Factors associated with reported modern contraceptive use among married men in Afghanistan.

BACKGROUND: Afghanistan has high maternal and infant mortality which is in part driven by high fertility and low modern contraceptive use. Using modern contraceptive methods can reduce maternal and infant mortality, however there are several barriers to modern contraceptive use in Afghanistan. Married men have the potential to hinder or facilitate their wives' contraceptive use. Internally displaced persons (IDP), a growing population in Afghanistan, are rarely included in reproductive health research. We explored whether married men's, including IDPs', gender-related attitudes and other factors were associated with reported modern contraceptive use to inform programming to meet reproductive health needs of married couples. METHODS: Cross-sectional study using data from 885 married men determined to have contraceptive need in seven Afghan provinces. We explored associations between sociodemographic factors, IDP status, wives' involvement in household decision-making and men's attitudes towards intimate partner violence (IPV) with reported modern contraceptive use using logistic regression analysis. RESULTS: Most men (78%) had ≥2 children, 60% reported any formal education, and 30% reported being IDPs. Only 38% of married men and 24% of IDPs with contraceptive need reported using modern contraception with their wives. Most (80% overall, 63% of IDPs) reported their wives' involvement in some/all household decisions, while 47% overall and 57% of IDPs reported IPV was justified in one or more listed circumstances. In bivariate analysis, men responding that IPV was not justified in any listed circumstance were more likely and IDPs less likely to report modern contraceptive use. In multivariable analysis, involvement by wives in household decision-making (AOR 2.57; 95% CI: 1.51, 4.37), owning a radio and/or television (AOR 1.69; 95% CI: 1.10, 2.59), having more children, age, and province of interview were independently associated with reported modern contraceptive use, while IDP status was not. CONCLUSIONS: Our findings reflect positive associations between wives' participation in household decisions and mass media exposure (television/radio ownership) with reported modern contraceptive use. Reproductive health initiatives engaging men to promote communication within couples and through mass media channels may further increase modern contraceptive use and advance Afghanistan's family planning goals. As fewer IDPs owned a radio/television, additional outreach methods should be tested for this group.

QUENTIN: reconstruction of disease transmissions from viral quasispecies genomic data.

Motivation: Genomic analysis has become one of the major tools for disease outbreak investigations. However, existing computational frameworks for inference of transmission history from viral genomic data often do not consider intra-host diversity of pathogens and heavily rely on additional epidemiological data, such as sampling times and exposure intervals. This impedes genomic analysis of outbreaks of highly mutable viruses associated with chronic infections, such as human immunodeficiency virus and hepatitis C virus, whose transmissions are often carried out through minor intra-host variants, while the additional epidemiological information often is either unavailable or has a limited use. Results: The proposed framework QUasispecies Evolution, Network-based Transmission INference (QUENTIN) addresses the above challenges by evolutionary analysis of intra-host viral populations sampled by deep sequencing and Bayesian inference using general properties of social networks relevant to infection dissemination. This method allows inference of transmission direction even without the supporting case-specific epidemiological information, identify transmission clusters and reconstruct transmission history. QUENTIN was validated on experimental and simulated data, and applied to investigate HCV transmission within a community of hosts with high-risk behavior. It is available at https://github.com/skumsp/QUENTIN. Contact: pskums@gsu.edu or alexz@cs.gsu.edu or rahul@sfsu.edu or yek0@cdc.gov. Supplementary information: Supplementary data are available at Bioinformatics online.

Prevalence and risk factors associated with STIs among women initiating contraceptive implants in Kingston, Jamaica.

