Family planning campaigns on television and contraceptive use in India.

OBJECTIVE: The paper examines the association between viewing family planning campaigns on television and being aware, improved intention to use, and current usage of modern contraceptives in India. DATA: The study uses detailed data of the currently married women from the current round of the National Family Health Survey. METHODS: We use the instrumental variable approach, propensity score matching method, besides the ordinary least square regression technique to estimate the association between viewing family planning campaigns on television and knowledge, intention to use, and current usage among the currently married women. CONCLUSION: The overall results suggest that currently married women who have seen family planning campaigns on television in the last few months are more likely to know, have a higher intention to use and use modern family planning methods. The effectiveness gets amplified when exposure to such campaigns is complemented with motivation provided by frontline health workers.

From Pill to Condom, or Nothing at all: HIV Diagnosis and Discontinuation of Highly Effective Contraceptives Among Women in Northeast Brazil.

This is a cross-sectional study examining highly effective contraceptive (HEC) use among HIV-positive women in Salvador, Brazil. We used multivariate logistic regression to look for predictors of alternative contraceptive choices among women who discontinued HEC after HIV diagnosis. Of 914 participants surveyed, 38.5% of participants used HEC before but not after diagnosis. Of these, 65.9% used condoms alone; 19.3% used no protection; and 14.8% reported abstinence. Use of condoms alone was associated with a history of other sexually transmitted infections (AOR 2.18, 95% CI 1.09-4.66, p = 0.029). Abstinence was associated with recent diagnosis (AOR 8.48, 95% CI 2.20-32.64, p = 0.002). Using no method was associated with age below 25 (AOR 5.13, 95% CI 1.46-18.00, p = 0.011); income below minimum wage (AOR 2.54, 95% CI 1.31-4.92, p = 0.006); HIV-positive partner status (AOR 2.69, 95% CI 1.03-7.02, p = 0.043); and unknown partner status (AOR 2.90, 95% CI 1.04-8.05, p = 0.042). Improved contraceptive counseling is needed after HIV diagnosis. Continuation of HEC should be encouraged for women wishing to prevent pregnancy, and may increase contraceptive coverage among HIV-positive women.

Patient Perspectives on Contraceptive use in North India: A Case for Increased Contraceptive Counseling by Providers.

Background: Given the underutilization of contraception in India, this study was undertaken to gauge cisgender female clients' knowledge of, attitudes toward, and barriers to contraceptive usage in North India. Methodology: The present study was done at a tertiary care Institute in North India, where 209 structured interviews were conducted with cisgender female patients attending the outpatient department. One-way chi-square tests for independence, Kruskal-Wallis test, and Wilcoxon test were applied to quantitative data. Themes from qualitative questions were coded and analyzed. Results: Differences in awareness among contraceptives were found to be highly statistically significant (H (9) = 1022.3, p < 2.2 e-16). Friends or colleagues comprised the predominant information source for most contraceptive methods. Participants' contraceptive usage was low, with 27.27% stating no prior use and 47.47% indicating occasional use (X2 (3, N = 198) = 66.121, p < 2.89 e-14). Lack of perceived need, concern for side effects, fear and desire for children were top reasons for non-use of contraceptive methods. Majority of the participants (79.45%) expressed comfort speaking with their spouse about contraception, 47.18% with a medical provider, 32.82% with friends, 15.38% with family, 2.05% with a health educator, and 3.59% with no one. Participants indicated little prior contraceptive counseling experience. Conclusion: Our study shows differential levels of awareness, usage, and barriers on contraceptive methods among participants. Results also suggest the importance of spouses and friends in clients' contraceptive decision-making process and their limited counseling experience with health care providers.

Using Household Socioeconomic Indicators to Predict the Utilization of Maternal and Child Health Services Among Reproductive-Aged Women in Rural Yemen.

Using principal component analysis (PCA) and integrating both individual and household factors, we had previously derived and proposed 3 socioeconomic indices (namely, wealth index, educational index, and housing quality index) that can be used to classify rural Yemeni women into different socioeconomic statuses (SES). In the current article, we examined whether the PCA-derived indices can be used to predict the use of maternal and child health care services in rural Yemen. We used data from subnational representative multistage sampling cross-sectional household survey conducted in rural Yemen in 2008-2009 among women (N = 6907) who had given birth. The resulting component scores for each SES index were divided into tertiles. Logistic regression was used to study the associations between the SES indices and 4 indicators of maternal health care use. Higher tertiles of each socioeconomic index increased the likelihood of adequate antenatal care use, delivery assistance, and contraceptive use, but decreased the likelihood of unmet need for contraception. Key maternal health indicators can be determined by socioeconomic indicators. Therefore, in planning maternal and child health interventions, considering disparities of care by socioeconomic factors should be taken into account.

