Risky Behaviors Research Articles

Geographic and psychosocial correlates of homelessness or unstable housing among USveterans in the Midwest.

The purpose of this study was to explore (1) the prevalence of physical and mental health conditions among veterans stratified by homelessness and unstable housing (HUH) in several Midwestern states, and (2) the correlation between HUH and sociodemographic, military, financial, risky behavior, health, and geographical characteristics. The study cohort consisted of 7260 HUH veterans and stably housed veterans in 2018-2022 in Veterans Integrated Service Network (VISN) 23. A multivariate logistic regression analysis was performed which revealed the strongest associations with HUH were any incarceration experience (adjusted odds ratio [AOR] = 0.21) and rural location (AOR = 0.33). Frontier and remote location scores (AOR = 1.23) were associated with increased risk of HUH among veterans. Our results suggest potential differences in risk for HUH among veterans living in rural versus frontier and remote locations, which may be important to consider to provide care to the many veterans in these areas.

Understanding the impact of a residential housing program for people living with HIV/AIDS: results from a realist evaluation

BackgroundIn Canada, the Public Health Agency surveillance of new HIV cases has demonstrated annual increasing rates since 2020. The rates of new HIV cases are highest in the province of...

Elevated risk of sexually transmitted infections among adolescents and young adults with borderline personality disorder: a retrospective longitudinal nationwide population-based study.

In this study, we examined the risk of sexually transmitted infections (STIs) among adolescents and young adults (AYAs) with borderline personality disorder (BPD). A total of 4649 AYAs with BPD and 46,490 age-, sex-, and socioeconomic-matched controls without BPD were enrolled from the National Health Insurance Research Database of Taiwan from 2001 to 2009 and were followed up until the end of 2011. Participants who contracted any STI during the follow-up period were identified. Cox regression analysis was conducted to examine the risk of contracting any STI among both patients and controls. A total of 4649 AYAs with BPD and 46,490 age-, sex-, and socioeconomic-matched controls without BPD were enrolled from the National Health Insurance Research Database of Taiwan from 2001 to 2009 and were followed up until the end of 2011. Participants who contracted any STI (ICD-9-CM code 042, 091-097, 087.11, 078.8, 078.88, 131, and 054.1) during the follow-up period were identified. Cox regression and sub-analyses stratified by sex, age, psychiatric comorbidity subgroups, and psychotropic medication usage were conducted to assess STI risk. AYAs with BPD were at a higher risk of contracting any STI (hazard ratio [HR] = 50.79, 95% confidence interval [CI] = 33.45-77.11) in comparison with controls, including HIV, syphilis, genital warts, gonorrhea, chlamydia, trichomoniasis, and genital herpes. The association of BPD with an increased risk of any STI was prevalent in both sexes, adolescents, and young adult patients. BPD with or without psychiatric comorbid subgroup were all associated with an elevated risk of contracting any STI relative to the control group. AYAs with BPD are highly susceptible to contracting STIs. Future studies should examine the role of the core symptoms of BPD, sexual orientation, risky sex behaviors, depressive and anxiety symptoms, and substance use before sex in the risk of STIs among AYAs with BPD.

Do caring teachers protect African American youth with adverse adolescent experiences from risky behaviors?

The current study aims to fill the existing research gaps by investigating the role of teacher care in protecting African American adolescents in under-resourced neighborhoods from negative outcomes of adverse life events. The study included 638 adolescents from four under-resourced neighborhoods in Chicago's Southside who were assessed to determine the moderating role of caring teachers on the relationship between adverse adolescent experiences and risky sexual behaviors, substance use, bullying perpetration, and violent behaviors. Caring teachers had a significant moderating effect on the association between adverse experiences and both bullying perpetration and violent behaviors. Adolescents who perceived their teachers as caring showed lower tendencies towards bullying and violence, even if they had adverse experiences. These results highlight the crucial role of teacher care in supporting African American adolescents from under-resourced neighborhoods who have experienced adverse life events. It emphasizes educators' role in shaping our youth's future, especially those facing adversity and at a crossroads in their lives.

