Pre-exposure prophylaxis among men who have sex with men in Côte d'Ivoire: a quantitative study of acceptability.

This cross sectional study was conducted in 2018 in Côte d'Ivoire to assess PrEP acceptability among men who have sex with men (MSM). Two hundred and one men were asked on their intention to use PrEP if made available. Logistic regression accounting for the sampling design was used to analyze associations between high PrEP acceptability and different independent variables including barriers and facilitators. Participants were mostly young (mean age = 25 years), educated (82% with secondary/postsecondary education) and single (95.5%). On average, 3.4 episodes of anal sex were reported monthly and 37.8% of men did not use a condom at last sex. Most MSM (72.6%) had heard of PrEP before enrollment. Overall, 35.3% reported that they would use PrEP very probably if made available. In multivariate analysis, factors associated with high PrEP acceptability were condom use at last sexual intercourse (Odds ratio (OR) = 2.51; 95%Confidence interval (95%CI) = 1.45-4.33); insertive sex as compared to versatile sex (OR = 2.56; 95%CI = 1.14-5.67); free PrEP delivery (OR = 2.45; 95%CI = 1.07-5.59), concerns about side effects (OR = 0.66; 95%CI = 0.48-0.90), and being preoccupied by the fact that post-PrEP antiretroviral therapy could be inefficient (OR = 0.25; 95%CI = 0.14-0.44). PrEP implementation among MSM in Côte d'Ivoire should be accompanied by awareness raising campaigns explaining its utility.

Highly-Exposed HIV-1 seronegative Female Commercial Sex Workers sustain in their genital mucosa increased frequencies of tolerogenic myeloid and regulatory T-cells.

We and others have shown that HIV-1 highly-exposed seronegative (HESN) female commercial sex workers (CSWs) maintain low genital inflammatory conditions to prevent HIV infection. HIV-1 interacts with toll-like receptors (TLR)-7/8 to induce interferon (IFN)-α, an important antiviral and immunomodulatory cytokine, which act together with interleukin (IL)-10, human leukocyte antigen (HLA)-G and immunoglobulin-like transcript (ILT)-4 to initiate a "tolerogenic/regulatory" anti-inflammatory loop. In view of further unravelling elements associated with natural immunity to HIV-1, we have characterised TLR-7, IFN-α, IL-10, HLA-G and ILT-4 expression profiles in the genital tract of female CSWs and HIV-1-uninfected non-CSWs from Benin. Endocervical myeloid HLA-DR+ cells from HESN CSWs expressed higher levels of IFN-α, TLR-7, IL-10 and HLA-G than those from both HIV-1-infected CSWs and HIV-1-uninfected non-CSWs. Further characterization of the endocervical myeloid HLA-DR+ cells in HESN CSWs revealed a population of "tolerogenic" CD103+ CD14+ CD11c+ myeloid cells expressing high levels of IFN-α and IL-10. Concomitantly, HESN CSWs had higher frequencies of endocervical regulatory CD4+ T-cells when compared to those from the two other groups of women. These novel findings provide strong evidence to support the implication of tolerogenic myeloid cells expressing high levels of antiviral molecules in shaping the genital mucosal immune response to prevent HIV infection.

Who mixes with whom among men who have sex with men? Implications for modelling the HIV epidemic in southern India.

