Heterosexual Risk Behaviors Research Articles

Structural vulnerabilities and PrEP awareness among Boston heterosexuals and people who inject drugs at risk for HIV: findings from 2018 to 2019 cycles from the Boston, MA site of the NHBS

ABSTRACT Little is known about biopsychosocial factors relating to pre-exposure prophylaxis (PrEP) awareness among people with either heterosexual or injection drug use HIV risk behaviors. Participants engaged in vaginal/anal sex with a person of the opposite sex (N = 515) or were people who injected drugs (PWID; N = 451) in the past 12 months from 2018-2019 in Boston, MA. We examined associations between PrEP awareness and: homelessness; perceived HIV-related stigma; country of birth; bacterial STDs, chlamydia, and/or gonorrhea in the past 12 months, lifetime hepatitis C virus (HCV) infection, sexual orientation, and poverty. More PWID (36.8%) were aware of PrEP than people with heterosexual HIV risk (28%; p = .001). Among people with heterosexual risk, homelessness (aOR = 1.99, p = .003), and among PWID: homelessness (aOR = 2.11, p = .032); bacterial STD (aOR = 2.96, p = .012); chlamydia (aOR = 6.14, p = .008); and HCV (aOR = 2.40, p < .001) were associated with increased likelihood of PrEP awareness. In the combined sample: homelessness (aOR = 2.25, p < .001); HCV (aOR = 2.18, p < .001); identifying as homosexual (aOR = 3.71, p = .036); and bisexual (aOR = 1.55, p = .016) were each associated with PrEP awareness. Although having an STD, HCV, identifying as homosexual or bisexual, and experiencing homelessness were associated with increased PrEP awareness, most participants were unaware of PrEP. Efforts to increase PrEP awareness could engage PWID and heterosexual HIV risk behavior.

Injection and Heterosexual Risk Behaviors for HIV Infection Among Non-gay Identifying Men Who Have Sex with Men and Women.

Non-gay identifying men who have sex with men and women (MSMW) are an important subgroup of men who have sex with men (MSM) and have been underrepresented in studies of MSM that only use gay venues to draw their samples. We assessed heterosexual and drug use risks of MSMW who use drugs in a sample of male entrants to the Mount Sinai Beth Israel drug treatment programs from 2005 to 2018. Blood samples were collected and tested for HIV and HSV-2 infections. Among HIV seronegative participants, MSMW had significantly greater odds of sharing used needles with others, and reporting unprotected sex with female casual partners and female commercial sex partners, compared to their counterparts who reported sex with women exclusively (MSWE). Although not recruited from gay venues, MSMW had a significantly higher HIV prevalence than MSWE (23% vs. 10%, p < 0.001). Interventions that are specifically tailored to HIV prevention among MSMW are needed to ameliorate the prevalence of HIV risks and infection.

A prospective study to assess the prevalence of hepatitis B infection in health care workers, voluntary blood donors, and patients with liver disorders at a tertiary care centre

Background: Hepatitis B virus (HBV) is highly infectious when compared with human immuno-deficiency virus (HIV), even minute quantity of infected blood as little as 0.0001 ml can transmit infection. A number of the routine therapeutic, diagnostic, prophylactic invasive procedures can spread HBV infection. The study was planned to assess the prevalence of hepatitis B surface antigen in health care workers, voluntary blood donors, and patients with liver disorders.Methods: The study was a cross sectional study carried out among 90 subjects during a period of one year in Indira Gandhi Medical College and Hospital, Shimla. These 90 subjects consisted of 30 patients with liver disorder, 30 health care workers and 30 voluntary blood donors. The blood samples were collected and sent for detection of HBsAg by ELISA.Results: Majority of the subjects 47 (52.2%) belonged to the age group of 21-30 years. Among voluntary blood donors, 90% were males. 64.4% of the subjects belonged to urban areas. 50% of the rural subjects were having liver disorders. Liver disorder was more common (71.5%) among heterosexual high risk behaviour subjects compared to only 25.7% with no high risk behaviour. Seropositivity was found highest among patients with liver disorder (66.7%) followed by health care workers (20%). Overall, the seropositivity was 28.9%.Conclusions: Patients with liver disorders especially chronic hepatitis were mostly seropositive. Among health care workers, being a doctor was a significant risk factor for acquiring hepatitis B infection. Thus, it is advised that all health care workers should be immunized for hepatitis B.