Additive and Moderating Effect of Parents and Friends on Health and Behavior Outcomes During Emerging Adulthood

Relationships with parents and friends may work together to increase the risk of adjustment problems in emerging adulthood. However, it is still undetermined if social relationships act in an additive (i.e., serve as unique predictors) or moderating (i.e., interact with other predictors) fashion. In a cross-sectional sample of 859 female college students ( M age = 19.53, SD = 1.49; 73.9% White) from a large university in the south-central United States, we assessed how parents and best friends impact emerging adult internalizing symptoms, risky behavior, and health problems. We found that low levels of best friend risky behavior attenuated the links between father-emerging adult relationship quality and risky behavior and internalizing symptoms, and high levels of father-emerging adult relationship quality magnified the association between mother-emerging adult relations and internalizing symptoms. Ultimately, these results indicate that relationships with parents and friends served as additive or unique predictors of emerging adult health and behavior.

Exploring risky health behaviors and vulnerability to sexually transmitted diseases among transnational undocumented labor migrants from Bangladesh: a qualitative study

BackgroundIn Bangladesh, remittances constitute a substantial portion of the country’s foreign exchange earnings and serve as a primary source of income. However, a considerable number of Bangladeshi citizens reside overseas without proper documentation, exposing them to significant challenges such as limited access to healthcare and socioeconomic opportunities. Moreover, their irregular migration status often results in engaging in risky health behaviors that further exacerbate their vulnerability. Hence, this study aimed to investigate the risky health behavior and HIV/STI susceptibility of Bangladeshi irregular international migrants residing across the globe with undocumented status.MethodsUsing a qualitative Interpretative Phenomenological Approach (IPA), 25 illegal migrants were interviewed who are currently living illegally or returned to their home country. The author used a thematic approach to code and analyze the data, combining an integrated data-driven inductive approach with a deductive approach. Concurrent processing and coding were facilitated by employing the Granheim model in data analysis.ResultsThe study identified four risky health behaviors among irregular Bangladeshi migrants: hazardous living conditions, risky jobs, suicidal ideation, and tobacco consumption. Additionally, the authors found some HIV/STI risk behavior among them including engaging in unprotected sex, consuming alcohol and drugs during sexual activity, and having limited access to medical facilities.ConclusionsThe findings of this study can be used by health professional, governments, policymakers, NGOs, and concerned agencies to develop welfare strategies and initiatives for vulnerable undocumented migrant workers.

LGBTQ+ Stigma and Health Effects: A Systematic Review of the Global Literature

This systematic review examines the global literature on LGBTQ+ stigma and health. Indeed, the LGBTQ+ community has experienced a poignant history of stigma, resulting in adverse health consequences. The current review synthesizes 46 articles conducted in multiple cultural settings. The focuses of the selected articles varied from mental health, physical health, suicide, drug and alcohol use, HIV stigma, and healthcare among LGBTQ+ communities. The selected studies similarly found that stigma and discrimination against LGBTQ+ individuals have fueled adverse mental health and health behaviors. These risky behaviors included eating disorders, self-harm, suicide, substance use, unprotected sex, avoidance of healthcare appointments, perceived stigma, as well as healthcare provider (HCP) stigma. Racism in the LGBTQ+ community, racial/ethnic identities of LGBTQ+ individuals, and cultural rejection of homosexuality were also discussed. Future research should pay more attention to intersectional stigma and the social networks of LGBTQ+ communities.

Mental health-related service and medicine use among a cohort of urban Aboriginal children and young people: Data linkage study.

The objective was to describe mental health service and psychotropic medicine use among a cohort of Aboriginal young people and quantify their relation to sociodemographic, family and health factors. In a prospective cohort study with data linkage, 892 Aboriginal children aged 0-17 years living in urban and regional areas of New South Wales, Australia, were included. We assessed mental health-related service use, paediatric service use and psychotropic medicine dispensing claims covered by the Australian Government Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme from July 2012 to June 2017. Most children (71%) did not have a record of mental health service or psychotropic medication use. 18.7% had ⩾1 mental health-related service claim; 26.7% had ⩾1 paediatric service claim; and 20.3% had ⩾1 psychotropic medicine dispensing claim. General practitioner services were the most accessed mental health-related service (17.4%) and 12.7% had been dispensed attention-deficit hyperactivity disorder medicines. Child characteristics associated with treatment included emotional and behavioural problems (prevalence ratio: 1.97, 95% confidence interval = [1.46, 2.64] for mental health services; prevalence ratio: 2.87, 95% confidence interval = [2.07, 3.96] for medicines) and risky behaviour (prevalence ratio: 1.56, 95% confidence interval = [1.12, 2.16] for mental health services; prevalence ratio: 2.28, 95% confidence interval = [1.54, 3.37] for medicines). Parent-related factors included chronic illness (prevalence ratio: 1.42, 95% confidence interval = [1.03, 1.95] for mental health services; prevalence ratio: 2.00, 95% confidence interval = [1.49, 2.69] for medicines) and functional limitations (prevalence ratio: 1.61, 95% confidence interval = [1.16, 2.24] for mental health services; prevalence ratio: 1.86, 95% confidence interval = [1.34, 2.59] for medicines). Most Aboriginal children and young people did not have claims for mental health services or medicines. Aboriginal children with emotional and behavioural problems, or parents with health problems were more likely to have mental health service or medicine claims.