In India, the identity of men who have sex with men (MSM) is closely related to the role taken in anal sex (insertive, receptive or both), but little is known about sexual mixing between identity groups. Both role segregation (taking only the insertive or receptive role) and the extent of assortative (within-group) mixing are known to affect HIV epidemic size in other settings and populations. This study explores how different possible mixing scenarios, consistent with behavioural data collected in Bangalore, south India, affect both the HIV epidemic, and the impact of a targeted intervention. Deterministic models describing HIV transmission between three MSM identity groups (mostly insertive Panthis/Bisexuals, mostly receptive Kothis/Hijras and versatile Double Deckers), were parameterised with behavioural data from Bangalore. We extended previous models of MSM role segregation to allow each of the identity groups to have both insertive and receptive acts, in differing ratios, in line with field data. The models were used to explore four different mixing scenarios ranging from assortative (maximising within-group mixing) to disassortative (minimising within-group mixing). A simple model was used to obtain insights into the relationship between the degree of within-group mixing, R0 and equilibrium HIV prevalence under different mixing scenarios. A more complex, extended version of the model was used to compare the predicted HIV prevalence trends and impact of an HIV intervention when fitted to data from Bangalore. With the simple model, mixing scenarios with increased amounts of assortative (within-group) mixing tended to give rise to a higher R0 and increased the likelihood that an epidemic would occur. When the complex model was fit to HIV prevalence data, large differences in the level of assortative mixing were seen between the fits identified using different mixing scenarios, but little difference was projected in future HIV prevalence trends. An oral pre-exposure prophylaxis (PrEP) intervention was modelled, targeted at the different identity groups. For intervention strategies targeting the receptive or receptive and versatile MSM together, the overall impact was very similar for different mixing patterns. However, for PrEP scenarios targeting insertive or versatile MSM alone, the overall impact varied considerably for different mixing scenarios; more impact was achieved with greater levels of disassortative mixing.

Familial sinistrality and handedness in patients with first episode schizophrenia: the EUFEST study.

The population with schizophrenia is characterised by a leftward shift in handedness-sinistrality. However, findings are inconsistent in chronic patients, and familial sinistrality (FS), defined as the presence of left-handed close relatives, might contribute to the discrepancies. Therefore the aim of this study was to investigate the strength of manual lateralisation in patients with first episode schizophrenia, taking into account familial sinistrality. The Edinburgh Inventory (EI) allowed us to categorise 179 patients from the EUFEST study and 189 controls presenting "strong handedness" (SH: EI absolute value between ∣81∣ and ∣100∣) or "weak-handedness" (WH: EI value between -80 and +80). The nominal logistic regression did not show an FS effect, but a nearly significant interaction between illness and FS (p =.07). There were fewer participants without FS presenting SH among patients (99/151: 65.6%) than among controls (134/164: 81.7%, p =.001). In contrast, the number of participants with FS presenting SH was similar between controls (68%) and patients (75%, p =.57). The presence of left-handed relatives (FS + ) tended to reduce manual lateralisation, but only in controls. This supports the notion that reduced manual lateralisation in schizophrenia is related to the illness rather than to familial left-handedness.

[The HIV epidemic among industrial male miners in Guinea: prevalence, associated factors and trends from 2001 to 2007]. / Épidémie du VIH chez les hommes travaillant dans les mines industrielles de Guinée : séroprévalence, facteurs de risque associés et tendance 2001-2007.

BACKGROUND: To estimate HIV prevalence, associated factors and trends from 2001 to 2007 among male miners in Guinea. METHODS: Two hundred and eighty-six male miners in 2001 and 579 in 2007 were tested for HIV and interviewed about their lifestyles and sexual practices. Investigations were conducted in the five mining companies operating in the country. A standard questionnaire was used for collecting data and SAS Windows 9.2 version (SAS Institute, Cary, North Carolina, USA) for statistical analysis. RESULTS: Median age was 45 years in 2001 and 39 years in 2007 (P=0.001). HIV prevalence was 4.5% (95% Confidence Interval [95% CI]: 2.1-7.0) in 2001 and 6.4% (95% CI: 4.4-8.4) in 2007. In multivariate analysis, HIV prevalence was associated with history of sexually transmitted infections (STIs) (Prevalence Ratio [PR]=2.21; P=0.03), and with paying for sex (PR=6.01; P=0.04), whereas it was significantly higher in divorced, separated or widowed men. HIV prevalence increased but not significantly between 2001 and 2007, whereas casual sex (P=0.03) and counseling activities against HIV (P<0.0007) decreased. CONCLUSION: HIV prevalence is high in this population and, although not statistically significant, the increase observed between 2001 and 2007 is worrying in a context where the population of miners became younger over time. Prevention of HIV/AIDS has to be reinforced among miners in Guinea.

[HIV prevalence, associated risk factors and evolution among truck drivers from 2001 to 2007 in Guinea]. / Prévalence du VIH, facteurs associés et tendances chez les camionneurs entre 2001 et 2007 en Guinée.

