Assessment of non-marital sexual behaviours of men in Bangladesh: a methodological experiment using a modified confidential ballot-box method.

This study assessed the effectiveness of a modified ballot-box method (MBBM) in eliciting non-marital sexual behaviours compared with face-to-face interview (FTFI). A cross-sectional survey collected data from men aged 18-49 years in Bangladesh using a multistage cluster sampling method. In total, 3499 and 3623 respondents were interviewed by MBBM and FTFI, respectively. In the MBBM, pre-recorded questions were administered using a portable audio-cassette player with two pairs of headphones used concurrently by the respondent and the interviewer. Overall, 18% of the respondents had non-marital sexual exposure in the past year. The MBBM elicited higher responses of non-marital sex (adjusted odds ratio (aOR) 1.3, 95% confidence interval [CI]: 1.1, 1.5) compared with FTFI. The interview methods did not, however, revealed significant differences in response to condom-use rates and the number of non-marital sexual partners. The MBBM is more effective than the FTFI method in eliciting higher responses rates of non-marital sexual contacts and may be recommended for reliable estimates of sexual behaviours.

Surveillance and modelling of HIV, STI, and risk behaviours in concentrated HIV epidemics.

BACKGROUND: HIV epidemics in most countries are highly concentrated among population subgroups such as female sex workers, injecting drug users, men who have sex with men, mobile populations, and their sexual partners. The perception that they are important only when they cause epidemic expansion to general populations has obscured a critical lack of coverage of preventive interventions in these groups, as well as appropriate methods for monitoring epidemic and behavioural risk trends. The difficulties in accessing such groups have likewise often cast doubt on the representativeness of observed disease and behavioural risk estimates and their validity and reliability, particularly those related to sampling and the measurement of risk behaviours. OBJECTIVES: To review methodological obstacles in conducting surveillance with population subgroups in concentrated HIV epidemics, elaborate on recent advancements that partially overcome these obstacles, and illustrate the importance of modelling integrated HIV, STI, and behavioural surveillance data. METHODS: Review of published HIV, STI, and behavioural surveillance data, research on epidemic dynamics, and case studies from selected countries. CONCLUSIONS: The population subgroups that merit regular and systematic surveillance in concentrated epidemics are best determined through extensive assessment and careful definition. Adherence to recently refined chain referral and time location sampling methods can help to ensure more representative samples. Finally, because of the inherent limitations of cross sectional surveys in understanding associations between complex sexual behaviours and HIV and STI transmission, mathematical models using multiple year data offer opportunities for integrated analysis of behavioural change and HIV/STI trends.

Measuring the impact of needle exchange programs among injecting drug users through the National Behavioural Surveillance in Bangladesh.

Bangladesh is a low HIV prevalence country, with buprenorphine injectors having the highest prevalence of HIV at 2.5% as of 1999. Using National HIV Behavioral Surveillance data, the impact of a needle exchange program (NEP) on sharing behavior among injecting drug users in two cities was measured. Results showed positive changes that varied with the different settings. Those who reported utilizing the NEP were compared with those who did not. Differences in Dhaka were significant for the average proportion of needles shared but not for the proportion of men who ever shared in the last week. In Rajshahi, where professional injectors were the norm, the impact of an NEP was greater and affected both the proportion of needles shared as well as the proportion of men never sharing. Behavioral surveillance methods have the potential to measure intervention impact through comparative analysis in certain settings.

Preventing HIV infection through peer education and condom promotion among truck drivers and their sexual partners in Tanzania, 1990-1993.

