Employment and contextual impact of safe and unsafe sexual practices for STI and HIV: the situation in China.

China's dual employment system plays a crucial role in sexually transmitted infections (STIs) and HIV-related safe and unsafe sexual practices among young Chinese people. Social and psychological determinants of safe and unsafe sexual practices for HIV infection among young people in Sichuan, China were examined. Our findings indicate that changes in China's social structure and employment system impact upon the social contextual involvement and socio-sexual practice of young Chinese people. The findings in the study suggest that the employment-related contextual involvement was a major predictor in the relationships between demography, information, and psychological risk-taking factors on one hand and the people's safe and unsafe sexual practices on the other. Self-employed people (officially called 'getihu') were more likely than the state-employed people to engage in unprotected sex with casual sexual partners. As China undergoes social restructuring and many state-employed people are laid off, the risk may also extend into the broader non-self-employed population as more state-employed people become involved not only in the self-employed getihu's socioeconomic activities but also in their unconventional socio-sexual practices. Collective vulnerability to STI and HIV, due to the current socio-sexual practices of the getihu young people, has created a new frontier for STI and HIV prevention in today's China, as well as demonstrating the importance of collective action with STI and AIDS prevention strategies within relevant social and sub-cultural contexts.

Condom use and HIV risk behaviors among U.S. adults: data from a national survey.

CONTEXT: How much condom use among U.S. adults varies by type of partner or by risk behavior is unclear. Knowledge of such differentials would aid in evaluating the progress being made toward goals for levels of condom use as part of the Healthy People 2000 initiative. METHODS: Data were analyzed from the 1996 National Household Survey of Drug Abuse, an annual household-based probability sample of the noninstitutionalized population aged 12 and older that measures the use of illicit drugs, alcohol and tobacco. The personal behaviors module included 25 questions covering sexual activity in the past year, frequency of condom use in the past year, circumstances of the last sexual encounter and HIV testing. RESULTS: Sixty-two percent of adults reported using a condom at last intercourse outside of an ongoing relationship, while only 19% reported using condoms when the most recent intercourse occurred within a steady relationship. Within ongoing relationships, condom use was highest among respondents who were younger, black, of lower income and from large metropolitan areas. Forty percent of unmarried adults used a condom at last sex, compared with the health objective of 50% for the year 2000. Forty percent of injecting drug users used condoms at last intercourse, compared with the 60% condom use objective for high-risk individuals. Significantly, persons at increased risk for HIV because of their sexual behavior or drug use were not more likely to use condoms than were persons not at increased risk; only 22% used condoms during last intercourse within an ongoing relationship. CONCLUSIONS: Substantial progress has been made toward national goals for increasing condom use. The rates of condom use by individuals at high risk of HIV need to be increased, however, particularly condom use with a steady partner.

PIP: The 1996 US National Household Survey on Drug Abuse obtained information on a comprehensive set of sex- and drug-related HIV risk behaviors. The sample was comprised of 9270 adults 18-59 years of age. A total of 21% of respondents (12.1% of married and 40.4% of unmarried adults) reported condom use in their most recent sexual encounter. Condoms were used by 19% of those whose last sexual intercourse occurred within a relationship compared with 62% of those whose last intercourse occurred outside of a relationship. Condom use in the context of a committed relationship was highest among respondents who were 18-25 years old (36.3%), Black (29.9%), low-income (24.2%), and from large metropolitan areas (21.2%) and among those with 2 or more sexual partners in the past year (35.3%). In contrast, condom use at last intercourse outside of an ongoing relationship was higher among males (65.3%), college graduates (66.2%), residents of the northeastern US (73.9%), those living in large metropolitan areas (68.9%), and those with two or more partners (65.5%). When the type of relationship was controlled, adults with HIV risk factors (homosexual sex, 6 or more partners, sex with HIV-infected persons, exchange of sex for drugs or money, use of illegal injection drugs in the past 3 years, crack cocaine use during the past year) were not significantly more likely to use condoms than those without these risk factors. Among individuals with one or more sex- or drug-related HIV risk factor, 22% used condoms during last intercourse within an ongoing relationship and 59.5% used condoms at last coitus in a casual relationship. Among adults with no such risk factors, these rates were 18.6% and 62.9%, respectively. Adoption of condom use by high-risk individuals must be increased, particularly with steady partners.

Sexual risk behavior among youth: modeling the influence of prosocial activities and socioeconomic factors.

