Longitudinal determinants of anal intercourse among women with, and without HIV in the United States.

BACKGROUND: Anal intercourse (AI) is not uncommon among U.S. women and, when condomless, confers a far greater likelihood of HIV transmission than condomless vaginal intercourse. We aim to identify determinants preceding AI, among women with, and women without HIV. METHODS: 3708 women living with (73%), and without HIV (27%) participating in the Women's Interagency HIV Study provided sexual behavior and other data at 6-monthly visits over a median of 9 years (1994-2014). We used generalized estimating equation models to examine sociodemographic, structural and behavioral determinants reported in the visit preceding (1) AI, and (2) condomless AI. RESULTS: AI was reported at least once over follow-up by 31% of women without, and 21% with HIV. AI was commonly condomless; reported at 76% and 51% of visits among women living without HIV, and with HIV, respectively. Women reporting AI were more likely to be younger (continuous variable, adjusted odds ratio (aOR) = 0.97, 95% confidence interval (CI):0.96-0.98), Hispanic (aOR = 1.88, CI:1.47-2.41) or White (aOR = 1.62, CI:1.15-2.30) compared to Black, and have at least high school education (aOR = 1.33, CI:1.08-1.65). AI was more likely following the reporting of either (aOR = 1.35, CI:1.10-1.62), or both (aOR = 1.77, CI:1.13-2.82) physical and sexual violence, excessive drinking (aOR = 1.27, CI:1.05-1.66) or any drug use (aOR = 1.34, CI:1.09-1.66), multiple male partners (aOR = 2.64, CI:2.23-3.11), exchange sex (aOR = 3.45, CI:2.53-4.71), one or more female sex partners (aOR = 1.32, CI:1.01-1.75), condomless vaginal intercourse (aOR = 1.80, CI:1.53-2.09), and high depressive symptoms (aOR = 1.23, CI:1.08-1.39). CONCLUSION: AI disproportionally follows periods of violence victimization, substance use, multiple sex partners and depression. Better prevention messaging and biomedical interventions that reduce acquisition or transmission risk are needed, but when AI occurs in the context of violence against women, as our findings indicate, focusing on gender-based violence reduction and immediate treatment to reduce HIV transmission risk is important.

Patterns and Trajectories of Anal Intercourse Practice Over the Life Course Among US Women at Risk of HIV.

INTRODUCTION: Condomless anal intercourse (AI) confers a far greater likelihood of HIV transmission than condomless vaginal intercourse (VI). However, little is known about AI practice over the life course of women, to what extent AI practice is condom-protected, and whether it is associated with other HIV risk behaviors. We aim to describe longitudinal AI practice among HIV-seronegative women and to identify subgroups with distinct trajectories of AI practice. METHODS: Using data from the Women's Interagency HIV Study, an observational cohort of US women with or at risk for HIV, we described AI practice among HIV-seronegative participants. Group-based trajectory modeling was used to identify distinct AI trajectories. We used multinomial regression to examine associations between baseline characteristics and trajectory group membership. RESULTS: A third of the 1,085 women in our sample reported any AI over follow-up (median follow-up = 14 years). AI decreased more sharply with age compared to VI. Consistent condom use during AI was low: twice the proportion of women never reported using condoms consistently during AI compared to during VI. 5 trajectory groups were identified: AI & VI persistors (N = 75) practiced AI and VI consistently over follow-up (AI & VI desistors (N = 169) tended to practice AI and VI when young only, while VI persistors (N = 549), VI desistors (N = 167), and AI & VI inactives (N = 125) reported varying levels of VI practice, but little AI. AI & VI persistors reported multiple male partners and exchange sex at more visits than other groups. Women who identified as bisexual/lesbian (vs heterosexual), who had ever experienced physical and sexual violence (vs never), and/or who reported above the median number of lifetime male sex partners (vs median or below) had approximately twice the odds of being AI & VI persistors than being VI persistors. CONCLUSIONS: We identified a small subgroup of women who practice AI and report inconsistent condom use along with other risk behaviors throughout the life course; they may therefore particularly benefit from ongoing access to HIV prevention services including pre-exposure prophylaxis. Owen BN, Baggaley RF, Maheu-Giroux M, et al. Patterns and Trajectories of Anal Intercourse Practice Over the Life Course Among US Women at Risk of HIV. J Sex Med 2020;17:1629-1642.

What Proportion of Female Sex Workers Practise anal Intercourse and How Frequently? A Systematic Review and Meta-analysis.

HIV is more efficiently acquired during receptive anal intercourse (AI) compared to vaginal intercourse (VI) and may contribute substantially to female sex workers' (FSW) high HIV burden. We aim to determine how common and frequent AI is among FSW globally. We searched PubMed, Embase and PsycINFO for studies reporting the proportion of FSW practising AI (prevalence) and/or the number of AI acts (frequency) worldwide from 01/1980 to 10/2018. We assessed the influence of participant and study characteristics on AI prevalence (e.g. continent, study year and interview method) through sub-group analysis. Of 15,830 identified studies, 131 were included. Nearly all (N = 128) reported AI prevalence and few frequency (N = 13), over various recall periods. Most studies used face-to-face interviews (N = 111). Pooled prevalences varied little by recall period (lifetime: 15.7% 95%CI 12.2-19.3%, N = 30, I2 = 99%; past month: 16.2% 95%CI 10.8-21.6%, N = 18, I2 = 99%). The pooled proportion of FSW reporting < 100% condom use tended to be non-significantly higher during AI compared to during VI (e.g. any unprotected VI: 19.1% 95%CI 1.7-36.4, N = 5 and any unprotected AI: 46.4% 95%CI 9.1-83.6, N = 5 in the past week). Across all study participants, between 2.4 and 15.9% (N = 6) of all intercourse acts (AI and VI) were anal. Neither AI prevalence nor frequency varied substantially by any participant or study characteristics. Although varied, AI among FSW is generally common, inconsistently protected with condoms and practiced sufficiently frequently to contribute substantially to HIV acquisition in this risk group. Interventions to address barriers to condom use are needed.