A Triadic Intervention for Adolescent Sexual Health: A Randomized Clinical Trial.

OBJECTIVES: In this study, we evaluate the efficacy of Families Talking Together (FTT), a triadic intervention to reduce adolescent sexual risk behavior. METHODS: Adolescents aged 11 to 14 and their female caregivers were recruited from a pediatric clinic; 900 families were enrolled; 84 declined. Families were randomly assigned to FTT or 1 of 2 control conditions. The FTT triadic intervention consisted of a 45-minute face-to-face session for mothers, health care provider endorsement of intervention content, printed materials for families, and a booster call for mothers. The primary outcomes were ever having had vaginal intercourse, sexual debut within the past 12 months, and condom use at last sexual intercourse. Assessments occurred at baseline, 3 months post baseline, and 12 months post baseline. RESULTS: Of enrolled families, 73.4% identified as Hispanic, 20.4% as African American, and 6.2% as mixed race. Mean maternal age was 38.8 years, and mean adolescent grade was seventh grade. At the 12-month follow-up, 5.2% of adolescents in the experimental group reported having had sexual intercourse, compared with 18% of adolescents in the control groups (P < .05). In the experimental group, 4.7% of adolescents reported sexual debut within the past 12 months, compared with 14.7% of adolescents in the control group (P < .05). In the experimental group, 74.2% of sexually active adolescents indicated using a condom at last sexual intercourse, compared with 49.1% of adolescents in the control group (P < .05). CONCLUSIONS: This research suggests that the FTT triadic intervention is efficacious in delaying sexual debut and reducing sexual risk behavior among adolescents.

Sexual risk-taking and subcortical brain volume in adolescence.

Background: The developmental period of adolescence marks the initiation of new socioemotional and physical behaviors, including sexual intercourse. However, little is known about neurodevelopmental influences on adolescent sexual decision-making. Purpose: We sought to determine how subcortical brain volume correlated with condom use, and whether those associations differed by gender and pubertal development. Methods: We used FreeSurfer to extract subcortical volume among N = 169 sexually experienced youth (mean age 16.07 years; 31.95% female). We conducted multiple linear regressions to examine the relationship between frequency of condom use and subcortical volume, and whether these associations would be moderated by gender and pubertal development. Results: We found that the relationship between brain volume and condom use was better accounted for by pubertal development than by gender, and moderated the association between limbic brain volume and condom use. No significant relationships were observed in reward areas (e.g., nucleus accumbens) or prefrontal cortical control areas. Conclusions: These data highlight the potential relevance of subcortical socioemotional processing structures in adolescents' sexual decision-making.

Virtually 'in the heat of the moment': insula activation in safe sex negotiation among risky men.

HIV is most prevalent among men who have sex with men (MSM), and although most MSM use condoms consistently during casual sex, some take risks. To better understand the psychology of those risky decisions, we examined neural correlates of playing a virtual sexual 'hook up' game in an functional magnetic resonance imaging scanner in MSM who had, in the past 90 days, been sexually risky (N = 76) or safe (N = 31). We found that during potentially risky sexual choices, previously risky MSM had more right insula activity than previously safe MSM. Real-life sexual risk was related to trait positive and negative urgency. Insula activity that differentiated risky and safe MSM was related to trait positive and negative urgency. Future work should further examine if, and to what extent, insula activation during safe sex negotiation drives MSM's rash risky sexual decision-making.

HIV pre-exposure prophylaxis and early antiretroviral treatment among female sex workers in South Africa: Results from a prospective observational demonstration project.

