Trends In Risk Behaviors Research Articles

The AIDS Epidemic Model 2023 for Estimating HIV Trends and Transmission Dynamics in Asian Epidemic Settings.

Thirteen Asian countries use the AIDS Epidemic Model (AEM) as their HIV model of choice. This article describes AEM, its inputs, and its application to national modeling. AEM is an incidence tool used by Spectrum for the Joint United Nations Programme on HIV/AIDS global estimates process. AEM simulates transmission of HIV among key populations (KPs) using measured trends in risk behaviors. The inputs, structure and calculations, interface, and outputs of AEM are described. The AEM process includes (1) collating and synthesizing data on KP risk behaviors, epidemiology, and size to produce model input trends; (2) calibrating the model to observed HIV prevalence; (3) extracting outputs by KP to describe epidemic dynamics and assist in improving responses; and (4) importing AEM incidence into Spectrum for global estimates. Recent changes to better align AEM mortality with Spectrum and add preexposure prophylaxis are described. The application of AEM in Thailand is presented, describing the outputs and uses in-country. AEM replicated observed epidemiological trends when given observed behavioral inputs. The strengths and limitations of AEM are presented and used to inform thoughts on future directions for global models. AEM captures regional HIV epidemiology well and continues to evolve to meet country and global process needs. The addition of time-varying mortality and progression parameters has improved the alignment of the key population compartmental model of AEM with the age-sex-structured national model of Spectrum. Many of the features of AEM, including tracking the sources of infections over time, should be incorporated in future global efforts to build more generalizable models to guide policy and programs.

Providing HIV pre-exposure prophylaxis to men who have sex with men and transgender women in hospitals and community-led clinics in Thailand: acceptance, patterns of use, trends in risk behaviors, and HIV incidence

ABSTRACT From May 2015 to June 2018, we conducted a PrEP demonstration project at two hospitals and four community-led clinics in Bangkok and Pattaya. HIV-negative, MSM and TGW aged ≥18 years old, reporting sex without a condom, were offered daily PrEP. Participants received HIV testing and completed a computer-based questionnaire at enrollment, 6 and 12 months. We collected self-reported PrEP adherence at months 1, 3, 6, 9, and 12. We used logistic regression to determine factors associated with the decision to take PrEP and calculated HIV incidence among baseline HIV-negative participants. Of 803 participants enrolled, 349 (43.5%) started PrEP. Participants were more likely to start PrEP if they were sex workers, had moderate or high self-perceived risk of HIV, or a high PrEP-knowledge score. Participants used PrEP for a median of 6.1 months. Reported condom use increased and the number of sex partners decreased during follow-up regardless of PrEP use. Six participants not-taking PrEP acquired HIV (HIV incidence 2.2 per 100 person-years), and five taking PrEP acquired HIV (HIV incidence 2.1 per 100 person-years). All five reported taking <4 pills the weeks before study visits.

Trends in risk behaviors and sexually transmitted infections among youth presenting to a sexually transmitted infection clinic in the United States, 2013-2017.

Background: Sexually transmitted infections (STIs) are increasing among adolescents and young adults (AYA) across the United States. However, data are scarce on trends in condom use, number of partners, and other STI risk factors among AYA. The present study evaluated associations between sexual behaviors and STI diagnoses over time among AYA. Methods: We evaluated linked encounters of AYA aged 13-26 attending an urban Northeast public STI clinic from 2013-2017. Demographics, risk behaviors, self-reported past year and lifetime STI, and STI diagnosis during clinic encounter (positive test for urine, oral, or anal chlamydia; urine, oral, or anal gonorrhea; urine trichomonas; HIV; and syphilis) were extracted from electronic health records. We estimated prevalence and performed trend analyses of the repeated cross-sectional data. Cochran-Armitage and Kruskal-Wallis trend test were conducted for categorical and continuous variables, respectively. Results: Among 3822encounters, clinical STIs demonstrated statistically significant increases including chlamydia (+9%, p = 0.001), gonorrhea (+5%, p = 0.008), and syphilis (+3%, p = 0.006) all of which significantly increased over time, as did any STI (+10%, p < 0.001). HIV and trichomonas rates remained low and unchanged. Self-reported STI increased as well, both past year (+9%) and lifetime (+14%). Greater proportions of AYA reported multiple partners (+9%, p < 0.001), and condomless oral (+12%, p = 0.001) and vaginal/anal (+7%, p = 0.001) sex. Conclusion: Among AYA presenting to a STI clinic, the proportion who engaged in condomless sex and had multiple partners increased over a 5year period, which corresponded to increased STI prevalence during this period. Preventions efforts for AYA should continue to emphasize the importance of condoms and partner selection.