Level and Factors Related to Unintended Pregnancy with a Brief Review of New Population Policies in Iran.

BACKGROUND: High rate of unintended pregnancies in Iran is one of problems in family planning. The main goal of this study was to determine the rate of unintended pregnancies and to examine factors among married women in Shiraz City, Iran. It also discusses the possible effects of new population policies on the rate of unintended pregnancy. METHODS: In this quantitative and survey study, data were collected by researcher-made questionnaire with interviewer from 400 pregnant women in Shiraz City referred to public and private health centers for prenatal care in 2013. Data were analyzed by SPSS both descriptively and analytically. RESULTS: Overall, 17% of total pregnancies were unintended. The highest rate occurred among couples whose level of education was under diploma. In addition, women above 39 yr old experienced a higher rate of unintended pregnancy. The most popular methods were pills, withdrawal, and condom. The highest rate of unintended pregnancy was related to withdrawal. Knowledge about modern contraceptives particularly emergency contraceptives was low. Age, residence place, use of traditional contraception methods, knowledge about contraceptives, fear of side effects and couple agreement on contraception method were the main predictors of unintended pregnancy. CONCLUSION: There is still unmet need in family planning. The main predictors of unintended pregnancies are high prevalence of traditional contraception methods and insufficient knowledge about modern contraception methods. Policymakers should pay more attention to these issues. Furthermore, although Iranian policy makers are worried about low fertility, they need to be aware that new population policy through restriction of access to family planning services is effective, but also may exacerbate the problem by leading to a higher chance of unintended pregnancy.

Using mHealth to Support Postabortion Contraceptive Use: Results From a Feasibility Study in Urban Bangladesh.

BACKGROUND: As access to mobile technology improves in low- and middle-income countries, it becomes easier to provide information about sensitive issues, such as contraception and abortion. In Bangladesh, 97% of the population has access to a mobile signal, and the equity gap is closing in mobile phone ownership. Bangladesh has a high pregnancy termination rate and improving effective use of contraception after abortion is essential to reducing subsequent unwanted pregnancies. OBJECTIVE: This study examines the feasibility and acceptability of implementing a short message service (SMS) text message-based mHealth intervention to support postabortion contraceptive use among abortion clients in Bangladesh, including women's interest in the intervention, intervention preferences, and privacy concerns. METHODS: This feasibility study was conducted in four urban, high abortion caseload facilities. Women enrolled in the study were randomized into an intervention (n=60) or control group (n=60) using block randomization. Women completed a baseline interview on the day of their abortion procedure and a follow-up interview 4 months later (retention rate: 89.1%, 107/120). Women in the intervention group received text message reminders to use their selected postabortion contraceptive methods and reminders to contact the facility if they had problems or concerns with their method. Women who did not select a method received weekly messages that they could visit the clinic if they would like to start a method. Women in the control group did not receive any messages. RESULTS: Almost all women in the feasibility study reported using their mobile phones at least once per day (98.3%, 118/120) and 77.5% (93/120) used their phones for text messaging. In the intervention group, 87% (48/55) of women were using modern contraception at the 4-month follow-up, whereas 90% (47/52) were using contraception in the control group (P=.61). The intervention was not effective in increasing modern contraceptive use at follow-up, but 93% (51/55) of women reported at follow-up that the text reminders helped them use their method correctly and 76% (42/55) said they would sign up for this service again. Approximately half of the participants (53%, 29/55) said that someone they did not want to know about the text message reminders found out, mostly their husbands or children. CONCLUSIONS: In this small-scale feasibility study, text reminders did not increase postabortion contraceptive use. Despite the ineffectiveness of the text reminder intervention, implementation of a mHealth intervention among abortion clients in urban Bangladesh was feasible in that women were interested in receiving follow-up messages after their abortion and mobile phone use was common. Text messages may not be the best modality for a mHealth intervention due to relatively low baseline SMS text message use and privacy concerns.

Contraceptive behavior of couples undergoing sterilization in an Eastern State of India.