BACKGROUND: Operational research is required to design delivery of pre-exposure prophylaxis (PrEP) and early antiretroviral treatment (ART). This paper presents the primary analysis of programmatic data, as well as demographic, behavioural, and clinical data, from the TAPS Demonstration Project, which offered both interventions to female sex workers (FSWs) at 2 urban clinic sites in South Africa. METHODS AND FINDINGS: The TAPS study was conducted between 30 March 2015 and 30 June 2017, with the enrolment period ending on 31 July 2016. TAPS was a prospective observational cohort study with 2 groups receiving interventions delivered in existing service settings: (1) PrEP as part of combination prevention for HIV-negative FSWs and (2) early ART for HIV-positive FSWs. The main outcome was programme retention at 12 months of follow-up. Of the 947 FSWs initially seen in clinic, 692 were HIV tested. HIV prevalence was 49%. Among those returning to clinic after HIV testing and clinical screening, 93% of the women who were HIV-negative were confirmed as clinically eligible for PrEP (n = 224/241), and 41% (n = 110/270) of the women who were HIV-positive had CD4 counts within National Department of Health ART initiation guidelines at assessment. Of the remaining women who were HIV-positive, 93% were eligible for early ART (n = 148/160). From those eligible, 98% (n = 219/224) and 94% (n = 139/148) took up PrEP and early ART, respectively. At baseline, a substantial fraction of women had a steady partner, worked in brothels, and were born in Zimbabwe. Of those enrolled, 22% on PrEP (n = 49/219) and 60% on early ART (n = 83/139) were seen at 12 months; we observed high rates of loss to follow-up: 71% (n = 156/219) and 30% (n = 42/139) in the PrEP and early ART groups, respectively. Little change over time was reported in consistent condom use or the number of sexual partners in the last 7 days, with high levels of consistent condom use with clients and low use with steady partners in both study groups. There were no seroconversions on PrEP and 7 virological failures on early ART among women remaining in the study. Reported adherence to PrEP varied over time between 70% and 85%, whereas over 90% of participants reported taking pills daily while on early ART. Data on provider-side costs were also collected and analysed. The total cost of service delivery was approximately US$126 for PrEP and US$406 for early ART per person-year. The main limitations of this study include the lack of a control group, which was not included due to ethical considerations; clinical study requirements imposed when PrEP was not approved through the regulatory system, which could have affected uptake; and the timing of the implementation of a national sex worker HIV programme, which could have also affected uptake and retention. CONCLUSIONS: PrEP and early ART services can be implemented within FSW routine services in high prevalence, urban settings. We observed good uptake for both PrEP and early ART; however, retention rates for PrEP were low. Retention rates for early ART were similar to retention rates for the current standard of care. While the cost of the interventions was higher than previously published, there is potential for cost reduction at scale. The TAPS Demonstration Project results provided the basis for the first government PrEP and early ART guidelines and the rollout of the national sex worker HIV programme in South Africa.

Effects of adaptive protective behavior on the dynamics of sexually transmitted infections.

Sexually transmitted infections (STIs) continue to present a complex and costly challenge to public health programs. The preferences and social dynamics of a population can have a large impact on the course of an outbreak as well as the effectiveness of interventions intended to influence individual behavior. In addition, individuals may alter their sexual behavior in response to the presence of STIs, creating a feedback loop between transmission and behavior. We investigate the consequences of modeling the interaction between STI transmission and prophylactic use with a model that links a Susceptible-Infectious-Susceptible (SIS) system to evolutionary game dynamics that determine the effective contact rate. The combined model framework allows us to address protective behavior by both infected and susceptible individuals. Feedback between behavioral adaptation and prevalence creates a wide range of dynamic behaviors in the combined model, including damped and sustained oscillations as well as bistability, depending on the behavioral parameters and disease growth rate. We found that disease extinction is possible for multiple regions where R0>1, due to behavior adaptation driving the epidemic downward, although conversely endemic prevalence for arbitrarily low R0 is also possible if contact rates are sufficiently high. We also tested how model misspecification might affect disease forecasting and estimation of the model parameters and R0. We found that alternative models that neglect the behavioral feedback or only consider behavior adaptation by susceptible individuals can potentially yield misleading parameter estimates or omit significant features of the disease trajectory.

Modificación de conocimientos sobre Infecciones de Transmisión Sexual en adolescentes / Modification of knowledge about Sexually Transmitted Infections in adolescents

Se realizó un estudio de intervención educativa, con los estudiantes de noveno grado del aula 3 de la ESBU 4 de abril del municipio Manzanillo, en el período comprendido de septiembre del 2012 a marzo del 2013 con el objetivo de elevar el nivel de conocimiento sobre las Infecciones de Transmisión Sexual en los adolescentes. Nuestro universo estuvo constituido por 28 estudiantes del noveno grado del aula 3, la muestra quedó formada por los 28 estudiantes que cumplieron con los criterios establecidos para el estudio. Para el trabajo con las variables (edad, sexo, enfermedades que se manifiestan como ITS, vías de transmisión, síntomas y práctica del sexo seguro) se confeccionó una encuesta que sirvió de instrumento de entrada y salida en los ítems modificables. Como medida estadística se utilizó la prueba de los signos. En el grupo de adolescentes estudiados predominaron los de 14 años del sexo femenino y se elevó el nivel de conocimientos sobre las ITS después de la aplicación del programa educativo(AU)

It was carried out an educational intervention study with ninth gradersof the classroom 3 at 4 de Abril Secondary School in Manzanillo, in the period of September, 2012 to March, 2013 with the objective of increasing the level of knowledge on SexuallyTransmitted Infections in adolescents. Our universe was constituted by 28 ninth graders of the classroom 3, and the sample was formed by the 28 students that accomplished the established criteria for the study. For the work with the variables (age, sex, illnesses that are manifested as STI, ways of transmission, symptoms and practice of the safe sex) it was made a survey that served as an entrance and exit instrument in the modifiableitems. As the statistic measure it was used the test of signs. In the group of adolescents those of 14 years of the feminine sex prevailed, and the level of knowledge on STIs increased after the application of the educational program(EU)

Mediation and moderation of an efficacious theory-based abstinence-only intervention for African American adolescents.