OBJECTIVE: The purpose of this study was to estimate correlation between HIV prevalence and behavior at risk for infection among truck drivers in Guinea and to report the trends of these indicators from 2001 to 2007. METHODS: A total of 313 truck drivers in 2001 and 600 in 2007 were selected, interviewed and then tested for HIV infection. Data were analyzed with SAS Windows 9.2. RESULTS: The prevalence HIV was 7.0% in 2001 and 5.3% in 2007 (p=0.30). Seroprevalence was positively correlated with monogamous marital status [prevalence ratio (PR)=10.00; p=0.02] in 2001, absence from home for longer than a month (PR=2.06; p=0.03), international hauls (PR=2.39; p=0.01), and alcohol consumption (RP=2.00; p=0.04) and negatively correlated with the ability to abstain in risk situations (PR=0.35; p=0.01) in 2007. Comparison of responses obtained in 2001 and 2007 showed a decrease in the number of casual sex partners (p<0.0001) and an increase in condom use (p<0.0001). Comparison also showed a decrease in the number of drivers who reported receiving counseling about HIV/AIDS from NGOs, state health care services and schools (p<0.0001). CONCLUSION: These two surveys showed high HIV prevalence among Guinean truck drivers in both 2001 and 2007. Condom use increased between 2001 and 2007 but remained inadequate. The correlation between monogamous marriage observed in 2001 was not found in 2007 but other risk factors such as alcohol consumption, prolonged absence from home, and international hauls were observed. The ability to abstain from sex in risk situations was associated with lower seroprevalence. During the study period, a decrease was observed in the number of truck drivers who reported receiving HIV/AIDS counseling from NGOs, state health care services, or schools. Prevention activities against HIV/AIDS must be reinforced in this high-risk population.

Correlates of unprotected anal sex at last sexual episode: analysis from a surveillance study of men who have sex with men in Montreal.

Recent increases in rates of unprotected anal sex (UAS) among men who have sex with men (MSM) signal the need to continually refine our understanding of factors associated with risky sexual behavior. Data were collected using a questionnaire eliciting information about the last sexual episode (LSE) with another man in the past 6 months. Logistic regression was used to identify both event-level and background correlates of UAS at LSE. 965 participants who reported having sex with a partner with whom they were not in a couple relationship at LSE were studied. Several event-level variables were significantly associated with UAS after adjusting for background factors, including finding the partner at LSE sexually attractive and using alcohol or cocaine at LSE. Our findings parallel the results of other HIV prevention studies which have highlighted the importance of interpersonal factors that influence risk-taking at the moment of a sexual act among MSM.

[HIV epidemic among female sex workers in Guinea: prevalence, associated risk factors, vulnerability and trend from 2001 to 2007]. / Epidémie du VIH chez les travailleuses du sexe en Guinée: prévalence, facteurs associés, vulnérabilité et tendances 2001-2007.

BACKGROUND: Estimate the associations between potential risk factors and HIV prevalence, as well as the trends from 2001 through 2007 of these indicators. Describe the vulnerability of female sex workers to in Guinea. METHODS: Female sex workers in Guinea were interviewed in 2001 (n = 339) and 2007 (n = 598) and then screened for HIV. This was a nationwide survey using a unique protocol. Associations between potential risk factors and HIV prevalence were tested, and their trends from 2001 through 2007 estimated, after adjustment using Generalized Estimating Equations. RESULTS: In 2001, HIV was associated with illiteracy (PR = 1.41; p = 0.2), and with genital ulcer symptom (PR = 1.89; p = 0.001). In 2007, it was associated with illiteracy (RP = 1, p = 0.03), and with older age (PR for 10 years = 1.29; p = 0.004). The profile of illiterate female sex workers included low price per sexual encounter in both 2001 and 2007, greater number of clients, and lesser exposure to HIV/Aids counselling in 2001. From 2001 to 2007, increases were noted for the number of clients by female sex workers (p < 0.0001), price per sexual encounter (p < 0.0001), condom use (p < 0.0001) and exposure to HIV/Aids counselling (p < 0.0001); decreases were noted for symptoms of sexually transmitted diseases (p < 0.0001) and HIV prevalence among female sex workers aged less than 20 years (p = 0.005). CONCLUSION: From 2001 through 2007, condom use and exposure to HIV/Aids counselling increased in Guinea while symptoms of sexually transmitted diseases and HIV prevalence declined. Nevertheless, illiterate female sex workers remained highly vulnerable.