BACKGROUND: There is limited information on rates of STIs in Jamaica due to syndromic management and limited aetiological surveillance. We examined the prevalence of Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Trichomonas vaginalis (TV) and characteristics associated with STIs among sexually active women who participated in a randomised trial of a progestin implant initiation in Jamaica (the Sino-Implant Study (SIS)). METHODS: SIS was a randomised trial conducted in Kingston, Jamaica, from 2012 to 2014 to evaluate whether initiation of the Sino-Implant (II) led to more unprotected sex among women ages 18-44 years. Data collected included self-reported demographic, sexual behaviour information; and vaginal swabs collected at baseline, 1-month and 3-month follow-up visits for a biomarker of recent semen exposure (prostate-specific antigen (PSA)) and for STIs. We examined associations between STIs and PSA, demographics, sexual behaviour and insertion of an implant, with a repeated-measures analysis using generalised estimating equations (SAS Institute, V.9.3). RESULTS: Remnant vaginal swabs from 254 of 414 study participants were tested for STIs. At baseline, 29% of participants tested for STIs (n=247) had laboratory-confirmed CT, 5% NG, 23% TV and 45% any STI. In a repeated-measures analysis adjusted for study arm (immediate vs delayed implant insertion), those with PSA detected did not have an increased prevalence of any STI (prevalence ratio (PR)=1.04 (95% CI 0.89 to 1.21)), whereas prevalence decreased for each 1-year increase in age (PR=0.98 (95% CI 0.97 to 0.99)). Immediate implant insertion was not associated with increases in any STI in subsequent visits (PR=1.09 (95% CI 0.94 to 1.27)). CONCLUSIONS: Although the prevalence of laboratory-confirmed STIs was high, the immediate initiation of a contraceptive implant was not associated with higher STI prevalence rates over 3 months. TRIAL REGISTRATION NUMBER: NCT01684358.

Measurement of Social Norms Affecting Modern Contraceptive Use: A Literature Review.

As a critical building block to developing social norms interventions to support healthy family planning and other reproductive health behaviors, we conducted a literature review to identify and evaluate social norm measures related to modern contraceptive use. Of 174 articles reviewed in full, only 17 studies met our criteria for inclusion. Across these articles, no single measure of norms was used in more than one study; failure to specify the boundaries of who was engaging in and influencing the behaviors of interest contributed to the variation. Most of the studies relied on cross-sectional data, only included condom use as their contraceptive use outcome, used individual- or interpersonal-level behavior change theories rather than social-level theories, and assumed a reference group, all of which limit the quality of the norm measures. We make several recommendations to bring greater consistency and comparability to social norm measures.

Sexual Relationship Power and Semen Exposure Among Female Patients at a Sexually Transmitted Infection Clinic in Kingston, Jamaica.

Women's power in sexual relationships is thought to be an important predictor of condom use. However, research on correlates of condom use often relies on participant reporting of behavior, which has questionable validity. We evaluated the association between scores from the modified Sexual Relationship Power Scale (SRPS-M) and biological detection of semen exposure in a prospective study of adult women attending a sexually transmitted infection clinic in Kingston, Jamaica with cervicitis or abnormal vaginal discharge in 2010-2011. At enrollment, women were counseled to avoid sex while on treatment and were asked to return in 6 days for a follow-up visit. At both study visits, women were administered a questionnaire and had vaginal swabs collected to test for prostate-specific antigen (PSA), a biological marker of recent semen exposure. We found no significant association at enrollment or follow-up between SRPS-M scores and semen exposure, as measured with either self-reported data or PSA positivity. Semen biomarkers could be used to develop and validate new scales on relationship power and self-efficacy related to condom use.

On the road again: concurrency and condom use among Uganda truck drivers.

Long-distance truck drivers have been shown to be a critical population in the spread of HIV in Africa. In 2009, surveys with 385 Ugandan long-distance truck drivers measured concurrency point prevalence with two methods; it ranged from 37.4% (calendar-method) to 50.1% (direct question). The majority (84%) of relationships reported were long-term resulting in a long duration of overlap (average of 58 months) across concurrent partnerships. Only 7% of these men reported using any condoms with their spouses during the past month. Among all non-spousal relationships, duration of relationship was the factor most strongly associated with engaging in unprotected sex in the past month in a multivariable analyses controlling for partner and relationship characteristics. Innovative intervention programs for these men and their partners are needed that address the realities of truck drivers' lifestyles.

Assortativity coefficient-based estimation of population patterns of sexual mixing when cluster size is informative.