HIV prevention through peer education and condom promotion among truck drivers and their sexual partners is described. Trends during an initial 18-month intensive phase, followed by a 24-month maintenance phase, were monitored with surveys. Trends for self-reported condom use were: increase among men (56 to 74%) during the first phase with a decrease (72%) during the maintenance phase. Respective figures for women were 51%, 91% and 70%. Multivariate analyses revealed that men most likely to report using condoms were unmarried, had children, were more educated, had previously reported a genital ulcer, and perceived themselves at risk for HIV infection (OR = 1.95-3.47). Women tending to use condoms were unmarried, aware of the limitations of condoms, not in denial as to the existence of HIV, harboured inaccurate information about HIV transmission and were afraid (OR = 1.35-2.52). Both sets of results suggest that the most sexually experienced men and women who did not have a permanent stable relationship and who perceived themselves at risk, were most likely to use a condom. Peer education was an effective tool for increasing knowledge and encouraging appropriate behaviour change. It was most effective as an intensive high-input intervention and sustainable with the relatively stable population of truck drivers.

AVERT: a user-friendly model to estimate the impact of HIV/sexually transmitted disease prevention interventions on HIV transmission.

OBJECTIVE: To introduce the newly developed AVERT model by describing the purpose, logic, advantages and limitations of the model, to validate the model's estimates against seroconversion data from a large randomized controlled trial, and to provide practical examples of its applications. DESIGN: Static, deterministic spreadsheet-type model based on per sex act HIV-1 transmission probabilities. METHODS: Data from a recently completed trial carried out in Cameroon were used to validate the estimated number of new HIV infections generated by the AVERT model. A relatively limited set of biological and behavioral parameters was used to estimate the impact of a targeted HIV/sexually transmitted disease (STD) prevention intervention in a South African mining community. RESULTS: The comparison of AVERT estimates with actual seroincidence data from the Cameroon trial not only confirmed the validity of the model's outputs but also illustrated its potential to provide additional options in data analysis. Modeling the pre-and post-intervention scenarios for the South African mining community with AVERT provided estimates of the number of HIV infections averted due to targeted periodic presumptive STD treatment and community-based peer education. CONCLUSIONS: With a small number of accessible input variables, AVERT can provide plausible and defendable impact estimates of intervention effects on the reduction of HIV transmission. The AVERT model may be a helpful tool for decision-makers and planners in setting appropriate program priorities and analysing the cost-effectiveness of different intervention packages.

HIV risk behavioral surveillance: a methodology for monitoring behavioral trends.

OBJECTIVE: This article summarizes issues and recommendations for conducting HIV risk behavioral surveillance surveys (BSS) based on experiences from ten BSS projects in eight countries in Asia and Africa. BACKGROUND: BSS consists of systematic and repeated cross-sectional surveys of HIV and sexually transmitted disease-related behaviors, with other knowledge and attitudinal variables added where appropriate. Its major purpose and utility is in detecting trends among selected vulnerable and high-risk population groups whose behavioral change can have the most impact on the epidemic. BSS is also useful for tracking trends in behaviors over time in regions exposed to HIV prevention activities, as a contributing component to the comprehensive monitoring and evaluation of interventions. RECOMMENDATIONS: (i) implement BSS as an essential adjunct to HIV/STD epidemiological surveillance; (ii) use BSS for evaluation purposes in combination with process data and triangulate results with qualitative research; (iii) choose sentinel groups based on epidemiological considerations, evaluation and monitoring needs, representative sampling frames, and political and cultural considerations; (iv) maintain 1-year intervals between survey waves for most groups in order to provide yearly updates on behavioral trends for programmatic adjustments; (v) use internationally standardized indicators and question wording; (vi) maintain strict quality control standards to enhance data validity and reliability; and (vii) develop a clear dissemination strategy during BSS design to increase the likelihood of utilization of BSS results. CONCLUSION: BSS represents a cost-effective way to determine whether programmatic behavioral targets and goals are being met, to identify persisting risk behaviors over time, and to indicate whether new intervention approaches are necessary.

