Articles tagged as "Sexual transmission and prevention"

December
13
2011

Sexual transmission

Risk for HIV and unprotected sexual behaviour in male primary partners of transgender women

Operario D, Nemoto T, Iwamoto M, Moore T. Arch Sex Behav. 2011 May 21.

Men who have sex with transgender women are a potentially high-risk population for HIV and other sexually transmitted infections. Operario and colleagues administered structured quantitative surveys to 174 men whose primary partner was a transgender woman. They assessed men's demographic characteristics, sexual behaviours, substance use, and social-psychological factors, including condom use self-efficacy and depression. Overall, 19% reported being HIV-positive (8% had been diagnosed with AIDS), 11% had at least one other sexually transmitted infection during the past year, and 16% reported being in a HIV serodiscordant relationship with their primary partner. In the past 3 months, 40% had unprotected anal or vaginal sex with any partner. In multivariate analysis, significant correlates of having unprotected sex included younger age, concurrent partnerships, alcohol intoxication, and low condom use self-efficacy; depression was marginally associated with having unprotected sex. Interventions are needed to reduce risk for HIV and other sexually transmitted infections among men who have sex with transgender women. Prevention programmes for these men should build condom use self-efficacy and address the contributions of alcohol intoxication, concurrent sex partnerships, and depression to sexual risk behaviour.

For abstract access click here

Editor’s note: A study of men in primary relationships with transgender women is very rare. Being in a ‘primary relationship’ was defined as two adults committed to each other above anyone else. The couples were identified through snowball referral techniques (Do you know couples like yours that could be interested in the study? Could you refer them to us?) and through direct approaches to couples in bars, nightclubs, book stores, community based organisations, health clinics, parks, and street locations where study advertisements were posted. The average relationship duration was 2.9 years and 47% of the couples in this convenience sample lived together. This paper describes the male partners¾they reported being bisexual (45%), homosexual (23%), heterosexual (23%), and other or not willing to categorise themselves (9%). Men whose primary partner was post-operative were more likely than those with a pre-operative transgender partner to identify as heterosexual (53% vs. 20%). Overall 58% of the men in this San Francisco Bay area study described the relationship as monogamous, however one in five of them, and 12% of their transgender partners, had sex with an outside partner during the current primary partnership. Whether or not these couples are serodiscordant (one in six are), couples-based interventions aimed at strengthening safer sex practices are warranted, without preconceived assumptions about the sexual orientation of the men. 

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September
25
2011

Blood donation

Deferral from donating blood of men who have sex with men: impact on the risk of HIV transmission by transfusion in France

Pillonel J, Heraud-Bousquet V, Pelletier B, Semaille C, Velter A, Saura C, Desenclos JC, Danic B; the blood donor epidemiological surveillance study group. Vox Sang. 2011 Jun 21. [Epub ahead of print]

In France, men who have sex with men are permanently excluded from blood donation. This policy is felt to be discriminatory by activist men who have sex with men. Furthermore, the policy is not fully respected because some men who have sex with men do not report their sexual behaviour before donating. Pillonel and colleagues estimated the fraction of the current risk of HIV attributed to men who have sex with men. They then constructed a model based on data obtained from behavioural and epidemiological surveys to assess the impact of a new strategy in which men who have sex with men would only be deferred if they report more than one sexual partner in the last 12 months. Thirty-one HIV seroconversions occurred among repeat donors between 2006 and 2008, giving a risk of one in 2,440,000 donations. Fifteen of these seroconversions (48%) were men who have sex with men. If all men who have sex with men had abstained from donating blood, the risk would have been 1 in 4,700,000 donations, half the current risk. The new strategy would result in an overall HIV risk of between 1 in 3,000,000 (close to the current risk) to 1 in 650,000 donations (3.7 times higher than the current risk). Changing the current deferral policy may increase the risk of transfusion-transmission of HIV. However, this does not take into account a possible better compliance by men who have sex with men with a less stringent policy that would be perceived as more equitable. Conversely, relaxing the policy could encourage some men who have sex with men to seek an HIV test in blood centres. Thus, further qualitative study is needed to assess possible changes in compliance linked to a new policy.

