ОЦЕНКА УРОВНЯ РАСПРОСТРАНЕННОСТИ И ФАКТОРОВ РИСКА ПЕРЕДАЧИ ВИЧ СРЕДИ ТРУДОВЫХ МИГРАНТОВ ИЗ РЕСПУБЛИКИ ТАДЖИКИСТАН

To analyze the extent and determinants of condom use with commercial sex partners among lower socioeconomic status groups in the Thai population.Respondents were sampled in Udon Thani, Saraburi and Bangkok in 1992. Completed sample size was 678 women in brothels, 330 male truck drivers and 1,075 men aged 17-45 years. Behavioral data and local sexual network information were collected using structured questionnaires (face-to-face interviews), focus groups and in-depth unstructured interviews.Data were analyzed using univariate and multivariate logistic regression.Condom use with commercial partners remains inconsistent. Consistent use was reported by 61% of women in brothels, 25% of truck drivers, and 29% of men in the low-income population. The single strongest predictor of consistent condom use for all groups is type of partnership. Consistent use drops significantly with regular (multivisit) commercial sex partners compared with casual (single visit) commercial partners; adjusted odds of consistent use are 0.22 for women and 0.25 for men. Brothel women report that one in five of their commercial partners is a 'regular', and 20% of the young men who report a commercial partner report a 'regular'.The strongest determinant of consistent condom use is the nature of the relational bond between the partners, rather than their individual characteristics, knowledge or attitudes. To raise condom use further, programs will have to move beyond the standard knowledge-attitudes-practices paradigm focus on individual attributes to address the contextual determinants of behavior.678 women in brothels, 330 male truck drivers, and 1075 men aged 17-45 years participated in focus groups and were interviewed in Udon Thani, Saraburi, and Bangkok in 1992 to analyze the extent and determinants of condom use with commercial sex partners among lower socioeconomic status groups in the Thai population. Consistent condom use was reported by 61% of women in brothels, 25% of truck drivers, and 29% of men in the low-income population. The single strongest predictor of consistent condom use for all groups is the nature of the relational bond between the partners, rather than their individual characteristics, knowledge or attitudes. Consistent use drops significantly with multivisit commercial sex partners compared with single visit commercial partners. Brothel women report that 20% of their commercial partners are regulars, while 20% of the young men who report a commercial partner also report visiting a "regular" commercial sex partner. To raise condom use further, programs will have to move beyond the standard knowledge, attitudes, and practices approach to address the contextual determinants of behavior.

BackgroundUnprotected intercourse with sex workers is one of the major risk factors for HIV infection. Consistent condom use is a prerequisite to lower the incidence of HIV.MethodsWe assessed the prevalence of condom use and its determinants among company workers engaged with commercial sexual partners in Ecuador. The study was based on a random sample of 115 companies and 1,732 workers stratified by province and working sector and utilized the “Behavioral Surveillance Surveys – Adult questionnaire” developed by Family Health International.ResultsOf the 1,561 sexually active workers, 311 (19.9 %) reported having intercourse with sex workers. Among them 25.9 % did not use a condom at the last sexual intercourse. As for condom use frequency over the last 12 months, 29/208 (13.9 %) reported never, 23 (11.1 %) sometimes, 24 (11.5 %) almost every time and 132 (63.5 %) every time. Factors adversely affecting condom use frequency over the last 12 months were female gender (OR = 4.56, 95 % CI: 1.45-14.4), older age (OR = 1.07, 95 % CI: 1.03-1.10), low educational level (OR = 4.69, 95 % CI: 1.95-11.3) and married workers living with spouse (OR = 7.66, 95 % CI: 3.08-19.1). By contrast, factors such as age at first sexual intercourse, job category, HIV transmission and prevention measure knowledge, single workers, previous exposure to HIV intervention programs and having a casual sexual partner were not affecting condom use frequency. When considering condom use during the last sexual intercourse or during the past 12 months with commercial sexual partners, results were similar.ConclusionsWorkers with low education, older age, female gender and those married living with their spouse should be targeted for specific educational interventions.

In all regions of sub-Saharan Africa the predominant mode of transmission of HIV is through heterosexual intercourse however there are large variations in the rate and extent of the spread of HIV in different populations. This study was conducted to identify the factors that influence the rapid spread of HIV in four African cities namely Cotonou (Benin) Yaounde (Cameroon) Kisumu (Kenya) and Ndola (Zambia). Results demonstrated that high rates of partner change and being married are risk factors for HIV infection in men in at least one city but are risk factors for women in all four cities. In addition condom use among sex workers did not show a difference between the low and high prevalence cities. Furthermore no evidence of changes towards safer sexual behavior was identified in the high HIV prevalence cities. The only factors that were more common in the two high HIV prevalence cities than in the two low HIV prevalence cities were young age at first intercourse for women young age at first marriage and large age difference between the spouses. It was also noted that the high levels of HIV infection among young people especially among female adolescents in Kisumu and Ndola highlight the importance of interventions targeted at young people and their partners.

To analyze the extent and determinants of condom use with commercial sex partners among lower socioeconomic status groups in the Thai population. Respondents were sampled in Udon Thani, Saraburi and Bangkok in 1992. Completed sample size was 678 women in brothels, 330 male truck drivers and 1,075 men aged 17-45 years. Behavioral data and local sexual network information were collected using structured questionnaires (face-to-face interviews), focus groups and in-depth unstructured interviews. Data were analyzed using univariate and multivariate logistic regression. Condom use with commercial partners remains inconsistent. Consistent use was reported by 61% of women in brothels, 25% of truck drivers, and 29% of men in the low-income population. The single strongest predictor of consistent condom use for all groups is type of partnership. Consistent use drops significantly with regular (multivisit) commercial sex partners compared with casual (single visit) commercial partners; adjusted odds of consistent use are 0.22 for women and 0.25 for men. Brothel women report that one in five of their commercial partners is a 'regular', and 20% of the young men who report a commercial partner report a 'regular'. The strongest determinant of consistent condom use is the nature of the relational bond between the partners, rather than their individual characteristics, knowledge or attitudes. To raise condom use further, programs will have to move beyond the standard knowledge-attitudes-practices paradigm focus on individual attributes to address the contextual determinants of behavior.