OBJECTIVES: Population sexual mixing patterns can be quantified using Newman's assortativity coefficient (r). Suggested methods for estimating the SE for r may lead to inappropriate statistical conclusions in situations where intracluster correlation is ignored and/or when cluster size is predictive of the response. We describe a computer-intensive, but highly accessible, within-cluster resampling approach for providing a valid large-sample estimated SE for r and an associated 95% CI. METHODS: We introduce needed statistical notation and describe the within-cluster resampling approach. Sexual network data and a simulation study were employed to compare within-cluster resampling with standard methods when cluster size is informative. RESULTS: For the analysis of network data when cluster size is informative, the simulation study demonstrates that within-cluster resampling produces valid statistical inferences about Newman's assortativity coefficient, a popular statistic used to quantify the strength of mixing patterns. In contrast, commonly used methods are biased with attendant extremely poor CI coverage. Within-cluster resampling is recommended when cluster size is informative and/or when there is within-cluster response correlation. CONCLUSIONS: Within-cluster resampling is recommended for providing valid statistical inferences when applying Newman's assortativity coefficient r to network data.

Exploring discordance between biologic and self-reported measures of semen exposure: a qualitative study among female patients attending an STI clinic in Jamaica.

We explored the use of qualitative interviews to discuss discrepancies between two sources of information on unprotected sex: biomarker results and self-reported survey data. The study context was a randomized trial in Kingston, Jamaica examining the effect of STI counseling messages on recent sexual behavior using prostate-specific antigen (PSA) as the primary study outcome. Twenty women were interviewed. Eleven participants were selected because they tested positive for PSA indicating recent semen exposure, yet reported no unprotected sex in a quantitative survey ("discordant"): 5 reported abstinence and 6 reported condom use. Nine participants who also tested positive for PSA but reported unprotected sex in the survey were interviewed for comparison ("concordant"). Qualitative interviews with 6 of the 11 discordant participants provided possible explanations for their PSA test results, and 5 of those were prompted by direct discussion of those results. Rapid PSA testing combined with qualitative interviews provides a novel tool for investigating and complementing self-reported sexual behavior.

Men's social networks, social norms, & family planning in Benin.

To address low family planning (FP) use and high unmet need in West Africa, attention has been paid to addressing FP-related social networks and norms. Most work focuses on women. This analysis assesses men's FP-related social networks and norms and their relation to FP use in Benin using data from baseline surveys from the Tékponon Jikuagou intervention. We descriptively analysed men's egocentric FP-related social networks and norms at the village level. Multivariable logistic regression analyses (N = 885) examined the relationship between FP-related social networks, norms, and men's current and future FP use. Twenty-three percent of men reported current modern contraception use and 47% reported intended future use. Most had few network members. While most believed it was acceptable to discuss FP, few talked with peers about FP and most did not discuss FP with their partner(s). In multivariable analyses, neither networks nor norms were significantly related to men's FP use. Men's networks being small and men rarely discussing FP indicate an opportunity for village-based approaches to engage men in FP discussions and spark FP dialogue within couples, between men, and within villages. Future work should further explore the relationship between men's social networks, norms, and FP use.

'We are ordinary men': MSM identity categories in Tbilisi, Georgia.

Men who have sex with men remain largely absent from the health statistics of many Eastern European countries. This relative dearth compared to other parts of the world may be attributed to the generally hidden nature of this population. The tendency to employ Western sexual identity labels, rather than locally meaningful categories of identity, may also make it difficult to identify men who have sex with other men. In a pilot study of HIV risk in Tbilisi (Georgia), we used a suite of qualitative techniques - focus groups, individual semi-structured interviews and pile-sort exercises - to probe the opinions, knowledge and experiences of 65 Georgian men. We identified locally meaningful men-who-have-sex-with-men types, demonstrating a complex intersectionality of sexual preference, socio-economic status, behaviour and geography. Positioning within these types appeared to impact a man's exposure to the social stigma of homosexuality; the sexual, physical and mental health risks that he faced; and his access to treatment and counselling. Our results suggest the use of imported identity categories limits researchers' ability to identify men who have sex with other men in Georgia and that further research aimed at elucidating locally meaningful categories is needed - research likely to lead to more-effective group interventions and facilitate a better understanding of holistic individual health needs.