BACKGROUND: As a part of a larger study for evaluating the effectiveness of a community-based family welfare program, this study assessed the contraceptive behavior of couples preceding sterilization and termination of pregnancies, if any during the interim period. METHODS: During May-June 2013, a cross-sectional study was undertaken in three districts of Odisha, an eastern state of India with poor maternal health indicators. Using a 15 × 14 cluster design with probability proportionate to size sampling 15 village clusters from each district were selected. Seven beneficiaries from the catchment area of two Accredited Social Health Activist of the selected villages were interviewed (14 respondents from each village) using a pretested predesigned questionnaire. RESULTS: A total of 630 clients with either of the partner having undergone sterilization were interviewed. Male partner having undergone vasectomy was < 1% (n = 3). The mean age (standard error mean [SEM]) of the respondent women was 34.54 ± 0.26 years. The mean age of the women at the time of sterilization was 27.12 (standard deviation [SD], 3.8, SEM 0.15 and median 26.83 years) years. Women as young as 22 years had undergone sterilization. Average family size was 2.81 with about 29 respondents (4.5%) having 5 or more children. The average duration between the last childbirth (LCB) to the date of sterilization was 18.37 months (range: 1-142 months, SD: 24 months, SE: 10 months). Seventy-two percent of the respondents did not use any method of contraception during this period. Methods adopted for contraception among the users was pill (20%) followed by condom (7%), and intrauterine contraceptive device (IUCD) was least used (0.2%). Ten percent of the women had undergone abortion before sterilization either once (7.9%) or more than once (2.1%). CONCLUSION: There was a gross delay in sterilization after LCB. Postpartum sterilization or IUCD were also not used frequently.

The pill and breast cancer: is there a connection?

PIP: Experts remain unsure if using oral contraceptives increases the chances that a woman will contract breast cancer. Although early studies generally indicated that there was no connection between pill usage and breast cancer, 3 recent longterm reports suggest otherwise. The Fertility and Maternal Health Drugs Advisory Committee of the Food and Drug Administration concluded that the new studies were inconclusive and recommended no changes to labeling of the pill. Known risk factors for breast cancer are a woman's age, menstrual history, reproductive experience, diet, benign breast disease, and family or personal history of breast cancer. In a reexamination of 1 of the studies, the risk of breast cancer was found to increase fourfold before age 54 for a subgroup of women--those who began menstruating before age 13, had no children, and had used the pill for more than 8 years. The 2nd study found that breast cancer risk by age 45 doubled for women using the pill for less than 10 years and quadrupled when used for at least 10 years. However, the overall risk did not increase according to length of pill usage. The 3rd study found a 200% increase in breast cancer among women aged 30-34 years who had previously used the pill, but no correlation in the overall results. Additional research following pill users over as long a period of time as possible should be undertaken. The National Cancer Institute will begin a 3-year study involving 2,000 American women in mid-1989 to examine roles of oral contraceptives, alcohol, and diet in breast cancer risk. It also will look at possible reasons for discrepancies found in the previous studies.^ieng

Determinants of genital human papillomavirus infection in young women.

Carcinoma of the cervix has several well-established epidemiologic risk factors, including multiple sexual partners and early age at first intercourse. Human papillomavirus (HPV) infection appears to have an etiologic role in the development of cervical neoplasia, but evidence linking HPV infection to known risk factors for cervical cancer has been inconsistent. The lack of expected correlations may be due to the inaccuracy of HPV assays previously used. A polymerase chain reaction DNA amplification method for the detection of HPV was used to investigate the determinants of genital HPV infection in a cross-sectional sample of 467 women attending a university health service. In contrast to studies using less accurate detection methods, the risk factors for HPV infection found here were consistent with those for cervical neoplasia. The risk of HPV infection was strongly and independently associated with increasing numbers of sexual partners in a lifetime, use of oral contraceptives, younger age, and black race. Age at first intercourse, smoking, and history of a prior sexually transmitted disease were correlated with, but not independently predictive of, HPV infection. These results demonstrate that the key risk factors for cervical carcinoma are strongly associated with genital HPV infection. This correlation suggests that HPV has an etiologic role in cervical neoplasia and reaffirms the sexual route of HPV transmission.

Risk factors for invasive cervical cancer among Latinas and non-Latinas in Los Angeles County.