BackgroundHIV transmission in rural areas of China is being fueled in part by migrant workers who acquire HIV outside of their hometowns. Recent surveillance statistics indicate that HIV prevalence among returning migrants has increased significantly.MethodsWe conducted a community-based cross-sectional study to assess HIV-related knowledge, attitudes and behaviors among migrant returnees in Nantong, Jiangsu Province, one of the largest exporters of migrant laborers.ResultsA total of 1625 subjects were enrolled with a response rate of 89%. All participants were male and of the majority Han ethnicity. The mean age was 39.0 years (SD = 6.7; range: 18 to 63), and most had a stable partner (N = 1533, 94.3%). Most correctly identified the major modes of HIV transmission (68.9%–82.0%), but fewer were able to identify ways that HIV cannot be transmitted. Nearly one-third of participants held positive attitudes toward having multiple sex partners, and nearly half believed that sex work should be legalized. Multiple logistic regression analysis indicated that risky sexual behavior (defined as sex with a casual or commercial sex partner) was associated with no stable partner; working abroad; correct condom use; age <22 at first sex; higher coital frequency; and having a positive attitude towards multiple sex partners.ConclusionsWe found high levels of reported sex with a casual or commercial sex partner and low levels of consistent condom use. HIV prevention interventions among migrant workers need to focus on younger migrants, migrants without stable partners, and migrants who travel abroad for work.

BackgroundDespite global efforts to control human immunodeficiency virus (HIV) among adolescents, the number of new infections among adolescents continues to increase. The increasingly widespread HIV epidemic among Chinese college students indicates an urgent need for more effective services in this context. To meet this need, we conducted a survey that aimed to produce a clear understanding of knowledge and sexual behavior concerning acquired immunodeficiency syndrome (AIDS) among college students. This study can serve as a reference for policy-makers and university administrators seeking to implement more targeted measures in this context.MethodsIn November 2024, a cross-sectional internet questionnaire survey was distributed at 13 universities in Guangzhou, China. The chi-square test was performed to examine the differences among respondents who exhibited different characteristics. A multivariate logistic regression analysis was conducted to explore the main influences on college students’ AIDS knowledge. Confidence intervals that did not contain zero or p values < 0.05 were considered to indicate statistical significance.ResultsA total of 12,632 valid questionnaires were collected. On this basis, a total of 11,587 (91.73%) students were determined to possess AIDS knowledge. The main influences on college students’ AIDS knowledge were age, school classification, major, accommodation method, place of origin and average monthly living expenses. The proportion of students who reported a history of sexual behavior increased alongside students’ grade. The relevant values were as follows: freshmen (5.16%), sophomores (11.9%), fourth-year and fifth-year students (15.59%), master’s students (29.27%) and doctoral students (55.22%). A total of 6.63% of the respondents who had engaged in sexual behaviors reported that they had engaged in noncommercial sex with causal sexual partners. During the past year, the percentages of respondents who did not insist on using condoms during sexual activities with their casual sexual partners, male same-sex sexual partners, or commercial sexual partners were 30.58, 51.81, and 81.25%, respectively. The percentages of students who possessed AIDS knowledge and insisted on using condoms during sexual activities with “casual sexual partners (72.16%)” or “male same-sex sexual partners (48.19%)” were greater than the corresponding percentages of students who did not possess such knowledge (p < 0.01). Individuals who did not possess AIDS knowledge reported that they did not insist on using condoms during sexual activities with male same-sex sexual partners. “Did not buy a condom” was identified as the main reason for the failure to use condoms during sexual activities with casual sexual partners (26.43%) and commercial sexual partners on the basis of monetary transactions (48.00%). The main reason for failing to use condoms during same-sex sexual activities was “I did not think that it was necessary to use it” (41.67%). The percentage of college students included in the survey who reported that they had acquired AIDS knowledge from social software was the highest (76.96%). A total of 30.90% of the respondents reported that their favorite way of acquiring AIDS knowledge was through their school courses.ConclusionThe level of AIDS knowledge exhibited by college students is affected by various factors. Improvements in AIDS knowledge can help raise awareness of the need for self-protection during high-risk sexual activities among college students. The risk of contracting AIDS and other sexually transmitted diseases can be reduced through the use of condoms. Social networks are the main source by which college students acquire AIDS knowledge, although such students typically hope to acquire AIDS knowledge from their school courses.

It is urgent to develop efficacious HIV prevention programs to curb the reported extremely high HIV prevalence and incidence among transgender women (male-to-female transgender persons) who reside in large cities in the USA. This study aimed to describe unprotected receptive anal sex (URAS) and unprotected insertive anal sex (UIAS) among high-risk transgender women in relation to partner types, psychosocial factors, and background variables. Based on purposive sampling from the targeted communities and AIDS service organizations in San Francisco and Oakland, a total of 573 transgender women who had a history of sex work were recruited and individually interviewed using a structured survey questionnaire. Significant correlates with URAS with primary, casual, and commercial sex partners were found (e.g., needs for social support, frequency of social support received, exposure to transphobia, self-esteem, economic pressure, norms toward practicing healthy behaviors, and self-efficacy toward practicing safe sex). Multiple logistic regression analyses revealed that transgender women who had engaged in URAS with commercial partners were more likely to have higher levels of transphobia or lower levels of the norms or self-efficacy to practice safe sex. Among the participants who did not have vaginoplasty (preoperative transgender women), 16.4% had engaged in insertive anal sex (IAS) with commercial partners in the past 30 days. The participants who were HIV positive and had engaged in IAS were more likely to be African-American or Caucasians, coinfected with sexually transmitted infections, or identified themselves as homosexual. Practices of IAS among transgender women have not been thoroughly investigated in relation to sexual and gender identity. UIAS with homosexual and bisexual men in addition to URAS may be a cause for high HIV incidence among transgender women. An HIV prevention intervention study must be developed and evaluated, which aims to reduce HIV-positive and -negative transgender women's URAS and UIAS.