Factors Associated With Delayed Contraceptive Implant Removal in Ethiopia.

BACKGROUND: In 2009, the Government of Ethiopia initiated the implant scale-up initiative, which expanded contraceptive access by training health extension workers (HEWs) to insert single-rod etonogestrel contraceptive implants (Implanon) at rural health posts. Removals were provided by referrals to higher levels of the health system. However, little was known about whether women were getting their implants removed at the recommended 3-year postinsertion date or what barriers they faced to removal. METHODS: Between June and July 2016, 1,860 Ethiopian women, who had a 1-rod etonogestrel implant inserted by either an HEW or another health care provider between 3 and 6 years prior, were surveyed. We describe the characteristics of the sample and use multivariable logistic regression to predict factors associated with keeping implants inserted beyond 3 years. RESULTS: Women who had received their implants from HEWs were significantly more likely to report keeping them inserted for more than 3 years (adjusted odds ratio=2.50; 95% confidence interval=1.19, 5.24), compared with those who got their implant from another health care provider. Women who reported distance to the facility or transportation as a barrier were also significantly more likely to keep their implant for more than 3 years. Married and educated women were less likely to keep their implants for an extended duration. Among women who had their implant for 3 years or less, women who had had it inserted by an HEW were significantly more likely to report that the provider was unable or refused to provide removal as a barrier. DISCUSSION: Efforts to expand lower level and community-based access to contraceptive implants that do not ensure reliable access to removals at the same level as insertions may lead to women using implants beyond the recommended duration.

Effects of a hepatitis C virus educational intervention or a motivational intervention on alcohol use, injection drug use, and sexual risk behaviors among injection drug users.

OBJECTIVES: We compared the effects of 2 interventions on alcohol use, use of a new syringe at last injection, and condom use at last sexual encounter in a community sample of injection drug users. METHODS: Between 2003 and 2006, 851 out-of-treatment injection drug users were recruited in Raleigh, NC, and Durham, NC, through street outreach and were randomly assigned to either a 6-session educational intervention or a 6-session motivational intervention. Intervention effects were examined at 6 and 12 months after enrollment. RESULTS: In multiple logistic regression analyses adjusted for baseline alcohol use and HCV status, participants assigned to the motivational intervention were significantly less likely than were participants in the educational intervention to be drinking at the 6-month follow-up (odds ratio = 0.67; 95% confidence interval = 0.46, 0.97). There were no significant between-group differences in use of a new syringe at last injection or condom use at last sexual encounter at either follow-up. CONCLUSIONS: Reducing alcohol use among persons with HCV may slow disease progression and provide important health benefits. Additional strategies are needed for slowing HCV disease progression until more effective HCV treatments are available.

Secrecy and risk among MSM in Tbilisi, Georgia.

There is concern that the tremendous economic, social, and political upheavals that the Republic of Georgia has undergone in the years since the fall of the Soviet Union may have created an environment fertile for HIV transmission. Notably absent from official statistics and HIV-related research in Georgia is discussion of men who have sex with men (MSM) and, therefore, little is known about the MSM population or its potential to acquire or transmit HIV. Data were collected from 30 MSM recruited through a testing and counseling center in Tbilisi, the capital of Georgia. Two focus groups with six men each and 18 individual in-depth interviews were conducted between October 2006 and February 2007. The study participants described a Georgian culture that is largely intolerant of sexual contact between men. In describing the various forms of discrimination and violence that they would face should their sexual identities be discovered, the MSM in this sample described a variety of behaviors that they and other Georgian MSM undertake to conceal their sexual behavior. Many of these could put these men and their partners at risk for HIV. Although official HIV rates in Georgia are still low, results from this qualitative study indicate that efforts to educate and to provide unobtrusive and anonymous testing and counseling services to MSM may be critical to the deterrence of an HIV epidemic in the Republic of Georgia.