OBJECTIVE: This secondary data analysis sought to determine what mediated reductions in self-reported sexual initiation over the 24-month postintervention period in early adolescents who received "Promoting Health among Teens," a theory-based, abstinence-only intervention (Jemmott, Jemmott, & Fong, 2010). METHOD: African American Grade 6 and 7 students at inner-city public middle schools were randomized to 1 of 5 interventions grounded in social-cognitive theory and the theory of reasoned action: 8-hr abstinence-only targeting reduced sexual intercourse; 8-hr safer-sex-only targeting increased condom use; 8-hr and 12-hr comprehensive interventions targeting sexual intercourse and condom use; 8-hr control intervention targeting physical activity and diet. Primary outcome was self-report of vaginal intercourse by 24 months postintervention. Potential mediators, assessed immediately postintervention, were theory-of-reasoned-action variables, including behavioral beliefs about positive consequences of abstinence and negative consequences of sex, intention to have sex, normative beliefs about sex, and HIV and sexually transmitted infection (STI) knowledge. We tested single and serial mediation models using the product-of-coefficients approach. RESULTS: Of 509 students reporting never having vaginal intercourse at baseline (324 girls and 185 boys; mean age = 11.8 years, SD = 0.8), 500 or 98.2% were included in serial mediation analyses. Consistent with the theory of reasoned action, the abstinence-only intervention increased positive behavioral beliefs about abstinence, which reduced intention to have sex, which in turn reduced sexual initiation. Negative behavioral beliefs about sex, normative beliefs about sex, and HIV/STI knowledge were not mediators. CONCLUSIONS: Abstinence-only interventions should stress the gains to be realized from abstinence rather than the deleterious consequences of sexual involvement.

Sexual violence and associated factors among women in HIV discordant and concordant relationships in Uganda.

HIV serodiscordance is a sexual partnership in which one partner is infected with HIV while the other is not. Managing emotional and sexual intimacy in HIV serodiscordant unions can be difficult due to concerns about HIV transmission and the challenge of initiating and maintaining safe sex. In situations where couples are jointly aware of their HIV status, women in serodiscordant unions may face increased risk of partner violence. We conducted an investigation to assess risk factors for HIV serodiscordance and determine if HIV serodiscordance is associated with incident sexual violence among a cohort of women attending HIV post-test club services at three AIDS Information Centers (AICs) in Uganda. Using a prospective study of 250 women, we elicited information about sexual violence using structured face-to-face interviews. Sexual violence and risk factors were assessed and compared among HIV positive women in HIV discordant unions, HIV negative women in discordant unions, and HIV negative women in negative concordant unions. Multivariable logistic regression was used to assess the association between participants' serostatus and sexual violence. HIV negative women in serodiscordant relationships (36.1±11.1 years, range: 19-65 years) were significantly older than either HIV positive women in serodiscordant relationships (32.2±9.0 years, range: 18-56 years), or HIV negative women in concordant relationships (32.3±11.0 years, range: 18-62), (p=0.033). Early age at sexual debut was associated with a 2.4-fold increased risk of experiencing sexual violence (OR 2.4, 95% CI 1.27-4.65). Based on unadjusted analysis, HIV positive women in discordant relationship were at highest risk for sexual violence compared to HIV negative women in discordant unions, and HIV negative women in negative concordant unions. HIV negative women in discordant relationships and those in concordant negative relationships showed no increased risk for sexual violence. However, couples' HIV serostatus was not significant related to incident sexual violence after controlling for potential confounding covariates. Nevertheless, the results were able to elucidate the sexual violence risk factor profile of participants based on couples' HIV serostatus. Couple counseling protocols at HIV voluntary counseling and testing centers in Uganda should identify those at risk for sexual violence and develop interventions to reduce its incidence.

Safer sex as the bolder choice: testosterone is positively correlated with safer sex behaviorally relevant attitudes in young men.