PIP: Public health personnel have long monitored the distributions and trends of communicable and noninfectious diseases. Only recently, however, have efforts been made to monitor risk factors or behaviors which are themselves determinants of disease. Behavioral surveillance systems have been brought on line over the past 25 years to monitor risk factors such as cigarette smoking, drug and alcohol consumption, dietary factors, and physical exercise. The HIV risk behavioral surveillance survey (BSS) methodology is designed to systematically monitor trends in HIV risk behaviors over time in key, high-risk population sub-groups whose behavioral change can have the most impact upon the epidemic. BSS is conducted through repeated cross-sectional surveys conducted at regular intervals on a national or regional scale. BSS is also useful in tracking behavior trends over time in regions exposed to HIV prevention activities, as a contributing component to the comprehensive monitoring and evaluation of interventions. Recommendations for conducting BSS are drawn from the collective experiences of 10 BSS projects conducted in Thailand, the Philippines, Senegal, India, Indonesia, Cambodia, Hong Kong, and China between 1993 and 1997.

Indicators and the measurement of STD case management in developing countries. STD PI6&7 Working Group.

The paper reviews methodologies for measuring quality of sexually transmitted disease (STD) case management through facility based assessments. These include observations and interviews of providers, as promoted by the World Health Organization's Global Programme on AIDS, and some of the viable alternatives including patient exit interviews, mystery patients, record review and patient encounter forms with supervisory visits. The paper concludes that the alternative approaches are feasible in resource poor settings and that they provide crucial data for evaluation and continued program development.

Targeted intervention research studies on sexually transmitted diseases (STD): methodology, selected findings and implications for STD service delivery and communications.

OBJECTIVE: To report the findings of qualitative studies designed for use in improving sexually transmitted disease (STD) programs. The studies explore illness conceptions and treatment behaviors for STD in five African countries. These targeted intervention research (TIR) studies were performed on clinic-based and community-based samples in representative communities and utilized a variety of qualitative research methods (e.g. in-depth and key informant interviews, focus group discussions). FINDINGS: Study findings revealed that community members' explanations of symptoms, classification of illnesses, and perceptions of whether symptoms are pathological or serious influence individual health-care-seeking behaviors. Data also showed that local terms for STD are often disparaging and do not fit into biomedical designations. STD patient care-seeking frequently reflects an ordered, albeit loosely constructed, process of elimination in pursuit of symptom relief, wherein alternative treatments are tried and proven effective or abandoned. CONCLUSIONS: The TIR studies highlight the importance of community-specific strategies aimed at increasing prompt care seeking at qualified biomedical facilities. Information from study data should lead programs to sensitize health professionals to community understanding about STD and to design services and communication programs that are meaningful and appropriate to local contexts.

PIP: Targeted intervention research (TIR) studies were performed in five African countries (Senegal, Ethiopia, Benin, Morocco, and Swaziland) to improve the utilization of a community perspective in sexually transmitted disease (STD) programs. TIR, conducted by program managers with the aid of a multidisciplinary technical advisory group, examines factors at five levels of analysis (individual, social network, organization, community, and policy) through a variety of qualitative methods. The TIR studies indicated that patients' conceptions of normal versus abnormal health are fundamental to the process of interpreting symptoms and subsequently seeking care. The interpretation of STD symptoms varied across settings (e.g., vaginal lesions and discharge were considered signs of healing in Morocco and Benin), but increasing pain and discomfort were key triggers to seeking treatment. The concept of sexual transmission was blended with other causes such as violation of religious or moral codes, consumption of certain foods, and supernatural forces. Care-seeking tended to reflect an ordered yet loosely constructed process of elimination in pursuit of symptom relief, beginning with alternative regimens. Barriers to biomedical STD care included the need for husband's permission, costs, confidentiality concerns, long waits in public clinics, and fear of judgmental health provider attitudes. Overall, the findings highlight the importance of location-specific strategies aimed at increasing prompt care-seeking at qualified biomedical facilities.

[The prevalence of HIV and risk behavior of prostitutes living in 2 populous regions of Bujumbura (Burundi)]. / Prévalence du VIH et comportements à risque chez les prostituées vivant dans deux quartiers populeux de Bujumbura (Burundi).