Good Feasibility of the New German Blood Donor Questionnaire

Background: We assessed the effect of the uniform donor questionnaire (UDQ) on deferral rates in first-time and repeat donors. We focused on the introduced question about unprotected sexual contact with a new partner. Another goal was a stratified comparison of the deferral rates of the donor questionnaire (DQ) and UDQ. Methods: Data on donors and deferrals using the DQ and UDQ were collected at four blood establishments. The comparison included a 2-year period by questionnaire version. For the comparison of the questionnaires, an adjusted multinomial logistic regression was performed. Results: The analysis included 260,848 donations. First-time (FTD) and repeat donations (RD) showed higher deferral rates with the UDQ (FTD +5.4%, RD +1.4%). Deferral due to a new partner was 3.0% in first-time and 0.4% in repeat donors. The majority of these occurred in the youngest age groups. The most frequent deferral criterion was ‘disease' (5.1%). Conclusion: The regression revealed stronger predictors for deferral than the questionnaire version. Especially younger age carried a higher and independent risk for deferral. The additional deferrals of mainly young first-time donors due to a new sexual partner may identify those donors with potential heterosexual risk behavior who would otherwise not be identified.

A Prospective Study on Prevalence of Hepatitis B Viral Infection in Voluntary Blood Donors, Health Care Workers and Patients with Liver Disorders - A Hospital Based Study

Background: HBV is exceptionally irresistible that even moment hints of tainted blood as meager as 0.0001 ml can transmit disease. A few of the standard remedial, demonstrative, prophylactic intrusive techniques can spread HBV disease. Therefore, this study was conducted to know the prevalence of hepatitis B surface antigen in voluntary blood donors, health care workers (medical and paramedical personnel) and patients with liver disorders. Methods: Present study was hospital based cross sectional study carried out among 60 subjects during a period of one year in Geetanjali Medical College & Hospital, Udaipur, Rajasthan. These 60 subjects consisted of 20 patients with liver disorder, 20 health care workers and 20 voluntary blood donors. Subjects were selected randomly. After obtaining informed consent, detailed history and examination was carried out. The blood samples were collected and sent for detection of HBsAg by ELISA. Results: Maximum subjects 31 (51.7%) belonged to the age group of 21-30 years overall as well as among the voluntary blood donors i.e. 60%. Among voluntary blood donors, 96% were males. 60% belonged to urban areas. Among rural subjects, maximum (54.2%) were having liver disorders. Liver disorder was more common (66.7%) among heterosexual high risk behavior subjects compared to only 22.8% with no high risk behavior. Seropositivity was found highest among patients with liver disorder (65%) followed by among health care workers (15%). Seropositivity was nil among voluntary blood donors. Overall the seropositivity was 26.7%. Conclusions: Patients with liver disorders especially chronic hepatitis were mostly seropositive. Among health care workers, being a doctor was an important risk factor for acquiring hepatitis B infection. Hence all health care workers should be immunized for hepatitis B.

Theory of planned behavior interventions for reducing heterosexual risk behaviors: A meta-analysis.

The meta-analysis reported here examined interventions informed by the theory of planned behavior (TPB) or theory of reasoned action (TRA) aimed at reducing heterosexual risk behaviors (prevention of STDs and unwanted pregnancy). Studies were eligible for inclusion if they were either randomized control trials or quasi-experimental studies that compared the TPB-based intervention against a control group. Search strategy consisted of articles identified in previous reviews, keyword search through search engines, examination of key journals, and contacting key experts. Forty-seven intervention studies were included in the meta-analysis. Random effects models revealed that pooled effect sizes for TPB-based interventions had small but significant effects on behavior and other secondary outcomes (i.e., knowledge, attitudes, normative beliefs, perceived behavioral control, and intentions). Significant heterogeneity found between effect sizes was explored using metaregression. Larger effects were found for interventions that provided opportunities for social comparison. The TPB provides a valuable framework for designing interventions to change heterosexual risk behaviors. However, effect sizes varied quite substantially between studies, and further research is needed to explore the reasons why.