Assessment of Risky Riding Behaviors Using the Motorcycle Rider Behavior Questionnaire (MRBQ) among University Students

Assessment of Risky Riding Behaviors Using the Motorcycle Rider Behavior Questionnaire (MRBQ) among University Students

Child Sexual Abuse in Boys: A Retrospective Investigation

Background: Although recent studies have increased public awareness of child sexual abuse, certain aspects of the issue remain unclear. While research on sexual abuse in girls is abundant, there is limited focus on boys in our country. This study aims to explore the characteristics of cases involving sexual abuse of boys in the province of Türkiye. Methods: The study is descriptive and retrospective in nature. A total of 245 boys who underwent forensic interviews for alleged sexual abuse between September 2017 and March 2023 at the Child Advocacy Center in the province of Türkiye were retrospectively examined. Results: The study included 245 boys aged 3-18 with a mean age of 11.04±3.39. The most common type of sexual abuse was non-penetrative contact (57.6%). Delayed disclosure was primarily attributed to factors such as threat, fear, and shame. Sexual abuse predominantly occurred in public places (56.5%). There were significant among age groups concerning the identity of the reporters, initial disclosure persons, the existence of abuse, and reporting time. However, no significant differences were found in the presence of multiple suspects, recurrent abuse, and the incident location. Post-abuse behavioral changes in children included fear of the perpetrator (15.5%), emotional changes (15.5%), physiological changes (9.4%), and the displaying of risky behaviors (4.1%). Conclusion: The study emphasized the importance of not overlooking sexual abuse among male children. The findings underscore the need for enhanced awareness and intervention strategies to address sexual abuse in boys within the country.

Non-response to ACE items is associated with demographic variables and health indicators in the 2021 Behavioral Risk Factor Surveillance System

BackgroundAdverse childhood experiences (ACE) encompass traumatic events occurring before age 18, with lasting impacts on health. While ACE disclosure is important for understanding these effects, some individuals decline to respond to ACE-related survey items due to sensitivity, privacy concerns, or psychological distress. This study explores the relationship between non-response to ACE items and health outcomes, shedding light on the implications for those who choose not to disclose. MethodsWe performed a secondary analysis of the 2021 Behavioral Risk Factor Surveillance System (BRFSS)—a national telephone survey querying health behaviors and conditions. Sociodemographic factors, ACE exposure, and non-response to ACE items were analyzed. ResultsIndividuals who decline to respond to ACE items exhibit similar patterns of health behaviors and conditions as those reporting ACE exposure. Non-response is linked to both healthier behaviors (lifetime HIV testing) and riskier behaviors (higher odds of smoking and e-cigarette use). Moreover, non-responders have higher odds of being underweight or obese, experiencing concentration difficulties, reporting poor self-rated health, and reporting multiple health diagnoses including depression, diabetes, high blood pressure, heart attack, and stroke. ConclusionsThe study underscores the need to address health disparities associated with ACE, regardless of disclosure status. Healthcare interventions should target respondents and non-respondents of ACE screeners, tailoring strategies to promote healthier coping mechanisms and mitigate maladaptive behaviors. These results emphasize the importance of trauma-informed care, early intervention, and targeted public health initiatives for individuals affected by ACE, irrespective of their disclosure choices.

A multilevel analysis of the determinants of HIV testing among men in Sub-Saharan Africa: Evidence from Demographic and Health Surveys across 10 African countries.

