Modelling the epidemiologic impact of achieving UNAIDS fast-track 90-90-90 and 95-95-95 targets in South Africa.

UNAIDS established fast-track targets of 73% and 86% viral suppression among human immunodeficiency virus (HIV)-positive individuals by 2020 and 2030, respectively. The epidemiologic impact of achieving these goals is unknown. The HIV-Calibrated Dynamic Model, a calibrated agent-based model of HIV transmission, is used to examine scenarios of incremental improvements to the testing and antiretroviral therapy (ART) continuum in South Africa in 2015. The speed of intervention availability is explored, comparing policies for their predicted effects on incidence, prevalence and achievement of fast-track targets in 2020 and 2030. Moderate (30%) improvements in the continuum will not achieve 2020 or 2030 targets and have modest impacts on incidence and prevalence. Improving the continuum by 80% and increasing availability reduces incidence from 2.54 to 0.80 per 100 person-years (-1.73, interquartile range (IQR): -1.42, -2.13) and prevalence from 26.0 to 24.6% (-1.4 percentage points, IQR: -0.88, -1.92) from 2015 to 2030 and achieves fast track targets in 2020 and 2030. Achieving 90-90-90 in South Africa is possible with large improvements to the testing and treatment continuum. The epidemiologic impact of these improvements depends on the balance between survival and transmission benefits of ART with the potential for incidence to remain high.

Intimate partner violence perpetration, standard and gendered STI/HIV risk behaviour, and STI/HIV diagnosis among a clinic-based sample of men.

BACKGROUND: The estimated one in three women worldwide victimized by intimate partner violence (IPV) consistently demonstrate elevated STI/HIV prevalence, with their abusive male partners' risky sexual behaviours and subsequent infection increasingly implicated. To date, little empirical data exist to characterise the nature of men's sexual risk as it relates to both their violence perpetration, and STI/HIV infection. METHODS: Data from a cross-sectional survey of men ages 18-35 recruited from three community-based health clinics in an urban metropolitan area of the northeastern US (n = 1585) were analysed to estimate the prevalence of IPV perpetration and associations of such violent behaviour with both standard (eg, anal sex, injection drug use) and gendered (eg, coercive condom practices, sexual infidelity, transactional sex with a female partner) forms of sexual-risk behaviour, and self-reported STI/HIV diagnosis. RESULTS: Approximately one-third of participants (32.7%) reported perpetrating physical or sexual violence against a female intimate partner in their lifetime; one in eight (12.4%) participants self-reported a history of STI/HIV diagnosis. Men's IPV perpetration was associated with both standard and gendered STI/HIV risk behaviours, and to STI/HIV diagnosis (OR 4.85, 95% CI 3.54 to 6.66). The association of men's IPV perpetration with STI/HIV diagnosis was partially attenuated (adjusted odds ratio (AOR) 2.55, 95% CI 1.77 to 3.67) in the multivariate model, and a subset of gendered sexual-risk behaviours were found to be independently associated with STI/HIV diagnosis-for example, coercive condom practices (AOR 1.67, 95% CI 1.04 to 2.69), sexual infidelity (AOR 2.46, 95% CI 1.65 to 3.68), and transactional sex with a female partner (AOR 2.03, 95% CI 1.36 to 3.04). CONCLUSIONS: Men's perpetration of physical and sexual violence against intimate partners is common among this population. Abusive men are at increased risk for STI/HIV, with gendered forms of sexual-risk behaviour partially responsible for this association. Thus, such men likely pose an elevated infection risk to their female partners. Findings indicate the need for interwoven sexual health promotion and violence prevention efforts targeted to men; critical to such efforts may be reduction in gendered sexual-risk behaviours and modification of norms of masculinity that likely promote both sexual risk and violence.

Identification of primary HIV-1C infection in Botswana.

