Emtonjeni-A Structural Intervention to Integrate Sexual and Reproductive Health into Public Sector HIV Care in Cape Town, South Africa: Results of a Phase II Study.

Integration of sexual and reproductive health within HIV care services is a promising strategy for increasing access to family planning and STI services and reducing unwanted pregnancies, perinatal HIV transmission and maternal and infant mortality among people living with HIV and their partners. We conducted a Phase II randomized futility trial of a multi-level intervention to increase adherence to safer sex guidelines among those wishing to avoid pregnancy and adherence to safer conception guidelines among those seeking conception in newly-diagnosed HIV-positive persons in four public-sector HIV clinics in Cape Town. Clinics were pair-matched and the two clinics within each pair were randomized to either a three-session provider-delivered enhanced intervention (EI) (onsite contraceptive services and brief milieu intervention for staff) or standard-of-care (SOC) provider-delivered intervention. The futility analysis showed that we cannot rule out the possibility that the EI intervention has a 10 % point or greater success rate in improving adherence to safer sex/safer conception guidelines than does SOC (p = 0.573), indicating that the intervention holds merit, and a larger-scale confirmatory study showing whether the EI is superior to SOC has merit.

Women's anal sex practices: implications for formulation and promotion of a rectal microbicide.

To gain insight into practices that may inform formulation and use of rectal microbicides, in-depth interviews were conducted with an ethnically diverse sample of 28 women who engage in anal intercourse. Microbicides are compounds under development to decrease sexually transmitted infections. Most women practiced anal sex in conjunction with vaginal intercourse. Anal sex typically was not preplanned, and few women reported preparation. Condom use was rare. Most women relied on saliva, vaginal fluids, prelubricated condoms, or used no lubrication at last intercourse. Women were uncertain about the amount of lubricant used during sex, with typical estimates of 1 to 2 teaspoons. This may prove challenging to the formulation and promotion of rectal microbicides, as substantially higher amounts may be required. Additional challenges include infrequent use of packaged lubricants, and typical male lubricant application, which may make women's control of rectal microbicides more difficult. Women overwhelmingly expressed interest in rectal microbicides.

A gender-specific HIV/STD risk reduction intervention for women in a health care setting: short- and long-term results of a randomized clinical trial.

This study assessed the short- and long-term effect of a gender-specific group intervention for women on unsafe sexual encounters and strategies for protection against HIV/STD infection. Family planning clients (N = 360) from a high HIV seroprevalence area in New York City were randomized to an eight-session, a four-session or a control condition and followed at one, six and 12 months post-intervention. Using an intention-to-treat analysis, women who were assigned to the eight-session group had about twice the odds of reporting decreased or no unprotected vaginal and anal intercourse compared to controls at one month (OR = 1.93, 95% confidence interval [CI] = 1.07, 3.48, p = 0.03) and at 12-month follow-up (OR = 1.65, 95% CI = 0.94, 2.90, p = 0.08). Relative to controls, women assigned to the eight-session condition reported during the previous month approximately three-and-a-half (p = 0.09) and five (p < 0.01) fewer unprotected sex occasions at one- and 12-month follow-up, respectively. Women in the eight-session group also reduced the number of sex occasions at both follow-ups, and had a greater odds of first time use of an alternative protective strategy (refusal, outercourse, mutual testing) at one-month follow-up. Results for the four-session group were in the expected direction but overall were inconclusive. Thus, gender-specific interventions of sufficient intensity can promote short- and long-term sexual risk reduction among women in a family planning setting.

The acceptability of the female condom: perspectives of family planning providers in New York City, South Africa, and Nigeria.

This article seeks to fill the gap in female condom acceptability research by examining family planning (FP) providers' attitudes and experiences regarding the female condom in three countries (South Africa, the US, and Nigeria) to highlight providers' potential integral role in the introduction of the female condom. The case studies used data drawn from three independent projects, each of which was designed to study or to change FP providers' attitudes and practices in relation to the female condom. The case study for New York City used data from semistructured interviews with providers in one FP consortium in which no special female condom training had been undertaken. The data from South Africa were drawn from transcripts and observations of a female condom training program and from interviews conducted in preparation for the training. The Nigerian study used observations of client visits before and after providers were trained concerning the female condom. In New York City, providers were skeptical about the contraceptive efficacy of the female condom, with only 8 of 22 providers (36%) reporting they would recommend it as a primary contraceptive. In South Africa, providers who had practiced insertion of the female condom as part of their training expressed concern about its physical appearance and effects on sexual pleasure. However, they also saw the female condom as a tool to empower clients to increase their capacity for self-protection. Structured observations of providers' counseling interactions with clients following training indicated that Nigerian providers discussed the female condom with clients in 80% of the visits observed. Despite the lack of a uniform methodology, the three case studies illuminate various dimensions of FP providers' perceptions of the acceptability of the female condom. FP providers must be viewed as a critical factor in female condom acceptability, uptake, and continued use. Designing training programs and other interventions that address sources of provider resistance and enhance providers' skills in teaching female condom negotiation strategies may help to increase clients' use of the female condom.

Prevention of sexual risk behavior for HIV infection with women.