Sub-Saharan Africa, the epicenter of the HIV epidemic, has seen significant reductions in new infections over the last decade. Although most new infections have been reported among women, particularly adolescent girls, men are still disadvantaged in accessing HIV testing, care, and treatment services. Globally, men have relatively poorer HIV testing, care, and treatment indices when compared with women. Gender norms and the associated concept of masculinity, strength, and stereotypes have been highlighted as hindering men's acceptance of HIV counseling and testing. Therefore, men's suboptimal uptake of HIV testing services will continue limiting efforts to achieve HIV epidemic control. Thus, this study aimed to identify individual, neighborhood, and country-level determinants of sub-optimal HIV testing among men in Sub-Saharan African countries. We analyzed demographic and health datasets from surveys conducted between 2016 and 2020 in Sub-Saharan African Countries. We conducted multivariable multilevel regression analysis on 52,641 men aged 15-49 years resident in 4,587 clusters across 10 countries. The primary outcome variable was ever tested for HIV. HIV testing services uptake among men in these ten Sub-Saharan African countries was 35.1%, with a high of 65.5% in Rwanda to a low of 10.2% in Guinea. HIV testing services uptake was more likely in men with increasing age, some form of formal education, in employment, ever married, and residents in relatively wealthier households. We also found that men who possessed health insurance, had some form of weekly media exposure, and had accessed the internet were more likely to have ever received an HIV test. Unlike those noted to be less likely to have ever received an HIV test if they had discriminatory attitudes towards HIV, comprehensive HIV knowledge, recent sexual activity, and risky sexual behavior were positive predictors of HIV testing services uptake among men. Furthermore, men in communities with high rurality and illiteracy were less likely to receive an HIV test. Individual and community-level factors influence the uptake of HIV testing among Sub-Saharan African men. There was evidence of geographical clustering in HIV testing uptake among men at the community level, with about two-thirds of the variability attributable to community-level factors. Therefore, HIV testing programs will need to design interventions that ensure equal access to HIV testing services informed by neighborhood socioeconomic conditions, peculiarities, and contexts.

Risky Behavior of Men who have Sex with Men (MSM) Increases the Risk of HIV and Syphilis Infection

The incidence of sexually transmitted infections in man who have sex with man (MSM) is increased among human immunodeficiency virus (HIV) patients. HIV and syphilis are two sexually transmitted diseases that frequently interact and modify the symptoms and signs of the disease. A case of a 27-year-old male with generalized multiple erythematous plaques including palms and soles since 4 days ago was reported. The patient has been diagnosed with HIV since 2017. The patient is sexually active with a male sex partner and rarely uses condoms. Diagnosis of syphilis is made based on anamnesis, physical examination, and laboratory tests. The treatment was benzathine penicillin G 2.4 million units in 3 doses. The combination of HIV and syphilis needs longer therapy and requires serological follow-up for up to 24 months.

Exploring variability in risk taking with large language models.

What are the sources of individual-level differences in risk taking, and how do they depend on the domain or situation in which the decision is being made? Psychologists currently answer such questions with psychometric methods, which analyze correlations across participant responses in survey data sets. In this article, we analyze the preferences that give rise to these correlations. Our approach uses (a) large language models (LLMs) to quantify everyday risky behaviors in terms of the attributes or reasons that may describe those behaviors, and (b) decision models to map these attributes and reasons onto participant responses. We show that LLM-based decision models can explain observed correlations between behaviors in terms of the reasons different behaviors elicit and explain observed correlations between individuals in terms of the weights different individuals place on reasons, thereby providing a decision theoretic foundation for psychometric findings. Since LLMs can generate quantitative representations for nearly any naturalistic decision, they can be used to make accurate out-of-sample predictions for hundreds of everyday behaviors, predict the reasons why people may or may not want to engage in these behaviors, and interpret these reasons in terms of core psychological constructs. Our approach has important theoretical and practical implications for the study of heterogeneity in everyday behavior. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Predicting Undergraduates’ willingness to engage in dangerous e-scooter use behaviors