Methods for identification of primary HIV infections seem increasingly important to understand pathogenesis, and to prevent transmission, which is particularly efficient during acute infection. Most current algorithms for HIV testing are based on detection of HIV antibodies and are unable to identify early infections before seroconversion. The efficiency of prospective cohorts, which is a standard approach for identifying primary HIV-1 infection, depends on a variety of epidemiological and cultural factors including HIV incidence and stigma and, not surprisingly, varies significantly in different geographical areas. We report a voluntary counseling and testing (VCT)-based approach to identifying primary HIV-1C infection that was developed as part of a primary HIV-1 subtype C infection study in Botswana. The referral strategy was based on: (1) collaboration with VCT centers at city clinics operated by the Ministry of Health; (2) partnering with the busiest non-government VCT center; (3) educating healthcare workers and the community about primary HIV infection; and (4) pairing with diverse VCT providers, including NGOs and private-sector organizations. Acute HIV-1 infections were defined by a negative HIV-1 serology combined with a positive HIV-1 RT-PCR test. Recent HIV-1 infections were identified by detuned EIA testing according to the classic STARTH algorithm. The VCT-based referral strategy resulted in the successful identification of 57 cases of acute and early HIV infection. A referral strategy of expanded VCT with viral RNA (Ribonucleic acid) testing to a national program in Botswana may be a promising approach for identification of primary HIV infections on a countrywide level. The program should offer VCT with viral RNA testing to the general public, facilitate proper counseling and risk reduction, and allow initiation of early HAART, and may reduce new viral transmissions.

Discussion of preferences for life-sustaining care by persons with AIDS. Predictors of failure in patient-physician communication.

OBJECTIVES: To assess the determinants of communication about resuscitation between persons with acquired immunodeficiency syndrome (AIDS) and their physician. DESIGN AND SETTING: Structured patient interview at a staff-model health maintenance organization (HMO), an internal medicine group practice at a private teaching hospital, and an AIDS clinic at a public hospital. PATIENTS: 289 persons with AIDS. MAIN RESULTS: Only 38% of patients had discussed their preferences for resuscitation with their physician. Using logistic regression, we found that patients were less likely to have discussed resuscitation with their physician if they were nonwhite (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.24 to 0.99), had never been hospitalized (OR, 0.52; 95% CI, 0.27 to 0.99), or were cared for in the HMO (OR, 0.44 relative to the private teaching hospital; 95% CI, 0.23 to 0.82). Patients were more likely to have discussed their preferences if they were not currently taking zidovudine (OR, 1.76; 95% CI, 1.02 to 3.03) and if they had decided to defer life-sustaining therapy (OR, 2.30; 95% CI, 1.35 to 3.91). Among nonwhites, those with a nonwhite physician were more likely to have discussed resuscitation (OR, 4.38; 95% CI, 1.13 to 16.93). Of patients who had not discussed their preferences for life-sustaining care, 72% wanted to do so. Patient desire for discussion of this issue did not vary by race, severity of illness, hospitalization status, use of zidovudine, or site of care. CONCLUSIONS: A majority of persons with AIDS in this study had not discussed their preferences for life-sustaining care with their physician, despite the desire to do so. Interventions to improve patient-physician communication about resuscitation for nonwhites and other groups at risk of inadequate discussion might lead to clinical decisions that are more consistent with patient preferences.

Province of residence and active syphilis infection among Zambian men and women: new evidence from population-based data.

This study examined the risk factors for active syphilis infection in a subset of nationally-representative population-based survey of Zambian men and women. Syphilis prevalence was 6.5% for women = 2107) and 7.4% for men (N = 1745). In the multivariate model, province was a strong risk factor for active syphilis infection, with Copperbelt, Eastern, Luapula, Lusaka, North-Western and Western Provinces presenting significantly higher risk for women, and Copperbelt, Eastern and Lusaka Provinces presenting significantly higher risk for men compared to the Northern Province. In addition to province, age, education, age at first intercourse, marital status, history of genital sore or discharge, and having ever paid for sex were independent predictors of syphilis infection. Given the ongoing HIV-1 epidemic in Zambia, more aggressive diagnosis and treatment of active syphilis infections, particularly in high-risk provinces, are important strategies to reduce reproductive morbidity and curb HIV-1 transmission.