This special issue documents a unique pattern of the HIV epidemic and its associated factors among men who have sex with men (MSM) in China. In high-income countries AIDS has disproportionately impacted MSM. MSM account for the preponderance of prevalent AIDS cases in the United States, Canada, the European Union, Australia, and New Zealand [1–11]. In contrast, in many low- and middle-income countries the HIV epidemic is driven by heterosexual sex, injection drug use, and/or contaminated blood collection and transfusion, with MSM comprising a small proportion of all HIV cases [10–12]. However, recent data show a trend of increase in HIV cases among MSM in Asia, Africa, South America, and Eastern Europe [8–16]. China is one of the countries facing the challenge of an emerging HIV epidemic in MSM. In China, rates of HIV infection in injecting drug users have fallen, remained stable and at low levels in female sex workers, but markedly increased in MSM. The latest national report revealed that the proportion of newly diagnosed HIV cases due to male homosexual contact has increased from 12.2% in 2007 to 32.5% in 2009; while the national HIV prevalence among MSM had a 4.5-fold increase in the past ten years (i.e., from 1.4% in 2001 to 6.3% in 2011) [17]. HIV cases resulting from transmission associated with illegal blood donations have been largely eliminated following the crackdown on unscrupulous blood donors in the late 1990s. The purpose of this special issue is to improve our understanding of the dynamics of the HIV epidemic and its associated factors that are driving the epidemic among MSM in China. One of the papers in this special issue is by Y. Zhou and colleagues and it describes differences in the prevalence of HIV and syphilis among MSM living in Chinese cities with differing levels of economic development. The authors report a pooled prevalence of 6.5% among MSM nationally, with higher rates in economically less developed cities than in the developed cities. The paper by E. P. F. Chow et al. on the other hand reveals that HIV prevalence among Chinese MSM has increased rapidly in all Chinese regions in recent years. One of the papers summarizes findings from three cross-sectional surveys in Beijing that demonstrate a disturbing rise in HIV incidence among MSM in Beijing. Y. Zeng and colleagues suggest that this epidemiologic trend is not limited to Beijing, as their paper revealed an increase in HIV prevalence from 13.0% to 19.7% from 2006 to 2013 with an increase of 1.0% per year among MSM in Chongqing. These findings support the inference that MSM in China have become an important risk group that should be targeted by HIV prevention programs. Risk factors associated with HIV among MSM in China are multidimensional. Such factors may be biological (sexually transmitted diseases, e.g., syphilis), behavioral (unprotected sexual behaviors, overlapping bisexual and commercial sex, and increasing substance use), or sociocultural/environmental (e.g., migration, stigma, and social support). Emphasis of familial tie and procreation in Chinese culture put pressure on MSM to lead a double life and conceal their sexual orientation to family. Consequently, MSM in China often encounter stigma and discrimination. Effective intervention and control measures for HIV need to take all of these multidimensional factors into account. In their contribution, E. P. F. Chow and colleagues review the involvement of MSM in high-risk activities (e.g., commercial sex and intravenous drug use) and the community and governmental responses to the HIV epidemic among Chinese MSM. D. Li and colleagues found that recent HIV infection is associated with bisexual activity and a negative attitude towards safe sex. Unprotected anal intercourse is a recognized risk factor for HIV transmission in MSM. J. T. F. Lau et al. report geographic variations in factors associated with unprotected anal intercourse among MSM in Shenzhen and Hong Kong. In Shenzhen such factors included being able to find someone to share one's sexual orientation, disclosure of sexual orientation to family members, HIV risk perception, and alcohol or drug use, while disclosure of sexual orientation to family members was the only significant factor identified among Hong Kong MSM. Recreational drug and alcohol use has increased considerably in China in the past three decades, accompanying a rapidly expanding economy, urbanization, and globalization. The global literature suggests that drug and alcohol use is associated with sexual risk behaviors. The independent association of nitrite inhalant use with more casual sex partners and HIV infection reported by D. Li and colleagues underscores the need for interventions targeting nitrite inhalant use. Y. Liu et al. also show that MSM who consumed alcohol more than once per week were more likely to use illicit drugs, have sex with women, have unprotected insertive or receptive anal sex with men, have more than ten lifetime male sex partners, predominantly practice insertive anal sex, and trade sex for money. M. Liao and colleagues had similar findings, with more frequent episodes of alcohol use being independently associated with unprotected anal sex, bisexual identity, multiple male sex partners, drug use, and higher levels of HIV/AIDS-related stigma and discrimination. Taken together, these findings provide the basis for strengthening alcohol use prevention and risk reduction initiatives among MSM as part of a comprehensive HIV risk reduction approach and for further exploring the interaction between alcohol use and HIV transmission. Chinese traditional culture emphasizes familial responsibilities; homosexual preferences are highly stigmatized and MSM face strong social pressure to conceal their sexual orientation. Stigma surrounding HIV/AIDS is a barrier to HIV prevention, treatment, and care. People who hold stigmatizing attitudes are also less likely to adopt preventive behaviors and more likely to have multiple sexual partners, a commercial sex partner, and engage in other HIV-related high risk behaviors. D. Huang et al. report low levels of stigmatizing attitudes to be associated with uptake of HIV testing services and utilization of free condoms/lubricants. The authors stress the importance of addressing HIV/AIDS-related stigmatizing/discriminatory attitudes and other barriers when delivering HIV-related interventions and testing services. The Chinese government has significantly scaled up HIV surveillance and prevention efforts among MSM over the past decade, including the use of community-based approaches via grassroots organizations. However, the lack of an enabling legal and financial environment undermines the role of community-based organizations in HIV surveillance and prevention. The hidden nature of homosexual activity coupled with the prevailing stigma and discrimination hinders the successful delivery of timely, high-quality and effective HIV prevention, care and treatment services that are responsive to the unique needs of MSM in China. We hope that the knowledge generated by the articles in this special issue will contribute to the development of innovative HIV prevention programs that will do just that. Yujiang Jia Muktar H. Aliyu Z. Jennifer Huang

