Facing HIV infection and unintended pregnancy: Rakai, Uganda, 2001-2013.

BACKGROUND: Unintended pregnancy is a persistent and global issue with consequences for the health and well-being of mothers and babies. The aim of this paper is to examine unintended pregnancy over time in the context of substantial human immunodeficiency virus (HIV) prevalence and increasing access to anti-retro viral therapy (ART). METHOD: Data are from the Rakai Community Cohort Study (RCCS) - a cohort of communities with 10,000-12,000 adults, ages 15-49, in Rakai District, Uganda. We examined prevalence of current pregnancies over time, intended pregnancy, and unintended pregnancies (unwanted, mistimed, ambivalent). We then examined risk factors for the different categories of unintended pregnancy among women who were currently pregnant. The full sample included 32,205 observations over 13 years. RESULTS: The prevalence of mistimed pregnancy and unwanted pregnancy both decreased significantly over time (p < .001). The prevalence of current pregnancies and intended pregnancy showed no significant changes over the thirteen year period. The same overall pattern was found when only examining HIV positive women in the sample; however, the trends were not significant. Out of the 2820 current pregnancies reported, 54.4% were intended, 29.8% were mistimed, 13.2% were unwanted, and 2.5% were ambivalent. After controlling for other predictors, HIV status had no independent effect on mistimed pregnancy but had a significant effect on unwanted pregnancy (RRR = 2.44, 95% CI = 1.65-3.61, p < .001] and ambivalent pregnancy [RRR = 2.07; CI: 1.03 to 4.18, p = 0.041]. In 2004, after the introduction of ART, there was a decreased risk in unintended pregnancy [RR = 0.75; CI: 0.66 to 0.84, p < .001]. Women with a secondary education or higher also had a decreased risk in unintended pregnancy [RR = 0.70; CI: 0.70 to 0.92, p = 0.002]. DISCUSSION: HIV was an important predictor of unwanted pregnancy. Unintended pregnancy decreased in the sample over time which may be due to an increase in ART availability and rising levels of education.

Contraceptive knowledge, perceptions, and concerns among men in Uganda.

BACKGROUND: Low contraceptive uptake and high unmet need for contraception remain significant issues in Uganda compared to neighboring countries such as Kenya, Ethiopia, and Rwanda. Although prior research on contraceptive uptake has indicated that male partners strongly influence women's decisions around contraceptive use, there is limited in-depth qualitative research on knowledge and concerns regarding modern contraceptive methods among Ugandan men. METHODS: Using in-depth interviews (N = 41), this qualitative study investigated major sources of knowledge about contraception and perceptions of contraceptive side effects among married Ugandan men. RESULTS: Men primarily reported knowledge of contraceptives based on partner's experience of side effects, partner's knowledge from health providers and mass media campaigns, and partner's knowledge from her peers. Men were less likely to report contraceptive knowledge from health care providers, mass media campaigns, or peers. Men's concerns about various contraceptive methods were broadly associated with failure of the method to work properly, adverse health effects on women, and severe adverse health effects on children. Own or partner's human immunodeficiency virus (HIV) status did not impact on contraceptive knowledge. CONCLUSIONS: Overall, we found limited accurate knowledge about contraceptive methods among men in Uganda. Moreover, fears about the side effects of modern contraceptive methods appeared to be common among men. Family planning services in Uganda could be significantly strengthened by renewed efforts to focus on men's knowledge, fears, and misconceptions.

Women's Experiences With Feelings and Attractions for Someone Outside their Primary Relationship.

The purpose of this article is to explore women's experiences with attractions and feelings for people outside their primary romantic relationship. In an anonymous Internet-based survey, 160 women answered open-ended questions about crushes. Women had varied experiences with, and diverse strategies for, managing crushes. The majority of women reported the crush did not impact their primary relationship; participants also reported that these crushes improved their desire for their partner. The majority of women in this sample did not communicate with their partners about their crushes. This research can be used by therapists and counselors working with patients experiencing these feelings.

Establishment of safety paradigms and trust in emerging adult relationships.