A case-control study among white women in Los Angeles County was conducted to investigate etiologic factors that might explain the high rates of invasive cervical cancer among Latinas. Two hundred patients with invasive squamous cell carcinoma of the uterine cervix and matched (age, sex, preferred language, and neighborhood) controls were interviewed, 98 pairs in English and 102 pairs in Spanish. Seven factors were found to contribute independently and significantly (P less than .01) to risk, each after adjustment for the other six: years since last Pap smear, years of education (protective), frequency-years douching, pack-years of smoking, years of barrier contraceptive use (protective), number of sexual partners before age 20, and recognized episodes of genital warts. An eighth variable, interval in years between menarche and first intercourse, was the second variable to enter the stepwise logistic regression analysis but lost its statistical significance when sexual partners before age 20 entered the model. Together, these eight variables accounted for almost 99% of the risk. There were no significant interactions between any of these variables and age, language of interview, or birth in a Latin country. There was no increased risk associated with use of oral contraceptives, either before or after adjustment for the other significant factors. Compared to English-speaking controls, Spanish-speaking controls smoked less, douched less, had fewer sexual partners before 20, and had essentially the same average interval between menarche and first intercourse and the same average number of episodes of genital warts; however, they had had a longer interval since their last Pap smear, fewer years of barrier contraceptive use, and fewer years of education. Education, presumably a correlate of an inadequately measured etiologic risk factor (possibly papillomavirus infection), was responsible for the greatest difference in risk between the Spanish- and English-speaking cases.

Case-control study of borderline ovarian tumors: reproductive history and exposure to exogenous female hormones.

Borderline ovarian tumors possess many of the same morphological features as their malignant counterparts, but they do not destructively invade the ovarian stroma, and the women in whom they develop generally have a favorable prognosis. Female residents of three urban counties of western Washington diagnosed with serous and mucinous borderline ovarian tumors between 1980 and 1985 (n = 116) were interviewed regarding past reproductive events. A random sample of women from the same counties (n = 158) was identified through random digit dialing and were interviewed. The risk of these ovarian tumors among women who had given birth to 1 or 2 children and to 3 or more children was, respectively, 0.7 and 0.4 that of nulliparous women. There was no consistent influence of increasing age at first live birth. Adjusting for parity, a history of lactation was associated with a 50% reduction in risk. Among nulliparous women, a further increase in risk was present in those who reported a history of infertility. Use of oral contraceptives was associated with a 60% reduction in risk. However, the size of the association was not dependent on duration, age at first use, or years since last usage. In conclusion, borderline tumors appear to have similar epidemiological patterns with regard to reproductive events as their more malignant counterparts.

PIP: Women residing in 3 urban counties of western Washington State diagnosed with serous and mucinous borderline ovarian tumors or grade 1 malignancies, between 1980 and 1985 were interviewed to assess risk factors related to reproductive history. 121 subjects were interviewed in person, and compared to 158 controls ascertained and interviewed by random sampling via telephone. The stratified analysis technique, adjusting for parity, revealed a 60% reduction of risk in users of oral contraceptives, although neither duration, nor age at 1st use or years since last use of pills had any effect. Similarly, lactation reduced risk 50%, without any influence of duration. The reduction in risk with pill use was largely confined to women who had their 1st child after age 21. Having had 1 or 2 children conferred 0.7 of the risk of nulliparas, and 3 or more children 0.4. A history of miscarriage, but not of induced abortion, was more common in cases than in controls. History of tubal ligation was negatively correlated with borderline tumors, in women whose sterilization was less than 12 years before diagnosis. In general, borderline tumors have similar epidemiological patterns to those of malignant ovarian tumors, with-increased risk for nulliparas, women reporting infertility, those who have used oral contraceptives, and those who have not lactated.

Risk factors for in situ cervical cancer: results from a case-control study.

A case-control study of 293 patients with in situ cervical cancer and 801 community controls was conducted between 1982 and 1984 in five geographic areas in the United States. Relative risk (RR) was elevated among women reporting multiple sexual partners (RR for greater than or equal to 5 partners = 5.0), a history of an abnormal Papanicolaou smear (RR = 5.0), interval since last Papanicolaou smear (RR for greater than or equal to 10-year interval versus 0- to 2-year interval = 4.1), use of oral contraceptives (RR for greater than or equal to 10 years use = 1.4), a history of nonspecific genital infection (RR = 2.6), and smoking (RR for current smokers = 1.9). Risk was low among diaphragm users (RR for greater than 2 years use = 0.5). Neither age at first coitus nor number of births was predictive of risk of in situ disease. Comparisons between this analysis and risk factors previously identified for invasive cervical cancer in this same study indicate that the risk factors were quite similar.