Relationship Factors Associated With Early Adolescent Dating Violence Victimization and Perpetration Among Latinx Youth in an Agricultural Community.

Latinx early adolescents within the United States are particularly vulnerable to dating violence; yet, little research has examined early dating experiences and violence outside large urban settings. Latinxs, in particular, may experience a unique window of opportunity for dating violence (DV) prevention during early adolescence, based on their trends in risk behavior over the adolescent period. This study extends the current research on dating violence by examining a highly understudied population, Latinx early adolescent girls and boys residing in an agricultural community, by assessing victimization and perpetration, and examining interpersonal-level factors as potential risk and protective factors for violence. Using data from a prospective cohort study of Latinx adolescents with relationship experience (past six months) (N = 296; girls: n = 147; boys: n = 149; mean age: 13.8), we assessed the association between dating relationship characteristics and dating violence victimization and perpetration using modified-Poisson regression models with robust standard errors stratified by gender. In multivariable analyses, we found that girls with gang-affiliated partners, partner-related withdrawal from friends, and girls who had used drugs or alcohol with a partner experienced greater risk for dating violence. Additionally, holding beliefs supportive of female sexual naivete and engaging in and communicating about sexual activity were associated with victimization among girls. No significant associations were found among boys. Findings affirm the need for multilevel DV prevention programming that starts in middle school and addresses social isolation, gang exposure, and traditional Latinx gender-norm beliefs regarding marianismo. These findings underscore the imperative to coordinate dating and gang violence prevention efforts by addressing common co-occurring interpersonal and environmental risk factors, including social isolation and culturally-specific traditional beliefs. Such factors could also assist providers, families, and peers in early identification of Latinx early adolescents at risk for DV, especially in rural contexts where resources are often limited.

425. Longitudinal Trends in Risk Behaviors and Sexually Transmitted Diseases among Adolescents and Young Adults at a Sexually Transmitted Diseases Clinic, 2013–2017

BackgroundSexually transmitted disease (STD) rates continue to rise in the United States (US). Over half of all new STDs occur in adolescents and young adults (AYA). Few studies have evaluated how sexual behaviors such as number of partners or condom use may contribute to this increase. We aimed to determine the association of sexual behaviors and condom use with STD incidence over time among AYA.MethodsWe reviewed all AYA ages 13–26 years attending a public STD clinic in Rhode Island from 2013–2017. We reviewed demographic and behavioral data including age, gender identity, risk group, race, ethnicity, insurance status, sexual behaviors, substance use, self-reported STD/HIV diagnosis (lifetime, past year), condom use, and HIV/STD testing results. We report proportions in 2013 and 2017, and performed trend analyses (Cocharn-Armitage test for categorical variables and Kruskal–Wallis trend test for continuous variables) to determine trends over time.ResultsA total of 3,822 AYA visited the clinic during the study time period. An increasing trend was observed for: multiple (≥5) partners (29% of AYA in 2013 vs. 38% in 2017, P < 0.001), self-reported past year and lifetime STD diagnosis (12 vs. 21%, P < 0.001 and 19 vs. 33%, P < 0.001, respectively), and lab-documented diagnosis of any STD (15 vs. 25%, P < 0.001), syphilis (2 vs. 5%, P = 0.006), any chlamydia (11 vs. 20%, P = 0.001), and any gonorrhea (3 vs. 8%, P = 0.008). A decreasing trend was observed for: white race (66% in 2013 vs. 43% in 2017, P < 0.001), uninsured (73 vs. 53%, P < 0.001), condomless sex during oral as well as vaginal/anal sex (22 vs. 10%, P = 0.001 and 16 vs. 8%, P = 0.001, respectively), and self-reported HIV diagnosis (2.5% to 0.9%, P = 0.016).ConclusionAmong AYA, risk behaviors such as condomless sex and multiple partners increased significantly from 2013–2017, which may be contributing to an increase in STDs. Increased public health efforts are needed to promote education and other interventions to address behaviors associated with STD transmission.Disclosures All authors: No reported disclosures.