Clients of female sex workers (FSWs) are an important bridging population for HIV and other sexually transmitted infections. However, the extent of risk to female noncommercial partners (NCPs) of clients has not been explored. Data originated from a cross-sectional behavioral and biological survey of FSW clients from 5 districts in Karnataka state, southern India. Clients were classified into 3 groups: married, single with at least 1 NCP, and single without an NCP. Bivariate and multivariable logistic regression models were constructed to examine the association between group membership and condom use patterns with FSWs and, where applicable, NCPs. HIV, herpes simplex virus type 2 (HSV-2), and other sexually transmitted infections were examined. Normalized weights were used to account for a complex sampling design. Most respondents in our sample (n = 2328) were married (61%). Compared with single respondents without an NCP, married clients were more likely to never use condoms with both occasional (adjusted odds ratio [AOR], 1.8; 95% confidence interval [CI], 1.3-2.5; P < 0.0001) and regular (AOR, 1.7; 95% CI, 1.1-2.6; P = 0.015) FSWs. Among clients with an NCP, married clients were at higher odds of never using a condom with their NCP (AOR, 5.5; 95% CI, 3.7-8.1; P < 0.0001). Overall prevalence for HIV, HSV-2, syphilis, and chlamydia or gonorrhea infection was 5.7%, 28.3%, 3.6%, and 2.1%, respectively. The prevalence of HSV-2 was 37%, 16%, and 19% among those who were married, those single without an NCP, and those single with an NCP, respectively. Married respondents were least likely to use condoms with both commercial and noncommercial sexual partners, while also having the highest prevalence of HSV-2. These results illustrate the risk posed to both commercial partners and NCPs of married clients.