Men who have sex with men and women in Bangalore, South India, and potential impact on the HIV epidemic.

OBJECTIVE: The aim of this study was to quantify differences in patterns of sexual behaviour among men who have sex with men and women (MSMW) compared with men who have sex with men only (MSMO), and to examine the extent to which bisexual behaviour may act as a bridge for introducing HIV infection into the general population. METHODS: A cross-sectional survey in Bangalore city in 2006, which sampled men seeking sex with men in public places and hammams (bath houses where transgender individuals sell sex to men). RESULTS: Among a sample of 357 men reporting same-sex behaviour; 41% also reported sex with a woman in the past year and 14% were currently married to a woman, only two of whom had informed their wives about having sex with men. Condom use was very inconsistent with all male partners, while 98% reported unprotected vaginal sex with their wives. MSMW reported lower rates of risky behaviour with other men than MSMO: fewer reported selling sex (17% vs 58%), or receptive anal sex with known (28% vs 70%) or unknown (30% vs 59%) non-commercial partners. CONCLUSION: Bisexual behaviour was common among men seeking sex with men sampled in this survey. Although MSMW reported lower rates of risky sexual behaviour with male partners than MSMO, inconsistent condom use with both male and female partners indicates a potential means of HIV transmission into the general population. HIV prevention programmes and services should reach bisexual men who potentially expose their male and female partners to HIV.

Assessment of intervention outcome in the absence of baseline data: 'reconstruction' of condom use time trends using retrospective analysis of survey data.

BACKGROUND: Avahan, the India AIDS Initiative, is a large-scale targeted intervention. Data on condom use prior to Avahan are unavailable. The authors used a novel method of analysing cross-sectional survey data to 'reconstruct' condom use rates in presurvey years, and to assess the relationship between Avahan and time trends in condom use among female sex workers (FSWs). METHODS: Among FSWs reporting consistent condom use (CCU) with clients in surveys from 21 districts in southern India (n=7358), data on length of time using condoms, and length of time selling sex, were converted into number of FSWs using condoms (numerator) and selling sex (denominator) by year, to give yearly rates of CCU from 2001 to year of survey. Linear regression with generalised estimating equations was used to assess time trends and to compare the rate of increase in condom use before and after Avahan initiation in 2003. RESULTS: In all 21 districts, the rate of increase in CCU from 2001 to time of the surveys was highly significant. Overall CCU increased from 27% (22%) with occasional (regular) clients in 2001, to 76% (68%) in 2006, respectively. The yearly rate of increase in CCU was significantly greater after (slope 2003-2006: 12.7% (12.0%) per year for occasional (regular) clients) than prior to Avahan (slope 2001-2003: 5.1% (5.3%) per year for occasional (regular) clients) implementation (p<0.0001). CONCLUSIONS: The findings indicate a positive relationship between implementation of the Avahan programme and rates of CCU increase among FSW. This method of analysis may be useful in other contexts where preintervention data are lacking.

The effects of scale on the costs of targeted HIV prevention interventions among female and male sex workers, men who have sex with men and transgenders in India.

