Faculty Bibliography

OBJECTIVE: To evaluate the case-finding effectiveness of a clinic-based partner notification effort for early syphilis in Madagascar. METHODS: We asked index cases who had proven early syphilis to identify and provide contact information of recent sex partners (in the past 3, 6, and 12 months for primary, secondary, and early latent syphilis, respectively). Named sex partners were contacted by index cases (patient notification) or, if approved by the index case, clinic staff members (provider notification); notified of their potential exposure to syphilis; and asked to come to the clinic for evaluation. We assessed case-finding effectiveness and calculated the 'brought-to-treatment' index (number of newly-diagnosed syphilis cases per number of index cases interviewed). RESULTS: Of 565 index cases, 534 reported recent sex with at least one sex partner. A total of 3167 sex partners were reported, of whom 276 were contactable (9% of 3167). Providers notified 76% and cases notified 24% of these partners. 270 partners were contacted (98% of 276), and of these, 199 presented to the clinic for evaluation (74% of 270). A total of 99 partners tested positive for syphilis and received treatment (50% of 199). The 'brought-to-treatment' index was 0.18 (99 diagnoses per 565 index cases). CONCLUSION: Partner notification was possible in this setting, resulting in treatment of syphilis-infected individuals who otherwise would likely have remained untreated. However, given <10% of the partners reported by index cases were contactable; the results highlight the limitations of partner notification and the need for additional sexually transmitted infection control strategies.

This study examines the relationship between criminal justice involvement and high-risk sexual partnerships among a random sample of 416 women in methadone treatment in New York City. Logistic regression models were used to estimate the associations between recent criminal justice involvement (arrest or incarceration in the past 6 months) and recent high-risk partnerships (multiple sex partners, sex trading, or sex with a risky partner in the past 6 months) when adjusting for sociodemographic factors and recent regular drug use. Women with recent criminal justice involvement demonstrated higher odds of engaging in high-risk sex partnerships. Although regular drug use was a significant confounder of several of these relationships, recent arrest or incarceration remained significantly associated with multiple sex partnerships, sex with a risky partner, and engaging in unprotected sex and a high-risk partnership even after controlling for regular drug use and other social stressors. This study highlights the vulnerability of drug-involved women offenders to human immunodeficiency virus (HIV) risk and points to the need for investigation into the role of arrest and incarceration as factors that may contribute to HIV infection.

INTRODUCTION: The Centers for Disease Control and Prevention (CDC) advise repeat HIV testing for partners of HIV-infected persons; injection drug users and their sex partners; individuals with recent multiple partnerships and their sex partners; those involved in sex trade; and men who have sex with men. Additional social and behavioral variables may be useful for identifying priority populations. METHODS: We analyzed data collected during a social network study conducted in a Brooklyn, NY, neighborhood to identify social and behavioral characteristics of respondents (N = 343) involved in HIV-discordant, herpes simplex virus-2- discordant, and chlamydia-discordant partnerships. RESULTS: HIV partnership discordance was associated with injection drug use but was generally not associated with sexual behaviors including multiple partnerships and sex trade. herpes simplex virus-2 and chlamydia partnership discordance were associated with multiple partnerships, sex trade, and same sex partnership history. Additional correlates of sexually transmitted infection (STI)/HIV-discordant partnerships included older age (>or=25 years), noninjection drug use, and incarceration history. Analyses suggested that screening tools composed of CDC-recommended sexual risk and injection drug indicators plus indicators of older age, noninjection drug use, and incarceration were more effective in identifying STI/HIV priority populations than tools composed of CDC indicators alone. CONCLUSIONS: Screening tools that include social and behavioral indicators may improve STI/HIV case-finding effectiveness.