Introduction Although anecdotal evidence suggests that HIV infections in Mexico were occurring in 1981, the first cases of AIDS in Mexico were documented in 1983. Since then, approximately 50 000 cases of AIDS have been reported nationwide and it is estimated that there are approximately 150 000 HIV-infected persons living in Mexico [1,2]. While it could be argued that there is some underreporting of AIDS in Mexico [2,3], the epidemic is still significantly less intense than that to the north (USA) or south (Central American countries, e.g. Honduras). One possible explanation for this is that, unlike in the countries surrounding it, the epidemic in Mexico has remained 'nuclear', primarily affecting men who have sex with men in urban areas of the country such as Mexico City, Guadalajara, Monterrey and Tijuana [4]. This relative containment of the epidemic is by no means accidental but rather the end result of many prevention efforts conducted by the government as well as by community-based organizations. The national response to AIDS in Mexico was early and strong, beginning shortly after the first cases were reported in 1983. HIV testing began the first year the test was available (1985) and in February of 1986 the National Committee for AIDS Prevention (CONASIDA) was founded. In 1988 a Presidential Decree transformed CONASIDA from a committee to a 'National Council', thus giving it a multisectorial composition that went beyond the scope of individual health sector response. While early national-level attention toward containing the epidemic has benefited the population at large, it is clear that prevention efforts of the Mexican government have been most successful in two areas: in the control of transfusion-transmitted HIV and in preventing infections among female commercial sex workers. Because HIV infection through blood and blood products represents only a small proportion of all cases of HIV/AIDS worldwide it has not received the attention this means of transmission merits [5]. Not only is it the most efficient way in which HIV can be transmitted, but transmission via blood and blood products is also the route most amenable to government control. As a result, devoting attention and resources to insuring the safety of the blood supply represents a unique opportunity and a cost-effective intervention for public health authorities to dramatically change the course of HIV infection in a given country. The changing epidemiology of AIDS in Mexico provides compelling proof of this conclusion. With the exception of patients with hemophilia, transfusion-transmitted HIV in developing countries primarily affects women – specifically women who receive blood for obstetric reasons [6]. Because of this observation, a country with a large proportion of infected women may overestimate the level of 'heterosexual' transmission, overlooking a hidden blood and blood products connection. For example, in 1986 there were 26 cases of AIDS in men for every one in women (26 : 1) in Mexico. Four years later, at the same time that the highest proportion of transfusion-transmitted cases were being reported nationwide, the number of infections among women had climbed so dramatically that the ratio dropped to five cases of AIDS in men for every one in women (5 : 1). Then, in 1999, the first year in which no transfusion-transmitted AIDS cases were reported in Mexico, the trend in male-to-female cases reversed direction ( for the first time ), with six cases of AIDS being reported in men for every one in women (6 : 1). In many countries, infection of the blood supply is chiefly an economic phenomenon. For example, prior to 1987, selling one's blood or plasma was such an attractive source of income for many impoverished Mexicans that commercial blood and plasma donors (who had, by definition, no inducement to know their HIV status prior to donation) formed a significant percentage of total blood suppliers. Thus, the control of transfusion-transmitted HIV in Mexico not only involved mandatory HIV testing but also banning the commercialization of blood and closing of commercial plasmapheresis centers. As noted above, this policy has all but eliminated HIV from the Mexican blood supply. Blood transmission of HIV in other countries continues to be a significant problem. Recent reports from China suggest that paid blood donors may be playing an important role in the spread of HIV there [7]. The impact of commercial sex on HIV transmission is well known and has long been considered a critical vector for the introduction of HIV infection into the general population [8,9]. As a result, interventions to limit the extent of HIV infection among commercial sex workers (CSW) are frequently viewed as a priority in many national prevention campaigns [10]. Perhaps the best-known of the successful interventions with CSW to date is the '100% condom use in brothels' initiative in Thailand [11]. This initiative has lead to a marked decrease in HIV incidence among Thai military recruits as well as to a decrease in the incidence of other sexually transmitted infections in that country. In contrast to Thailand and many other countries though, HIV seroprevalence among female CSW in Mexico has remained low since the beginning of epidemiological investigation, with seroprevalence averaging below 1% in large, repetitive serosurveillance studies. This finding suggests that many of the early interventions targeting CSW in Mexico might have limited the impact of HIV in this group. Yet, it could also be argued that the nuclear epidemiology of HIV in Mexico described above has simply meant that female CSW in Mexico are at less risk of exposure to infection than CSW in other countries. If this observation is so, the low seroprevalence among Mexican CSW may not be credited to public health intervention but rather reflect lack of opportunity to be exposed to HIV. In this article, we will review the major interventions conducted to date in Mexico as part of the National AIDS Prevention and Control Program. We will also review the available data published in journals or presented at the International AIDS Conferences for insights into Mexican HIV prevention successes and failures that may have implications for AIDS programs in other developing countries. The control of HIV transmission through blood and blood products When the AIDS epidemic began in Mexico in the early 1980s there was no coordinated system of blood procurement and a large proportion of the blood available in the country was obtained from paid donors. In addition, an unknown number of commercial plasma collection centers throughout the nation also obtained their products from paid donors. Evidence now suggests that these centers frequently re-used contaminated equipment during blood collection resulting in the introduction of HIV to previously healthy donors. As a result, not only did the centers collect and distribute infected blood products, but they also acted as an efficient means for accelerating that process by transmitting HIV to previously uninfected repeat clients during the plasmapheresis process. Until recently, the impact of transfusion-transmitted HIV on the AIDS epidemic in Mexico had been quite significant. In only 4 years (1984–1988) blood and blood product transfusion associated AIDS in Mexico went from being unheard of to comprising over 10% of all cases. Until 1987, paid blood and plasma donors provided approximately one-third of all blood products in Mexico [12]. Stereotypically, a paid donor would be a young man from a rural area who had migrated to one of the shanty towns that surround large cities like Mexico City, Guadalajara, Monterrey and Tijuana. He would be unemployed/underemployed, disenfranchised, and had no risk factors for HIV infection prior to his migration. After hearing about the opportunity from a friend or family member, he would become a regular customer at one of the local blood banks or plasmapheresis centers, being paid to donate as frequently as the individual center's policy allowed, perhaps as often as every 2 or 3 days. The more times he donated, the higher his risk became for becoming infected with HIV during the blood collection process. If he did become infected, he would almost certainly transmit that infection into the national blood supply – and to other donors at the same center as well – during his subsequent donations. Additionally, he might also transmit HIV to his wife or girlfriend during sex and, through them, to his children. In May of 1986, when HIV testing of all blood donors became mandatory in Mexico, the full extent of the tragedy of HIV among paid donors first began to surface. In two separate but concurrent studies carried out between 1986 and 1987, a prevalence of 7% was found among 9100 paid donors [12] compared to a seroprevalence of only 0.67% among 319 153 persons who donated blood without remuneration [13]. Further evidence of the extreme health risk disparity faced by paid donors in Mexico at that time is evident when their seroprevalence is compared to that of related donors (0.12%) or volunteer donors (0.09%) [12,14]. When the data were analyzed retrospectively, the scope of the risk faced by paid donors became dramatically clear. For example, the prevalence among paid donors at one plasmapheresis center increased in 5 months, from 6% in June 1986 to 9.2% in October of the same year [14]. Furthermore, seroconversion was documented in 22.1% of these subjects during this period. A case–control study of this population revealed that a history of four or more donations per month (odds ratio, 5.4; 95% confidence interval, 1.9–16.3) was associated with HIV infection. As described above, it is believed that donors were iatrogenically infected with HIV during the plasmapheresis process, probably as a result of improper infection control measures. The procedure included recycling of plasmapheresis equipment, reuse of needles or syringes, and even the injection of small amounts of infected plasma or blood. As the number of donations per month was as high as 12, it is feasible that once the infection was introduced into a specific blood or plasma bank, subsequent uninfected donors became infected at the blood or plasma facility at the time of donation. In 1989, the first case of AIDS in a Mexican paid plasmapheresis donor was reported [15] and by 1990 the reporting of this high-risk group became mandatory in Mexico [16]. Thus a new 'risk group' was defined in Mexico and later adopted by the Panamerican Health Organization: the professional blood donor. However, paid donor is not routinely reported as a risk group in many epidemiological reports and thus it may not be recognized as an important contributor to the spread of HIV in a given country (see Fig. 1).Fig. 1.: AIDS cases in Mexico in 1997 by risk group. Mexico versus WHO/UNAIDS.In May of 1987, as a consequence of poor compliance by blood and plasma banks with the 1986 law that mandated HIV screening of blood and blood products, the executive and legislative branches of the government approved a law prohibiting the sale of blood and blood products in Mexico [6,17]. This law was not without controversy and much opposition. Since Mexico lacked a culture of volunteer blood donation, ready sources of HIV testing, and an organized blood collection infrastructure, there was a major fear among public health officials that shutting down the blood and plasma industry would severely compromise the blood supply, prompting the emergence of a black market in blood and blood products. Because of this possibility, a two-pronged response was quickly approved and implemented. Campaigns promoting volunteer blood donations were begun all over the country while, at the same time, the necessary laboratory infrastructure for HIV testing was established. Within 4 months, a network of 70 laboratories capable of screening donors for HIV was set up in the country's 32 states. In addition, blood collection and distribution centers were established in collaboration with the Mexican Red Cross. Table 1 summarizes the steps taken by Mexico for the control of transfusion-transmitted HIV.Table 1: The Prevention of transfusion-transmitted HIV in Mexico. The implementation of the strategies described above has had dramatic consequences for public health in Mexico. Not only is the future health of the general public more assured – the number of transfusion- associated cases peaked within a year of the blood sale ban and no new cases of AIDS secondary to blood transfusion have been reported since 1999 (see Fig. 1) – but so is the future health of blood donors. After paid donors were banned in 1987 the HIV seroprevalence among donors decreased from 2.6% in 1986 to 0.7% in 1988 [6]. In 1989, HIV seroprevalence among blood donors in Mexico further decreased and has remained low (below 0.08% in all years). For example, only 385 out of 1 099 755 blood units tested positive for HIV in 1999 (0.04% prevalence) and 377 out of 1 140 632 were HIV infected in 2000 (0.03% prevalence), (see Figs 2 and 3). As a result of the change in government policy, it is estimated that over 8000 transfusion-transmitted infections have been prevented.Fig. 2.: AIDS cases associated with blood transfusion in Mexico (through July 2000, by date of diagnosis.Fig. 3.: HIV prevalence among blood donors, Mexico 1986–2000. From the National HIV Laboratory Network.This improvement is certainly a cause for relief but the true extent of the widespread damage caused by the paid donor system has yet to be calculated. Close to 400 cases of AIDS among paid donors were reported to the National AIDS Registry before this transmission of HIV was finally contained. This number of cases represents more than twice those reported among hemophiliacs in Mexico [17,18]. Close to 2500 cases of AIDS considered secondary to transfusion of HIV infected blood have been reported, and those account for only the primary infections [2,19,20]. As noted above, many of the paid donors, as well as the recipients of contaminated blood and blood products may have infected their sex partners (and subsequent children). This possibility is a key observation. Before the tragedy was contained, women in Mexico – particularly poor women – were at risk from contaminated blood from not one but two sources. They were at risk directly, via obstetric-related blood transfusions and they were at risk indirectly from sexual partners who were professional donors and who were infected at the time of blood or plasma collection. We believe that it is this 'double jeopardy' that Mexican women faced that led to the rapid transition in male : female ratio of AIDS cases in the mid 1980s and the apparent 'heterosexualization' of the AIDS epidemic. It is reasonable to suppose that without the now present safeguards placed on the blood supply in Mexico, this double jeopardy would have continued and the male : female ratio of infection would have continued to decrease until Mexico achieved a 'pattern 2' (primarily heterosexual) epidemic. Support for this assumption may be inferred by observing the rapid transition of the male : female case ratio in countries that continue to support a paid donor blood collection system. For example, in areas of India and China where epidemic HIV infection in paid donors has been noted, the epidemic has become overwhelmingly 'heterosexual' [21]. Support for this conclusion may also be found more concretely in the results of a study to determine the risk factors for HIV-infection among women in Mexico. Of 454 women who had an HIV test performed in 1992, multivariate analysis revealed that only a history of blood transfusion, low literacy and having sex with an HIV infected partner were associated with being HIV-infected [22]. In summary, the Mexican experience highlights the critical role that mandatory screening of all donors, prohibiting paid donations, and maintaining strict control of the plasma industry can have on the epidemiology of HIV/AIDS. Such simple control measures undoubtedly require resources but, above all, require political will for their implementation. The prevention of HIV infection among female commercial sex workers Commercial sex in Mexico takes place in the 32 federal states of Mexico under one of two legal frameworks: 'abolitionist' or 'reglamentarist' [23]. The abolitionist movement seeks to eliminate prostitution entirely by making its practice a misdemeanor. More commonly though, prostitution is allowed but controlled by legislation. The reglamentarist system restricts prostitutes' activities to certain areas of the city or establishments and requires them to be licensed and have periodic health exams. Most of Mexico (except for the Federal District where Mexico City is located, and the States of Mexico, Puebla and Guanajuato) functions under a reglamentarist system. The public health threat posed by the reglamentarist system – specifically the requirement for periodic health exams – is the potential for corruption (a sex worker might have the opportunity to 'buy' a clean record) and the potential for a false sense of security on the part of CSW clients. This false sense of security, which may lead some clients to request or insist on sex without a condom, is not just a product of political corruption. Unfortunately even periodic health exams are not sufficient to protect clients from recently acquired HIV infection or sexually transmitted infections (STI). There is continuing debate among public health experts about whether the abolitionist or reglamentarist legal framework provides a better system for preventing HIV infection among sex workers. Thailand's experience, however, would seem to suggest that strictly enforced rules and regulations governing both sex workers and their clients (such as 100% condom use in brothels) can be the cornerstone of a successful program of public health safety [11,24]. Commercial sex in Mexico City takes place under an abolitionist system that has been in place since 1940 when the practice of commercial sex was first banned in that city. In Mexico City, any individual who is found practicing commercial sex may be fined and arrested for 24–36 h [25]. Under this legislation the police are also permitted to detain women who are on the street simply because their personal appearance is considered 'offensive to modesty and good custom', even if there is no evidence that the women were actively engaging in prostitution. Nevertheless, patronizing the services of CSW is tolerated and excused, if not condoned. are arrested or This double is In the Mexico City of young health found that 6% of men reported having their first sexual with a CSW The proportion of men who have been clients of CSW during their is undoubtedly Unfortunately this system CSW in a status and them of health services and legal This in the corruption of police and other authorities who routinely from In 1986 an place CSW that, in may have been in the Mexican AIDS epidemic to its nuclear In that female CSW began at National AIDS (CONASIDA) and to request HIV testing and risk In these women provided an opportunity for public health officials to to an population that is and of with the CONASIDA began to to with these women and them into the public health process. Perhaps the most intervention that place during this time was a between the of in Mexico City and the of Health that allowed CONASIDA to a of and interventions with sex workers without the of the local In this way CONASIDA was to with sex workers and their without them to testing of early revealed that HIV incidence among female CSW in Mexico City was below 1% in the 1980s and has remained low since among 1997 women tested for HIV in This finding is in marked contrast to the prevalence of HIV among male CSW in Mexico or to the epidemic among male and female CSW in other countries. the same time interval, for example, the HIV seroprevalence for sex workers in Thailand increased from in 1988 to over in 1990 A of HIV among sex workers has been in India and [21]. on the seroprevalence of HIV found among CSW who are tested in a CONASIDA it is that factors described below may have a low prevalence of HIV among female CSW in Mexico, the that HIV prevalence has remained low to this could also be to increased condom use like other women in Mexico, are to HIV in one or more of four through the transfusion of contaminated blood or blood products during or for obstetric through the use of contaminated needles injection through infection at the time of blood or plasma professional blood plasma or through sex with a who is HIV For the to be – that low HIV prevalence in female CSW is not primarily to increased condom use – it would be necessary to evidence that the of transmission described above in a risk for HIV infection to female the result could that other or means of than transmission from of those In to and evidence be in to the at the of Health and CONASIDA was and was not known about the transmission from contaminated blood or blood products As noted above, transfusion-transmitted HIV primarily affects specifically women who receive blood for obstetric reasons [6]. There was no evidence that female CSW in Mexico were at less risk of blood transfusions than other the low prevalence of HIV among female CSW was probably to a risk from contaminated equipment There was no that HIV may be transmitted via contaminated needles by equipment or during was in was whether the low prevalence of use among female among those CONASIDA and in was sufficient to account for the low prevalence of HIV among them as For other countries with a low prevalence of use among female CSW have the incidence of HIV dramatically in their female CSW the low prevalence of use among female CSW in Mexico undoubtedly the of HIV in this it did not to be more than condom use for the continued low prevalence of HIV. infection at the time of blood or plasma As has been described above professional blood and plasma donors became infected with HIV until this practice was banned in It was thus possible that could also have been professional donors and thus be at risk for HIV infection through this However, of cases of AIDS among professional blood donors have been among which is by the that men were much more to be professional donors. from sex There are at in which sexual in the of may be with a continued low prevalence of HIV among female an HIV seroprevalence in the general population to a significant transmission if the prevalence of HIV is not spread throughout the population and infected clients not female and if the specific sexual in by CSW not HIV In the first the low prevalence of HIV in the general population of Mexico in 1986 six per meant that sex workers as a group faced risk of exposure from their clients The with this explanation was that had found a high prevalence of in many American countries It was that evidence would be before a could be that are less to female CSW than male CSW and that, the risk for infection from this group was than for female In the it was that female CSW did not practice sexual considered to be of high risk with their clients so the or of a For the of transmitting of transmission and evidence would be before a could be that female CSW in Mexico or only in HIV transmitting As a result of the in a major study was in observation, key and to a of commercial sex in the urban area of Mexico City This allowed the of street and where commercial sex From this it was estimated that approximately of the population of Mexico City were women in commercial sex 000 A of these women were to in a study which included sexual as well as testing for and The results of these studies a low prevalence of among female sex workers and the studies which that the HIV prevalence among these women was quite low (see Table A significant was also found between the risk of having an and the of a street have higher of In addition, a level and the number of years practicing commercial sex were associated with being for HIV and prevalence among female commercial sex workers in Mexico. from The results of the were also of major While all women reported having with their reported having sex and reporting having In addition, reported an in condom use since about However, in contrast to their with their reported with their or In multivariate risk factors for sex with clients included a low street no use of a to use clients of and use of services the years subsequent studies conducted in Mexico City as well as in other cities throughout the country have continued to a low prevalence of HIV among female commercial sex workers (see Table 3). As noted above, this finding is in marked contrast to the HIV seroprevalence among sex workers in other developing HIV prevalence studies among female commercial sex workers in Mexico. In an to further sexual and to risk factors for HIV infection among men in Mexico, a of studies have been conducted by group. studies that men at and had a higher seroprevalence of HIV infection than men versus and that reported condom use was quite with only reporting regular condom use As noted above, the practice of has been reported to be among American men in to a of men conducted in this practice to not be as in Mexico City in In that study of men reported that they had sex in their with reporting and The HIV prevalence in this was among men and among men This study also that men might be to the services of male or female CSW when not in a