BACKGROUND: The India AIDS Initiative (Avahan) project is involved in rapid scale-up of HIV-prevention interventions in high-risk populations. This study examines the cost variation of 107 non-governmental organisations (NGOs) implementing targeted interventions, over the start up (defined as period from project inception until services to the key population commenced) and first 2 years of intervention. METHODS: The Avahan interventions for female and male sex workers and their clients, in 62 districts of four southern states were costed for the financial years 2004/2005 and 2005/2006 using standard costing techniques. Data sources include financial and economic costs from the lead implementing partners (LPs) and subcontracted local implementing NGOs retrospectively and prospectively collected from a provider perspective. Ingredients and step-down allocation processes were used. Outcomes were measured using routinely collected project data. The average costs were estimated and a regression analysis carried out to explore causes of cost variation. Costs were calculated in US$ 2006. RESULTS: The total number of registered people was 134,391 at the end of 2 years, and 124,669 had used STI services during that period. The median average cost of Avahan programme for this period was $76 per person registered with the project. Sixty-one per cent of the cost variation could be explained by scale (positive association), number of NGOs per district (negative), number of LPs in the state (negative) and project maturity (positive) (p<0.0001). CONCLUSIONS: During rapid scale-up in the initial phase of the Avahan programme, a significant reduction in average costs was observed. As full scale-up had not yet been achieved, the average cost at scale is yet to be realised and the extent of the impact of scale on costs yet to be captured. Scale effects are important to quantify for planning resource requirements of large-scale interventions. The average cost after 2 years is within the range of global scale-up costs estimates and other studies in India.

[HIV and sexually transmitted disease among female sex workers in Benin]. / VIH et infections sexuellement transmissibles chez les travailleuses du sexe au Bénin.

BACKGROUND: This report describes a follow-up study conducted in 2005 to evaluate programs intended to reduce HIV/AIDS among registered and unregistered female sex workers (FSW) and their male clients in six major urban areas in Benin (Cotonou, Abomey-Bohicon, Parakou, Porto-Novo, Kandi, Malanville). The objectives of this second study combining laboratory testing and behavioral questionnaires were to estimate the prevalence of HIV and sexually transmitted diseases (STI), to determine the sociodemographic and behavioral characteristics of FSW, and to assess changes in the behavior of registered FSW in the first four cites (Cotonou, Abomey-Bohicon, Parakou, and Porto-Novo) included in the initial study in 2002. DESIGN AND METHODS: A cross-sectional study was conducted in a cohort of 930 self-identified FSW. The chi-square or Fisher's exact test were used to test correlation between HIV and social, demographic and behavioral factors and the Wilcoxon test to compare the distribution of continuous variables. Correlation was measured based on prevalence odd ratios (POR) obtained by multivariate logistic regression. RESULTS: The overall prevalence of HIV, Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) were 30.5%, 3.6% and 5.7% respectively. The prevalence of HIV was highest in Parakou (48.2%) and lowest in Abomey/Bohicon (16.4%). The prevalence of NG and CT were highest in Abomey/Bohicon and Porto-Nova respectively. Multivariate logistic regression analysis showed that HIV prevalence increased significantly for FSW who had had more than 10 clients in the previous week (POR = 1.40, 95% CI: 1.02-1.94), who had no other source of income (POR = 1.47, 95% CI: 1.08-2.00), who were currently unmarried or separated (POR = 2.63, 95% CI: 1.73-4.02), and who had never been married (POR = 2.07, 95% CI: 1.43-3.00). Older age and having had no non-paying partner in the last seven days were positively correlated with HIV infection. Between 2002 and 2005 there was a significant increase in the number of FSW who reported condom use with all clients (79% vs. 90%, p < 0.0001) and with all sexual partners (78% vs. 87%, p = 0.0007) during the last 7 days as well as in the median number of visits to a health care facility in the last 12 days (3 vs. 6, p < 0.0001). Overall these follow-up data showed a large decrease in the prevalence of HIV/STI. This finding supports continuation of programs aimed at FSW especially with regard to risk awareness, condom use, and STI screening and treatment.

Criteria for initiating highly active antiretroviral therapy and short-term immune response among HIV-1-infected patients in Côte d'Ivoire.