OBJECTIVE: To measure associations among depression, sexual risk behaviors, and sexually transmitted infection (STI) among white and black youth in the United States. DESIGN: Analysis of prospective cohort study data. Wave I of the National Longitudinal Study of Adolescent Health occurred in 1995 when participants were in grades 7 through 12. Six years later, all Wave I participants who could be located were invited to participate in Wave III and to provide a urine specimen for STI testing. SETTING: In-home interviews in the continental United States, Alaska, and Hawaii. PARTICIPANTS: Population-based sample. A total of 10 783 Wave I (adolescence) and Wave III (adulthood) white and black respondents with sample weight variables. Main Exposures Chronic depression (detected at Waves I and III) and recent depression (detected at Wave III only) vs no adult depression (not detected at Wave III). OUTCOME MEASURES: Multiple sexual partners and inconsistent condom use in the past year and a current positive test result for Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis (adulthood). RESULTS: Recent or chronic depression in adulthood was more common for blacks (women, 19.3%; men, 11.9%) than for whites (women, 13.0%; men, 8.1%). Among all groups (white men and women, and black men and women), adult depression was associated with multiple partners but not with condom use. Among black men, depression was strongly associated with STI (recent: adjusted prevalence ratio, 2.36; 95% confidence interval, 1.26-4.43; chronic: adjusted prevalence ratio, 3.05; 95% confidence interval, 1.48-6.28); having multiple partners did not mediate associations between depression and STI. CONCLUSIONS: Integration of mental health and STI programs for youth is warranted. Further research is needed to elucidate how depression may influence the prevalence of STI among black men.

Incarceration is associated with multiple and concurrent partnerships, which are determinants of sexually transmitted infections (STI), including HIV. The associations between incarceration and high-risk sex partnerships may exist, in part, because incarceration disrupts stable sex partnerships, some of which are protective against high-risk sex partnerships. When investigating STI/HIV risk among those with incarceration histories, it is important to consider the potential role of drug use as a factor contributing to sexual risk behavior. First, incarceration's influence on sexual risk taking may be further heightened by drug-related effects on sexual behavior. Second, drug users may have fewer economic and social resources to manage the disruption of incarceration than nonusers of drugs, leaving this group particularly vulnerable to the disruptive effects of incarceration on sexual risk behavior. Using the 2002 National Survey of Family Growth, we conducted multivariable analyses to estimate associations between incarceration in the past 12 months and engagement in multiple partnerships, concurrent partnerships, and unprotected sex in the past 12 months, stratified by status of illicit drug use (defined as use of cocaine, crack, or injection drugs in the past 12 months), among adult men in the US. Illicit drug users were much more likely than nonusers of illicit drugs to have had concurrent partnerships (16% and 6%), multiple partnerships (45% and 18%), and unprotected sex (32% and 19%). Analyses adjusting for age, race, educational attainment, poverty status, marital status, cohabitation status, and age at first sex indicated that incarceration was associated with concurrent partnerships among nonusers of illicit drugs (adjusted prevalence ratio (aPR) 1.55, 95% confidence interval (CI) 1.06-2.22) and illicit drug users (aPR 2.14, 95% CI 1.07-4.29). While incarceration was also associated with multiple partnerships and unprotected sex among nonusers of illicit drugs (multiple partnerships: aPR 1.66, 95% CI 1.43-1.93; unprotected sex: aPR 1.99, 95% CI 1.45-2.72), incarceration was not associated with these behaviors among illicit drug users (multiple partnerships: aPR 1.03, 95% CI 0.79-1.35; unprotected sex: aPR 0.73, 95% CI 0.41-1.31); among illicit drug users, multiple partnerships and unprotected sex were common irrespective of incarceration history. These findings support the need for correctional facility- and community-based STI/HIV prevention efforts including STI/HIV education, testing, and care for current and former prisoners with and without drug use histories. Men with both illicit drug use and incarceration histories may experience particular vulnerability to STI/HIV, as a result of having disproportionate levels of concurrent partnerships and high levels of unprotected sex. We hypothesize that incarceration works in tandem with drug use and other adverse social and economic factors to increase sexual risk behavior. To establish whether incarceration is causally associated with high-risk sex partnerships and acquisition of STI/HIV, a longitudinal study that accurately measures incarceration, STI/HIV, and illicit drug use should be conducted to disentangle the specific effects of each variable of interest on risk behavior and STI/HIV acquisition.

