Coparenting and sexual partner concurrency among white, black, and Hispanic men in the United States.

BACKGROUND: Concurrent sexual partnerships (partnerships that overlap in time) increase the spread of infection through a network. Different patterns of concurrent partnerships may be associated with varying sexually transmitted infection (STI) risk depending on the partnership type (primary vs. nonprimary) and the likelihood of condom use with each concurrent partner. We sought to evaluate coparenting concurrency, overlapping partnerships in which at least 1 concurrent partner is a coparent with the respondent, which may promote the spread of STIs. METHODS: We examined sexual partnership dates and fertility history of 4928 male respondents in the 2002 National Survey of Family Growth. We calculated coparenting concurrency prevalence and examined correlates using Poisson regression. RESULTS: Among men with ≤ 1 pair of concurrent partnerships, 18% involved a coparent. 33% of black men involved in coparenting concurrency were <25 years, compared to 23% of Hispanics and 6% of whites. Young black men (age, 15-24 years) were more likely to engage in coparenting concurrency than white men, adjusting for sociodemographic characteristics, sexual and other high-risk behaviors, and relationship quality. Compared to white men aged 15 to 24 years, black and Hispanic men were 4.60 (95% confidence interval: 1.10, 19.25) and 3.45 (95% confidence interval: 0.64, 18.43) times as likely to engage in coparenting concurrency. CONCLUSION: Almost 1 in 5 men engaging in concurrent sexual partnerships in the past year was a coparent with at least one of the concurrent partners. Understanding the context in which different types of concurrency occur will provide a foundation on which to develop interventions to prevent STIs.

Predictors of adherent use of diaphragms and microbicide gel in a four-arm, randomized pilot study among female sex workers in Madagascar.

BACKGROUND: Participants' protocol adherence may influence assessments of the effectiveness of new female-controlled methods for sexually transmitted infection prevention. METHODS: In 2005 we conducted a randomized pilot study among female sex workers (FSWs) in Madagascar in preparation for sexually transmitted infection prevention trial of diaphragms and a vaginal microbicide. Participants (n = 192) were randomized into 4 arms: diaphragm plus microbicide (Acidform), diaphragm plus placebo gel hydroxyethyl cellulose (HEC), Acidform alone, or HEC alone. FSWs were seen weekly for 4 weeks. Using multivariable regression with generalized estimating equations, we assessed predictors of adherent product use during all sex acts in the last week. We collapsed the gel-diaphragm arms together and the gel-only arms together for this analysis. RESULTS: Between 43% and 67% of gel-diaphragm users (varying by visit) reported using study products during all sex acts in the last week, compared with 20% to 45% of gel-only users. Adherence increased with follow-up [visit 4 vs. visit 1 risk ratio (RR) for gel-diaphragm users: 1.55, P <0.01; for gel-only users, RR: 1.58, P = 0.01]. Gel-diaphragm users whose casual partners were never aware of products (RR: 2.02, P = 0.03) and who had experienced partner violence after requesting condom use (RR: 1.45, P <0.01) were more adherent. Gel-only users reporting lower sexual frequency (1-9 weekly acts vs. >or=19 acts, RR: 1.98, P <0.01) and no sex with primary partners in the past week (RR: 1.54, P = 0.02) were more adherent. CONCLUSIONS: Gel-diaphragm users had better adherence than gel-only users, and predictors of adherence differed between groups. Addressing modifiable factors during counseling sessions may improve adherence.

A formal decision analysis identifies an optimal treatment strategy in a resource-poor setting.