INTRODUCTION: Higher testosterone (T) is tied to risk-taking, especially in financial domains but also in health domains relevant to acquiring sexually transmitted infections (STIs). However, safer sex constructs could themselves carry the possibility of "social risk" due to sexual stigma or embarrassment, or could involve boldness or confidence because they could represent status displays of frequent sexual activity. AIM: To determine how T and behaviorally relevant attitudes about sexual risk-taking are linked, to better understand biopsychosocial aspects of sexual health related to STIs. METHODS: In 78 first-year male college students, we examined correlations between salivary T and behaviorally relevant safer sex attitudes assessed via questionnaires. MAIN OUTCOME MEASURES: T, via saliva; safer sex attitudes, via a composite and the University of California, Los Angeles Multidimensional Condom Attitudes Scale (MCAS). RESULTS: Higher T was significantly correlated with higher scores on the following: safer sex likelihood composite, r(73)=0.33, P=0.003; the MCAS safer sex resilience, r(32)=0.36, P=0.037; and the MCAS condom purchase comfort, r(32)=0.37, P=0.031. Associations between T and safer sex likelihood and resilience were still robust after controlling for potential confounds, though the association between T and purchase comfort diminished to a trend. CONCLUSIONS: Higher T was positively linked with safer sex attitudes, especially those most closely tied to STI risk avoidance. Thus, future research and interventions for STI prevention should address the possibility that safer sex may be paradoxically perceived as a "bold" or "risky" choice even as it decreases STI risk.

Biomarker validation of reports of recent sexual activity: results of a randomized controlled study in Zimbabwe.

Challenges in the accurate measurement of sexual behavior in human immunodeficiency virus (HIV) prevention research are well documented and have prompted discussion about whether valid assessments are possible. Audio computer-assisted self-interviewing (ACASI) may increase the validity of self-reported behavioral data. In 2006-2007, Zimbabwean women participated in a randomized, cross-sectional study that compared self-reports of recent vaginal sex and condom use collected through ACASI or face-to-face interviewing (FTFI) with a validated objective biomarker of recent semen exposure (prostate-specific antigen (PSA) levels). Of 910 study participants, 196 (21.5%) tested positive for PSA, an indication of semen exposure during the previous 2 days. Of these 196 participants, 23 (11.7%) reported no sex in the previous 2 days, with no difference in reported sexual activity between interview modes (12.5% ACASI vs. 10.9% FTFI; Fisher's exact test: P = 0.72). In addition, 71 PSA-positive participants (36.2%) reported condom-protected vaginal sex only; their reports also indicated no difference between interview modes (33.7% ACASI vs. 39.1% FTFI; P = 0.26). Only 52% of PSA-positive participants reported unprotected sex during the previous 2 days. Self-report was a poor predictor of recent sexual activity and condom use in this study, regardless of interview mode, providing evidence that such data should be interpreted cautiously.

Effect of heterosexual intercourse on mucosal alloimmunisation and resistance to HIV-1 infection.

BACKGROUND: Unprotected sexual intercourse between regular heterosexual partners could elicit alloimmune responses that might be associated with inhibition of in-vitro HIV-1 infectivity. We investigated this hypothesis in people practising unprotected sex and those using protection. METHODS: We recruited 82 participants from an outpatient genitourinary medicine clinic. 29 monogamous heterosexual couples having unprotected sex; and 15 women and 10 men having condom protected or no sex. We used the mixed leucocyte reaction (MLR), stimulating one partner's peripheral blood mononuclear cells (PBMC) with the other partner's irradiated PBMC and compared the resulting response with control PBMC. We studied resistance to HIV-1 infection by challenging activated CD4-positive T cells with CCR5-binding and CXCR4-binding HIV-1 strains, and comparing the infectivity in participants having unprotected sex with those practising protected sex. We used the correlation coefficient to establish the significance of the relation between MLR and HIV-1 infectivity. FINDINGS: We recorded a significant increase in the stimulation indices in PBMC from women whose cells were stimulated with irradiated PBMC (2%, 10%, or 50%) from their regular partners. The mean with 10% partner's cells was 8.6 (SD 7.7), compared with those from unrelated cells (4.7 [3.9], p=0.009). Significant alloimmune responses were also seen in corresponding male partners, but only with 50% stimulating cells (p=0.013). Dose-dependent inhibition of activated CD4-positive T cells to HIV-1 infection with both binding strains was noted in vitro in women practising unprotected intercourse, compared with those having protected sex or having no sex for more than 1 year. Highly significant differences were found for CCR5 (p=0.0001) and for CXCR4 (p=0.001) strains of HIV-1 at all four virus-concentrations. Male partners also showed in-vitro inhibition of HIV-1 but this was less than that in women. INTERPRETATION: Unprotected sexual intercourse might result in alloimmunisation stimulated by HLA antigens in seminal or cervicovaginal fluid. Mucosal alloimmunisation may reduce infection by HIV-1, and the role of such immunisation in preventive and therapeutic vaccination should be investigated.