ObjectiveThe goal of this study was to understand the knowledge about AIDS, identify the correlates and determine the prevalence of HIV infection, syphilis, HCV among migrant workers in Zhejiang, China.MethodsA cross-sectional study using face-to-face anonymous questionnaire interviews was conducted and blood samples were collected for HIV, syphilis and Hepatitis C infection screening.Results17,377 (92.8%) of 18,730 migrant workers approached were interviewed. Among 17,377 participants, the HIV/AIDS knowledge rate was 66.2%. A total of 12,694 (73%) of the participants reported having ever had sexual intercourse, with 30.1% of single participants reporting having had sexual intercourse. Among those respondents with sexual experiences, 7.5% admitted they had two or more sexual partners and 4.9% reported having had sex with casual (unpaid) partners in the previous 12 months, whilst 3.7% had paid for sex. More than half of those who had paid for sex (59.4%) had not used a condom every time in their sexual acts with the sex workers. Multiple logistic regression analysis indicated that high risk sexual behavior (defined as sex with a casual or commercial sex partner without using a condom consistently) was associated with being divorced or widowed (P<0.05 for single); male gender; shorter duration of stay in Zhejiang; working in factory, market or domestic service (P<0.05 for odd job); having a province of origin inside Zhejiang; and drug use. The prevalence of HIV and HCV infections were 0.02% (95% CI: 0.01%–0.06%) and 0.40% (95%CI: 0.31%–0.51%), respectively. The prevalence of syphilis among those who were sexually active was 0.55% (95% CI: 0.43%–0.70%). Risk factors for syphilis included shorter duration of stay in Zhejiang, ethnic minority status, being divorced or widowed and having had multiple sex partners.ConclusionsMuch greater efforts are needed to promote safer sex, and programs for the control of syphilis need to be tailored for migrant workers in China.