For abstract access click here

Editor’s note: Donor selection and continuous improvements in screening assays have improved the viral safety of the blood supply dramatically since 1985. Nonetheless, there is residual risk because of the window period which occurs after a donor has become infected and before markers of infection can be detected. Therefore, donor selection remains an important element to reduce the risk that a contaminated blood donation will slip through to be transfused. In France, despite the lifetime blood donation deferral policy in place for all men who have had sex with men, half of the current risk of HIV transmission by transfusion is attributed to blood donors who are such men. Clearly, some men who have sex with men donate blood while in the window period, hiding their sexual behaviour, possibly because they view the current policy as discriminatory. Alternately, they may be donating blood after a risk exposure to get a free RNA test, aware of the fact that NAT (nucleic acid amplification) testing is used to try to detect acute infection. The lifetime deferral policy for men who have sex with men is being challenged in several countries, with some countries proposing that men who have sex with men who have been sexually abstinent for one year or more be allowed to donate and others considering whether to make their policies consistent for everyone, i.e. exclusion from donation if the person has had more than one sexual partner in the previous 12 months. The key information missing from risk calculations and decision-making can only come from qualitative studies: will relaxing the policy send the message that self-deferral is not important, increasing the risk, or will a policy perceived to be more equitable improve blood safety by enhancing responsibility?

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August
28
2011

Sexual Transmission

Intravaginal practices, bacterial vaginosis, and HIV infection in women: individual participant data meta-analysis

Low N, Chersich MF, Schmidlin K, Egger M, Francis SC, van de Wijgert JH, Hayes RJ, Baeten JM, Brown J, Delany-Moretlwe S, Kaul R, McGrath N, Morrison C, Myer L, Temmerman M, van der Straten A, Watson-Jones D, Zwahlen M, Hilber AM. PLoS Med. 2011;15;8(2).

Identifying modifiable factors that increase women's vulnerability to HIV is a critical step in developing effective female-initiated prevention interventions. The primary objective of this study was to pool individual participant data from prospective longitudinal studies to investigate the association between intravaginal practices and acquisition of HIV infection among women in sub-Saharan Africa. Secondary objectives were to investigate associations between intravaginal practices and disrupted vaginal flora; and between disrupted vaginal flora and HIV acquisition. Low and colleagues conducted a meta-analysis of individual participant data from 13 prospective cohort studies involving 14,874 women, of whom 791 acquired HIV infection during 21,218 woman years of follow-up. Data were pooled using random-effects meta-analysis. The level of between-study heterogeneity was low in all analyses (I(2) values 0.0%-16.1%). Intravaginal use of cloth or paper (pooled adjusted hazard ratio [aHR] 1.47, 95% confidence interval [CI] 1.18-1.83), insertion of products to dry or tighten the vagina (aHR 1.31, 95% CI 1.00-1.71), and intravaginal cleaning with soap (aHR 1.24, 95% CI 1.01-1.53) remained associated with HIV acquisition after controlling for age, marital status, and number of sex partners in the past 3 months. Intravaginal cleaning with soap was also associated with the development of intermediate vaginal flora and bacterial vaginosis in women with normal vaginal flora at baseline (pooled adjusted odds ratio [OR] 1.24, 95% CI 1.04-1.47). Use of cloth or paper was not associated with the development of disrupted vaginal flora. Intermediate vaginal flora and bacterial vaginosis were each associated with HIV acquisition in multivariable models when measured at baseline (aHR 1.54 and 1.69, p<0.001) or at the visit before the estimated date of HIV infection (aHR 1.41 and 1.53, p<0.001), respectively. This study provides evidence to suggest that some intravaginal practices increase the risk of HIV acquisition but a direct causal pathway linking intravaginal cleaning with soap, disruption of vaginal flora, and HIV acquisition has not yet been demonstrated. More consistency in the definition and measurement of specific intravaginal practices is warranted so that the effects of specific intravaginal practices and products can be further elucidated.