Population-based case-control study of ovarian cancer in Shanghai.

A case-control study of 229 ovarian cancer cases (including 172 epithelial tumors) and an equal number of population-based controls was conducted during 1984 to 1986 in Shanghai, China, a low-risk area for ovarian cancer. Similar to studies in high-risk areas, the risk of epithelial tumors was high for nulliparous women (odds ratio, 1.6; 95% confidence interval, 0.8 to 3.2) and decreased with increasing number of livebirths (P less than 0.01). Early menarche and late menopause were associated with increased risk, with the trend in risk for age at menarche being statistically significant. In contrast to other studies, oral contraceptive use was not associated with reduced risk, although there was some reduction in risk for those with a prior tubosterilization or intrauterine device use. Risk was also elevated among those reporting a prior ovarian cyst, medroxyprogesterone use, a first degree family history of cancer, and occupational exposure to paint. Risk factors for the nonepithelial tumors were similar to the other cancers, although the power to detect differences was limited.

Contraception for the insulin-dependent diabetic woman: the view from one clinic.

Experience in a large diabetic clinic has confirmed the suspicion that insulin-dependent diabetic women are at considerably increased risk of thromboembolic disease if they take combined estrogen/progestogen oral contraceptive preparations. The most obvious alternative, an intrauterine device, is associated with an unexpectedly high failure rate, probably because of an unusual metabolic interaction with the diabetic endometrium. In a small group of diabetic women the progestogen-only pill was found to be a successful form of contraception not associated with any side effects except for menstrual irregularities. For most diabetic women the choice of contraceptive should therefore be between a progestogen-only pill and a mechanical method. Female sterilization and injectable progesterone each have their place in particular circumstances. Careful counseling of each patient is essential to ensure the best choice of contraceptive and correct application of the chosen method.

PIP: Experience in a clinic for diabetics is recounted in terms of successful methods of contraception for the insulin-dependent woman. Earlier reports of increased risk to side effects (especially thromboembolic disease) and failure in women with diabetes using combined (estrogen/progestin) oral contraception were confirmed. The failure rate could be lowered by allowing the women to adjust their insulin dose, but the incidence of thrombotic disorder remains high. Of 120 insulin-dependent women taking the combined pill (compared with 156 nonuser diabetics) 6 patients had thrombotic episodes, whereas none of the controls did. The use of IUDs is discouraged among diabetic women because of an extremely high failure rate, probably caused by an unusual metabolic interaction with the diabetic endometrium. In this clinic, a small (n=45) group of women was given progesten-only contraceptives (norethisterone, .35 mg orally) and, of the 29 completing over a year on the preparation, 15 have had fairly regular bleeding and 14 have experienced very irregular cycles. Aside from the menstrual irregularity, the progesten-only pill proved successful; no pregnancies have occurred. This method is the recommended one for diabetic women. Equally successful with proper fitting and instruction were mechanical methods. Sterilization is only indicated when the family is completed or pregnancy is absolutely contraindicated.

The effectiveness of condom use in heterosexual prostitution in The Netherlands.

OBJECTIVES: To assess the extent to which condoms are used effectively in commercial heterosexual intercourse. Data on the number of condoms that had broken or slipped off, the sexual technique during which this had occurred and the perceived cause of failure were collected. The use of non-water-soluble lubricants and non-fortified condoms during anal intercourse, and the demand for a greater variety of condom sizes were also examined. SUBJECTS AND METHODS: One hundred and twenty-seven female prostitutes and 91 male clients from different parts of The Netherlands were interviewed face-to-face between July 1990 and March 1991. RESULTS: Of those who used condoms during vaginal intercourse, 49% of the prostitutes had experienced condom breakage in the previous 6 months, and 16% of the clients in the previous 12 months. The breakage rate was 0.8% for prostitutes and 1.5% for clients. Condom quality was seldom reported as the cause; breakage was generally attributed to human factors, such as rough or prolonged intercourse, incorrect handling of the condom or the use of insufficient lubricant. Prostitutes also identified penis size as a cause. Condoms slipping off before or after ejaculation was reported less frequently than breakage. Thirteen per cent of clients and 36% of prostitutes expressed a need for either smaller or larger condoms. Of the prostitutes, 9% used oil or vaseline as a lubricant. CONCLUSIONS: In view of the low rate of condom failure in heterosexual prostitution in The Netherlands, the potential spread of HIV by this means is small. The use of a greater variety of condom sizes may further reduce the failure rate. Few prostitutes remain ignorant about the adverse effects of oil-based lubricants on condoms.