The validity of self-reported health-care utilization by AIDS patients.

OBJECTIVES: To examine the validity of self-reported health-care utilization among persons with AIDS. DESIGN: A comparison of survey data with information collected from medical and financial records. METHODS: Personal interviews provided information on utilization within a 4-month period for inpatient admissions (n = 296), ambulatory visits (n = 284), and hours of homecare (n = 106). Risk group, socioeconomic characteristics, disease stage, functional status, memory, and respondent's recall ability were also measured. Reporting error was defined as the difference between self reports and medical/financial records. Variations among subgroups of patients were examined using t tests and multiple regression. To determine whether reporting errors affected analysis of utilization data, we compared coefficients from parallel utilization models using each data source to predict use/non-use and total utilization. RESULTS: Mean overall reporting errors were small and not significantly different from zero. Reporting errors were lowest for hospital admissions and highest for homecare. High utilizers underreported all types of services. The interviewer evaluation of recall was an independent and significant predictor of reporting errors for admissions and ambulatory visits. Reporting errors varied by selected subgroup characteristics, but the direction and significance of the error depended on the type of utilization measured. In the parallel utilization models, few differences appeared between models using self-reports and medical/financial records to identify correlates of use/non-use, but some differences between the models of total utilization were apparent. CONCLUSIONS: Self-reports of utilization by AIDS patients with a recall period of 4 months or less provide, on average, valid data for analytic purposes. However, caution should be applied to reports by high or low users or by respondents judged by interviewers to have major recall problems.

Readiness of high-risk populations in the HIV Network for Prevention Trials to participate in HIV vaccine efficacy trials in the United States.

OBJECTIVE: To determine the willingness of populations at high risk of HIV-1 infection to participate in HIV vaccine efficacy trials, determine factors influencing decision-making, and evaluate knowledge levels of vaccine trial concepts. DESIGN: Cross-sectional study. METHODS: HIV-1-negative homosexual men, male and female injecting drug users and non-injecting women at heterosexual risk were recruited in eight cities in the United States (n=4892). RESULTS: A substantial proportion of the study population (77%) would definitely (27%) or probably (50%) be willing to participate in a randomized vaccine efficacy trial. Increased willingness was associated with high-risk behaviors, lower education level, being uninsured or covered by public insurance, and not having been in a previous vaccine preparedness study. Altruism and a desire for protection from the vaccine were major motivators for participation. Major concerns included positive HIV-1 antibody test due to vaccine, safety of the vaccine, and possible problems with insurance or foreign travel. Baseline knowledge of vaccine trial concepts was low. CONCLUSIONS: It is likely that high-risk volunteers will be willing to enroll in HIV vaccine efficacy trials. A variety of participant and community educational strategies are needed to address participant concerns, and to ensure understanding of key concepts prior to giving consent for participation.

The effects of intravenous drug use and gender on the cost of hospitalization for patients with AIDS.

At present limited data exist describing the hospital use patterns of intravenous drug users (IVDUs) and women with AIDS. Our objective was to determine if frequency of hospitalization, length of stay (LOS), and cost per hospitalization varied by risk status and gender, controlling for a variety of confounders, including severity of illness as measured by the Turner-Kelly-Ball and Justice AIDS severity of illness systems. We performed a population-based cohort study that compared all women (n = 69) and male IVDUs (n = 74) with AIDS diagnosed in Massachusetts in 1987 with a random sample of all male, nonintravenous drug-using patients diagnosed in that year (n = 148). Frequency of hospitalization, LOS, and cost of hospital care were obtained from hospital billing records for 1987 and 1988. Regression analysis showed 42% longer lengths of stay (p < or = 0.001) and 38% higher cost (p < or = 0.001) per hospitalization for IVDUs with AIDS compared with non-IVDU homosexual AIDS patients. No statistically significant differences by gender were observed. Our results suggest that hospital care for IVDUs is likely to be more expensive. Policymakers should incorporate these data when planning for AIDS care. In addition, instruments to assess severity of illness should incorporate information on intravenous drug use.