Eleven year performance of an Integrated Counseling and Testing Center in a tertiary care hospital in Himachal Pradesh, India

Introduction: The integrated counseling and testing centre (ICTC) has proved to be an essential human immunodeficiency virus (HIV) infection prevention intervention, especially in nations where poverty, social inequality, and weak health infrastructure exist. Objectives : The study was conducted to (i) assess the performance of ICTC in a referral hospital over a period of 11 years (ii) understand the regional risk determinants of HIV-positive clients. Materials and Methods : In this record based hospital study, data from January 2000 to December 2010 of all ICTC attendees and HIV-positive clients (excluding pregnant women; surveillance in this group is being conducted routinely) was collected by reviewing the records, compiled, and analyzed. Results : A total of 19,234 clients were counseled, of which 17,411 were tested and 970 were detected positive for HIV. The HIV seropositivity amongst the total tested clients was 5.57%. The intake of clients attending ICTC consistently increased from 781 clients in 2000 to 5574 clients in 2010. Amongst the total 970 HIV positives the ratio between male and female positives was 3:2 (m = 584; f = 386). Of these, 42.1% were in the age group of 25-44 years and children (<15 years) accounted for 7.8%. The heterosexual route of transmission was documented in 77.4%. In 13.6% (n = 132) HIV-positive clients, the route of transmission was not identified. The provider initiated client visits increased significantly from 4.85% in 2006 to 82.05% in 2010 than the direct walk-in clients (P < 0.0000001). However, the HIV-positive clients were three times more in the direct walk-in clients than in the provider initiated clients (P < 0. 0000001). Conclusion : Increased utilization of ICTC reflects the overall attitudinal changes in behavior and heterosexual high risk behavior continues to be the major route of HIV transmission.

Supplemental Material for Theory of Planned Behavior Interventions for Reducing Heterosexual Risk Behaviors: A Meta-Analysis

Supplemental Material for Theory of Planned Behavior Interventions for Reducing Heterosexual Risk Behaviors: A Meta-Analysis

S11.1 Sexual Behaviour in Britain in the New Millennium: A New Era?

BackgroundIn 2001, Britain’s second National Survey of Sexual Attitudes and Lifestyles (Natsal-2) demonstrated increased sexual risk behaviour in contrast to Natsal-1, undertaken a decade earlier. STI diagnoses also increased between...

Particularities of tuberculosis in HIV‐infected patients: 10‐year experience of a Portuguese hospital

The incidence of tuberculosis (TB) has dramatically increased since the advent of the human immunodeficiency virus (HIV) pandemic. In Portugal, tuberculosis is still common in HIV‐negative patients, despite earlier diagnosis and countrywide directly observed therapy strategies. With the purpose of comparing some demographic and clinical aspects of TB in HIV‐infected and uninfected patients, the authors reviewed the files of patients admitted with a diagnosis of tuberculosis between January 2002 and December 2011. During this time period, there were 234 cases of tuberculosis, 43 (18%) of which occurred in HIV‐infected patients. In this group, 74% of patients were male, with a mean age of 38±11 years and the majority (51%) acquired HIV from heterosexual risk behavior. The most common site of infection was the lung, in both groups, but cases of extrapulmonary TB were significantly higher in the HIV‐infected group (67% versus 39%, p&lt;0.01). Disseminated TB was the most common extrapulmonary diagnosis in the former group (28%) and lymph node TB (8%) in the latter. The duration of hospitalization was not statistically different between the two groups (mean of 26±16 days in HIV‐infected patients and 21±15 days in the HIV‐negative group, p=0.21). The mean CD4 count at TB diagnosis was 180±177/mm3. In 11 (26%) of the patients, HIV was diagnosed during the TB episode and in 5 cases, the diagnosis of tuberculosis occurred with immune reconstitution syndrome. In the majority of patients (60%), TB was the first AIDS‐defining condition. In 26 (60%) of patients there was microbiologic confirmation of TB, mainly by direct observation (69%), positive culture (46%) and molecular diagnostic technics (27%). While most patients were treated with the 4‐drug standard regimen, 16 (37%) of cases received alternative treatment. The mean duration of treatment was 8.5±4.8 months and the majority of patients (58%) were considered cured. About one‐third of patients were lost to follow‐up (32%). Tuberculosis is a heterogeneous disease, varying accordingly with the immunologic status of the host. The risk of extrapulmonary and disseminated TB increases with immunosuppression but, in this cohort, it did not seem to influence the length of hospitalization. The authors alert to the need of HIV screening whenever TB occurs, allowing for earlier diagnosis and prompt start of antiretroviral therapy.