There is a critical need to understand the interplay between relationship trust and public health outcomes. The purpose of this study was to develop an understanding of emerging adult women's processes of establishing trust in sexual relationships. Twenty-five women aged 18-24 years participated in semi-structured interviews. Throughout the interviews, women compared and contrasted experiences in which they felt comfortable engaging in sexual intercourse with a partner versus times in which they did not feel comfortable. Analysis was based on a critical qualitative research orientation. When asked to speak to instances when they felt comfortable having sex, most women spoke about relationship trust. Many participants conceptualised trust based on past experiences with bad relationships or sexual violence. Based on their previous experiences of feeling unsafe or undervalued, emotional and physical security became prioritised in relationship development. Trust was developed through friendship, communication over time, and through shared life experiences. This research is among the first to qualitatively investigate trust formation and other impersonal dynamics related to sexual health decision-making. Insights from this study should be translated into future action by public health practitioners to promote healthy sexual relationships and communication about sexual health topics as a form of trust building.

Sexual desire discrepancy as a feature, not a bug, of long-term relationships: women's self-reported strategies for modulating sexual desire.

INTRODUCTION: Sexual desire discrepancy is commonly reported by couples in long-term romantic relationships. Given the idiosyncratic nature of desire, and the lack of a "one size fits all" model approach to address desire concerns, it is useful to understand more about the range of ways that women and their partners modulate sexual desire. AIM: This study aims to assess women's strategies to influence their sexual desire and the self-reported effectiveness of these strategies. METHODS: One hundred seventy-nine women who had been in a relationship with a male partner for 5+ years completed an anonymous Internet-based survey. MAIN OUTCOME MEASURES: Participants responded to three open-ended items about the strategies they use to address desire issues and how helpful those strategies are. RESULTS: The most common responses regarding what participants did to get desire back on track included: communication, trying to meet partner's needs, having sex without desire, and having patience/letting time work out the problem. Women also mentioned several specific strategies they had employed: communication, scheduling sex, lingerie, and a date night. However, a large number of women discussed that the issue was not resolved, and they were dissatisfied with attempted strategies. CONCLUSIONS: This research provides valuable insight into the construction of women's sexual desire and the strategies used to navigate sexual desire in long-term relationships.

The development and validation of a brief Quality of Sexual Experience (QSE) scale: results from a nationally representative sample of men and women in the United States.

INTRODUCTION: Much scientific research focuses on assessing and understanding individuals' perceptions of sexual pleasure, enjoyment and satisfaction. Many existing measures of pleasure and satisfaction provide valuable information but are limited in their ability to assess event-level quality. AIMS: To develop a scale for measuring the event-level quality of a sexual experience that could be used regardless of the age, gender, sexual orientation, and relationship status of the individual and across sexual activity types. METHODS: Interviews about the measurement of sexual quality and pleasure were conducted with 15 experts in the field of sexual health and informed the development of an event-level scale to measure the quality of sexual experiences. Scale items were administered to a cross-sectional nationally representative probability survey of Americans ages 18 to 60. MAIN OUTCOME MEASURES: Socio-demographic items; Quality of Sexual Experience (QSE) scale items; event-level items related to overall sexual quality ("Quality item"), comparison to other sexual events ("Comparison item"), and orgasm ("Orgasm item"). RESULTS: QSE scores were significantly correlated with responses to the Quality Item (r=0.901, P<0.001 for both women and men). Better experiences were associated with significantly higher QSE scores than were worse experiences; significant linear relationships were found for both women (GLM F[4,1461]=129.46, P<0.001) and men (GLM F[4,864]=71.84, P<0.001). QSE scores were significantly related to responses on the Orgasm Item for women [F[3,1430]=246.53, P<0.001] and men [F[3,858]=117.24, P<0.001]. CONCLUSIONS: The QSE scale is a valid and reliable event-level measure of the quality of a sexual experience in both women and men with outstanding psychometric properties. Clinical and research implications are discussed.

Sexual satisfaction and sexual health among university students in the United States.

Despite the World Health Organization's definition of sexual health as a state of well-being, virtually no public health research has examined sexual well-being outcomes, including sexual satisfaction. Emerging evidence suggests that sexual well-being indicators are associated with more classic measures of healthy sexual behaviors. We surveyed 2168 university students in the United States and asked them to rate their physiological and psychological satisfaction with their current sexual lives. Many respondents reported that they were either satisfied (approximately half) or very satisfied (approximately one third). In multivariate analyses, significant (P < .05) correlates of both physiological and psychological satisfaction included sexual guilt, sexual self-comfort, self-esteem (especially among men), relationship status, and sexual frequency. To enhance sexual well-being, public health practitioners should work to improve sexual self-comfort, alleviate sexual guilt, and promote longer term relationships.

HIV-Risk Behaviors of Men Who Perpetrate Intimate Partner Violence in Rakai, Uganda.