Sexual activity among high-school-aged youths has steadily increased since the 1970s, emerging as a significant public health concern. Yet, patterns of youth sexual risk behavior are shaped by social class, race, and gender. Based on sociological theories of financial deprivation and collective socialization, we develop and test a model of the relationships among neighborhood poverty; family structure and social class position; parental involvement; prosocial activities; race; and gender as they predict youth sexual risk behavior. We employ structural equation modeling to test this model on a cross-sectional sample of 370 sexually active high-school students from a midwestern city; 57 percent (n = 209) are males and 86 percent are African American. We find that family structure indirectly predicts sexual risk behavior through neighborhood poverty, parental involvement, and prosocial activities. In addition, family class position indirectly predicts sexual risk behavior through neighborhood poverty and prosocial activities. We address implications for theory and health promotion.

PIP: Sexual activity among high school-aged youths has increased steadily since the 1970s, with more than half of high school students in 1990 being sexually active, and only about half of those individuals reporting that they or their sex partners used condoms during their most recent sexual intercourse. Patterns of youth sexual risk behavior and their consequences are, however, partly defined by social class, race, and gender. Based upon sociological theories of financial deprivation and collective socialization, the authors develop and test a model of the relationships among neighborhood poverty; family structure and social class position; parental involvement; prosocial activities; race; and gender as they predict youth sexual risk behavior. Structural equation modeling is used to test the model upon a cross-sectional sample of 209 male and 161 female sexually active high school students from Michigan. The students are 86% Black and of mean age 14.63 years. Family structure was found to indirectly predict sexual risk behavior through neighborhood poverty, parental involvement, and prosocial activities, while family class position indirectly predicts sexual risk behavior through neighborhood poverty and prosocial activities. Implications for theory and health promotion are considered.

Sexual initiation with older male partners and subsequent HIV risk behavior among female adolescents.

Data from a 1993-1994 survey of 150 black and Hispanic teenagers were used to examine differences in HIV risk-related behavior between young women who have a first sexual partner three or more years older than themselves and those whose first partner is their age. Compared with teenagers whose first partner had been roughly their age, the 35% of adolescents with an older partner had been younger at first intercourse (13.8 years vs. 14.6) and less likely to use a condom at first intercourse (63% vs. 82%). They also were less likely to report having used a condom at last intercourse (29% vs. 44%) or having used condoms consistently over their lifetime (37% vs. 56%) or in the previous six months (44% vs. 66%). Some 38% of teenagers with an older first partner had ever been pregnant, compared with 12% of those with a peer-age first partner. The mean number of partners and history of sexually transmitted diseases did not differ between the two groups.

The association between substance use, condom use and sexual risk among low-income women.

Substance use is frequently assumed to be associated with higher levels of sexual risk-taking and lower levels of condom use. An analysis of 668 black, Hispanic and white low-income women at public health and public assistance facilities in Miami show that 19% engaged in risky sexual behavior over the preceding six months, 24% in substance use and 31% in condom use. Overall, substance users are nearly four and one-half times more likely to take sexual risks than nonusers, but are about half as likely to have relied on condoms. When the probability of condom use is considered in the context of both substance use and sexual risk, substance users who take sexual risks appear just as likely to rely on condoms as are nonusers who take sexual risks and those who do not (odds of 0.43-0.49). However, substance users who do not take sexual risks are much less likely to use condoms (odds of 0.15). This pattern holds among black, Hispanic and white women, and suggests that perceptions of risk and the risks that partners bring to sexual encounters may be more important determinants of condom use than substance use per se.

PIP: 668 Black, White, and Hispanic low-income women at 21 public health, sexually transmitted disease (STD), and family planning clinics or state economic service centers in Miami provided data on their sex behavior, drug and alcohol consumption, and condom use. The data were collected from September 1994 through February 1995. Any participant who reported having had sex with three or more partners in the preceding 6 months, exchanging sex for drugs or money in the preceding 6 months, or having a sex partner who they believe has had sex with men or had injected drugs was classified as a sexual risk-taker. Any woman who had taken any recreational drugs in the past 6 months or had drank alcohol before having sex over the same period was classified as a substance user. 19% of the women engaged in risky sex behavior over the preceding 6 months, 24% in substance use, and 31% in condom use. Overall, the substance users are almost 4.5 times more likely to take sexual risks than nonusers, and about half as likely to have used condoms. Substance users who take sexual risks seem just as likely to use condoms as nonusers who take sexual risks and those who do not. However, substance users who do not take sexual risks are far less likely to use condoms. This pattern holds among Black, White, and Hispanic women, and suggests that perceptions of risk and the risks that partners bring to sexual encounters may be more important determinants of condom use than substance use alone.