OBJECTIVE: Decision analytic techniques use formal specifications of utility for the four fundamental decision events: true positives, false positives, true negatives, and false negatives. An optimal policy is the one with the lowest expected net cost. In this paper, decision analytic techniques for treatment selection based on patient characteristics are applied to a resource-poor setting. STUDY DESIGN AND SETTING: A cohort of 986 female sex workers in Antananarivo and Tamatave, Madagascar were tested for cervical infection at baseline and again 2 months later after presumptive treatment for gonorrhea and chlamydia. RESULTS: Three equivalent approaches to identify the optimal policy based on patient characteristic subgroups are demonstrated. Two of them require exhaustive searches of all possible alternatives. The third identifies the optimal policy as an analytic expression that compares a decision function with a threshold and leads to a closed-form solution. With this approach, the optimal policy can be expressed in four equivalent forms using basic epidemiological measures: likelihood ratio, predicted probability of disease, logistic regression parameters, and total risk score. CONCLUSION: These methods illustrate the application of a decision analysis to clinical epidemiology. Management of cervical infection for sex workers in Madagascar occurs under severe resource constraints, and therefore requires an algorithm for identifying optimal treatment regimens.

Vaginal microbicide and diaphragm use for sexually transmitted infection prevention: a randomized acceptability and feasibility study among high-risk women in Madagascar.

BACKGROUND: In preparation for a randomized controlled trial (RCT), we conducted a pilot RCT of the acceptability and feasibility of diaphragms and candidate vaginal microbicide for sexually transmitted infection prevention among high-risk women in Madagascar. METHODS: Participants were randomized to four arms: (1) diaphragm (worn continuously) with Acidform applied in the dome; (2) diaphragm (worn continuously) with placebo gel hydroxyethylcellulose (HEC) in the dome; (3) HEC applied intravaginally before sex; (4) Acidform applied intravaginally before sex. All women were given condoms. Participants were followed weekly for 4 weeks. We fit unadjusted negative binomial regression models with robust variance estimators to generate the proportion of sex acts with casual partners where condoms and experimental study products were used. RESULTS: Retention was 98% among 192 participants. Experimental product use with casual partners was high, reported in 85%, 91%, 74%, and 81% of sex acts for women in the Acidform-diaphragm, HEC-diaphragm, HEC-alone, and Acidform-alone arms, respectively. However, the proportion reporting product use during 100% of acts with casual partners over the full follow-up period was much lower: 28% to 29% in the gel-diaphragm arms and 6% to 10% in gel-alone arms. Women used condoms in 62% to 67% of sex acts with casual partners, depending on the randomization arm. Participants found diaphragms easy to insert (97%) and remove (96%). Acidform users (with or without the diaphragm) reported more genitourinary symptoms than HEC users (14% vs. 5% of visits). CONCLUSIONS: A sexually transmitted infection prevention RCT of candidate microbicide with and without the diaphragm appears acceptable and feasible in this population.

Men's circumcision status and women's risk of HIV acquisition in Zimbabwe and Uganda.

OBJECTIVE: To assess whether male circumcision of the primary sex partner is associated with women's risk of HIV. DESIGN: Data were analyzed from 4417 Ugandan and Zimbabwean women participating in a prospective study of hormonal contraception and HIV acquisition. Most were recruited from family planning clinics; some in Uganda were referred from higher-risk settings such as sexually transmitted disease clinics. METHODS: Using Cox proportional hazards models, time to HIV acquisition was compared for women with circumcised or uncircumcised primary partners. Possible misclassification of male circumcision was assessed using sensitivity analysis. RESULTS: At baseline, 74% reported uncircumcised primary partners, 22% had circumcised partners and 4% had partners of unknown circumcision status. Median follow-up was 23 months, during which 210 women acquired HIV (167, 34, and 9 women whose primary partners were uncircumcised, circumcised, or of unknown circumcision status, respectively). Although unadjusted analyses indicated that women with circumcised partners had lower HIV risk than those with uncircumcised partners, the protective effect disappeared after adjustment for other risk factors [hazard ratio (HR), 1.03; 95% confidence interval (CI), 0.69-1.53]. Subgroup analyses suggested a non-significant protective effect of male circumcision on HIV acquisition among Ugandan women referred from higher-risk settings: adjusted HR 0.16 (95% CI, 0.02-1.25) but little effect in Ugandans (HR, 1.33; 95% CI, 0.72-2.47) or Zimbabweans (HR, 1.12; 95% CI, 0.65-1.91) from family planning clinics. CONCLUSIONS: After adjustment, male circumcision was not significantly associated with women's HIV risk. The potential protection offered by male circumcision for women recruited from high-risk settings warrants further investigation.