Determinants of condom use among intravenous drug users.

OBJECTIVE: To examine the factors associated with condom use among a cohort of sexually active intravenous drug users (IVDU). DESIGN: Data were collected via personal interview at the fourth-month assessment point of a longitudinal study monitoring HIV infection and risk behaviors among IVDU. SETTING: A community-based methadone clinic. PARTICIPANTS: A total of 158 sexually active heterosexual male and female IVDU, including both methadone patients and out-of-treatment individuals with a history of opiate abuse. MAIN OUTCOME MEASURES: We describe a new approach to identify the determinants of condom use. Previous studies have described subjects as either 'condom users' or 'condom non-users', using an individual's overall behavior as the unit of analysis. By analyzing condom use during the most recent sexual encounter, we avoided the problem of interpreting inconsistent condom use. Data were analyzed using forward stepwise logistic regression. RESULTS: Thirty-four per cent of the heterosexual subjects (n = 160) reported using a condom during their last sexual encounter. Being HIV-positive and having either a causal or commercial partner were each associated with increased probability of using a condom (odds ratio, 10.6, 4.4 and 12.1, respectively). No interactions with sex were found. CONCLUSIONS: Our results suggest that knowing that one is HIV-positive is an important determinant of condom use; HIV testing may therefore increase the use of condoms. In addition, interventions to change sexual behaviors may need to focus on the type of sexual partner.

PIP: This study was conducted to assess the factors associated with condom use among a cohort of sexually active intravenous drug users (IVDU) sampled from a community-based methadone clinic in Philadelphia, Pennsylvania. Personal interview data were taken from 158 sexually active heterosexual male and female IVDUs at the 4-month assessment point of a longitudinal study monitoring HIV infection and risk behaviors among them. The patient sample included methadone patients and out-of-treatment individuals with a history of opiate abuse. to avoid the problem of interpreting inconsistent condom use, investigators queried condom use among participants only at their most recent sexual encounter. 34% reported using a condom at last sexual encounter. Being HIV-seropositive and having either a casual or commercial partner were each associated with increased probability of using a condom. Knowing that one is HIV-seropositive is therefore an important determinant of condom use which suggests that HIV testing may increase condom use. Interventions to change sexual behavior may also need to focus upon the type of sexual partner.

Incident HIV-1 infection in a cohort of young women in Butare, Rwanda.

OBJECTIVE: To determine the incidence of HIV-1 infection and associated risk factors among young, seronegative, and sexually active women in a mixed rural and urban population in southern Rwanda. DESIGN: A prospective cohort study. METHODS: Between October 1991 and April 1993, we completed a 2-year follow-up survey among HIV-1-seronegative women aged < or = 30 years at the time of their initial HIV-1 screening during pregnancy. All women aged < or = 25 years and a randomly selected sample of 26-30-year olds were invited to participate from five prenatal clinics in the Butare region. The interview focused on potential risk factors for HIV-1 acquisition during the 2-year interval between blood collection. RESULTS: Out of 1524 women selected, 1150 (75%) participated in the follow-up survey. The 2-year incidence of HIV-1 infection was 2.7% [95% confidence interval (CI), 1.8-3.9]. Teenage women were at the highest risk (incidence, 10.5%; 95% CI, 5.2-19.4), with incidence leveling off with increasing age (P < 0.001). Women who began sexual activity recently were also at higher risk; the lowest risk category consisted of women aged 26-30 years with 5 or more years of sexual experience. The more urban the geographic residence of the woman, the more likely she was to have acquired HIV-1 infection (P < 0.001). In the urban and peri-urban zones, the poorest women were at significantly higher risk of incident HIV-1 infection than women reporting higher household income. In a multivariate analysis, young maternal age, marital status (being single, divorced or widowed), multiple sexual partners, and a history of sexually transmitted diseases remained strongly associated with incident HIV-1 infection. Geographic residence, hormonal contraception, and receipt of injections were no longer significantly associated with incident HIV-1 infection when these other factors were accounted for simultaneously. CONCLUSION: Among young Rwandan women, the early years of sexual activity are particularly dangerous for acquisition of HIV-1 infection. Interventions should focus on young teenagers before they become sexually active.