Determinants of high-risk sexual behaviour and condom use among adults in the Arusha region, Tanzania.

Determinants of multiple sexual partners and condom use among adults were assessed through a population-based survey in one urban, one semi-urban and one rural community in the Arusha region, northern Tanzania. The study samples were obtained by randomly selecting clusters of 10 households from the 3 communities. Informed verbal consent was sought from each respondent for participation in the study. High-risk sexual behaviours and condom use were assessed using a structured questionnaire. It was observed that significantly more men than women reported having multiple sexual partners (49% vs 25.2%; OR = 1.69; 95% CI = 1.51-1.90) and urban men were significantly more likely to report having multiple sexual partners than men in rural areas. In both men and women, early sexual debut was associated with having multiple sexual partners while travel, alcohol use, and sex under the influence of alcohol were significantly associated with multiple sexual partners in men only. AIDS-related discussion was significantly associated with having fewer sexual partners in both men and women. Of the 1551 respondents, 320 (20.6%) reported having ever used a condom and of the 320 respondents who had ever used a condom, 34 (10.6%) reported having used it at the last sexual intercourse. Significantly more men than women reported having ever used a condom (34.1% vs 14.1%; OR = 1.77; 95% CI = 1.56-2.01). In both men and women, early sexual debut and being young, unmarried, travelling out of the Arusha region and having multiple sexual partners were associated with increased condom use. For both men and women, frequent discussion of AIDS with family members or friends was associated with increased condom use. These data suggest that interventions targeting adolescents and young adults may be effective for control of HIV transmission in Tanzania. In particular, creation of opportunities for people to come together and discuss AIDS might be an important strategy.

PIP: 1551 adults aged 15-54 years responded to survey questions between January 1993 and March 1994 designed to assess the determinants of their multiple sex partner behavior and condom use. Study participants were randomly selected from Matufa rural village, Babati semi-urban, and Unga limited in the Arusha region of northern Tanzania. 49% of men compared to 25.2% of women reported having multiple sex partners, with urban men being significantly more likely to report having multiple sex partners than men in rural areas. Among both men and women, early sexual debut was associated with having multiple sex partners, while travel, alcohol use, and sex under the influence of alcohol were significantly associated with multiple sex partners among men only. AIDS-related discussion was significantly associated with having fewer sex partners among both men and women. 320 respondents reported ever having used a condom, 34 indicating such use during their most recent sexual intercourse. 34.1% of men and 14.1% of women reported ever using a condom. For both men and women, early sexual debut and being young, unmarried, travelling out of the Arusha region, and having multiple sex partners were associated with increased condom use. The frequent discussion of AIDS with family members or friends was also associated with increased condom use. Creating opportunities for people to come together and discuss AIDS may help limit the spread of HIV in Tanzania.

Psychographic predictors of risky sexual practice.

PIP: A survey conducted in Zimbabwe in 1997 sought to identify the key socioeconomic, demographic, and psychographic determinants of high-risk sexual practices in a national sample of 1987 adult men and women. Specifically, the study developed profiles of the types of persons who were most likely to have more than one sexual partner without using a condom in the 6-12 weeks before the survey, least likely to have used condoms with casual partners, and least likely to have used condoms with steady partners. The factors with the strongest associations with these three indicators of risky sexual practices were excessive consumption of alcohol, history of a sexually transmitted disease (STD), and embarrassment in acquiring condoms. Those who believed that condom users are more likely than nonusers to have an STD were less likely to use condoms, as were respondents who thought it is easy to tell if someone has HIV/AIDS. A significant proportion of respondents felt that condom use with a regular partner or spouse amounts to distrust and indicates adultery. These psychographic factors, which were more salient than any demographic or socioeconomic factors, will be used to identify potential targets for condom marketing in Zimbabwe. For example, IEC campaigns are being designed to communicate that alcohol users have a higher risk of HIV/STDs, that familiarity with condoms engenders trust, and that condom purchase should not be a source of embarrassment.^ieng

Predictors of African American adolescents' condom use and HIV risk behavior.

