only one consistently associated with less risky behavior. A higher ranking for condoms was associated with higher levels of risk behavior, while the ranking of testing made no difference in any behavior. These results present challenges for AIDS prevention strategies that rely primarily on promoting condoms and testing. HIV prevention programs need to assess their impact on behavior.

Multiple sexual partnerships among poor urban dwellers in Kampala, Uganda.

BACKGROUND: This study examined 2 issues of current importance for AIDS prevention in Uganda: the frequency of multiple sexual partnerships and whether optimistic perceptions about the severity of AIDS are associated with riskier sexual behavior. METHODS: Four hundred five men and women aged 20-39 from 2 poor neighborhoods of Kampala were interviewed about their sexual behavior over the prior 6 months and about other partners during current relationships. They also completed a 7-item scale measuring perception of the severity of HIV/AIDS. RESULTS: About 21.2% of men and 2.9% of women reported ongoing concurrent partnerships; 28.8% and 6.8% reported more than 1 partner in the past 6 months. About 22.2% of men and 32.4% of women believed their partner had had other partners during the relationship. Overall, 56.1% of men and 57.0% of women reported potentially being involved in a multiple or concurrent partnership. Respondents rating AIDS as more severe were more likely to be monogamous. CONCLUSIONS: Multiple sexual partnerships may be more common in Uganda than generally supposed, and optimism about the severity of AIDS is associated with having multiple partners. These findings have important implications for HIV/AIDS epidemiology and prevention.

Social discrimination, concurrent sexual partnerships, and HIV risk among men who have sex with men in Shanghai, China.

We examined the potential mediating role of sex partner concurrency in explaining associations between experiences of homophobia and financial hardship and HIV risk behavior among a sample of 477 men who have sex with men (MSM) recruited in Shanghai, China from 2004 to 2005. We found significant positive direct associations of experiences of homophobia and financial hardship with having unprotected anal sex with men. These associations were not mediated by male partner concurrency. However, male partner concurrency had a direct effect on having unprotected anal sex with men. Male and female partner concurrency did not mediate the significant association between experiences of homophobia and having unprotected anal/vaginal sex with both men and women, but was positively associated with having unprotected anal/vaginal sex with both men and women. These results suggest that homophobia, financial hardship, and sex partner concurrency should be addressed to help reduce sexual risk for HIV among MSM in China.

Family structure and adolescent sexual behavior in a poor area of São Paulo, Brazil.

PURPOSE: In Brazil, as elsewhere, behavior during adolescence can place young people at risk for serious medical and social problems, including sexually transmitted infections, unintended pregnancy, drugs, crime, and violence. Few studies internationally have examined the influence of family structure on risk behavior among low-income youths. METHODS: This cross-sectional study included 296 young people in one of the poorest areas of São Paulo who were recruited through a vocational school and completed an anonymous, self-administered questionnaire. We examined associations between family structure and various risk behaviors. RESULTS: Ages ranged from 13-24 years (82%, 15-18); 67% were of Afro-Brazilian ancestry, and 56% were female. Median family monthly income was about US$200. Less than half lived with both parents, and 14% lived with neither parent. Rates of many risk behaviors, including involvement in crime and violence, drug and alcohol use, and sexual risk, were lowest among those living with both parents, higher among those living with one parent, and highest among those living with neither parent. For example, 26% of females living with both parents, 37% with one parent, and 71% with neither parent were sexually active (p = .003). Family structure and a personal or parental history of drug or alcohol problems were significant independent predictors of sexual activity. CONCLUSIONS: The presence of both parents is an important protective factor for Brazilian youth vulnerable to multiple risks. Prevention programs should explore ways to support parents to be present and involved in the lives of their adolescent children.

Developing an AIDS prevention intervention for incarcerated male adolescents in Brazil.

The objective of this study was to investigate knowledge, attitudes, and practices regarding AIDS among incarcerated male adolescents in Brazil and to develop an AIDS prevention intervention for this population. A questionnaire administered to 275 boys in São Paulo covered demographic and social characteristics, drugs, and HIV risk perception and behavior. Subsequently, we collected qualitative data on the development and implementation of a prevention program. Ninety-eight percent of adolescents were sexually experienced, most initiating by age 13; 22% were fathers. Injection drug use was reported by 5.5%, 12% had exchanged sex for money, 35% had more than 15 partners and 8% had homosexual experience. Although 72% had used condoms, only 9% used them consistently, and only 35% used one in their last intercourse before incarceration. Predictors of condom use included carrying condoms and endorsing the statement "I would use condoms with my girlfriend." Many said their lives include other risks more important than AIDS, such as survival in the crime scene. Initial efforts at prevention based on commonly used approaches of providing information to guide future rational decisions generated limited participation. However, when we worked with them to develop interventions based on their interests and needs, using modalities such as music, hip-hop arts, graffiti, and helping them to create an AIDS prevention compact disk, they responded with enthusiasm. These incarcerated adolescents are at extremely high social risk and report high levels of risk behavior for HIV infection. Interventions for these youth were better received when developed in collaboration with them and based on their beliefs, aspirations, and culture. The intervention that resulted went beyond AIDS to include issues such as violence, drugs, sexuality and human rights.

Unprotected sex and associated risk factors among young Asian and Pacific Islander men who have sex with men.

Young Asian and Pacific Islander (API) men who have sex with men (MSM) are at high risk for HIV, but little is known about their risk behavior. We examined the patterns and predictors of unprotected anal intercourse among 253 API MSM aged 15-25 recruited from gay-identified venues in Seattle, Washington, and San Diego, California, from May to August 1999. Overall, 33% reported unprotected anal intercourse in the past 3 months. Multivariate analyses found that unprotected anal intercourse was associated with self-identifying as gay or bisexual, having multiple sexual partners, having sex with a steady partner, having been tested for HIV, and not perceiving peer norms supportive of safer sex. Young API MSM engage in unprotected sex at high rates. There is an urgent need to help these men reduce sexual risk behavior by implementing HIV prevention programs that address the issue of self-accepting sexual orientation, the potential problem with using HIV testing as a risk reduction strategy, the possible risk of HIV transmission in steady relationships and multiple sexual partnerships, and the importance of establishing safer sex practices as peer norms.