Paying the medical cost of the HIV epidemic: a review of policy options.

The complex health care needs of people with HIV infection highlight inadequacies in our health care financing system and raise the question of how best to pay for care. AIDS requires a broad continuum of care to maintain high quality and reasonable costs. A simultaneous need is to assure access to care for patients with HIV infection who lack insurance or entitlement to health care benefits. We suggest new and practical payment mechanisms that can encourage the availability of comprehensive care for people with HIV infection. We suggest changes in state and federal payment policies that would make the cost of providing AIDS care more of a collective, community responsibility. We recommend mandated workplace insurance, extension of Medicaid eligibility to all with incomes below the federal poverty level, an opportunity for individuals with incomes to 200% of the poverty level to purchase Medicaid coverage, mechanisms to encourage public and private agencies to pay for continued health insurance after loss of employment, and a shortened waiting period for Medicare disability.

A comparison of HIV-1 antibody classes, titers, and specificities in paired semen and blood samples from HIV-1 seropositive men.

Twenty-eight paired blood and semen samples obtained from human immunodeficiency virus type 1 (HIV-1) seropositive men at various stages of disease progression were evaluated for titer and immunoglobulin (Ig) class by an enzyme-linked immunosorbent assay (ELISA). Blood antibody titers ranged from 40,000 to 4,000,000 with a median of 40,000. Semen titers ranged from 400 to 40,000 with a median of 400. HIV-1 antibody titers in matched semen and blood samples showed a strong positive correlation (r = 0.963). The ratio of semen:blood titers ranged from 1:1000 to 1:10 with a median of 1:100. There was no correlation between blood or semen antibody titer and stage of disease of the patients. However, there was a trend toward higher (greater than or equal to 4000) semen antibody titers in men with evidence of genital tract inflammation greater than 10(6) white blood cells/ml semen; 3/5 versus 5/23, p greater than 0.1 Fisher exact test). All HIV-1 antibodies detected were of the IgG class; no IgA or IgM class antibodies of titers greater than or equal to 40 were found in either blood or semen. Thirteen paired blood and semen samples from individual patients were analyzed for antibody specificity by Western blot. In some cases antibody profiles in semen were different from those in blood; strong antibody reactivity against the gp160 viral coat antigen band was consistently detected in semen and blood, whereas the prevalence of detectable antibody reactivity against the p55 and p17 HIV-1 antigen bands was significantly reduced in semen.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of patients' socioeconomic status and physicians' training and practice on patient-doctor communication.

To determine characteristics of patients and doctors that are associated with effective communication, patient-doctor communication was studied in 100 ambulatory patients who underwent echocardiography to evaluate previously undefined cardiac problems. As a marker for effective communication, this report examined how often the patient and doctor agreed about basic aspects of care, including symptoms, test results, therapy, and prognosis. Communication between the patient and physician was less effective when the patient was of lower socioeconomic status, as determined by occupation or insurance coverage. Characteristics of physician's training and practice were not significantly associated with better communication. Physicians were unable to predict when their responses would or would not agree with those of their patients. These findings suggest that there is the risk of less effective communication between patients of lower socioeconomic status and their physicians, and that physicians may be unaware that less effective communication is occurring.

Using administratively collected hospital discharge data for AIDS surveillance.