Behaviorally bisexual men and their risk behaviors with men and women.

Gay and bisexual men are often treated as a homogenous group; however, there may be important differences between them. In addition, behaviorally bisexual men are a potential source of HIV infection for heterosexual women. In this study, we compared 97 men who have sex with men only (MSM) to 175 men who have sex with men and women (MSMW). We also compared the 175 MSMW to 772 men who have sex with women only (MSW). Bivariate and multiple logistic regression analyses were performed to assess correlates of MSMW risk behaviors with men and with women as well as whether MSMW, compared with MSW, engaged in more risky behaviors with women. Compared with MSM, MSMW were less likely to be HIV-positive or to engage in unprotected receptive anal intercourse. In contrast, MSMW were more likely than MSW to be HIV-positive and to engage in anal intercourse with their female partners; however, rates of unprotected anal intercourse were similar. The study findings suggest that there may be important differences in HIV risk behaviors and HIV prevalence between MSM and MSMW as well as between MSMW and MSW.

Medical Providers and Harm Reduction Views on Pre-Exposure Prophylaxis for HIV Prevention Among People Who Inject Drugs.

Despite high pre-exposure prophylaxis (PrEP) acceptability among people who inject drugs (PWID) and PrEP providers, PrEP uptake is low and little is known about how to promote PrEP among PWID. This qualitative study with providers in North Carolina explored views on PrEP delivery approaches for PWID. Interviewers conducted semistructured interviews with 10 PrEP providers and 10 harm reduction (HR) providers. Interviews were transcribed and analyzed. Many participants expressed acceptability for providing PrEP referrals at syringe exchange sites, stationing PrEP providers at syringe exchange sites to provide PrEP prescriptions, and providing standing orders for PrEP at syringe exchange sites. Barriers were identified, including low PrEP awareness and limited resources. Many advocated for co-location of HR and PrEP services and scaled-up outreach services. PrEP providers emphasized maintenance of clinical requirements, while HR providers emphasized flexibility when treating PWID. Promoting PrEP uptake and adherence among PWID likely requires integration of HR and PrEP services.

Scaling-up Normative Change Interventions for Adolescent and Youth Reproductive Health: An Examination of the Evidence.

Adolescent and youth reproductive health (AYRH) outcomes are influenced by factors beyond individual control. Increasingly, interventions are seeking to influence community-level normative change to support healthy AYRH behaviors. While evidence is growing of the effectiveness of AYRH interventions that include normative change components, understanding on how to achieve scale-up and wider impact of these programs remains limited. We analyzed peer-reviewed and gray literature from 2000 to 2017 describing 42 AYRH interventions with community-based normative change components that have scaled-up in low/middle-income countries. Only 13 of 42 interventions had significant scale-up documentation. We compared scale-up strategies, scale-up facilitators and barriers, and identified recommendations for future programs. All 13 interventions addressed individual, interpersonal, and community-level outcomes, such as community attitudes and behaviors related to AYRH. Scale-up strategies included expansion via new organizations, adapting original intervention designs, and institutionalization of activities into public-sector and/or nongovernmental organization structures. Four overarching factors facilitated or inhibited scale-up processes: availability of financial and human resources, transferability of intervention designs and materials, substantive community and government-sector partnerships, and monitoring capacity. Scaling-up multifaceted normative change interventions is possible but not well documented. The global AYRH community should prioritize documentation of scale-up processes and measurement to build evidence and inform future programming.

Getting to intent: Are social norms influencing intentions to use modern contraception in the DRC?

Meeting the reproductive health needs of women in post-conflict settings is a global health priority. In the Democratic Republic of the Congo, social norms perpetuate gender-based violence and contribute to low contraceptive use and high fertility. The Masculinité, Famille, et Foi (MFF) intervention is working with communities in Kinshasa to create normative environments supportive of modern contraception access and use. Our analysis uses survey data collected from 900 men and women in 17 community groups prior to the MFF intervention. We aimed to measure the extent to which social norms influence intentions to use modern contraception. Using multiple items to assess social norms and reference groups related to family planning and gender equity, we identified four distinct social norms constructs through factor analysis. Through structural equation modeling, we found that social norms influence intentions to use modern contraception overall, but that normative influence varies by gender.