For abstract access click here

Editor’s note: With the exciting findings of the 1% tenofovir gel trial CAPRISA 004 setting the stage for the FACTS001 trial of similar pre- and post-sex vaginal gel dosing, it is increasingly important to understand the motivations for and health effects of intravaginal practices. Such practices may disrupt the lining of the vagina and/or change the normal protective bacterial flora and pH (acidity) of the vagina. An effective microbicide could be washed or wiped away or become inactive or even harmful when intravaginal cleaning is practiced. This meta analysis pooled individual participant data from 10 prospective studies in Kenya, Malawi, South Africa, Tanzania, Uganda, and Zimbabwe to analyse the effects of specific intravaginal practices. Data from over 15,000 women, 791 of whom acquired HIV infection, were analysed. Studies in South Africa revealed a lower prevalence and those in Zimbabwe a higher prevalence of any current intravaginal practice, with sex workers in Kenya having the highest prevalence. Some practices appear to increase risk of acquiring HIV, e.g. cleaning with soap, while others did not, e.g. washing with water alone. Sexual and reproductive health programmes should routinely raise the issue of intravaginal cleaning and encourage women to use less harmful vaginal practices to reduce risk now while we await confirmation of an effective intravaginal microbicide, 1% tenofovir gel.

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June
19
2011

Male circumcision

The Shang Ring Device for adult male circumcision: a proof of concept study in Kenya

Barone MA, Ndede F, Li PS, Masson P, Awori Q, Okech J, Cherutich P, Muraguri N, Perchal P, Lee R, Kim HH, Goldstein M. J Acquir Immune Defic Syndr. 2011 Feb 21.

 

The objective of this study was to assess safety, preliminary efficacy, and acceptability of the Shang Ring, a novel disposable device for adult male circumcision, in Kenya where 40 HIV-negative men were recruited in Homa Bay, Kenya. Circumcisions were performed by a trained physician or nurse working with one assistant. Follow-up was conducted at 2, 7, 9, 14, 21, 28, 35 and 42 days after circumcision. Rings were removed on day 7. Pain was assessed using a visual analog scale (0=no pain,10=worst possible). Men were interviewed at enrollment and on days 7 and 42. All 40 procedures were completed successfully. Mean procedure and device removal times were 4.8 (sd±2.0) and 3.9 (sd±2.6) minutes, respectively. There were six mild adverse events, including three penile skin injuries, two cases of edema, and one infection; all resolved with conservative management. In addition, there were three partial ring detachments between days 2-7. None required treatment or early ring removal. Erections with the ring were well tolerated, with a mean pain score of 3.5 (sd±2.3). By day 2, 80% of men were back to work. At 42 days all participants were very satisfied with their circumcision and would recommend the procedure to others. The results of Barone and colleagues demonstrate that the Shang Ring is safe for further study in Africa. Acceptability of the Shang Ring among participants was excellent. With short procedure times, less surgical skill required, and the ease with which it can be used by non-physicians, the Shang Ring could facilitate rapid roll-out of male circumcision in sub-Saharan Africa.

 For abstract access click here

Editors’ note: WHO and UNAIDS recommend three surgical techniques for adult male circumcision: the forceps guided method, the sleeve resection method, and the dorsal slit method (www.malecircumcision.org). In the absence of task sharing and other methods to optimise the volume and efficiency of male circumcision service delivery, these methods entail 20 to 30 minutes of surgical time. This study of the Shang Ring shows promise and suggests that further data should be collected in sub-Saharan African settings with this device. The Shang Ring consists of 2 concentric plastic rings that are available in China in 32 sizes for use with neonates to adults. Following local anaesthesia, the locking rings compress the foreskin with no need for sutures. In addition to the impressive number of minutes saved per procedure, this study found the rings to be acceptable with all 32 of the men who attended the 6 week follow-up visit stating that they would recommend circumcision generally and specifically with the Shang Ring. Given the millions of adult male circumcisions that countries are aiming to achieve by 2015, there is tremendous interest in the potential time-saving features of medical devices. The WHO Technical Advisory Group on Innovations in Male Circumcision, which has a mandate to examine data on new circumcision devices formally submitted to it, will hold its first meeting in July 2011. You can expect further innovations in male circumcision service delivery in the future.