The objectives of this study were twofold: to improve methods of identifying possible and acquired immunodeficiency syndrome (AIDS)-related hospital discharges in administrative databases and to measure AIDS-reporting completeness in Massachusetts both overall and by subgroup. We used fiscal year 1988 discharge data from the Massachusetts Rate Setting Commission (RSC) and data from the Massachusetts AIDS Reporting System (ARS). We identified 3362 discharges of adult patients (> 12 years old) from the RSC file that had diagnosis codes which are human immunodeficiency virus (HIV)-specific (042.x, 043.x, 044.x, or 795.8) or pertain to AIDS-defining "manifestations." Medical records of 650 patients apparently not reported to the ARS were reviewed. THe best set of codes overall consisted of either (a) the 042.x code or (b) the 043.x, 044.x, or 795.8 code plus selected manifestation codes (sensitivity, 93%; specificity, 86%; predictive value positive, 71%). Of the 927 AIDS cases identified from the 3362 discharges, only 36 had not been reported. AIDS cases among women (odds ratio (OR) = 2.9; 95% confidence interval (CI): 1.33 to 6.33), intravenous drug users (OR = 4.2; 95% CI: 2.20 to 8.02), and persons residing outside the Boston metropolitan area (OR = 2.3; 95% CI: 1.18 to 4.57) were more likely to be unreported than those among comparison groups.

Infectiousness of HIV between male homosexual partners.

To estimate the risk of transmission of HIV per receptive anal sexual contact, 329 homosexually-active men, representing 155 sexual partnerships, were enrolled into a study. Information on HIV infection status and sexual behavior within and outside the primary relationship was collected. Of these 329 men, 24 had AIDS and 31 had ARC. Of the 155 couples, 35 consisted of partners that were both HIV +; 62 of partners that were both HIV-; and 58 were discordant. A binomial model was fit to data obtained in the first visit to estimate per contact risk of HIV transmission. Assuming a constant risk of transmission per sexual contact between infected and uninfected partners, the estimated risk is about 5 to 30 per 1000 receptive anal exposures to ejaculate. Although the average risk of HIV transmission per sexual contact appears to be low, there appears to be great variability in infectivity. To model this variability over time and across individuals, more complex models must be fit to longitudinal studies of sexual partners.

Incidence of primary opportunistic infections in two human immunodeficiency virus-infected French clinical cohorts.

BACKGROUND: Clinical guidelines for the prevention of opportunistic infections in human immunodeficiency virus (HIV)-infected individuals have been developed on the basis of natural history data collected in the USA. The objective of this study was to estimate the incidence of primary opportunistic infections in HIV-infected individuals in geographically distinct cohorts in France. METHODS: We conducted our study on 2664 HIV-infected patients from the Tourcoing AIDS Reference Centre and the hospital-based information system of the Groupe d'Epidémiologie Clinique du SIDA en Aquitaine enrolled from January 1987 to September 1995 and followed through December 1995. We estimated: (1) CD4-adjusted incidence rates of seven primary opportunistic infections in the absence of prophylaxis for that specific infection or any antiretroviral drugs other than zidovudine; and (2) CD4 lymphocyte count decline. RESULTS: The highest incidence rates for all opportunistic infections studied occurred in patients with CD4 counts < 200/microl. With CD4 counts < 50/microl, the most common opportunistic infections were toxoplasmic encephalitis (12.6 per 100 person-years) and Pneumocystis carinii pneumonia (11.4 per 100 person-years). Mycobacterium tuberculosis was the least common opportunistic infection (< 5.0/100 person-years). Even with CD4 counts > 300/microl, cases of Pneumocystis carinii pneumonia and toxoplasmic encephalitis were reported. The mean CD4 lymphocyte decline per month was 4.6 cells/microl. There was a significant association between HIV risk behaviour and the incidence of cytomegalovirus infection, between calendar year and the incidence of Pneumocystis carinii pneumonia, toxoplasmic encephalitis and Candida esophagitis, and between geographical area and the incidence of Pneumocystis carinii pneumonia and cytomegalovirus infection. CONCLUSIONS: Geographical differences exist in the incidence of HIV-related opportunistic infections. These results can be used to define local priorities for prophylaxis of opportunistic infections.

Non-injection substance use correlates with risky sex among men having sex with men: data from HIVNET.

