Sexual Risk Behaviors, Alcohol Abuse, and Intimate Partner Violence Among Sex Workers in Mongolia: Implications for HIV Prevention Intervention Development

This study examines HIV/STI risk behaviors, alcohol abuse, intimate partner violence, and psychological distress among 48 female sex workers in Mongolia to inform the design of a gender-specific, HIV/STI prevention intervention for this population. Quantitative findings demonstrate that over 85% of women reported drinking alcohol at harmful levels; 70% reported using condoms inconsistently with any sexual partner; 83% reported using alcohol before engaging in sex with paying partners; and 38% reported high levels of depression. Focus group findings provide contextual support and narrative descriptions for the ways that poverty, alcohol abuse, interpersonal violence, and cultural norms that stigmatize and marginalize women are intertwined risk factors for STIs, including HIV, among these vulnerable women

Predictors of Discordant Reports of Sexual and HIV/Sexually Transmitted Infection Risk Behaviors Among Heterosexual Couples

Objectives: Assessments undertaken as part of couple-based HIV/sexually transmitted infection (STI) prevention intervention studies offer opportunities to expand our understanding of couple reporting of sexual and HIV/STI risk behavior. Increases in heterosexual transmission of HIV worldwide support more attention on the quality and use of couple-level sexual risk assessment. Study Design: This study examined interpartner concordance of self-reported sexual behaviors and HIV/STI risk behaviors among 217 women and their main male sexual partners at high risk for HIV/STI transmission and further explored specific individual and relationship characteristics by partner gender associated with discordant reporting of sexual and HIV/STI risk behaviors. Results: Consistent with prior studies, findings suggest fair to substantial agreement between partners on reports of most sexual and HIV/STI risk behavior, but only poor to fair agreement on reports of concurrent sexual behaviors and drug or alcohol use. Factors significantly associated with discordant reporting of sexual behaviors included length of couple relationship, level of relationship satisfaction, female partner’s marital status, and male partner’s HIV status, ethnicity, and age. Conclusions: Individual- and relationship-level factors predicting discordant partner reports of sexual and sexual risk behaviors highlight an opportunity to improve couple assessment by anticipating such discrepancies and developing effective mechanisms of quality assurance to avoid, address, or better explain such discordance in couple data sets

Lack of Awareness of Partner STD Risk Among Heterosexual Couples

CONTEXT: Individuals’ accurate assessment of their exposure to the risk of HIV and other STDs requires awareness of their sexual partners’ risk behaviors and disease status. METHODS: In a sample of 217 couples enrolled in a risk intervention trial in 1997–2002, both partners reported on their own risk behaviors and their perceptions of their partner's behavior; concordance of partners’ reports was examined using kappa statistics. Individual and relationship characteristics predicting lack of awareness of a partner's risk behavior were explored using multivariate logistic regression. RESULTS: Three percent of women and 14% of men were unaware that their partner had recently had a concurrent partner. Eleven percent and 12%, respectively, were unaware that their partner had ever injected drugs; 10% and 12% were unaware that their partner had recently received an STD diagnosis; and 2% and 4% were unaware that their partner was HIV‐positive. Women's lack of awareness of partner risk was associated with increasing age (odds ratio, 1.1), being of a race or ethnicity other than black or Latina (15.8) and having a Latino partner (3.7); it was positively associated with a man's report that he was married (4.4) and with relationship satisfaction as reported by both the woman and her partner (1.2 for each). Among men, lack of awareness was positively associated with partner's age (1.1) and with having a partner who was formerly married (8.2). CONCLUSIONS: Couple‐based interventions that assess each partner's awareness of the other's risk behavior may help programs better target couples’ STD prevention needs

Intimate Partner Violence and HIV Among Drug-Involved Women: Contexts Linking These Two Epidemics—Challenges and Implications for Prevention and Treatment

Intimate partner violence (IPV) and HIV are two serious overlapping public health epidemics that disproportionately affect drug-involved women. This article reviews research that has identified a number of contexts that may explain the links between IPV and HIV transmission risks. These contexts include sexual coercion, fear of violence, negotiation of condom use, extra dyadic relationships, disclosure of sexually transmitted infections or HIV seropositivity to intimate partners, drug involvement of women and their male partners, low social status of drug-involved women, relationship dependencies, and sex ratio imbalances. The article focuses on how the bidirectional relationship between IPV and HIV risks may be mediated by a history of childhood sexual abuse and post-traumatic stress disorder. Also addressed are the challenges that substance user treatment programs face in dealing with female clients who experience IPV and the implications for HIV prevention