BACKGROUND: Participants' protocol adherence may influence assessments of the effectiveness of new female-controlled methods for sexually transmitted infection prevention. METHODS: In 2005 we conducted a randomized pilot study among female sex workers (FSWs) in Madagascar in preparation for sexually transmitted infection prevention trial of diaphragms and a vaginal microbicide. Participants (n = 192) were randomized into 4 arms: diaphragm plus microbicide (Acidform), diaphragm plus placebo gel hydroxyethyl cellulose (HEC), Acidform alone, or HEC alone. FSWs were seen weekly for 4 weeks. Using multivariable regression with generalized estimating equations, we assessed predictors of adherent product use during all sex acts in the last week. We collapsed the gel-diaphragm arms together and the gel-only arms together for this analysis. RESULTS: Between 43% and 67% of gel-diaphragm users (varying by visit) reported using study products during all sex acts in the last week, compared with 20% to 45% of gel-only users. Adherence increased with follow-up [visit 4 vs. visit 1 risk ratio (RR) for gel-diaphragm users: 1.55, P <0.01; for gel-only users, RR: 1.58, P = 0.01]. Gel-diaphragm users whose casual partners were never aware of products (RR: 2.02, P = 0.03) and who had experienced partner violence after requesting condom use (RR: 1.45, P <0.01) were more adherent. Gel-only users reporting lower sexual frequency (1-9 weekly acts vs. >or=19 acts, RR: 1.98, P <0.01) and no sex with primary partners in the past week (RR: 1.54, P = 0.02) were more adherent. CONCLUSIONS: Gel-diaphragm users had better adherence than gel-only users, and predictors of adherence differed between groups. Addressing modifiable factors during counseling sessions may improve adherence.

BACKGROUND: The study was conducted to investigate past and future pregnancy preferences and contraceptive need among Malagasy sex workers. STUDY DESIGN: We analyzed data on pregnancy and contraceptive use collected during the baseline visit of a randomized, prospective formative trial which assessed diaphragm and microbicide acceptability among sex workers. To be eligible, women could not be pregnant or planning pregnancy for the next 2 months. RESULTS: Women (N=192) from four cities (Antananarivo, Antsiranana, Mahajanga and Toamasina) reported a median of 10 sex acts per week. Fifty-two percent reported a prior unwanted pregnancy, 45% at least one induced abortion and 86% that preventing future pregnancy was moderately to very important. During the last sex act, 24% used a hormonal method, 36% used a male condom, 2% used a traditional method and 38% used no method. Nearly 30% of participants reported that pregnancy prevention was moderately or very important but used no contraception at last sex; these women were categorized as having "unmet need" for contraception. In multivariable binomial regression analyses, factors associated with unmet need included low knowledge of contraceptive effectiveness [age- and site-adjusted prevalence ratio (PR): 2.1; 95% confidence interval (CI): 1.4-3.0] and low self-efficacy to negotiate condom use (age- and site-adjusted PR: 2.0; 95% CI: 1.4-3.0). CONCLUSIONS: Among these women, prior unwanted pregnancy and induced abortion were common and preventing future pregnancy was important, yet gaps in contraceptive use were substantial. Contraceptive knowledge and self-efficacy should be improved to promote contraceptive use by sex workers.