A survey of English teenagers' sexual experience and preferences for school-based sex education

Rates of sexually transmitted infections and teenage pregnancy amongst the under-16s are causing increasing concern. There is limited evidence about the sexual behaviour and sex education preferences of this age group, especially of those from Black and minority ethnic groups. This study aimed to provide data on early heterosexual risk behaviour, and to examine preferences for the content and delivery of sex and relationships education (SRE), across ethnicity, gender and school year to inform priority setting and sex education strategies. A cross-sectional study of 3334 13–17-year-olds from 10 English urban and suburban secondary schools was conducted. Multivariate analysis was performed to examine the independent effect of demographic variables on sexual experience and preferences for sex education. A number of important differences in the sexual experience and condom use of males and females across the ethnic groups were identified. Differences in preferences for the content and delivery of sex education were also identified, particularly between male and female pupils. The findings indicate the potential for quite wide variation in sexual experience and preferences within school classrooms. The challenge for educators is therefore to develop SRE curricula that are inclusive within the constraints of school teaching.

Are HIV Epidemics among Men Who Have Sex with Men Emerging in the Middle East and North Africa?: A Systematic Review and Data Synthesis

Men who have sex with men (MSM) bear a disproportionately higher burden of HIV infection than the general population. MSM in the Middle East and North Africa (MENA) are a largely hidden population because of a prevailing stigma towards this type of sexual behavior, thereby limiting the ability to assess infection transmission patterns among them. It is widely perceived that data are virtually nonexistent on MSM and HIV in this region. The objective of this review was to delineate, for the first time, the evidence on the epidemiology of HIV among MSM in MENA. This was a systematic review of all biological, behavioral, and other related data on HIV and MSM in MENA. Sources of data included PubMed (Medline), international organizations' reports and databases, country-level reports and databases including governmental and nongovernmental organization publications, and various other institutional documents. This review showed that onsiderable data are available on MSM and HIV in MENA. While HIV prevalence continues at low levels among different MSM groups, HIV epidemics appear to be emerging in at least few countries, with a prevalence reaching up to 28% among certain MSM groups. By 2008, the contribution of MSM transmission to the total HIV notified cases increased and exceeded 25% in several countries. The high levels of risk behavior (4-14 partners on average in the last six months among different MSM populations) and of biomarkers of risks (such as herpes simplex virus type 2 at 3%-54%), the overall low rate of consistent condom use (generally below 25%), the relative frequency of male sex work (20%-76%), and the substantial overlap with heterosexual risk behavior and injecting drug use suggest potential for further spread. This systematic review and data synthesis indicate that HIV epidemics appear to be emerging among MSM in at least a few MENA countries and could already be in a concentrated state among several MSM groups. There is an urgent need to expand HIV surveillance and access to HIV testing, prevention, and treatment services in a rapidly narrowing window of opportunity to prevent the worst of HIV transmission among MSM in the Middle East and North Africa. Please see later in the article for the Editors' Summary.

Bacterial STDs and perceived risk among sexual minority young adults.

Most sexual health interventions focus on heterosexual sexual risk behavior. Health practitioners face a lack of information about the sexual health of sexual minority young adults (aged 18-26). Three indicators of sexual minority status (identity, behavior and romantic attractions) were assessed in 10,986 young adults who participated in Wave 3 of the National Longitudinal Study of Adolescent Health (2001-2002). Logistic regression analyses examined associations between these indicators and individuals' perceived risk for STDs and actual infection with STDs. Data from the 1,154 respondents who had current or recent bacterial STDs were investigated further to determine whether they had underestimated their risk. Outcomes varied by sexual minority status indicator and by sex. Bisexual females had significantly higher odds of STDs than heterosexual females (odds ratios, 1.4), and females attracted to both sexes had significantly higher odds of STDs than females attracted only to males (1.8). In contrast, none of the sexual minority status indicators predicted STDs for males. Among respondents who had an STD, females who reported only same-sex sexual relationships were more likely to believe they were at very low risk for STDs than were females reporting only opposite-sex sexual relationships (17.2); homosexual females had a higher likelihood of this outcome than heterosexual females (19.7). Health practitioners need to assist sexual minority young adults, particularly females, in under-standing their risk for STDs and in taking safer-sex precautions.