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June
19
2011

Mobility: sea, land, and sex

Southern Africa ports as spaces of HIV vulnerability: case studies from South Africa and Namibia

Tansey E, Nosiphotheyise N, Borland R, West H. Int Marit Health 2010;62(4):233-40.

There is increasing recognition that in order to respond to the HIV epidemic migrants and mobile populations must be included in national and regional responses. While migration in and of itself does not necessarily contribute to increased risk of HIV infection, some migrants and mobile populations do face increased HIV risk. With its immense coastline and extensive transport industry, Southern Africa provides an excellent case study to examine the HIV risks and vulnerabilities of mobile workers and local communities through port settings. The International Organization for Migration's research in Southern African ports illustrates why HIV policies and programmes must focus on spaces where migrants and mobile populations interact with sedentary populations (including sex workers and other sexual partners) in environments conducive to multiple concurrent partnerships, in order to reduce HIV risk and increase access to treatment, care, and support for all.

For abstract access click here

Editors’ note: Although migrants and mobile populations are identified as key populations, they face different individual, environmental, and structural factors influencing their risk of HIV. These case studies focus on two port settings as ‘spaces of vulnerability’. They are Durban Port, South Africa’s main trade gateway and the busiest and biggest port in Africa, and Walvis Bay, Namibia’s only deep-water port and a key node for two highways linking Namibia to Angola, Zambia, Botswana, and South Africa. Land transport workers and seafarers stay at these ports for relatively short periods but they may interact with sex workers, creating a triangle of risky sex with dock workers and other local people. Lack of recreational opportunities, lack of tailored HIV information, poor access to health services, language difficulties, and separation from regular sexual partners create conditions for HIV transmission, particularly when migration and poverty among women underpin local sex work, alcohol disinhibits sexual behaviour, and HIV awareness and risk perception are low. This article emphasises combination prevention strategies and lays out 12 recommendations to address gaps and challenges. If you would like to become involved in the Global Partnership on HIV and Mobile Workers in the Maritime Sector that was formed in 2009, you can write to seafarers@iom.int.

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June
19
2011

Mental health and HIV risk

Poor mental health and sexual risk behaviours in Uganda: A cross-sectional population-based study

Lundberg P, Rukundo G, Ashaba S, Thorson A, Allebeck P, Ostergren PO, Cantor-Graae E. BMC Public Health. 2011 Feb 21;11:125

Poor mental health predicts sexual risk behaviours in high-income countries, but little is known about this association in low-income settings in sub-Saharan Africa where HIV is prevalent. This study investigated whether depression, psychological distress and alcohol use are associated with sexual risk behaviours in young Ugandan adults. Household sampling was performed in two Ugandan districts, with 646 men and women aged 18-30 years recruited. Hopkins Symptoms Checklist-25 was used to assess the presence of depression and psychological distress. Alcohol use was assessed using a question about self-reported heavy-episodic drinking. Information on sexual risk behaviour was obtained concerning number of lifetime sexual partners, ongoing concurrent sexual relationships and condom use. Depression was associated with a greater number of lifetime partners and with having concurrent partners among women. Psychological distress was associated with a greater number of lifetime partners in both men and women and was marginally associated (p = 0.05) with having concurrent partners among women. Psychological distress was associated with inconsistent condom use among men. Alcohol use was associated with a greater number of lifetime partners and with having concurrent partners in both men and women, with particularly strong associations for both outcome measures found among women. Poor mental health is associated with sexual risk behaviours in a low-income sub-Saharan African setting. HIV preventive interventions should consider including mental health and alcohol use reduction components into their intervention packages, in settings where depression, psychological distress and alcohol use are common.