IntroductionThe misuse of electronic scooters (e-scooters), particularly among young adults, is increasingly being linked to hospital admissions and injuries in cities across the globe. Yet, despite growing concern about dangerous e-scooter use, there remains a dearth of research on the determinants of engaging in risky behaviors while using an e-scooter. MethodA sample of 262 Australian undergraduate students completed measures relating to the theory of planned behavior, risk perceptions, and knowledge of laws in the context of three e-scooter risk behaviors: riding over the speed limit on footpaths, riding without a helmet, and riding after consuming alcohol, as well as a risk identity implicit association test. Participants then recorded their willingness to engage in each of the three behaviors. ResultsThe model predicted a modest portion of variance in willingness to engage in each of the three e-scooter risk behaviors. Subjective norm predicted all behaviors, while attitude, risk perceptions, and perceived behavioral control each predicted two of the three behaviors. Gender had a significant total effect on willingness for each behavior, partially mediated by the theory of planned behavior constructs, while knowledge of laws had minimal effects and only on helmet use. ConclusionsSocial cognition factors show promise in explaining willingness to engage in dangerous e-scooter use and may provide an important formative basis for future research and behavior change interventions to reduce such risky behaviors.

A decadal analysis of road traffic accident-related mortality among women of reproductive age: A cross-sectional study in East Azerbaijan Province, Iran.

Given the extensive impact of road traffic accidents (RTAs) consequences and their potential ramifications on the health of both current and future generations, this study examines the social and demographic factors that influence RTA-related mortality among women of reproductive age. The study population consisted of cases retrieved from the database of the Legal Medicine Organization, encompassing all women aged 15-49 who succumbed to road accidents between 2011 and 2021. The mean age of women in the reproductive age group from East Azerbaijan province between 2011 and 2021 was 33.67 years, with a standard deviation of 9.18. RTAs on main roads accounted for the majority of incidents (395 cases, 50.8%), with 93.7% (728 cases) attributed to road traffic. In 54.4% of these cases, the affected organ was the head and neck, and the primary cause of death in 52.1% was head trauma. Across all age groups, injuries to the neck and head were the most common, followed by injuries to the abdomen, chest, back, and sternum. The higher incidence of road accidents in the 25-29 age group highlights the need for targeted interventions to address risky behaviors, inexperience, and peer influences in this demographic. Our observation of passengers experiencing the highest mortality rate emphasizes the vulnerability of road users, particularly pedestrians, in traffic accidents. Pedestrian violations in the 17-30 age group further emphasize the importance of education and awareness campaigns aimed at reducing risky behavior.

Digitisation of Sibling and Social Relationships of Vulnerable Children in the Czech Republic: Implications for Digital Social Work

ABSTRACTThe aim of the research was to determine the impacts of digital technology use on the sibling and other social relationships of vulnerable children from their perspective as well as from the perspective of their parents and social workers. The research employed a qualitative research strategy and thematic analysis. We carried out semi‐structured interviews with 10 children and their parents (7) and 10 social workers. The main topics related to the impact of digital technology use were identified as (1) children's addiction to digital technology, (2) digital technology and the online environment as an unlimited leisure and socialisation tool, (3) the shift of risky behaviours to the online environment and the threat of other online ‘risks’ and (4) digital technology as a modern tool for communication with children or their parents. Discussion provides recommendations on how digital technology can be used in social work practice with vulnerable children and their families.

Perspectives for the Prevention of Noncommunicable Diseases in Tanzania: Is Knowledge Translated into Practice?

In Tanzania, where over a third of the society is impoverished, the burden of NCDs which account for about two-fifths of all disability-adjusted life years (DALYs) and one-third of premature deaths has doubled in the past two decades. However, notwithstanding a wider realization of the escalating burden of NCDs across Tanzania, the link between NCD awareness and lifestyle practices at the population level is not well characterized. We aimed to establish the gap between NCD knowledge and healthy behaviors. This multi-regional community-based cross-sectional study was conducted in 5 regions of Tanzania between September 2022 and June 2023. A 22-item standardized tool evaluating various NCD risk behaviors was used in knowledge assessment and a cut-off of ≥70% was used to denote good knowledge. Bivariate analyses were performed to compare knowledge of NCD risk factors across various NCD risk subgroups. All tests were two tailed, and the significance was set at p<0.05. A total of 5121 individuals were consecutively enrolled. The mean age was 47.2 years and females comprised over three-fifths (60.8%) of the participants. With regard to behavioral NCD risks, physical inactivity, unhealthy diet, smoking and alcohol consumption were present in 79.0%, 70.2%, 2.1% and 17.6% of participants, respectively. Moreover, biological risk factors, ie, excess body weight, hypertension, and diabetes were present in 68.4%, 55.8% and 13.0% of participants, respectively. The mean knowledge score was 77.1% and 70.3% of participants demonstrated good knowledge of NCD risk factors. Except for smoking, individuals who showed awareness of various NCD risk factors were found to have significant rates of risky behaviors. Despite sufficient NCD risk knowledge, incongruent lifestyle practices persist, highlighting a crucial concern. This suggests that awareness of NCDs and their risks may influence motivation for change but may not necessarily result in lifestyle modification.