Associations between substance use and sexual behavior were examined among 3220 seronegative men who have sex with men (MSM) in a HIV vaccine preparedness study. Relationships between current and past substance use and current sexual risk were evaluated using crude odds ratios and logistic regression to adjust for confounding variables. Heroin and injection drug use were uncommon (< 2%). Substances most often used were alcohol (89%), marijuana (49%), nitrite inhalants (29%), amphetamines or similarly acting stimulants (21%), cocaine 14% and hallucinogens (14%). Increased adjusted odds for unprotected sex were significantly associated with current heavy alcohol use (OR 1.66; CI 1.18, 2.33), past alcohol problems (OR 1.25; CI 1.05, 1.48), and current drug use (OR 1.26; CI 1.08, 1.48). When associations with specific drugs and nitrite inhalants were examined separately, current use of cocaine and other stimulants (OR 1.25; CI 1.01, 1.55), hallucinogens (OR 1.40; CI 1.10, 1.77), and nitrite inhalants (some (OR 1.61; CI 1.35, 1.92); heavy (OR 2.18; CI 1.48, 3.20)), were independently associated with unprotected sex. Those with past drug use or past heavy alcohol use but not currently using demonstrated no increase in sexual risk, suggesting an important role for substance-focused interventions in risk reduction efforts among MSM.

The stability of preferences for life-sustaining care among persons with AIDS in the Boston Health Study.

BACKGROUND: Clinicians recognize the importance of eliciting patient preferences for life-sustaining care, yet little is known about the stability of those preferences for patients with serious disease. OBJECTIVES: To examine the stability of preferences for life-sustaining care among persons with AIDS and to assess factors associated with changes in preferences. DESIGN: Two patient surveys and medical record reviews, administered four months apart in 1990-1991. SETTING: Three health care settings in Boston. PATIENTS: 252 of 505 eligible persons with AIDS who participated in both baseline and follow-up surveys. MAIN OUTCOME MEASURES: A single question assessing desire for cardiac resuscitation and a scale of preferences for life-extending treatment conditional on hypothetical health states. RESULTS: Approximately one-fourth of the respondents changed their minds about life-sustaining care during a four-month period. Of patients who initially desired cardiac resuscitation, 23% decided to forego it four months later, and of those who initially said they would decline care, 34% later said they would accept it. Of those who initially desired any of the life-extending treatments, 25% decided to forego them four months later, and of those who initially said they would decline life-extending care, 24% later said they would accept some treatment. Patients reporting changes in physical function, pain, or suicide ideation were more likely to modify their desires to be resuscitated (all p< or =0.05). Patients lacking an advance directive, not completing high school, or becoming more severely ill were more likely to change their preferences on the Life Extension scale (p< or =0.05). Patients who discussed their preferences with at least one physician were just as likely as others to change desires for cardiac resuscitation. Age, gender, race, emotional health, clinical severity, social support, and site of care were not significant correlates of change for either measure. CONCLUSIONS: Health care providers should periodically reassess preferences for life-sustaining care, particularly for patients with progressive disease, given the instability in patient preferences. However, predictors of instability may vary with how preferences are measured. In particular, changes in health status may be related to instability of preferences for certain types of treatments.

A Monte Carlo simulation of advanced HIV disease: application to prevention of CMV infection.

BACKGROUND: Disagreement exists among decision makers regarding the allocation of limited HIV patient care resources and, specifically, the comparative value of preventing opportunistic infections in late-stage disease. METHODS: A Monte Carlo simulation framework was used to evaluate a state-transition model of the natural history of HIV illness in patients with CD4 counts below 300/mm3 and to project the costs and consequences of alternative strategies for preventing AIDS-related complications. The authors describe the model and demonstrate how it may be employed to assess the cost-effectiveness of oral ganciclovir for prevention of cytomegalovirus (CMV) infection. RESULTS: Ganciclovir prophylaxis confers an estimated additional 0.7 quality-adjusted month of life at a net cost of $10,700, implying an incremental cost-effectiveness ratio of roughly $173,000 per quality-adjusted life year gained. Sensitivity analysis reveals that this baseline result is stable over a wide range of input data estimates, including quality of life and drug efficacy, but it is sensitive to CMV incidence and drug price assumptions. CONCLUSIONS: The Monte Carlo simulation framework offers decision makers a powerful and flexible tool for evaluating choices in the realm of chronic disease patient care. The authors have used it to assess HIV-related treatment options and continue to refine it to reflect advances in defining the pathogenesis and treatment of AIDS. Compared with alternative interventions, CMV prophylaxis does not appear to be a cost-effective use of scarce HIV clinical care funds. However, targeted prevention in patients identified to be at higher risk for CMV-related disease may warrant consideration.