For abstract access click here

Editors’ note: In high-income countries poor mental health is closely linked to risky sexual behaviours, with depression, in particular, seemingly associated with low self-efficacy, poor coping strategies, and self-destructiveness. Studies in middle-income countries have found depressive symptoms associated with transactional sex and intimate partner violence for women and inconsistent condom use for men (South Africa) and with multiple partners for women and paying for sex in men (Botswana). This first study in a low income sub-Saharan Africa setting—in Uganda which has one of the world’s highest alcohol per capita consumptions—found that depression, psychological distress, and alcohol use were all associated with having a greater number of lifetime partners and with having concurrent sexual partners, with stronger associations among women. Excessive alcohol use can cause behavioural disinhibition but it may also be a marker for a psychological state conducive to risky sexual behaviours, such as depression or psychological distress. Depression and multiple partners may be indirectly linked through a common cause, such as poverty with food insecurity or having an abusive partner, both of which may lead to hopelessness and risky sex. Psychological distress may lead to casual sex as a coping strategy, impulsivity, and decreased self-efficacy. Although it was cross-sectional in design, this study suggests mutually independent causal pathways for depression/psychological distress and alcohol use in influencing sexual risk behaviours and provides support for integrating mental health components and brief interventions for alcohol within HIV prevention programming in low-income countries.

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May
15
2011

Sex work

The role of brothels in reducing HIV risk in Sonagachi, India

Ghose T, Swendeman DT, George SM. Qual Health Res. 2011 Jan 25

High rates of empowerment, HIV-related knowledge, and condom use among sex workers in Sonagachi, India have been attributed to a community-led intervention called the Sonagachi HIV/AIDS Intervention Programme (SHIP). In this research Ghose and colleagues examined the crucial role of brothels in the success of the intervention. In-depth, semistructured interviews were conducted with 55 participants of SHIP. The results indicate that brothels help sex workers reduce HIV risk by (a) serving as targeted sites for SHIP's HIV intervention efforts, (b) being operated by madams (women managers of brothels) who participate in SHIP's intervention efforts and promote healthy regimes, (c) structuring the economic transactions and sexual performances related to sex work, thus standardizing sex-related behaviour, and (d) promoting community empowerment among brothel residents. Implications of these results are discussed for future efforts to replicate SHIP's success in other sex work communities.

For abstract access click here

Editors’ note: The Sonagachi HIV/AIDS Intervention Program (SHIP), started in 1992 as peer-run condom education programme, is recognised worldwide for its results: high levels of empowerment, HIV-related knowledge, and condom use among sex workers in Sonagachi, the largest red-light area of Kolkata (formerly Calcutta), West Bengal, India. This study reveals the role of brothels as SHIP became a community-based programme that helped sex workers to collectivise and form a union (Durbar) around a sex work identity, mobilise against harassment, and reduce exposure to violence and HIV risk. Brothels are mediators of HIV risk, with the negotiating power of sex workers shaped by the social and institutional environment of the brothel. SHIP actively targeted brothels to mobilize sex workers to establish safety norms for sex worker-client interactions, create a stable and fixed menu of prices, and set a fixed fee rate for Madams’ cut of the earnings to create mutually beneficial business partnerships. As norming processes took root, and rules and norms were strictly enforced, sex workers developed an enhanced sense of empowerment over their living and working space. Brothels participating in SHIP became structured work environments, provided stable housing, crystallized sex worker solidarity, and catalysed collective mobilisation. The success of SHIP underscores the transformative power of structural intervention programmes that seek to shape the risk environment of sex work, the oldest profession on earth.