Unprotected sex following HIV testing among women in Uganda and Zimbabwe: short- and long-term comparisons with pre-test behaviour.

BACKGROUND: Despite widespread condom promotion for HIV prevention, prospective measurement of condom use before and after HIV testing is infrequent. METHODS: We analysed data from a prospective study of hormonal contraception and HIV acquisition among Zimbabwean and Ugandan women (1999-2004), in which HIV testing and counselling were performed approximately every 3 months. We used zero-inflated negative binomial (ZINB) models to examine the number and proportion of unprotected sex acts, comparing behaviour reported 2-6 months before HIV testing with behaviour reported both 2-6 months (short-term analysis) and 12-16 months (long-term analysis) after HIV testing. RESULTS: Short- and long-term analyses were similar, so we present only long-term findings from 151 HIV-infected and 650 uninfected participants. The proportion of HIV-infected women reporting any unprotected acts in a typical month declined from 74% (pre-infection behaviour) to 56% (12-16 months after HIV diagnosis). In multivariable models, HIV-infected women were twice as likely to report that all sex acts were protected by condoms after diagnosis compared with beforehand [adjusted odds ratio (aOR): 1.99, 95% confidence interval (CI): 1.12-3.53]; uninfected women were somewhat less likely to report that all acts were protected (aOR: 0.82, 95% CI: 0.64-1.04). HIV-infected women also reduced their number of unprotected acts by 38% (95% CI: -16 to -55%). However, their proportion of unprotected acts changed little (7% reduction, 95% CI: -18 to + 6%). Uninfected women reported little change in number or proportion of unprotected acts over the same time period. CONCLUSIONS: HIV-infected women reduced the number, but not the proportion, of unprotected acts. HIV-negative women did not increase condom use after testing and counselling, but neither did they decrease condom use, suggesting that testing negative was not interpreted as endorsement of risky behaviour.

Socio-demographic characteristics associated with HIV and syphilis seroreactivity among pregnant women in Blantyre, Malawi, 2000-2004.

OBJECTIVES: We aimed to evaluate socio-demographic factors associated with HIV and syphilis seroreactivity in pregnant Malawians presenting for antenatal care in late third trimester of pregnancy. METHODS: Between December 2000 and March 2004 at Queen Elizabeth Central Hospital Blantyre, Malawi, we collected cross-sectional clinical and socioeconomic data from consenting women. HIV-1 status was determined using rapid HIV antibody tests and syphilis seroreactivity was determined using Rapid Plasma Reagin (RPR) and confirmed with Treponema pallidum hemagglutination assay (TPHA). RESULTS: Of 3,824 women screened for HIV, 1156 (30%) were HIV seropositive and 198 (5%) were RPR and TPHA seroreactive. In the multivariate analysis, HIV infection was positively associated with elevated socio-economic status, being formerly married, and age, but not with education level. HIV prevalence was lower in women of Yao ethnicity than in other women (OR: 0.78, 95%CI: 0.64-0.95). Increased maternal education was negatively associated with syphilis seroreactivity. CONCLUSIONS: The seroprevalence of HIV and syphilis among women attending the antenatal ward in Blantyre remains unacceptably high. Demographic correlates of HIV and syphilis infections were different. Our results demonstrate the need for better strategies to prevent HIV and syphilis in women and calls for optimizing antenatal syphilis screening and treatment in Malawi.

Male circumcision and women's risk of incident chlamydial, gonococcal, and trichomonal infections.