This paper defines the components of gender-specific interventions for HIV infections for women, i.e. negotiation skills with male partners for condom use, integration of strategies against HIV and other STD infections and for contraception, the urgent need for female controlled methods, the importance of the inclusion of heterosexual men and an expansion to couples in prevention programs. This paper also presents a critical update in HIV prevention articles for women since the beginning of the AIDS epidemic through March 1996. All reviewed interventions were conducted in the U.S., Canada or Puerto Rico and described a psychological, behavioral, or educational component that addressed sexual risk reduction and included a behavioral evaluation. Manual and computer searches identified 47 studies that targeted women and provided a female-specific analysis of intervention effects. Overall, the findings demonstrate that HIV prevention programs can be effective in reducing risky sexual behavior among women. Program effectiveness varied by intervention type, session duration, and whether studies included women alone or both men and women. The most efficacious HIV prevention programs were specifically directed toward women, focused on relationship and negotiation skills, and involved multiple, sustained contacts. Evidence also indicated that community-level interventions hold promise. It is recommended that outcomes for women be expanded to include strategies beyond the male condom, such as refusing or avoiding unsafe sex or using the female condom.

A gender-specific intervention for at-risk women in the USA.

Women are the fastest growing group in the USA to become infected with HIV. Also, the mode of transmission is changing with heterosexual behaviour being the predominant source. As these changes occur, HIV infection becomes more common in women who have not typically been considered at high risk. This paper describes an intervention designed to decrease unsafe sexual encounters and to focus on a highly meaningful concern in the lives of these women: relationships with men. The sessions encouraged making decisions, choice, partner selection, sexual rights, refusal of any unwanted sex, female controlled methods and other elements of empowerment. An eight-session and a four-session curriculum were created to assess dose factors as well.

Longitudinal changes in sexual risk behavior among HIV+ and HIV- male injecting drug users.

UNLABELLED: Injecting drug users (IDUs) play a prominent role in the transmission of human immunodeficiency virus (HIV), particularly in urban areas such as New York City, where they comprise nearly half of all adult acquired immunodeficiency syndrome (AIDS) cases. Intervention studies have demonstrated that IDUs are responsive to safer sex messages, but sexual behavior appears to be more resistant to change than drug use behavior. This multidisciplinary study (without an intervention component) assesses changes in sexual risk behavior as a function of time, HIV status, and disease progression in a cohort of HIV+ and HIV- male IDUs (N = 144) for 4 years. RESULTS: For HIV+ and HIV- men, there were increases in abstinence and monogamy, with decreases in the frequency of unprotected vaginal/anal sex and sexual risk index scores. With the exception of monogamy, HIV+ men reported lower levels of risk. Although there was also a decline in substance use, this accounted for only some of the decline in sexual risk behavior. Among the HIV+ men, a CD4 level below 200 was associated with more abstinence and monogamy. HIV-related medical symptoms were associated with increased abstinence, less unprotected sex, and lower sexual risk index scores. Lower neuropsychological memory test scores were associated with increased abstinence and lower sexual risk index scores. Neurological impairment and depression were not associated with sexual risk behavior. CONCLUSION: IDU men in New York City have modified their sexual behavior toward safer practices. Lower levels of risk are found among HIV+ men, particularly those with more progressed HIV illness. Nevertheless, a substantial amount of sexual risk behavior remained in this cohort, indicating the continued need for education and intervention.

Sexual risk behavior changes among HIV+ and HIV-female injecting drug users over 4 years.

This paper examines the sexual risk behavior of female injecting drug users who participated in a 4 year longitudinal study. Both HIV+ and HIV- women showed increases in monogamy, decreases in the frequency of unprotected vaginal/anal sex, and decreases in a risk index score throughout the study. HIV+ women had fewer occasions of unprotected sex than HIV-. However, a substantial proportion of the sample continued to engage in unprotected sex. Among the HIV+ women, depressed mood was significantly related to abstinence and to fewer occasions of unprotected sex, but CD4, medical symptoms, neurological impairment, and memory test performance were not associated with sexual risk behavior.

Reliability of sexual risk behavior interviews with psychiatric patients.

Test-retest interviews examining recent sexual activity were administered to 27 severely ill psychiatric patients after stabilization. Three reports were judged to be questionable. For the 16 sexually active patients among the remaining 24, high test-retest reliability was found for number of sexual partners, frequency of episodes, and proportions of episodes involving vaginal intercourse and use of condoms. The interviews did not exacerbate psychiatric symptoms.

Sexual functioning in HIV+ and HIV- injected drug-using women.

As part of a natural history study of HIV disease in injected drug users, 38 HIV positive (HIV+) asymptomatic or low-symptomatic women and 37 HIV negative (HIV-) women, mostly of minority inner-city background, underwent a comprehensive survey of sexual functioning. At study baseline, the sample as a whole showed a relatively high prevalence of problems in all major phases of the sexual response cycle and in vaginismus and vaginal pain. Statistically significant group differences indicate higher rates of problems in sexual functioning in HIV+ women even at an early stage of disease progression.

Lifetime sexual behaviors among predominantly minority male runaways and gay/bisexual adolescents in New York City.

Lifetime sexual behaviors were examined among two samples of predominantly minority, male adolescents in New York City aged 12 to 18 (M = 16.3), believed to be at high risk for HIV infection: 59 runaway males in two residential shelters and 60 males attending a community agency (HMI) for gay and bisexual youths. Interviews regarding psychosexual milestones indicated that 93% of these youths had engaged in oral, anal or vaginal intercourse and/or anilingus, with a median of 11.0 female partners among runaway males and a median of 7.0 male partners among HMI males. Both groups initiated sexual activity at a relatively early mean age of 12.6 years. Each group reported a unique developmental sequence of psychosexual milestones. Consistent condom use was reported by 13% of the youths. One quarter of the youths reported involvement in prostitution. These findings detail the need for AIDS prevention programs for these youths.