Feasibility of chemoprophylaxis studies in high risk HIV-seronegative populations.

Administration of antiretroviral medications-recommended to prevent HIV infection after occupational exposure-has not been evaluated for safety or efficacy following nonoccupational exposure. HIV-seronegative persons at increased risk for HIV exposure completed a self-administered questionnaire assessing their willingness to join studies of this approach. Of 4,572 respondents, 60% were willing to join a study of a "morning-after" pill; dosing three times a day and mild side effects reduced willingness to 30%. Men who have sex with men (MSM) who reported unprotected anal intercourse in the prior 6 months were significantly more likely to be willing to join a morning-after study than MSM who did not (p = 0.006). MSM favored a preventive HIV vaccine over oral chemoprophylaxis; other populations preferred oral chemoprophylaxis. Interest in studies declined as the hypothetical regimen became more demanding. Studies must emphasize the unknown efficacy of this approach, given increased interest among MSM at greater risk of exposure.

Social and behavioural determinants of consistent condom use among hotel and bar workers in Northern Tanzania.

Bar and hotel workers (n=519) in Moshi, Tanzania were interviewed to obtain information about potential predictors of condom use. Samples were collected for the diagnosis of sexually transmitted diseases (STDs), including HIV. Consistent condom use was defined as always using condoms with sexual partners in the past five years. Overall consistent condom use in this population was 14.1%. In multivariate analyses, consistent condom use was inversely associated with low condom self-efficacy (adjusted odds ratio [AOR], 0.20; 95% confidence interval (CI), 0.06-0.71), low condom knowledge (AOR, 0.11; CI, 0.01-0.80), and having more than three children (AOR, 0.23; 95% CI, 0.09-0.54). Other significant predictors included perceived condom acceptability and using condoms when last exchanged sex for money or gift. These results indicate that increased specific condom knowledge, improved self-efficacy, and reduced social stigma could be effective strategies in the promotion of condom use in this population.

HIV and hepatitis B infection and risk behavior in young gay and bisexual men.

OBJECTIVES: To estimate the prevalence of and identify risk factors for human immunodeficiency virus type 1 (HIV-1) and hepatitis B virus (HBV) infections and unprotected anal intercourse among young homosexual and bisexual men. METHODS: The authors performed a cross-sectional analysis of data from a prospective cohort of 508 young gay and bisexual men ages 18-29. RESULTS: HIV-1 seroprevalence was 2.4%, with five (1.3%) of 390 college students and seven (6.0%) of 117 non-students infected. After adjusting for confounders, HIV-1 infection was associated with having a history of a sexually transmitted disease other than HIV-1 or hepatitis B. The prevalence of hepatitis B markers in unvaccinated men was 12.9%. The presence of hepatitis B markers in unvaccinated men was significantly associated with Asian ethnicity, off-campus residence, and history of a sexually transmitted disease other than HIV-1 or hepatitis B and inversely associated with recent non-intravenous drug use. Eighteen percent of the participants reported having had sex with women during the previous 12 months, and 26.4% reported a history of unprotected anal intercourse during the previous six months. Men who reported unprotected anal intercourse were more likely to have at least one steady partner, to have met their partners in anonymous settings, and to be identified as probably alcohol dependent. CONCLUSIONS: Although the prevalence of HIV-1 infection among young homosexual and bisexual men in Boston was relatively low, the high rates of unprotected anal intercourse suggest a potential for future HIV-1 and hepatitis B transmission. Interventions should focus on young men with histories of sexually transmitted diseases, alcohol abuse, and depression.