HIV acquisition among adolescents and young adults (AYA, 15-24 years) is influenced by individual factors, community factors, and public policies and programs. We explored the association of HIV incidence and prevalence with these factors over time among AYA in Rakai, Uganda. We examined trends over nine survey rounds (2005-2020) of the Rakai Community Cohort Study (RCCS), an open population-based surveillance cohort of individuals living in 30 continuously followed communities in south-central Uganda (n= 35,938 person rounds). We evaluated the associations between individual and community-level factors including HIV community viremia (CV, a measure of community-level ART use and HIV prevalence) and HIV incidence and prevalence. Logistic GEE, Poisson GLM and univariate models were run for HIV prevalence, HIV incidence, and predictors of interest, respectively. HIV incidence and prevalence declined over time after round 14 (2010-2011) by 66% among AYA men and after round 17 (2015-16) by 60% among young women. Between survey round 11 (2007-2008) and round 19 (2017-2019), the proportions reporting being sexually experienced declined from 58% to 38% in adolescent men (15-19) and from 65% to 35% among adolescent women. The prevalence of VMMC among adolescent men increased from 20% in round 11 to 79% in round 19. At the community-level, we found substantial increases in ART use among PLHIV ( 5% in round 11 and 86% in round 19) with corresponding declines in community viremia. In multivariable analyses, a combination of individual and community-level factors were found to predict HIV incidence and prevalence among AYA, notably VMMC among young men and community viremia among young women. Declines in HIV incidence and prevalence occurred first among AYA men and later among AYA women. These coincided with declines in sexual experience and with public policies that increased access to VMMC and ART. Combination HIV prevention with AYA needs to address risk factors at multiple levels. This work was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD, grants R01HD091003, RO1HD070769, R01HD050180, R01 HD074949, and P2CHD058486), the National Institute of Allergy and Infectious Diseases (grants R01AI143333, R01AI110324, U01AI100031, U01AI075115, R01AI110324, R01AI102939, and K01AI125086-01), the National Institute of Mental Health (grants R01MH115799, R01MH107275, R01 MH128232, F31MH134699), and the Division of Intramural Research of the National Institute for Allergy and Infectious Diseases. SAG, JSS, ISC, TL, YW, ES, SH, AND PK conceived and designed the study. ISC, JT and YW oversaw data cleaning and statistical analysis and directly accessed and verified the underlying data reported in the manuscript. AK and DM accessed the data, created the figures for the resubmission and edited the text. AK and DTL, FN, DS, JK, MKG, MJW, LWC, FMS oversaw data collection. All authors had full access to the data in the study, participated in the interpretation of data and revising the manuscript, and had final responsibility for the decision to submit for publication. Evidence before this study: Age-specific rates of HIV incidence are often highest among AYA and particularly young women. Risk factors for HIV infection among AYA include earlier sexual initiation, multiple partners, and inconsistent condom use. Combination prevention including community-wide uptake of ART and male medical circumcision has been associated with declines in HIV incidence in Rakai, Uganda in the overall population. 1,2 A 2019 review of HIV incidence among adolescent girls and young women from 10 high-prevalence African countries found that few studies have examined incidence over time, and among those that there was limited evidence of incidence declines. 3 Added value of this study: Using data from 2005-2020 and the Rakai Community Cohort Study (RCCS) in southcentral Uganda, we found evidence that community-level factors including community viremia and ART use, VMMC among young men, and declines in sexual experience were associated with lower risk of HIV acquisition and seroprevalent infection among AYA. Declining HIV incidence and prevalence over time among AYA coincided with policy changes expanding access to ART and VMMC.Implications of all the available evidence: Age of sexual initiation and community-level factors play critical roles in HIV transmission in Rakai and in declines over time in youth HIV incidence and prevalence. HIV prevention for AYA needs to address individual factors and public policies to improve access to ART and VMMC.