This study evaluated predictors of risky and safer behavior in a sample of low-income African American adolescents, assessed their perceptions of the risk associated with their sexual behavior, and examined differences between adolescents who used condoms consistently, inconsistently, or engaged only in unprotected intercourse. African American adolescents (N = 312) completed measures related to AIDS knowledge, frequency of condom use, attitudes toward condoms, and sexual behavior over the preceding 2 months. Multiple regression analyses for the sexually active youths (N = 114) revealed that lower self-efficacy, higher perceived risk, and male gender were associated with high-risk behavior. Positive attitudes toward condoms and younger age had the strongest association with condom use. Consistent condom users were more knowledgeable and held more positive attitudes toward condoms, and nonusers were older. Regardless of their behavior, the adolescents generally did not perceive themselves to be a risk for HIV infection. The findings suggest that precautionary practices (condom use) and high-risk behavior (unprotected sex with multiple partners) may have different correlates. In addition, the data indicate that theoretical models developed with homosexual male populations may also be generalizable to African American adolescents' sexual behavior.

PIP: To facilitate identification of factors that place low-income African American adolescents at increased risk of human immunodeficiency virus (HIV), interviews were conducted with 312 youth 12-19 years of age attending a Public Health Service-funded clinic in Mississippi. The analysis was restricted to the 114 sexually active youth in this sample. The full variable set included age, gender, acquired immunodeficiency syndrome (AIDS) knowledge, condom attitude, perceived risk of AIDS, self-efficacy, social provision, church attendance, AIDS Risk Index, and Condom Use Index. Correlations between these variables were small to moderate (0.0 to -0.48). Separate regression analyses revealed significant relationships between the full variable set and the AIDS Risk Index (p 0.0001) and the Condom Use Index (p 0.02). Half of the teens reported unprotected intercourse in the preceding 2 months, yet most perceived themselves at low risk for AIDS. Multivariate analyses of variance revealed that variables most predictive of unprotected sex with multiple partners differed from those associated with condom use. Males who reported lower self-efficacy in avoiding AIDS and perceived themselves at greater risk were most likely to engage in high-risk behaviors. Consistent condom users were younger than intermittent and non-users and had more positive attitudes about condoms and higher AIDS knowledge scores. Interventions aimed at Black teens may need to expand beyond condom promotion to include broader media and community-based educational programs.

Risk factors for intravenous drug use and sharing equipment among young male drug users in Longchuan County, south-west China.

OBJECTIVES: To identify the risk factors for intravenous drug use and sharing of equipment in Longchuan County in south-west China. METHODS: Demographic information and sexual and drug-use-related behavior between 1 January 1991 and 1 August 1994 were collected retrospectively from a cohort of young male drug users aged 18-29 years in 82 villages. RESULTS: A total of 433 drug users were identified. The cumulative incidence of intravenous drug use was 40.0% during the 3.7-year study period. The annual incidence increased from 10% in 1991 to over 30% in 1994. Risk factors for intravenous drug use among drug users, according to the multivariate model, included having had premarital/extramarital sex [odds ratio (OR), 1.5; 95% confidence interval (CI), 1.01-2.3], having a family member who used drugs in 1991 (OR, 1.8; 95% CI, 1.1-2.9), and currently not married (OR, 1.6; 95% CI, 0.98-2.7). Being Buddhist protected against intravenous drug use (OR, 0.4; 95% CI, 0.2-0.9). The population attributable fraction was 30% for not being currently married, 17% for having had premarital/extramarital sex and 14% for having a family member who used drugs. The risk factor for sharing of equipment was being of Jingpo ethnicity (OR, 5.8; 95% CI, 2.5-13.8). The average incidence of sharing equipment was 19.6% per year. The population attributable fraction for sharing equipment was 58.5% for being Jingpo. CONCLUSIONS: The incidence of intravenous drug use and sharing equipment is increasing. Therefore, it is urgent that vigorous, effective intervention programs be initiated in southern Yunnan. Unmarried, sexually promiscuous Jingpo drug users with a family history of drug use should be especially targeted. Given the problems of transport and communication in this remote area of China, intervention programs which use existing social, governmental and community networks should be implemented.