Rapid organizational network analysis to assess coordination of services for HIV testing clients: an exploratory study.

Recognizing that HIV testing provides a gateway opportunity to connect with at-risk populations, we explored an approach to collect, analyze and present data on the network of connections between HIV testing organizations and other health and social service agencies operating in Durham County, NC. We surveyed 26 health and social service organizations, including 6 providing HIV testing services, and presented the results including frequency tabulations, network visualizations and metrics, and GIS maps to the participating organizations. Mapping the landscape of organizational relationships was seen as a practical and expedient approach to facilitating cross-sector collaborative efforts to improve community health.

Assessing prevalence of missed laboratory-confirmed sexually transmitted infections among women in Kingston, Jamaica: results from a secondary analysis of the Sino-Implant clinical trial.

OBJECTIVES: To assess potentially missed sexually transmitted infections (STIs), we compared clinically diagnosed STIs to laboratory-confirmed diagnoses of gonorrhoea (GC), chlamydia (CT) and trichomonas (Tvag). DESIGN: Secondary analysis of a randomised controlled trial. SETTING: We used data and specimens previously collected for the Sino-Implant Study in Kingston, Jamaica. PARTICIPANTS: The Sino-Implant Study randomised 414 women to receive a levonorgestrel implant at either baseline or 3 months post-enrolment to evaluate unprotected sex after implant initiation. This analysis used 254 available vaginal swab samples. OUTCOME MEASURES: Clinically diagnosed STIs were determined from medical records by assessing clinical impressions and prescriptions. Laboratory-confirmed STIs included GC, CT and Tvag tested by Aptima Combo 2 for CT/GC and Aptima Tvag assays (Hologic, San Diego, California, USA). Log-binomial regression models fit with generalised estimating equations were used to estimate associations of clinically diagnosed STIs with laboratory-confirmed diagnoses and demographic and behavioural characteristics. RESULTS: Overall, 195 (76.8%) women had laboratory-confirmed STI (CT, GC or Tvag) while only 65 (25.6%) women had clinically diagnosed cervicitis and/or vaginitis during the study period. Clinical diagnosis missed 79.7% of laboratory-confirmed STIs: 85% of GC (n=17/20), 78.8% of CT (n=141/179) and 80.0% of Tvag (n=180/225). Hormonal contraceptive use in the month prior to the study visit was significantly associated with clinical diagnosis at any time point (prevalence ratio (PR): 1.65, 95% CI 1.07 to 2.54). As age increased, clinically missed infections significantly decreased (PR: 0.98 per year increase, 95% CI 0.97 to 1.00). CONCLUSIONS: The prevalence of laboratory-confirmed STIs was much higher than what was captured by clinical diagnosis. GC, CT and Tvag were not accurately detected without lab confirmation. Missed diagnoses decreased with older age. Increased laboratory capacity and refinement of the syndromic approach are needed to protect the health of sexually active Jamaican women. TRIAL REGISTRATION NUMBER: NCT01684358.

Comprehensive mathematical modeling in drug addiction sciences.

The science of mathematical modeling aims to describe and evaluate complex phenomena. In epidemiology, modeling allows scientists to simulate the consequences of various intervention and prevention scenarios. In biology, modeling allows one to describe and simulate complex neurophysiologic processes. Similar modeling techniques apply to both scenarios. At the 2006 College on Problems of Drug Dependence (CPDD) workshop, we presented four types of models: traditional epidemiologic, traditional neurobiological/behavioral, knowledge repository epidemiologic, and knowledge repository neurological/behavioral. We discussed commonality and differences in the approaches, interpretations, utility, and limitations. The authors believe that both traditional and knowledge repository models can be very useful in complementary ways to the general scientific community studying substance abuse.