OBJECTIVES/OBJECTIVE:To describe: (a) the prevalence and individual and network characteristics of group sex events (GSEs) and GSE attendees; and (b) HIV/sexually transmitted infection (STI) discordance among respondents who said they went to a GSE together. METHODS AND DESIGN/METHODS:In a sociometric network study of risk partners (defined as sexual partners, persons with whom respondents attended a GSE, or drug injection partners) in Brooklyn, NY, we recruited a high-risk sample of 465 adults. Respondents reported on GSE attendance, the characteristics of GSEs, and their own and others' behaviors at GSEs. Sera and urines were collected, and STI prevalence was assayed. RESULTS:Of the 465 participants, 36% had attended a GSE in the last year, 26% had sex during the most recent of these GSEs, and 13% had unprotected sex there. Certain subgroups (hard drug users, men who have sex with men, women who have sex with women, and sex workers) were more likely to attend and more likely to engage in risk behaviors at these events. Among 90 GSE dyads, in which at least 1 partner named the other as someone with whom they attended a GSE in the previous 3 months, STI/HIV discordance was common [herpes simplex virus (HSV-2): 45% of dyads, HIV: 12% of dyads, and chlamydia: 21% of dyads]. Many GSEs had 10 or more participants, and multiple partnerships at GSEs were common. High attendance rates at GSEs among members of large networks may increase community vulnerability to STI/HIV, particularly because network data show that almost all members ofa large sociometric risk network either had sex with a GSE attendee or had sex with someone who had sex with a GSE attended. CONCLUSIONS:Self-reported GSE attendance and participation were common among this high-risk sample. STI/HIV discordance among GSE attendees was high, highlighting the potential transmission risk associated with GSEs. Research on sexual behaviors should incorporate measures of GSE behaviors as standard research protocol. Interventions should be developed to reduce transmission at GSEs.

Globally, unplanned pregnancies and sexually transmitted infections (STIs) persist as significant threats to women's reproductive health. Barriers to the use of modern contraceptives by women might inhibit uptake of novel woman-controlled methods for preventing STIs/HIV. Use of modern contraceptives and perceptions and attitudes towards contraceptive use were investigated among women in Antananarivo, Madagascar, using qualitative research. The hypothetical acceptability of the diaphragm--a woman-controlled barrier contraceptive device that also holds promise of protecting against STIs/HIV--was assessed. Women consecutively seeking care for vaginal discharge at a public health clinic were recruited for participation in a semi-structured interview (SSI) or focus group discussion (FGD). Audiotaped SSIs and FGDs were transcribed, translated and coded for predetermined and emerging themes. Of 46 participating women, 70% reported occasional use of male condoms, mostly for preventing pregnancy during their fertile days. Although women could name effective contraceptive methods, only 14% reported using hormonal contraception. Three barriers to use of modern contraceptives emerged: gaps in knowledge about the range of available contraceptive methods; misinformation and negative perceptions about some methods; and concern about social opposition to contraceptive use, mainly from male partners. These results demonstrate the need for programmes in both family planning and STI prevention to improve women's knowledge of modern contraceptives and methods to prevent STI and to dispel misinformation and negative perceptions of methods. In addition, involvement of men will probably be a critical component of increased uptake of woman-controlled pregnancy and STI/HIV prevention methods and improved health.

BACKGROUND: Persistent high levels of sexually transmitted infection (STI) in Madagascar indicate current prevention strategies are inadequate. STI/HIV prevention based in social venues may play an important role in reaching individuals at risk of infection. We identified venues where people meet sexual partners and measured the need and potential for venue-based prevention. METHODS: Interviews were conducted in 7 Madagascar towns with 1) community informants to identify social venues, 2) individuals socializing at a sample of venues to assess sexual behavior among venue patrons, and 3) venue representatives to assess the potential for venue-based intervention. RESULTS: Community informants identified numerous venues (range: 67-211 venues, depending on the town); streets, bars, and hotels were most commonly reported. Among 2982 individuals socializing at venues, 78% of men and 74% of women reported new sexual partnership or sex trade for money, goods, or services in the past 4 weeks and 19% of men and 18% of women reported symptoms suggestive of STI in the past 4 weeks. STI symptom levels were disproportionately high among respondents reporting either sex trade or new sexual partnership in the past 4 weeks. Twenty-eight percent of men and 41% of women reported condom use during the last sex act with a new partner. Although 24% to 45% of venues had hosted STI/HIV interventions, interventions were deemed possible at 73% to 90% venues according to 644 interviews with venue representatives. CONCLUSIONS: Venue-based intervention is possible and would reach a spectrum of populations vulnerable to STI/HIV including sex workers, their clients, and other high-risk populations.