BACKGROUND: Male circumcision (MC) decreases the risk of human immunodeficiency virus (HIV) acquisition in men. We explored associations between MC of the primary sex partner and women's risk of acquisition of chlamydial (Ct), gonococcal (GC), or trichomonal (Tv) infections. METHODS: We analyzed data from a prospective study on hormonal contraception and incident human immunodeficiency virus/sexually transmitted infection (STI) among women from Uganda, Zimbabwe, and Thailand. At enrollment and each follow-up visit, we collected endocervical swabs for polymerase chain reaction identification of Ct and GC; Tv was diagnosed by wet mount. Using Cox proportional hazards models, we compared time to STI acquisition for women according to their partner's MC status. RESULTS: Among 5925 women (2180 from Uganda, 2228 from Zimbabwe, and 1517 from Thailand), 18.6% reported a circumcised primary partner at baseline, 70.8% reported an uncircumcised partner, and 9.7% did not know their partner's circumcision status. During follow-up, 408, 305, and 362 participants had a first incident Ct, GC, or Tv infection, respectively. In multivariate analysis, after controlling for contraceptive method, age, age at coital debut, and country, the adjusted hazard ratio (HR) comparing women with circumcised partners with those with uncircumcised partners for Ct was 1.25 [95% confidence interval (CI) 0.96-1.63]; for GC, adjusted HR 0.99 (95% CI 0.74-1.31); for Tv, adjusted HR 1.05 (95% CI 0.80-1.36), and for the 3 STIs combined, adjusted HR 1.02 (95% CI 0.85-1.21). CONCLUSIONS: MC was not associated with women's risk of acquisition of Ct, GC, or Tv infection in this cohort.

Evidence-based planning of a randomized controlled trial on diaphragm use for prevention of sexually transmitted infections.

OBJECTIVES: We conducted formative research to evaluate the acceptability and feasibility of continuous diaphragm use among low-income women highly exposed to sexually transmitted infections (STIs) in Madagascar. GOAL: To identify potential obstacles to researching the effectiveness of diaphragm use for STI prevention in a randomized controlled trial. STUDY DESIGN: Mixed methods to collect complex information. In a quantitative pilot study, women were asked to use diaphragms continuously (removing once daily for cleaning) for 8 weeks and promote consistent male condom use; they were interviewed and examined clinically during follow-up. Focus group discussions (FGDs) were conducted pre-/postpilot study. Audiotaped FGDs were transcribed, translated, coded, and analyzed. RESULTS: Ninety-three women participated in prepilot FGDs, 91 in the pilot study, and 82 in postpilot FGDs. Diaphragm use was acceptable and feasible, but participants reported lower condom use in FGDs than during interviews. Most participants reported in interviews that they used their diaphragms continuously, but FGDs revealed that extensive intravaginal hygiene practices may impede effective continuous diaphragm use. Despite counseling by study staff, FGDs revealed that participants believed the diaphragm provided effective protection against STIs and pregnancy. CONCLUSIONS: Mixed methods formative research generated information that the prospective pilot study alone could not provide and revealed contradictory findings. Results have methodological and ethical implications that affect trial design including provision of free hormonal contraceptives, and additional instructions for vaginal hygiene to avoid displacing the diaphragm. Mixed methods formative research should be encouraged to promote evidence-based study design and implementation.

Self-reported condom use is associated with reduced risk of chlamydia, gonorrhea, and trichomoniasis.

OBJECTIVES: To evaluate the association between self-reported condom use and prevalent and incident chlamydia, gonorrhea, and trichomoniasis. STUDY DESIGN: Prospective study of 414 males attending a sexually transmitted infection (STI) clinic in Jamaica. Condom use and STI status were assessed at enrollment and at 4 follow-up visits. RESULTS: The analyses on condom use and prevalent STI included data from 414 men, while those on incident STI were based on 1111 intervals from 355 men. We diagnosed prevalent STI (chlamydia, gonorrhea, and/or trichomoniasis) in 54.6% (n = 226) of the participants at enrollment. About 14% (n = 51) of participants had at least 1 of the study STIs during follow-up. Follow-up visits in which participants reported consistent condom use (100% of acts) for the past 7 days had less incident STI (adjusted OR, 0.4; 95% CI, 0.2-0.9) compared with visits where no condom use was reported. Self-reported condom use was more closely correlated with incident than prevalent STI. For example, the adjusted OR for prevalent infection for participants reporting consistent versus no condom use in past 7 days was 0.7 (95% CI, 0.4-1.2). Classifications based on the number of unprotected acts yielded findings similar to those based on the proportion of acts protected. CONCLUSIONS: Consistent condom use was associated with reduced risk of incident urethral STI. Research on condom effectiveness should focus on incident STI outcomes, where the temporal relationship between condom use and infection is clearer.