Perceived Social Mobility and Smartphone Dependence in University Students: The Roles of Hope and Family Socioeconomic Status.

Drawing upon the cognitive-behavioral model of pathological Internet use (PIU) and tunnel effect, this study aimed to construct a moderated mediation model from the perspective of social ecology. Specifically, the model investigated the relationship between perceived social mobility and smartphone dependence, with a focus on the mediating role of hope and the moderating effect of family socioeconomic status (SES) underlying this relationship. A cross-sectional study was conducted with 718 Chinese university students (Mage = 19.19, 70.2% female) from Beijing, Henan, and Tianjin, who anonymously filled out the Perceptions of Socioeconomic Mobility Scale, Mobile Phone Addiction Index Scale, Openness to the Future Scale, and family socioeconomic status questionnaire. Preliminary data analysis was executed using SPSS 22.0, and the moderated mediation effect was tested using the latent moderated structural equations approach in Mplus 8.3. The results showed that (a) less perceived social mobility was linked with greater smartphone dependence; (b) hope mediated the aforementioned relationship; and (c) family SES moderated the first-stage path of the indirect effect through hope. For university students with low (rather than high) family SES, their level of hope increased with the improvement of perceived social mobility, and in turn, that of smartphone dependence decreased. These findings suggest that positive perceptions of upward social class mobility and hopeful attitudes toward future opportunities and personal development among disadvantaged university students may alleviate their reliance on smartphones. Researchers and policymakers should pay attention to the role of individuals' perceptions of the macro environment in motivating specific risky behaviors among university students. Future interventions are essential to mitigate pessimistic environmental perceptions and foster a sense of hope among university students.

Risky sexual behavior and associated factors among reproductive age women in eastern African countries: a multilevel analysis of the recent demographic and health survey

IntroductionRisky sexual behavior exposes an individual to the risk of contracting sexually transmitted infections including human immunodeficiency virus (HIV). Even though risky sexual behavior is a devastating problem in low- and middle-income countries, studies on risky sexual behavior and associated factors among reproductive-age women in Eastern African countries are limited. Therefore, this study aimed to assess the magnitude of risky sexual behavior and associated factors among reproductive-age women in Eastern African countries that help to target high-risk groups and set appropriate intervention.MethodThe appended and recent Demographic and Health Survey dataset of 10 Eastern African countries from 2012 to 2022 was used for data analysis. A total of 111,895 participants were included in this study as a weighted sample. Associated factors were determined using a multilevel mixed-effects logistic regression model. Significant factors in the multilevel mixed-effect logistic regression model were declared significant at p-values < 0.05. The adjusted odds ratio (AOR) and confidence interval (CI) were used to interpret the results.ResultThe overall magnitude of risky sexual behavior among reproductive-age women in Eastern African countries was 28.16% (95% CI 27.90%, 28.43%), which ranged from 3.80% in Ethiopia to 67.13% in Kenya. In the multivariable analysis, being a younger woman, being an educated woman, being tested for human immunodeficiency virus, having work, drinking alcohol, and being an urban dweller were factors that were significantly associated with higher odds of risky sexual behavior.ConclusionThe overall magnitude of risky sexual behavior among reproductive-age women in Eastern African countries was high. Individual-level (being a younger woman, being an educated woman, being tested for human immunodeficiency virus, having work, and drinking alcohol) and community-level (being an urban dweller) variables were associated with higher odds of risky sexual behavior. Therefore, policymakers and other stakeholders should give special consideration to urban dwellers, educated, worker and younger women. Better to improve the healthy behavior of women by minimizing alcohol consumption and strengthening HIV testing and counseling services to reduce the magnitude of risky sexual behavior.