Nascent HIV epidemics among men who have sex with men appear to be emerging in the Middle East and North Africa

Background: Men who have sex with men (MSM) in the Middle East and North Africa (MENA) forms a highly hidden population, and there are widely held perceptions of virtually nonexistent data on MSM and HIV in this region. Our objective was to delineate, for the first time, the evidence on the epidemiology of HIV among MSM in MENA. Methods: This was a systematic review of all biological, behavioral, and contextual data on HIV and MSM in MENA. Sources of data included Medline using free text and MeSH headings, international organizations’ reports and databases, country-level reports and databases including governmental and non-governmental organizations publications, as well as various other institutional documents. Results: This review showed that there is considerable data on MSM and HIV in MENA. The prevalence of HIV among MSM in MENA countries ranged between 0 and 15%. By 2008, the contribution of MSM transmission to the total HIV notified cases increased and exceeded 25% in many countries. The high levels of risk behavior (2-42 partners on average in the last year) and of biomarkers of risks (HSV-2 at 3-54%), the overall low rate of consistent condom use (2-22%), the relative frequency of male sex work (20-76%), and the substantial overlap with heterosexual risk behavior and injecting drug use (up to 17% of MSM inject drugs and up to 37% of male injecting drug users exchange sex for money) suggest potential for further spread. Conclusions: This systematic review and data synthesis indicated that HIV appears to be spreading among MSM in at least a few countries and could be already in a concentrated state among several MSM groups. There is a need to expand surveillance and access to HIV testing, prevention, and treatment services in a rapidly narrowing window of opportunity to prevent the worst of HIV transmission among MSM in MENA.

HIV Knowledge and Attitudes toward HIV Testing of South Side Chicago Housing Authority Residents

High HIV infection rates in the United States are increasingly due to heterosexual risk behaviors, with increased rates in blacks and women. A survey of HIV knowledge and attitudes about HIV testing was conducted in an inner-city public housing population that included a convenience sample of residents of South Side Chicago Housing Authority facilities. The questionnaire addressed knowledge about HIV transmission and disease, health care options, condom use, prior HIV testing, and preferred places for HIV testing and education. Five hundred residents, ages 13-50 years completed the survey, during the period from November 2002 until April 2003. Eighty-three percent of the respondents were female and 50% of those surveyed were from 18-30 years of age. Race/ethnicity was not questioned in order to improve response rate. A comparable sample conducted earlier showed that population was 99% black race. Most respondents were knowledgeable about HIV transmission risk factors, although misinformation about transmission, treatment and prevention existed. Knowledge that HIV therapy is available was high (71%), while 25% thought an HIV vaccine was available and 13% thought there was a cure for HIV. Two thirds of sexually active respondents reported condom use in the past year. Three quarters reported previous testing for HIV and 90% of those tested returned for results. Most respondents wanted to learn more about HIV risk factors, testing and treatment but preferred primary care clinics to specialized places for HIV testing. Targeted HIV education interventions in the public housing facilities or primary care clinics are warranted.

Disconnects in presumed heterosexual HIV transmission in Malawi

Obtaining large-scale sexual network data is difficult [1] and doing so in a poor country is especially difficult. We congratulate Helleringer and Kohler [2] on their pioneering study of a sexual network on Likoma Island, Malawi. Their approach represents an important step toward appropriate research designs for elucidating HIV transmission dynamics in sub-Saharan Africa. Despite this achievement, their results undermine their assertion that the Likoma sexual network sustains epidemic HIV transmission. In fact, their findings add to the already considerable evidence against penile–vaginal intercourse as the primary driver of HIV transmission in sub-Saharan Africa [3]. In moderate prevalence Likoma, Helleringer and Kohler observed an ‘apparently paradoxical distribution of HIV prevalence’. They found that persons in the core (bicomponents) of the main component of the sexual network were less likely to be HIV infected than those in peripheral positions in the main component or in small network components. This finding is at odds with prior empirical research, which indicates that, when significant HIV transmission occurs, persons located in the core of the corresponding risk network are more likely to be infected. In one high prevalence community, persons in the core of the injection and sexual network had considerably higher HIV prevalence and more frequent risk behaviors than those in peripheral or more isolated positions [4]. In that study, injection and homosexual risk behaviors were positively associated with prevalent HIV infection, but heterosexual risk behaviors were not. Similarly, among heterosexuals in a very low prevalence setting with little ongoing HIV transmission, infected persons were, with one exception, isolates, in small components, or on the periphery of the main component of the risk network [5,6]. In Likoma, it is surprising that self-reported symptoms of sexually transmitted infections (STI) are almost evenly distributed across the sexual network, and are not concentrated in the core as expected. Furthermore, no sexual risk variable (condom use, number of sex partners, STI symptoms, or age difference between sex partners) shows a meaningful association with prevalent HIV infection. Taken together, these observations suggest that the measured sexual network might not underlie HIV transmission in Likoma, and that other unmeasured blood and sexual exposures might be involved. To establish the primary modes of HIV transmission in sub-Saharan Africa with confidence, more appropriate research designs are required. Specifically, it is critical to assess blood and sexual exposures comprehensively (beyond just injections and vaginal intercourse) for incident cases and controls, trace their corresponding contacts and sequence-infected persons' HIV isolates [7–9].