Sustaining safe sex: a longitudinal study of a sample of homosexual men.

OBJECTIVE: TO assess the maintenance of safe sexual practice. (We use the term 'safe' sex throughout the paper, since 'safe' is the term adopted by the Australian National Committee on AIDS). DESIGN: Maintenance was assessed by comparing sexual behaviour with both regular and casual partners reported in a 1986/1987 survey (time 1) with behaviour reported in a second survey in 1991 (time 2). METHOD: The 145 homosexually active participants were a non-clinical sample recruited in 1986/1987 by advertisement and followed-up in 1991. A structured questionnaire was administered at both times. Items included questions about the nature of the men's sexual relationships and their sexual practices. RESULTS: Our findings indicate that the majority of men had sustained safe sex practices. HIV prevention strategies adopted included condom use, avoidance of anal intercourse and negotiated safety (i.e., the negotiated practice of unprotected anal intercourse within regular partnerships of concordant serostatus). CONCLUSIONS: Negotiated safety is not the same as relapse.

PIP: This study assesses the extent to which safe sex practices are being maintained in a longitudinally followed cohort of 145 homosexually active men. The nonclinical sample was recruited in 1986/87 by advertisements and followed-up in 1991 with questionnaires on the nature of their sexual relationships and their sexual practices. Sex behavior with regular partners was compared with sex behavior with casual partners over the time period. The majority had sustained safe sex practices including condom use, avoidance of anal intercourse, and negotiated safety. This latter practice refers to the negotiated practice of unprotected anal intercourse with regular partners of concordant serostatus and should not be considered a relapse to unsafe sex.

Safer sex among gay men: what is the ultimate goal?

PIP: Sex between homosexual partners in anything other than a mutually monogamous relationship between 2 HIV-negative people involves some risk of virus transmission; a condom must be used during anal intercourse to be considered safe. People, however, have the right to take risks and harm reduction is a long-term, stepwise process. Gay men receive multiple messages which either advocate risk-taking or preach that their sexual needs are bad. Instead of blaming people who occasionally engage in unprotected anal intercourse, people should be trained in skills to reduce their risk; safe sex should be eroticized; and attention should be given to interpersonal or social conditions which may lead to unsafe sex. Society must be challenged to support the messages of risk reduction and the sexual needs of all members of society. The authors further call for the recognition of various risk reduction strategies such as negotiated safety taken by gay men despite the potential problem of this strategy which relies upon the ability of sex partners to reveal their serostatus. The authors also stress that while the goal of eliminating unsafe sex and new HIV infections must be upheld, it is untenable. The understanding that this goal will never be realized, however, does not mean that efforts should not continue to educate and convince people to take better care of themselves. While no infringing upon individual rights, researchers should help prevent all future HIV infections.^ieng

Safer sex maintenance among gay men: are we moving in the right direction?

PIP: Public health messages aimed at checking the sexual spread of HIV call for an end to unsafe sex practices. This goal, is however, unrealistic. The position is neither sustainable nor epidemiologically necessary, but is an unnecessary restriction on the desire and action of individuals and couples trying to create a sustainable combination of safety and pleasure based on a thorough understanding of what is safer sex. Focusing exclusively upon the practice of anal intercourse between men who have sex with men, the author argues that while unprotected anal intercourse is unsafe, it is not always and in every circumstance equally unsafe. For example, 2 men may be regular sex partners who enjoy an honest, trusting, and steady relationship. When and if 1 of the men has casual sex with a 3rd men, he does not engage in anal sex. While this behavior is not absolutely safe, it is safer than having, for example, unprotected anal sex with both his regular partner an casual partners. Humans function under heuristic rules where risk tends not to be eliminated but simply minimized. This behavior is an extremely deep feature of human interaction and should be encouraged instead of condemned. A high proportion of recent returns to unsafe sex among these men involves this sort of negotiated instead of absolute safer sex. These emergent strategies of negotiated safety must be encouraged and facilitated instead of condemned as irresponsible. Finally, the author recommends caution in translating epidemiological markers into prescriptions for individual behavior; he also recommends trying to reflect the complexity of what is happening in study populations in epidemiological categories and recognizing the robust humanity of men under study instead of seeking out their weaknesses.^ieng