Enrollment of minority women and their main sexual partners in an HIV/STI prevention trial

There is a paucity of empirical reports that quantitatively assess the success of recruitment strategies in randomized clinical trials (RCTs) using sampling units other than the individual. As innovations in HIV and sexually transmitted infection (STI) preventive intervention protocols and targets of change evolve, there is a need to examine the efficacy of attendant adaptations to recruitment protocols and strategies in the enrollment of study participants. This article examines factors related to enrollment of women and their main, male sexual partners in an RCT of a relationship–based HIV/STI preventive intervention conducted from 1997 to 2001. Among eligible participants (N = 388), findings indicate that race/ethnicity, employment status, marital status, and language preference were significantly associated with enrollment among eligible, potential participants. Additionally, being HIV–positive and having a past or current STI were significantly associated with enrollment. These findings underscore the need to ensure sufficient representation of all risk groups in RCTs, especially those testing innovative HIV/STI preventive intervention approaches or using novel enrollment strategies

Promoting Female Condom Use to Heterosexual Couples: Findings from a Randomized Clinical Trial

CONTEXT: The female condom remains the only female‐initiated method for preventing pregnancy and STDs, including HIV. Innovative methods for promoting its use, and for involving male partners in its use, are needed. METHODS: A sample of 217 women and their main male sexual partners were randomly assigned to one of three study conditions: a six‐session relationship‐based STD prevention intervention provided to the couple together, the same intervention provided to the woman only or a single‐session education control provided to the woman only. Assessments were conducted at baseline and three months postintervention. Contrast coding was used to examine whether the effects of the two active interventions differed from those of the control intervention, and whether the effects of the two active interventions differed from each other. Regression analyses were used to estimate treatment effects. RESULTS: During follow‐up, participants in either active intervention were more likely to use a female condom with their study partner and with all partners, and used female condoms at a higher rate with all partners, than individuals assigned to the control intervention; at the end of three months, they were more likely to intend to use the condom in the next 90 days. No significant differences in outcomes were found between the active intervention groups. CONCLUSIONS: Focusing on both a woman and her main male sexual partner is efficacious in increasing female condom use and intention to use among heterosexual couples at risk for HIV and other STDs

Reducing Intimate and Paying Partner Violence Against Women Who Exchange Sex in Mongolia

Women who exchange sex for money or other goods, that is, female sex workers, are at increased risk of experiencing physical and sexual violence from both paying and intimate partners. Exposure to violence can be exacerbated by alcohol use and HIV/STI risk. The purpose of this study is to examine the efficacy of a HIV/STI risk reduction and enhanced HIV/STI risk reduction intervention at decreasing paying and intimate partner violence against Mongolian women who exchange sex and engage in harmful alcohol use. Women are recruited and randomized to either (a) four sessions of a relationship-based HIV/STI risk reduction intervention (n = 49), (b) the same HIV/STI risk reduction intervention plus two additional motivational interviewing sessions (n = 58), or (c) a four session control condition focused on wellness promotion (n = 59). All the respondents complete assessments at baseline (preintervention) as well as at immediate posttest, 3 and 6 months postintervention. A multilevel logistic model finds that women who participated in the HIV/STI risk reduction group (OR = 0.14, p < .00), HIV/STI risk reduction and motivational interview group (OR = 0.46, p = .02), and wellness (OR = 0.20, p < .00) group reduced their exposure to physical and sexual violence in the past 90 days. No significant differences in effects are observed between conditions. This study demonstrates the efficacy of a relationship-based HIV/STI risk reduction intervention, a relationship-based HIV/STI risk reduction intervention combined with motivational interviewing, and a wellness promotion intervention in reducing intimate and paying partner violence against women who exchange sex in Mongolia. The findings have significant implications for the impact of minimal intervention and the potential role of peer networks and social support in reducing women’s experiences of violence in resource poor settings

Examining the Temporal Relationship Between Criminal Justice Involvement and Sexual Risk Behaviors among Drug-Involved Men