To investigate the sexual transmission behaviors among HIV-positive MSM population engaging in unprotected sexual behaviors, as well as the relationship with health conditions and partner notification. A total of 308 HIV-positive MSM participants engaged in unprotected sexual behaviors were recruited by "snowballing" sampling in Shanghai and Chengdu. The questionnaire covered such items as the time of HIV infection diagnosis, CD4⁺ T cells count, viral load, antiviral therapy, anxiety and depressive symptoms, sexual partner types and sexual behaviors in the past six months, disclosure to fixed sexual partners and casual sexual partners among others. Of the 308 participants surveyed, the report rate of those having at least one-time sexual transmission behaviors during the past 6 months was 70.1% (216/308). Participants who had primary sexual partners and casual sexual partners following their HIV infection diagnosis accounted for 89.0% (274/308) and 68.2% (210/308) respectively. Of the aforementioned participants, 59.1% (162/274) and 94.3% (198/210) respectively had not disclosed their HIV infection to primary and casual sexual partners. Of thoes who did not disclose their HIV infection to primary sexual partners, 91.9% (147/162) reported sexual transmission behaviors. Of thoes who did not disclose their HIV infection to casual sexual partners, 89.9% (178/198) continue sexual transmission. As found in a multi-factor analysis, the infection risk exposure of those with heterosexual sexual orientation and engagement in sexual transmission behaviors was six times higher than those with homosexual orientation (aOR = 5.896, 95% CI: 1.808-19.232). For those who did not, or partially disclose their HIV infection to male casual sexual partners or commercial sexual partners, the risk exposure of further transmission was 29 times and 19 times higher than those disclose it to their sexual partners (no disclosure: aOR = 28.957, 95% CI: 7.511-65.004; partial disclosure: aOR = 18.956, 95% CI: 6.995-57.417). The highest risk came from those who continue their sexual transmission behavior within six months of their HIV infection diagnosis; the lowest risk came from those continue such behavior more than one year and within two years of their diagnosis (aOR = 0.048, 95% CI: 0.033-0.788); such risk rose to some extent for those continue such behavior over two years of their diagnosis. Compared to those without antiviral therapy, participants with the therapy pose less risk in sexual transmission behaviors. More than two-thirds of HIV-positive MSM population who engage in unprotected sexual behaviors reported sexual transmission behaviors. In this regard, increasing antiviral therapy and promoting sexual partner disclosure constituted an effective strategy to minimize further transmission among HIV-positive MSM population. Intervention of sexual transmission behaviors should be addressed to those diagnosed of HIV infection within six months.

In Ethiopia, young people with disabilities (YPWD) are often marginalized and not recognized as being sexual, and only little is known about their sexual reproductive health (SRH) status. We therefore aimed to assess the SRH status and associated factors among 426 YPWD in Addis Ababa, Ethiopia. A cross-sectional survey was conducted in 2012. Data were collected by trained interviewers using a structured questionnaire. Fifty-two percent of YPWD ever had sexual intercourse. Seventy-five percent started sex between 15 and 19 years. Only 35% had used contraceptive during their first sexual encounter. Fifty-nine percent of the sexually experienced YPWD had multiple lifetime sexual partners; 19%, a casual sexual partner; and 21%, a commercial sexual partner. Only 48% consistently used condoms with their casual or commercial sexual partners. Twenty-four percent of the sexually experienced YPWD had a history of sexually transmitted infections. Our findings indicate that YPWD in Ethiopia are sexually active, but also highly involved in risky sexual practices. There is a need for in-depth research to better understand the determinants of risky sexual behavior and to propose preventive approaches.

BackgroundThe prevalence of HIV among antenatal clients in South Africa has remained at a very high rate of about 29% despite substantial decline in several sub-Saharan countries. There is a paucity of data on risk factors for incident HIV infection among antenatal mothers and women within the reproductive age bracket in local settings in the Eastern Cape, South Africa.ObjectiveTo establish the risk factors for incident HIV infection among antenatal clients aged 18–49 years attending public antenatal clinics in rural Eastern Cape, South Africa.DesignThis was an unmatched case–control study carried out in public health antenatal clinics of King Sabata District Municipality between January and March 2014. The cases comprised 100 clients with recent HIV infection; the controls were 200 HIV-negative antenatal clients. Socio-demographic, sexual, and behavioral data were collected using interviewer-administered questionnaires adapted from the standard DHS5 women's questionnaire. Multivariate logistic regression models were used to identify the independent risk factors for HIV infection. A p<0.05 was considered statistically significant.ResultsThe independent risk factors for incident HIV infection were economic dependence on the partner, having older male partners especially among women aged ≤20 years, and sex under the influence of alcohol.ConclusionsTherefore, effective prevention of HIV among antenatal mothers in KSDM must target the improvement of the economic status of women, thereby reducing economic dependence on their sexual partners; address the prevalent phenomenon of cross-generation sex among women aged <20 years; and regulate the brewing, marketing, and consumption of alcohol.