This study was designed to determine the prevalence of HIV infection and associated high-risk behavior in female sex workers in two areas of Bujumbura (Bwiza and Musanga), Burundi. Between June 15th and July 15th 1993, 320 female sex workers responded to an anonymous questionnaire and gave a blood sample on filter paper for detection of HIV antibodies. The mean age of the prostitutes was 24.6 (+/- 5.9) years (range 15 to 46). The HIV infection rate was 42.2% (135 of the 320). Univariate analysis showed that the proportion of HIV-infected female sex workers was higher in the Musaga area than in Bwiza (48.3% versus 34.3%; p = 0.012). The prevalence of HIV infection increased with age (24.3% for those aged between 15 and 19; 40.8% for those aged between 20 and 24 and more than 51.4% infected in the over 25 age-group; p < 0.001). The median number of sexual partners in the preceding month was 3 (range 1 to 50) and was not correlated with HIV infection (Wilcoxon's test: p = 0.516). HIV infection was highly correlated with a previous history of STDs (62.7% versus 32.7%; p < 0.001) and was also correlated with STD symptoms (87.5% versus 51.7%; p = 0.01). The only factors correlated with HIV infection in multivariate analysis were age (p = 0.008; Trend's test) and previous history of STDs (p < 0.001). Only 40.2% (127 of 316) of the female sex workers had used condoms with their clients during the preceding month. Intervention strategies to combat HIV transmission among individuals with high levels of sexual activity in Burundi should focus on the female sex workers and their clients, particularly the manual laborers, drivers, soldiers, prisoners and other men who regularly use prostitutes. The prevention of HIV infection in individuals of high-risk groups is the best strategy to reduce HIV transmission in the general population of developing countries.

Validation of a method to estimate age-specific human immunodeficiency virus (HIV) incidence rates in developing countries using population-based seroprevalence data.

The authors have conducted an analysis to validate a computer model that uses age-specific human immunodeficiency virus (HIV) prevalence data to estimate age-specific HIV incidence rates. Data for the analysis are from a cohort study of volunteer male workers in Bujumbura, the capital city of Burundi. Testing for HIV prevalence was conducted at baseline, and HIV-negative subjects were retested annually from 1990 to 1993 to determine rates of seroconversion. Input parameters required for the model include age-specific HIV prevalence and estimates of age-specific mortality rates for HIV-negative and HIV-positive subjects. Incidence rate estimates from the model were 2.0, 2.7, 1.0, 1.5, and 1.8 per 100 person-years for age groups 20-24, 25-29, 30-34, 35-39, and 40-44 years, respectively. Corresponding observed incidence rates for the same age groups were 1.6, 1.8, 2.2, 2.3, and 1.5 per 100 person-years, respectively. Most observed incidence rates fell within the 95% confidence limits of the model estimates. Expected numbers of cases within age intervals did not differ significantly from observed number of cases. The authors conclude that the model proved to be successful in approximating observed incidence rates and that it is a useful tool, particularly in countries where prevalence data are available and where HIV prevalence has stabilized, which is when the underlying assumptions in the model are best met. The model provides crucial information about incidence rates that might not be evident from prevalence data alone.

PIP: The authors conducted an analysis to validate a computer model which uses age-specific HIV prevalence data to estimate age-specific HIV incidence rates. Data for the analysis are from a cohort study of volunteer male workers in Bujumbura, Burundi. Subjects were tested at baseline for infection with HIV, with the HIV-negative subjects retested annually from 1990 to 1993 to determine rates of seroconversion. The computer model requires the input of age-specific HIV prevalence and estimates of age-specific mortality rates for HIV-negative and HIV-positive subjects. The model produced incidence rate estimates of 2.0, 2.7, 1.0, 1.5, and 1.8 per 100 person-years for age groups 20-24, 25-29, 30-34, 35-39, and 40-44 years, respectively. Corresponding observed incidence rates for the same age groups were 1.6, 1.8, 2.2, 2.3, and 1.5 per 100 person-years, respectively. Most observed incidence rates fell within the 95% confidence limits of the model's estimates such that the expected numbers of cases within age intervals failed to differ significantly from the observed numbers of cases. The authors believe that the model successfully approximated the observed incidence rates. It may therefore be highly useful in countries where prevalence data are available and where HIV prevalence has stabilized.