OBJECTIVES: The aims of this study were to determine the predictors of CD4 count below 200 cells/microL and to propose an algorithm for antiretroviral therapy initiation; and to assess the determinants of immune response to highly active antiretroviral therapy (HAART) in Côte d'Ivoire. METHODS: A total of 615 consecutive patients attending an HIV/AIDS day hospital were enrolled in the study. We constructed a score system based on the results of a multivariate logistic regression analysis of the predictors of CD4 count <200 cells/microL with the intention of proposing an algorithm able to accurately designate patients eligible for HAART. We also identified factors associated with a short-term increase in CD4 count >50 cells/microL after HAART initiation. RESULTS: Total lymphocyte count <1200 cells/microL (P<0.0001), lower haemoglobin levels (P<0.0001), and Centers for Disease Control and Prevention (CDC) clinical stages C (P=0.005) and B (P=0.045), as compared with stage A, were associated with CD4 count <200 cells/microL. Nonetheless, no accurate algorithm for HAART initiation was found. Three hundred and three of the 615 patients were treated. Of these 303 patients, 79.5% showed an increase of >50 cells/microL in CD4 count 6 months after HAART initiation (median increase 128 cells/microL). Adherence >or=95% (P=0.022) and increase in absolute total lymphocyte count during follow-up (P<0.0001) were associated with a short-term positive immune response. CONCLUSIONS: Our results support the effectiveness of generic drug combinations in sub-Saharan Africa. In order to enhance the management of HIV disease in sub-Saharan Africa, efforts should target the development of low-cost CD4 cell count laboratory tests.

How much could a microbicide's sexually transmitted infection efficacy contribute to reducing HIV risk and the level of condom use needed to lower risk? Model estimates.

OBJECTIVE: This study explores the potential contribution of a microbicide's sexually transmitted infection (STI) efficacy in reducing a female sex worker's (FSW) risk of STI and HIV infection. The study then investigates whether the threshold for the reduction in condom use following microbicide introduction that can be tolerated without increasing HIV risk is affected by STI efficacy. METHODS: A dynamic model describing the transmission of a bacterial STI between FSW and their clients was coupled with a static HIV model. The model uses data from Cotonou, Benin (1998-9), for illustration, to estimate the change in risk following the introduction of 50% HIV efficacious microbicides of different STI efficacies, used in 50% of sex acts when a condom is not used. The condom migration thresholds were estimated. The degree to which the findings are influenced by STI prevalence was explored. RESULTS: For highly transmissible STI, there is a non-monotonic relationship between STI prevalence and microbicide impact on HIV with the relative reduction in HIV risk first increasing, due to the proportion of HIV risk attributable to the STI increasing, but then decreasing at high prevalences as the STI becomes harder to control. A less transmissible STI can still be impacted upon with a moderate/high STI efficacy microbicide even at high STI prevalences. This relationship is also reflected in the condom migration thresholds. CONCLUSIONS: A microbicide's STI efficacy may have a substantial impact on STI and HIV incidence among high-risk groups. The variation in the condom migration thresholds for different STI efficacies and STI prevalences may be difficult to measure accurately.

Differences in immunoregulatory cytokine expression patterns in the systemic and genital tract compartments of HIV-1-infected commercial sex workers in Benin.

Initial exposure to human immunodeficiency virus type 1 (HIV-1) during heterosexual transmission occurs in the genital tract. Although much of the literature on the immune response to HIV-1 infection is based on studies performed at the systemic level, our understanding of tissue-specific immunity is lacking. Levels of both genital mucosal and blood interleukin (IL)-2, IL-4, IL-6, IL-10, tumor necrosis factor (TNF)-alpha, and interferon (IFN)-gamma production were compared between 57 HIV-1-uninfected and 52 HIV-1-infected female commercial sex workers (CSWs) as well as 73 HIV-1-uninfected non-CSW control women at low risk for exposure. HIV-1-infected CSWs had significantly higher genital mucosal levels of TNF-alpha and IFN-gamma compared with those in both the HIV-uninfected CSW and non-CSW groups. In contrast, the serum levels of all the cytokines tested were lower in HIV-1-infected CSWs compared with those in the other groups. The increased production of genital mucosal pro-inflammatory cytokines in HIV-1-infected CSWs possibly reflects susceptibility to HIV-1 infection and disease progression/perpetuation at the initial site of exposure.

Satisfaction with health services for STIs, HIV, AIDS among a high-risk population in West Africa.