HIV Incidence and Risk Behaviours of People Who Inject Drugs in Bangkok, 1995–2012

BackgroundThree consecutive prospective studies were conducted among people who inject drugs (PWID) from May 1995 through June 2012 in Bangkok, Thailand. We examined data from these studies to evaluate HIV incidence and explore trends in risk behaviours. MethodsWe used data from a 1995–1998 cohort study, a 1999–2004 HIV vaccine trial, and a 2005–2012 HIV pre-exposure prophylaxis (PrEP) study to examine per-quarter trends in HIV incidence, using a restricted cubic spline function for time in a Poisson regression. We also examined temporal trends in HIV-associated risk behaviours. FindingsHIV incidence declined from 5.7 per 100 person-years during the cohort study, to 2.7 per 100 person-years in the vaccine trial, to 0.7 per 100 person-years among PrEP study placebo recipients. Incidence peaked at 12.1 per 100 person-years in 1996 and declined to <1 per 100 person-years during 2005–2012. Reports of injecting drugs and sharing needles also declined from the cohort study to the PrEP study (p < 0.0001). Heroin was the most common drug injected during the cohort study and the vaccine trial, but stimulants (e.g., methamphetamine) and sedatives (e.g., midazolam) were injected more often during the PrEP study. InterpretationHIV incidence among PWID declined during 2005–2012. Several factors likely contributed to the decline, including decreases in the frequency of injecting and sharing, improved access to HIV testing and antiretroviral therapy, and the use of PrEP. Expanding access to effective HIV prevention tools can hasten control of the HIV epidemic among PWID. FundingThe Bangkok Metropolitan Administration and U.S. Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention.

Getting better all the time: Trends in risk behavior among American adolescents since 1990.

Getting better all the time: Trends in risk behavior among American adolescents since 1990.

Working With Persons Who Inject Drugs and Live in Rural Areas: Implications From China/Vietnam for the USA.

To describe a small city/rural area HIV prevention project (the Cross Border Project) implemented in Ning Ming County, Guangxi Province, China, and Lang Son province, Vietnam, and consider its implications for addressing the opioid/heroin epidemic in small cities/rural areas in the USA. The description and the outcomes of the Cross Border project were taken from published reports, project records, and recent data provided by local public health authorities. Evaluation included serial cross-sectional surveys of people who inject drugs to assess trends in risk behaviors and HIV prevalence. HIV incidence was estimated from prevalence among new injectors and through BED testing. The Cross Border project operated from 2002 to 2010. Key components of the project 2 included the use of peer outreach workers for HIV/AIDS education, distribution of sterile injection equipment and condoms, and collection of used injection equipment. The project had the strong support of local authorities, including law enforcement, and the general community. Significant reductions in risk behavior, HIV prevalence, and estimated HIV incidence were observed. Community support for the project was maintained. Activities have been continued and expanded since the project formally ended. The Cross Border project faced challenges similar to those occurring in the current opioid crisis in US small cities/rural areas: poor transportation, limited resources (particularly trained staff), poverty, and potential community opposition to helping people who use drugs. It should be possible to adapt the strategies used in the Cross Border project to small cities/rural areas in the US opioid epidemic.

Downwards trends in adolescent risk-taking behaviours in New Zealand: Exploring driving forces for change.

Downwards trends in adolescent risk-taking behaviours in New Zealand: Exploring driving forces for change.

Trends in HIV and HCV Risk Behaviors and Prevalent Infection Among People Who Inject Drugs in New York City, 2005-2012.