PIP: To identify the risk factors for intravenous drug use and sharing of equipment in Longchuan County in south-west China, information was collected on demographics, as well as on sexual and drug-use-related behavior between January 1, 1991 and August 1, 1994, from a cohort of young male intravenous drug users (IDU) 18-29 years old residing in 82 villages. A total of 433 drug users were identified, 121 of whom were interviewed at rehabilitation centers; 192 were IDU. After excluding 3 immigrants and 28 IDU who began injecting before 1991, 402 drug users (241 non-IUD and 161 new IDU) were included for the non-concurrent cohort study of IDU. The cumulative incidence of intravenous drug use was 40.0% during the 3.7-year study period. The annual incidence increased from 10% in 1991 to over 30% in 1994. Risk factors for intravenous drug use among drug users, according to the multivariate model, included having had premarital or extramarital sex [odds ratio (OR), 1.5; 95% confidence interval (CI), 1.01-2.3], having a family member who used drugs in 1991 (OR. 1.8; 95% CI, 1.1-2.9), and currently not married (OR, 1.6; 95% CI, 0.98-2.7). Being Buddhist protected against intravenous drug use (OR, 0.4; 95% CI, 0.2-0.9). The population attributable fraction was 30% for not being currently married, 17% for having had premarital or extramarital sex, and 14% for having a family member who used drugs. The risk factor for sharing of equipment was being of Jingpo ethnicity (OR, 5.8; 95% CI, 2.5-13.8). The average incidence of sharing equipment was 19.6% per year. The population attributable fraction for sharing equipment was 58.5% for being Jingpo. The incidence of intravenous drug use and sharing equipment is increasing. Therefore, it is urgent that vigorous, effective intervention programs be initiated in southern Yunnan. Unmarried, sexually promiscuous Jingpo drug users with a family history of drug use should be especially targeted. Given the problems of transport and communication in this remote area of China, intervention programs that use existing social, governmental and community networks should be implemented.

AIDS and adolescents: protecting the next generation.

PIP: While few adolescents world-wide have AIDS, it is estimated that half the people infected with HIV became infected when they were 15-24 years old. Health professionals assert that HIV exists in adolescent populations that are marked by sexually transmitted diseases and/or adolescent pregnancies. Research has revealed that most young people worldwide first experience sexual intercourse while they are in their teens. This situation has been exacerbated by rural-urban migration and the breakdown of traditional sources of information, by the risk-taking nature of adolescence that leads to drug and alcohol abuse, by cultural norms that lead young women to preserve their virginity by engaging in anal sex, by the poverty that causes youth to trade sex for survival. The HIV/AIDS prevention efforts aimed at young people have been successful in increasing their knowledge about transmission of the infection but not in changing their risky behavior. In order to change adolescent social norms, influential young people should be used as peer educators, parents and teachers should be enlisted in prevention efforts, young people should be involved in the planning of the programs, and all of the needs of the adolescents should be addressed. In addition, HIV/AIDS programs must provide services for those youth who are already infected. It is difficult for prevention programs to engage in safer sex training because of a lack of consensus about whether to give adolescents information only or to provide condoms. The AIDS epidemic has at least provided an opportunity for societies to address how sex education should proceed and has given rise to the innovative idea that adolescents require their own health services.^ieng

Condom knowledge, attitudes and use among patients attending the public STD clinic in Singapore.

Three hundred patients (255 males and 45 females) attending the public STD clinic in Singapore were interviewed regarding their frequency of condom use, attitudes towards condoms, problems related to condom use and places of purchase of the condoms. Among respondents with regular partners, 55.2% of males and 48.8% of females never used condoms, only 12.4% of males and 16.3% of females used condoms consistently. Among respondents with non-regular partners, only 2.2% of males used condoms consistently. The commonest reasons why male respondents did not use condoms consistently were that condoms decreased sensation, condoms made sex mechanical, the use of other forms of contraception, no condoms were available, and the perception that there was no risk of contracting STD/AIDS. Condoms were most commonly obtained from sex partners, supermarkets, roadside sundry shops and the Maternal & Child Health Clinics (MCHCs). About 8% of both males and females had experienced some problems with condoms before. Greater efforts to promote the practice of protected intercourse among the STD patient population as well as in the general population are required in order to control the spread of STD and AIDS in Singapore.

Contraceptive use, sensation seeking and adolescent egocentrism.

The relations between contraceptive use, sensation seeking, and adolescent egocentrism were examined among 145 high school juniors and seniors (all female) attending high school in the Atlanta area. Sex without contraception was found to be significantly related to scores on the Sensation Seeking Scale, including the total score and two out of the four subscales. Sex without contraception was also found to be related to egocentrism, in particular to subjects' estimates of the probability of becoming pregnant as a result of engaging in sex without contraception. No significant relationship was found between sensation seeking and egocentrism.