Prostate-specific antigen to ascertain reliability of self-reported coital exposure to semen.

OBJECTIVE: The objective of this study was to assess the validity of women's reports of recent unprotected sex by testing for prostate-specific antigen (PSA) in vaginal samples. STUDY DESIGN: The authors conducted prospective research with 332 female sex workers attending 2 public dispensaries in Madagascar. RESULTS: Among women who reported no sex or protected sex only within the past 48 hours, 21% and 39%, respectively, tested positive for PSA. Among those testing positive for PSA, no differences in PSA concentrations were found among those reporting no sex, protected sex only, or at least one unprotected act. CONCLUSIONS: The substantial disagreement between self-reports and measurement of a biologic marker of semen exposure in vaginal specimens substantiates that self-reports of sexual behavior cannot be assumed to be valid measures. Future sexually transmitted infection/HIV and pregnancy prevention studies should confirm the validity of self-reports or use end points that do not rely on self-reported data.

Socio-demographic and behavioural factors associated with high incidence of sexually transmitted infections in female sex workers in Madagascar following presumptive therapy.

BACKGROUND: Too little is known about the many women who generate income in Madagascar by trading sex. METHODS: Clinical and laboratory exams were offered to 493 non-care seeking female sex workers (SWs) in Antananarivo and 493 in Tamatave. SWs were recruited by peers in their community; they were interviewed, counselled and treated for sexually transmitted infections (STIs) at recruitment and re-evaluated 2 months later. RESULTS: One hundred and eighty six (38%) of the SWs in Antananarivo and 113 (23%) in Tamatave did not complete primary school (P < 0.0001). The incidence rates per person per month in Antananarivo and Tamatave, respectively, were 0.09 and 0.08 for gonorrhoea; 0.05 and 0.03 for chlamydia; 0.24 and 0.15 for trichomoniasis; 0.07 and 0.05 for syphilis. At follow-up, consistent condom use with clients was reported by 56 (12%) SWs in Antananarivo and 137 (29%) in Tamatave (P < 0.0001); 320 (70%) SWs in Antananarivo and 11 (2%) in Tamatave reported sex with a non-paying partner in the past month (P < 0.0001). In Antananarivo, 422 (92%) of the SWs thought they were at no or low risk of having an STI compared to 100 (21%) in Tamatave (P = 0.02). At follow-up, 277 (61%) SWs reported no birth control for their last sex act in Antananarivo, compared to 26 (5%) in Tamatave (P < 0.0001). Socio-demographic and behavioural risk factors for incident gonorrhoea, chlamydia and trichomoniasis varied by city. CONCLUSIONS: Strategies to address the needs of women who trade sex should include educational and economic opportunities; should tackle male partners of SWs; promote dual protection against unintended pregnancy and STIs, while taking into account local socio-demographic and behavioural characteristics.

Genetic typing of the porin protein of Neisseria gonorrhoeae from clinical noncultured samples for strain characterization and identification of mixed gonococcal infections.

Molecular methods that characterize the Neisseria gonorrhoeae porin protein Por are needed to study gonococcal pathogenesis in the natural host and to classify strains from direct clinical samples used with nucleic acid amplification-based tests. We have defined the capabilities of por variable region (VR) typing and determined suitable conditions to apply the method to direct clinical specimens. Nested PCR from spiked urine samples detected 1 to 10 copies of template DNA; freezing spiked whole urine greatly reduced the ability to amplify porB. In a laboratory model of mixed gonococcal infections, the por type of one strain could be determined in the presence of a 100-fold excess of another. por VR typing was used to examine clinical samples from women enrolled in studies conducted in Baltimore, Md., and Madagascar. por type was determined from 100% of paired cervical swab and wick samples from 20 culture-positive women from Baltimore; results for eight individuals (40%) suggested infection with more than one strain. In frozen urine samples from Madagascar, porB was amplified and typed from 60 of 126 samples from ligase chain reaction (LCR)-positive women and 3 samples from LCR-negative women. The por VR types of 13 samples (21%) suggested the presence of more than one gonococcal strain. Five por types, identified in >45% of women with typed samples, were common to both geographic areas. Molecular typing is an important adjunct to nucleic acid amplification-based diagnostics. Methods that utilize direct clinical samples and can identify mixed infections may contribute significantly to studies of host immunity, gonococcal epidemiology, and pathogenesis.