We assess trends in HIV and hepatitis C virus (HCV) risk behaviors and prevalent infection among people who inject drugs (PWID) in New York City (NYC). PWID in NYC were sampled using respondent-driven sampling in 2005, 2009, and 2012 (serial cross sections) for the Centers for Disease Control and Prevention-sponsored National HIV Behavioral Surveillance study. Participants were interviewed about their current (≤12 months) risk behaviors and tested for HIV and HCV. The crude and adjusted risk ratio (RR) and 95% confidence interval (95% CI) for linear time trends were estimated using generalized estimating equations regression with a modified Poisson model. The sample comprised 500, 514, and 525 participants in 2005, 2009, and 2012, respectively. Significant (P < 0.05) linear trends in risk behaviors included a decline in unsafe syringe sources (60.8%, 31.3%, 46.7%; RR = 0.86, 95% CI: 0.81 to 0.92), an increase in all syringes from syringe exchanges or pharmacies (35.4%, 67.5%, 50.3%; RR = 1.15, 95% CI: 1.09 to 1.22), and an increase in condomless vaginal or anal sex (53.6%, 71.2%, 70.3%; RR = 1.14, 95% CI: 1.09 to 1.19). Receptive syringe sharing (21.4%, 27.0%, 25.1%), sharing drug preparation equipment (45.4%, 43.4%, 46.7%), and having ≥2 sex partners (51.2%, 44.0%, 50.7%) were stable. Although HIV seroprevalence declined (18.1%, 12.5%, 12.2%), HCV seroprevalence was high (68.2%, 75.8%, 67.1%). In multivariate analysis, adjusting for sample characteristics significantly associated with time, linear time trends remained significant, and the decline in HIV seroprevalence gained significance (adjusted RR = 0.76, 95% CI: 0.64 to 0.91, P = 0.003). This trend analysis suggests declining HIV prevalence among NYC PWID. However, HCV seroprevalence was high and risk behaviors were considerable. Longitudinal surveillance of HIV and HCV risk behaviors and infections is needed to monitor trends and for ongoing data-informed prevention among PWID.

HIV decline associated with changes in risk behaviours among young key populations in Nepal: analysis of population-based HIV prevalence surveys between 2001 and 2012.

We assessed changes in HIV prevalence and risk behaviours among young key populations in Nepal. A total of 7505 participants (aged 16-24 years) from key populations who were at increased risk of HIV infection (2767 people who inject drugs (PWID); 852 men who have sex with men/transgender (MSM/TG); 2851 female sex workers (FSW) and 1035 male labour migrants) were recruited randomly over a 12-year period, 2001-2012. Local epidemic zones of Nepal (Kathmandu valley, Pokhara valley, Terai Highway and West to Far West hills) were analysed separately. We found a very strong and consistent decline in HIV prevalence over the past decade in different epidemic zones among PWID and MSM/TG in Kathmandu, the capital city, most likely due to a parallel increase in safe needle and syringe use and increased condom use. A decrease in HIV prevalence in 22 Terai highway districts, sharing an open border with India, was also consistent with increased condom use among FSW. Among male labour migrants, HIV prevalence was low throughout the period in the West to Far West hilly regions. Condom use by migrant workers involved with FSW abroad increased while their condom use with Nepalese FSW declined. Other risk determinants such as mean age at starting first injection, injection frequency, place of commercial sex solicitation, their mean age when leaving to work abroad did not change consistently across epidemic zones among the young key populations under study. In Nepal, the decline in HIV prevalence over the past decade was remarkably significant and consistent with an increase in condom use and safer use of clean needles and syringes. However, diverging trends in risk behaviours across local epidemic zones of Nepal suggest a varying degree of implementation of national HIV prevention policies. This calls for continued preventive efforts as well as surveillance to sustain the observed downward trend.

Declining trends in risk behaviors and HIV/ STIs among Clients of FSWs in India: findings from large scale bio-behavioral surveys from three high prevalent Southern states

Declining trends in risk behaviors and HIV/ STIs among Clients of FSWs in India: findings from large scale bio-behavioral surveys from three high prevalent Southern states

Demographic changes and trends in risk behaviours, HIV and other sexually transmitted infections among female sex workers in Bangalore, India involved in a focused HIV preventive intervention

The primary objectives of this study were to assess the changing demographic characteristics of female sex workers (FSWs) in the urban Bangalore district, India, and trends in programme coverage, HIV/sexually...