Little is known about men who perpetrate IPV in communities also at risk for HIV infection. Using data from the Rakai Community Cohort Study (RCCS), five survey rounds were used (n = 21,157, observation from n = 10,618 men) to examine HIV risk and prevention behaviors among men who reported acts of violence against their wife/primary partner in the past 12 months. Overall, 10.4% men reported perpetrating physical violence and 17.3% perpetrating verbal violence, 3.1% reported sexual violence, 3.1% used violence to have sex with their wife/partner, and 1.1% used verbal coercion. Factors associated with IPV were: age 20-24 years, lower socio-economic status, being married, no male circumcision, drinking alcohol before sex, no consistent condom use, multiple sex partners in the past 12 months, multiple partners ever, and working in a bar. Protective HIV behaviors predicted fewer reports of perpetration and HIV-risk behaviors predicted more reports of perpetrating IPV.

How Condom Discontinuation Occurs: Interviews With Emerging Adult Women.

We have almost no data on how and when couples stop using condoms. This qualitative study investigated the process of condom discontinuation. From November 2013 to April 2014, a total of 25 women living in a college town in the Midwest, ages 18 to 25, participated in semistructured interviews centered around three domains: partner interactions, contraceptive use, and sexually transmitted infection (STI) prevention. Analysis followed a critical qualitative research orientation. Participants described actively seeking the best options to prevent pregnancy, perceiving condom discontinuation in favor of hormonal methods as a smart decision, and reported wanting to discontinue using condoms due to physical discomfort. Oftentimes, nonverbal communication around contextual instances of condom unavailability paved the way for discontinuation. Participants indicated the decision to stop using condoms was neither deliberate nor planned. Condom discontinuation rarely occurred at one point in time; instead, it was preceded by a period of occasional use. Even after participants described themselves as not using condoms, sporadic condom use was normal (typically related to fertility cycles). This study provides a more detailed understanding of how and why emerging adults negotiate condom discontinuation, thereby enhancing our ability to design effective condom continuation messages. Attention should be paid to helping emerging adults think more concretely about condom discontinuation.

SCREENING FOR SEXUALLY TRANSMITTED INFECTIONS (STIs) AMONG A HETEROGENEOUS GROUP OF WSW(M).

OBJECTIVES: This study explored predictors of STI screening among a heterogeneous group of women who have sex with women and men. METHODS: Following bivariate analyses, a multivariate logistic regression model was conducted to assess the relationship between testing and sociodemographic, relationship characteristics. RESULTS: The majority of participants reported not receiving STI screening in the past year. Gender expression, and not sexual orientation, was a significant predictor of screening. For each increase in masculinity, participants had lower odds of receiving an STI test. CONCLUSIONS: More research is needed to understand how gender expression of WSW(M) relates to preventative health behaviors.

In their own words: a qualitative content analysis of women's and men's preferences for women's genitals.

Research increasingly shows genital attitudes have an impact on sexual well-being and health seeking behaviours. This study explored what women and men like and dislike about women's genitals. Data are from open-ended items, part of a cross-sectional Internet-based survey anonymously completed by 496 women and 198 men. Overall, both women and men had positive attitudes towards women's genitals, although there was overlap between likes and dislikes. Some of the most common likes for women related to aesthetics and for men related to tactile and sexual aspects. Men listed more likes than dislikes. The emphasis on both positive and negative messages provides a more complete image of the complex ways people interact with their own and other's bodies and can help tailor clinical and educational messages.

Community understandings of and responses to gender equality and empowerment in Rakai, Uganda.

Women's rights and gender empowerment programmes are now part of the international agenda for improving global public health, the benefits of which are well documented. However, the public health community has, yet, to address how people define and understand gender equality and how they enact the process of empowerment in their lives. This study uses safe homes and respect for everyone (SHARE), an anti-violence intervention in rural Rakai, Uganda, as a case study to investigate perceptions of gender equality. Investigators analysed 12 focus groups of adult women and men to explore how macro-level concepts of gender equality are being processed on an interpersonal level and the effects on health outcomes. Respondents generally agreed that women lack basic rights. However, they also expressed widespread disagreement about the meanings of gender equality, and reported difficulties integrating the concepts of gender equality into their interpersonal relationships. Community members reported that equality, with the resulting shift in gender norms, could expose women to adverse consequences such as violence, infidelity and abandonment with increased sexual health risks, and potential adverse effects on education. Efforts to increase women's rights must occur in conjunction with community-based work on understandings of gender equality.