Vaginal discharge.

Preview A variety of genital pathogens, many of which are sexually transmitted, cause infections of the vagina and cervix. Discharge is often a prominent and telling symptom. Which infectious agents should be suspected when the discharge is accompanied by itching? Vulvar pain? Odor? Which laboratory tests are most helpful in making a diagnosis? The authors answer these and other questions in this overview of genital infections in women.

Participatory mapping of sex trade and enumeration of sex workers using capture-recapture methodology in Diego-Suarez, Madagascar.

BACKGROUND: Capture-recapture methodology has been employed to estimate the size of hidden or difficult-to-reach human populations such as sex workers, homeless persons, and intravenous drug users. This study took place in the context of efforts to improve the quality of curative and preventive services for sexually transmitted infections offered to sex workers in Diego-Suarez, Madagascar in partnership with sex workers. GOAL: The goal of this study was to better understand sex-trading practices, map out sex work sites, and estimate the size of a mobile sex-worker population in Diego-Suarez, Madagascar using methods that can be reproduced in other resource-poor settings. STUDY DESIGN: Forty sex workers were trained to function as field researchers. Key informants in designated neighborhoods were identified and interviewed. Basic maps of sex-trade sites were designed by hand. The number of sex workers in Diego-Suarez was estimated using capture-recapture methodology. An educational brochure was used to "capture" sex workers during a first phase, and "recapture" 2 weeks later. RESULTS: Most sex trade was street based and mobile. Capture-recapture methods estimated a total of 2684 sex workers (95% CI: 2588-2780) in Diego-Suarez, or approximately 12% of the 15- to 49-year-old female population in the city. CONCLUSION: Geographic mapping and capture-recapture proved to be low-cost and relatively easy to use techniques for counting a hard-to-reach population, such as female street-based sex workers. Sex workers can be capable fieldworkers, and their active participation in research concerning sex work should be considered whenever possible. A high proportion of women of reproductive age were found to engage in sex work, indicating that there is an urgent need to scale up sexually transmitted infection and HIV prevention activities targeting sex workers, their sexual partners, and the general population.

Evidence-based treatment guidelines for sexually transmitted infections developed with and for female sex workers.

BACKGROUND: Sex work is frequently one of the few options women in low-income countries have to generate income for themselves and their families. Treating and preventing sexually transmitted infections (STIs) among sex workers (SWs) is critical to protect the health of the women and their communities; it is also a cost-effective way to slow the spread of HIV. Outside occasional research settings however, SWs in low-income countries rarely have access to effective STI diagnosis. OBJECTIVES: To develop adequate, affordable, and acceptable STI control strategies for SWs. METHODS: In collaboration with SWs we evaluated STIs and associated demographic, behavioural, and clinical characteristics in SWs living in two cities in Madagascar. Two months post-treatment and counselling, incident STIs and associated factors were determined. Evidence-based STI management guidelines were developed with SW representatives. RESULTS: At baseline, two of 986 SWs were HIV+; 77.5% of the SWs in Antananarivo and 73.5% in Tamatave had at least one curable STI. Two months post-treatment, 64.9% of 458 SWs in Antananarivo and 57.4% of 481 women in Tamatave had at least one STI. The selected guidelines include speculum exams; syphilis treatment based on serologic screening; presumptive treatment for gonorrhoea, chlamydia, and trichomoniasis during initial visits, and individual risk-based treatment during 3-monthly follow-up visits. SWs were enthusiastic, productive partners. CONCLUSIONS: A major HIV epidemic can still be averted in Madagascar but effective STI control is needed nationwide. SWs and health professionals valued the participatory research and decision-making process. Similar approaches should be pursued in other resource-poor settings where sex work and STIs are common and appropriate STI diagnostics lacking.