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May
15
2011

Good participatory practice

'Who is Helsinki?' Sex workers advise improving communication for good participatory practice in clinical trials

Ditmore MH, Allman D. Health Educ Res. 2011 Jan 24

After premature closures in 2004 of biomedical HIV prevention trials involving sex workers in Africa and Asia, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and Global Advocacy for HIV Prevention (AVAC) undertook consultations to establish better participatory guidelines for such trials in order to address ethical concerns. This study investigated sex workers' knowledge and beliefs about research ethics and good participatory practices and the perspectives of sex workers on research participation. A 33-question survey based on criteria identified by UNAIDS and AVAC was translated into three other languages. Participants were recruited through mailing lists and contacts with existing sex work networks. In total, 74 responses from Europe, the Americas and Asia were received. Thirty percent of respondents reported first-hand involvement in biomedical HIV prevention trials. Seventy percent indicated a lack of familiarity with codes of ethics for research. This paper focuses exclusively on communication issues described in survey responses. Communication was an important theme: the absence of clear communication between trial participants and investigators contributed to premature trial closures in at least two sites. Sex workers had recommendations for how researchers might implement good participatory practices through improved communication, including consultation at the outset of planning, explaining procedures in non-technical terms, and establishing clear channels for feedback from participants.

For abstract access click here

Editors’ note: Following the closures of the Cameroon and Cambodia pre-exposure prophylaxis trials in 2004, some researchers thought that sex workers were against research in general and understood poorly the ethical concerns expressed by sex workers. This study sought to determine what sex workers from different parts of the world believe about good participatory practice (GPP). Although notions of ethics and ethical guidelines were not well understood in this group of 74 sex workers who answered a 33-question survey in English, French, Portuguese, or Spanish, many responses indicated an intuitive understanding of ethical standards. Of the 10 principles in the UNAIDS/AVAC Good Participatory Practice Guidelines for Biomedical HIV Prevention Trials, respondents emphasised the importance of building research literacy and respect. As one participant put it: ‘Respect requires ongoing education and awareness by the researchers of their own privilege, and power, as well as societal oppressions at work’. These are words that should move us all.

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March
27
2011

Men who have sex with men

Ongoing HIV-1 transmission among men who have sex with men in Amsterdam: a 25-year prospective cohort study

Jansen IA, Geskus RB, Davidovich U, Jurriaans S, Coutinho RA, Prins M, Stolte IG. AIDS 2011, 25:493-501

To examine the suggested resurgence of the HIV epidemic among men who have sex with men, Jansen and colleagues studied trends in HIV-1 incidence rates, sexual risk behaviour, risk factors for HIV-1 seroconversion, and source of HIV-1 infection among men who have sex with men in the Amsterdam Cohort Studies from 1984 to 2009. Trends in HIV-1 incidence and risk factors for HIV-1 infection were studied using Poisson regression. Trends in sexual risk behaviour were evaluated using logistic regression, correcting for intra-individual correlation via generalized estimating equations. Trends in the source of HIV-1 infection were modelled via logistic regression. Of 1642 HIV-1-negative individuals, 217 seroconverted during follow-up. HIV-1 incidence rates strongly decreased from 8.6/100 person-years in 1985 to 1.3/100 person-years in 1992; remained relatively stable around 1.0/100 person-years between 1992 and 1996, and slowly increased to 2.0/100 person-years in 2009 (P = 0.14; linear trend 1996-2009). Reports of unprotected anal intercourse increased significantly from 1996 onwards. HIV-1 seroconversion was associated with receptive unprotected anal intercourse with casual partners, more than five sexual partners, a history of gonorrhoea (all in the preceding 6 months), and a lower educational level. Currently, men who have sex with men are more likely to have contracted HIV-1 from casual partners than from steady partners, but trends of recent years suggest that steady partners became a growing source with increasing age. Following increases in sexual risk behaviour from 1996 onwards, HIV-1 continues to spread among men who have sex with men. Targeted prevention messages should continue to focus on sexual behaviour with casual partners, but also on sexual behaviour within steady relationships.