The goal of this study was to develop an instrument and assess the degree of satisfaction regarding HIV/STIs services for women working in, associated with, or living in or nearby, prostitution environments. This study took place in seven West-African countries (Benin, Burkina Faso, Ghana, Mali, Niger, Senegal, Togo) participating in the West Africa Aids Program (AIDS3). A validated six-dimension questionnaire was used to interview 698 women. The main inclusion criterion was having had recourse to adapted services offered through the AIDS3 program in the last six months. Results showed that women surveyed are satisfied overall. Two dimensions scored low: 'Technical skills perceived' and 'Accessibility'. Regression analyses showed that those most satisfied were women who had used the adapted services many times and women connected with community groups. Although these results are consistent with results published previously in other contexts, they now allow the AIDS3 program to consider the voices of women rarely listened to: West-African women living and working in prostitution environments.

Sexual identity and its contribution to MSM risk behavior in Bangaluru (Bangalore), India: the results of a two-stage cluster sampling survey.

In India, there are categories of MSM (hijras, kothis, double-deckers, panthis and bisexuals), which are generally associated with different HIV-risk behaviors. Our objective was to quantify differences across MSM identities (n = 357) and assess the extent they conform to typecasts that prevail in policy-orientated discourse. More feminine kothis (26%) and hijras (13%) mostly reported receptive sex, and masculine panthis (15%) and bisexuals (23%) insertive anal sex. However, behavior did not always conform to expectation, with 25% and 16% of the sample reporting both insertive and receptive anal intercourse with known and unknown noncommercial partners, respectively (p < 0.000). Although behavior often complied with stereotyped role and identity, male-with-male sexual practices were fluid. Reification of these categories in an intervention context may hinder our understanding of the differential HIV risk among MSM.

Interventions among male clients of female sex workers in Benin, West Africa: an essential component of targeted HIV preventive interventions.

OBJECTIVES: To assess the impact of interventions targeted towards female sex workers (FSWs) and their male clients on client HIV/STI prevalence and sexual behaviour. METHODS: From 1993 to 2006, an HIV/STI preventive intervention focusing on condom promotion and STI care was implemented among FSWs in Cotonou, Benin, and then expanded to cover their male sexual partners in 2000. The interventions were scaled up to five other cities of Benin in 2001-2002. Serial cross-sectional surveys of HIV/STI prevalence and sexual behaviour were carried out among clients in Cotonou in 1998, 2002 and 2005; and in the five other cities (O/Cotonou) in 2002 and 2005. RESULTS: Significant declines in gonorrhoea prevalence among clients of FSWs: Cotonou, from 5.4% in 1998 to 1.6% in 2005; O/Cotonou: from 3.5% in 2002 to 0.59% in 2005. Chlamydia prevalence also declined O/Cotonou, from 4.8% to 1.8%, while HIV prevalence remained stable. Reported condom use by clients with both FSWs and casual non-FSW partners, but not regular partners, increased significantly. While condom use at last sex with an FSW was similar in Cotonou to O/Cotonou around the time of implementation of the interventions (56% in 1998 vs 49% in 2002, respectively), it had risen to similar levels by 2005 (95% and 96%, respectively). CONCLUSIONS: These results demonstrate that it is possible to implement preventive and clinical services for clients of FSWs, and suggest that such interventions, integrated with those targeted towards FSWs, can have a significant effect on sexual behaviour and STI prevalence (particularly gonorrhoea) among this population.

Evaluating large-scale HIV prevention interventions: study design for an integrated mathematical modelling approach.