Heterosexual Risk Behaviors Among Urban Young Adolescents

Urban 6th graders (n = 294) participate in a survey assessing early heterosexual risk behaviors as part of the Reach for Health Middle Childhood Study. About half the boys (47%) and 20% of girls report having a girlfriend or boyfriend; 42% of boys and 10% of girls report kissing and hugging for a long time. Stepwise regressions model the relationships between heterosexual behaviors and gender, background characteristics, and parenting practices and peer influences. In the final model, being male, parental approval of having a girlfriend or a boyfriend, lower parental oversight of activities, having older or mixed-aged peers, and expressing peer norms supporting sexual behaviors are significant risk factors of heterosexual behaviors. Findings indicate the importance of parenting practices and peer influences on early sexual behaviors and inform strategies for helping urban young adolescents delay sexual initiation.

Heterosexual Behavioral Maintenance and Change Following HIV Counseling and Testing

This study investigated heterosexual HIV risk behaviors, changes in stage of change for safer sex and factors associated with such changes, among a diverse sample of 560 heterosexually active individuals presenting at publicly funded HIV C&T sites. Questionnaires were administrated before HIV C&T, and three months afterwards. Positive serostatus was the most significant predictor of safer behavior after C&T. Many seronegative participants stopped sex with non-main partners. Behaviors with main partners were particularly resistant to change. Predictors of change varied by stage at pre-test. C&T services should tailor approaches and referrals based on stage of change and other client characteristics.

SEROPREVALENCE OF ANTI-HCV AND HEPATITIS B SURFACE ANTIGEN IN HIV INFECTED PATIENTS

Human immunodeficiency virus (HIV) is known to influence the natural history of infections with certain hepatitis viruses and interactions between HIV and hepatitis viruses may potentiate HIV replication. There is high degree of epidemiological similarity between hepatitis B virus and HIV as regard to high-risk group and route of transmission. Transmission of hepatitis C virus (HCV) through blood transfusion and intravenous drug abuse is well documented. Present study deals with the study of concurrent infection of HBV and HCV with HIV infection. In the study of 110 HIV seropositive patients, 34(30.4%) were positive for HBV and 8(7.27%) for HCV. The difference of concomitant infection was highly significant compared to controls. (p value < 0.0001). Heterosexual high risk behaviour was observed in 89(80.91%) of 110 HIV positive patients, out of which 23(25.8%) and 5(5.62%) were HBsAg and anti-HCV positive respectively. History of transmission was unclear in remaining patients. Concomitant infection of HIV and HBV was found to be significantly more in the symptomatic group (40.68%) compared to asymptomatic group (19.6%). As HIV infection is known to affect the natural history of both HBV and HCV infection, screening of their concurrent association is necessary.

Heterosexual risk behaviour among young teenagers in Scotland

This paper provides the first detailed data on the heterosexual sexual experience of a large sample of 14-year-olds in Scotland. The paper investigates the prevalence, nature and correlates of early heterosexual intercourse, and the extent and correlates of condom use. Questionnaires were administered in 24 schools under examination conditions ( N=7630). Eighteen per cent of boys and 15% of girls reported having had intercourse. Sixty per cent reported condoms were “used throughout”. The most important correlate of sexual experience was low level of parental monitoring; the key predictor for condom use was whether or not the respondent talked to their partner about protection before having sexual intercourse. Copyright 2002 The Association for Professionals in Services for Adolescents. Published by Elsevier Science Ltd. All rights reserved.