Abstract

Editors’ note: The Amsterdam Cohort Studies (ACS) recently achieved 25 years of follow-up documenting changes over this period in behavioural risk and HIV incidence in men who have sex with men. The proportion of men reporting unprotected anal intercourse in the preceding 6 months decreased from 78% in 1984 to 33% in 1988 before increasing to 38% in 1995 and 55% in 2009. Men were more likely to practice unprotected anal intercourse after the introduction of combination antiretroviral therapy in 1996 than in the 5 years prior, a trend seen with both casual and steady partners. HIV incidence has remained relatively stable increasing from 1.4 per 100 person years in 1996 to 2.0 per 100 person years in 2009. Other national and international studies in the North are reporting increases in sexually transmitted diseases and new diagnoses of HIV infection among men who have sex with men, reinforcing the need for sustained HIV prevention strategies. The data from AMC suggest that these should focus on reducing risk with both casual and steady partners.

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February
21
2011

Sexual transmission: sexual behaviour

Timing is everything: international variations in historical sexual partnership concurrency and HIV prevalence

Morris M, Epstein H, Wawer M. PLoS One. 2010 Nov 24;5(11):e14092

Higher prevalence of concurrent partnerships is one hypothesis for the severity of the HIV epidemic in the countries of Southern Africa. But measures of the prevalence of concurrency alone do not adequately capture the impact concurrency will have on transmission dynamics. The importance of overlap duration and coital exposure are examined here. Morris and colleagues conducted a comparison of data from three studies of sexual behaviour carried out in the early 1990s in Uganda, Thailand, and the USA. Using cumulative concurrency measures, the three countries appeared somewhat similar. Over 50% of both Thai and Ugandan men reported a concurrency within the last three partnerships and over 20% reported a concurrency in the last year, the corresponding rates among US men were nearly 20% for Blacks and Hispanics, and about 10% for other racial/ethnic groups. Concurrency measures that were more sensitive to overlap duration, however, showed larger differences. The point prevalence of concurrency on the day of interview was over 10% among Ugandan men compared to 1% for Thai men. Ugandan concurrencies were of much longer duration - a median of about two years - than either the Thai (1 day) or US concurrencies (4-9 months across all groups), and involved 5-10 times more coital risk exposure with the less frequent partner. In the US, Blacks and Hispanics reported higher prevalence, longer duration and greater coital exposure than Whites, but were lower than Ugandans on nearly every measure. Together, the differences in the prevalence, duration and coital exposure of concurrent partnerships observed align with the HIV prevalence differentials seen in these populations at the time the data were collected. There were substantial variations in the patterns of concurrent partnerships within and between populations. More long-term overlapping partnerships, with regular coital exposure, were found in populations with greater HIV epidemic severity.

Abstract:                                              

Editors’ note: In this ecological study, Thai men and American men and women reported considerably more lifetime sexual partners than did their Ugandan counterparts despite the fact that HIV prevalence peaked at more than ten times higher in Uganda than in the other two countries. Rather than lifetime numbers of partners, concurrency of partnerships may largely explain the different epidemic trajectories of Uganda, Thailand, and the USA. Concurrency or overlapping partnerships can be of short duration, e.g. a single episode of sex with a second partner during an ongoing relationship with a primary partner, or longer duration, e.g. lasting months or years if one person has regular sexual contact with two or more people. While Thai men and some groups in the USA were as likely as Ugandan men to report at least one concurrent partnership in the previous year, the duration of these partnerships was much shorter and coital exposure was less than for the concurrent partnerships reported by Ugandan men. UNAIDS recommends a simple nine-question approach to measure concurrency: for each of the most recent 3 partnerships, determine the dates of first and last sex and the status of the relationship on the day of the interview. The answers determine cumulative prevalence (over a time period), overlap duration, and point prevalence (day of the interview). The authors argue that point prevalence at the time of the interview is the most important and can be determined by asking for each of the most recent 3 partners: ‘Are you still sexually active with this partner?’ or ‘Do you expect to have sex with this partner again?’. Clearly, the duration of overlap, the frequency of sex in each partnership, and the numbers of people with overlapping partnerships influence the speed at which HIV will be transmitted through the sexual network, particularly when one or more people have acute HIV infection. The lessons learned from these three countries as they address distinctly different forms of concurrency are that effective, locally-developed, non-moralistic strategies can raise awareness about risk from unprotected sex, whether concurrent, casual, or commercial, change sexual norms, and reduce HIV transmission.

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