Although criminal justice involvement has repeatedly been associated with human immunodeficiency virus (HIV)/sexually transmitted infection prevalence and sexual risk behaviors, few studies have examined whether arrest or incarceration uniquely contributes to sexually risky behavior. We examined the temporal relationship between criminal justice involvement and subsequent sexual HIV risk among men in methadone maintenance treatment in New York City. A random sample of 356 men was interviewed at baseline (time 1), 6-month (time 2), and 12-month (time 3) follow-ups. Propensity score matching, negative binomial, and multiple logistic regression were used to isolate and test the effect of time 2 arrest and incarceration on time 3 sexual risk behaviors. Incidence of time 2 criminal justice involvement was 20.1% for arrest and 9.4% for incarceration in the prior 6 months. Men who were arrested at time 2 demonstrated increased number (adjusted incidence rate ratio [IRR]=1.62; 95% confidence intervals [CI]=1.11, 2.37) and proportion (IRR=1.36; 95% CI=1.07, 1.72) of unprotected vaginal sex acts at time 3. Men incarcerated at time 2 displayed increased number (IRR=2.07; 95% CI=1.23, 3.48) and proportion (IRR=1.45; 95% CI=1.06, 1.99) of unprotected vaginal sex acts at time 3. Within this sample of drug-involved men, arrest and incarceration are temporally associated with and may uniquely impact successive sexual risk-taking. Findings underscore the importance of HIV prevention interventions among individuals with low-intensity criminal justice involvement. Developing prevention efforts aimed at short-term incarceration, community reentry, and alternatives to incarceration settings will address a large and under-researched segment of the criminal justice population. Alternative approaches to current criminal justice policy may result in public health benefits

Couple-Based HIV Prevention for Low-Income Drug Users From New York City: A Randomized Controlled Trial to Reduce Dual Risks

Objective: Dual threats of injection drug use and risky sexual practices continue to increase transmission of HIV and other sexually transmitted Infections (STIs) among drug-using couples in low-income communities in the United States. Two hypotheses were tested: (1) “intervention effect”—whether the HIV risk-reduction intervention provided to the couple or individual partners would be more efficacious in decreasing number of unprotected sexual acts and having a lower cumulative incidence of biologically confirmed STIs over the 12-month follow-up period compared with the attention control condition; and (2) “modality effect”—whether the HIV risk-reduction intervention would be more likely to decrease the number of unprotected sexual acts and have a lower cumulative STI incidence when delivered to a couple compared with the same intervention delivered to an individual. Design: Using a randomized controlled trial, 282 HIV-negative drug-using couples (564 individuals) were randomly assigned to receive either of the following: (1) couple-based risk reduction; (2) individual-based HIV risk reduction, or (3) couple-based wellness promotion, which served as an attention control condition. Results: Over 12-month follow-up, there was a 30% reduction in the incidence rate of unprotected acts of intercourse with the study partners compared with participants in the attention control arm. Moreover, over 12-month follow-up there was a 29% reduction in the same outcome in the couple arm compared with the individual arm with a 41% reduction at the 12-month follow-up. Conclusion: A couple-based approach that addresses drug and sexual risks and targets low-income active drug users may help curb the HIV epidemic

Physical and sexual violence, childhood sexual abuse and HIV/STI risk behaviour among alcohol-using women engaged in sex work in Mongolia

Although the prevalence of human immunodeficiency virus (HIV) in Mongolia is low, it could increase without strategic prevention strategies. Female sex workers (FSWs) often experience barriers to prevention, including interpersonal violence. This study investigated if childhood sexual abuse (CSA) or recent physical or sexual violence was associated with HIV sexual risk behaviours and if CSA modified associations between recent violence and HIV sexual risk behaviours. Two-hundred twenty-two women who (1) were at least 18 years old and clients at the National AIDS Foundation; (2) reported vaginal or anal sex in the past 90 days in exchange for money or goods and (3) met criteria for harmful alcohol use in the past year were enrolled. In-person interviews assessed sexual risk behaviours and violence in childhood and adulthood. Negative binomial regression, ordinary least squares regression and modified Poisson regression were performed. Sexual risk with paying partners was associated with penetrative CSA and sexual violence by paying partners. CSA and recent violence were not associated with sexual risk behaviours with intimate partners. CSA modified the association between recent sexual violence and unprotected sex with intimate partners. Findings highlight the need for integrated violence and sexual risk reduction services to ensure safe and effective prevention for FSWs