BACKGROUND: There is an urgent need to evaluate HIV prevention interventions, thereby improving our understanding of what works, under what circumstances and what is cost effective. OBJECTIVES: To describe an integrated mathematical evaluation framework designed to assess the population-level impact of large-scale HIV interventions and applied in the context of Avahan, the Indian AIDS Initiative, in southern India. The Avahan Initiative is a large-scale HIV prevention intervention, funded by the Bill & Melinda Gates Foundation, which targets high-risk groups in selected districts of the six states most affected by the HIV/AIDS epidemic (Maharashtra, Karnataka, Tamil Nadu, Andhra Pradesh, Nagaland and Manipur) and along the national highways. METHODS: One important component of the monitoring and evaluation of Avahan relies on an integrated mathematical framework that combines empirical biological and behavioural data from different subpopulations in the intervention areas, with the use of tailor-made transmission dynamics models embedded within a Bayesian framework. RESULTS: An overview of the Avahan Initiative and the objectives of the monitoring and evaluation of the intervention is given. The rationale for choosing this evaluation design compared with other possible designs is presented, and the different components of the evaluation framework are described and its advantages and challenges are discussed, with illustrated examples. CONCLUSIONS: This is the first time such an approach has been applied on such a large scale. Lessons learnt from the CHARME project could help in the design of future evaluations of large-scale interventions in other settings, whereas the results of the evaluation will be of programmatic and public health relevance.

Correlates of sexual activity and inconsistent condom use among high-school girls in Dominica / Correlatos de la actividad sexual y el uso no sistemático del condón entre las jóvenes de la escuela secundaria en Dominica

OBJECTIVE: To determine factors associated with sexual activity and inconsistent condom use among high-school girls in Dominica. METHODS: A cross-sectional study was conducted at five high-schools in Dominica in 2000 to assess behaviour that may put high-school girls at risk for HIV The main outcome variable, sexual activity, was defined as vaginal or anal sex, and inconsistent condom use defined as none to infrequent condom use. The convenience sample consisted of 204 girls (median age 16 years). RESULTS: Forty-one per cent (41%) of girls reporting at least one episode of sexual activity. Sexual intercourse was associated with past sexual coercion (OR = 7.2, 95% CI 2.4, 21.8), oral sex (OR = 8.0, 95% CI 3.0, 21.0) and smoking marijuana (OR = 8.2, 95% CI 2.9, 23.0). Among sexually active girls, 59% were inconsistent condom users. Variables associated with inconsistent condom use were being coerced (OR 2.8, 95% CI 0.9, 8.2) and low socio-economic status (OR 3.3, 95% CI 1.1, 9.6). CONCLUSION: Sexual activity and inconsistent condom use occur frequently among high-school girls in Dominica. Therefore, strategies directed at delaying the onset of sexual activities such as providing accurate and age-appropriate information on sexuality in the context of the economic and social conditions of their daily lives, and increasing condom use are important in HIV prevention in this population.

OBJETIVO: Determinar los factores asociados con la actividad sexual y el uso no sistemático del condón entre las estudiantes de Secundaria en Dominica. MÉTODOS: Se llevó a cabo un estudio transversal en cinco escuelas secundarias en Dominica en el año 2000 a fin de evaluar conductas que pueden poner a las estudiantes de Secundaria en riesgo de adquirir el VIH. La principal variable de resultado fue la actividad sexual definida como sexo vaginal o anal, y el uso no sistemático del condón fue definido como uso poco frecuente o no uso en lo absoluto del condón. La muestra de conveniencia consistió en 204 muchachas (16 años de edad mediana). RESULTADOS: El cuarenta y un por ciento (41%) de las estudiantes reportaron al menos un episodio de actividad sexual. La relación sexual estuvo asociada con coerción sexual en el pasado (OR = 7.2, 95% CI 2.4, 21.8), sexo oral (OR = 8.0, 95% CI 3.0, 21.0) y el fumar marihuana (OR = 8.2, 95% CI 2.9, 23.0). Entre las muchachas sexualmente activas, 59% no eran usuarias sistemáticas del condón. Las variables asociadas con el uso no sistemático del condón fueron el actuar bajo coacción (OR 2.8, 95% CI 0.9, 8.2) y el bajo nivel socio-económico (OR 3.3, 95% CI 1.1, 9.6). CONCLUSIÓN: La actividad sexual y el uso del condón no sistemático ocurren con frecuencia entre las estudiantes de secundaria en Dominica. Por lo tanto, las estrategias dirigidas a retardar el comienzo de las actividades sexuales, tales como brindar información exacta y apropiada a la edad sobre la sexualidad en el contexto de las condiciones económicas y sociales de sus vidas diarias, y el uso creciente del condón, son importantes en la prevención del VIH en esta población.