P3.432 Trends in Risk Behavior and HIV and Syphilis Infection Among MSM Who Attend in STI Clinics in Guatemala

Background Men who have sex with men (MSM) have one of the highest HIV prevalence rates of any high risk population in Central America. Since 2007, the Sentinel Surveillance and Control of Sexually Transmitted Infections (VICITS) strategy has been implemented in two public health clinics targeting MSM in Guatemala City. This combination prevention strategy provides diagnosis and treatment of STIs, HIV testing, condom distribution, and educational activities. Method From 2007 to 2012, MSM were recruited through the Internet or by community-based organisation staff to attend two VICITS clinics in Guatemala City. Clinic attendees were asked demographic and behavioural information and tested for HIV and syphilis. Variables included in trend analysis included HIV and syphilis test results and condom use with casual partner in the past month. All analyses were performed using Stata 9.0. Results A total of 433 MSM attended VICITS clinics from 2007 to 2012. HIV prevalence was 10.3% from 2009–2010 (n = 117, 95% CI: 5.4–17.2) and 11.7% from 2011–2012 (n = 179, 95% CI: 7.4–17.4). Syphilis prevalence was 6.6% from 2009–2010 (n = 106, 95% CI: 2.7–13.1) and 5.9% from 2011–2012 (n = 153, 95% CI: 2.7–10.9). Consistent condom use with a casual partner in the last month was 61.9% (n = 56, 95% CI: 49.1–74.7) from 2009–2010 and 62.7% (n = 72, 95% CI: 51.7–73.8) from 2011–2012. No significant changes in attendance from 2007 to 2012 were noted at both clinics. Discussion No changes in HIV and syphilis prevalence among MSM attending VICITS clinics in Guatemala City were observed. Consistent condom use should be continued to be emphasised in casual relationships. Routine monitoring of sentinel surveillance data allows for timely feedback of HIV prevention services and provides key information for early HIV diagnosis, as an intervention that has shown evidence of effectiveness programme.

Bidi and Hookah Use Among Canadian Youth: Findings From the 2010 Canadian Youth Smoking Survey

IntroductionAlthough cigarette use among Canadian youth has decreased significantly in recent years, alternative forms of tobacco use are becoming increasingly popular. Surveillance of youth tobacco use can help inform prevention programs by monitoring trends in risk behaviors. We examined the prevalence of bidi and hookah use and factors associated with their use among Canadian youth by using data from the 2010–2011 Youth Smoking Survey (YSS).MethodsWe analyzed YSS data from 28,416 students (2006–2007) and 31,396 students (2010–2011) in grades 9 through 12 to examine prevalence of bidi and hookah use. We conducted multivariate logistic regression analyses of 2010–2011 YSS data to examine factors associated with bidi and hookah use.ResultsFrom 2006 through 2010, prevalence of hookah use among Canadian youth increased by 6% (P = .02). Marijuana use emerged as a consistent predictor of bidi and hookah use. Males, youth of black, Latin, or other descent, and youth of Asian descent were more likely to use bidis (odds ratio [OR], 1.5; OR, 15.6; OR, 14.9) or hookah (OR, 1.3; OR, 2.4; OR, 1.5). Current cigarette smokers were more likely than nonsmokers to be current users of bidis (OR, 6.7) and hookahs (OR, 3.0), and occasional and frequent alcohol drinkers were also more likely than nondrinkers to be current hookah users (OR, 2.8; OR, 3.6).ConclusionAlthough bidi use has not changed significantly among Canadian youth, the increase in hookah use warrants attention. Understanding the factors associated with use of bidis and hookahs can inform the development of tobacco use prevention programs to address emerging at-risk youth populations.

Drug Users in Amsterdam: Are They Still at Risk for HIV?

Background and AimsTo examine whether drug users (DU) in the Amsterdam Cohort Study (ACS) are still at risk for HIV, we studied trends in HIV incidence and injecting and sexual risk behaviour from 1986 to 2011.MethodsThe ACS is an open, prospective cohort study on HIV. Calendar time trends in HIV incidence were modelled using Poisson regression. Trends in risk behaviour were modelled via generalized estimating equations. In 2010, a screening for STI (chlamydia, gonorrhoea and syphilis) was performed. Determinants of unprotected sex were studied using logistic regression analysis.ResultsThe HIV incidence among 1298 participants of the ACS with a total follow-up of 12,921 person-years (PY) declined from 6.0/100 PY (95% confidence interval [CI] 3.2–11.1) in 1986 to less than 1/100 PY from 1997 onwards. Both injection and sexual risk behaviour declined significantly over time. Out of 197 participants screened for STI in 2010–2011, median age 49 years (IQR 43–59), only 5 (2.5%) were diagnosed with an STI. In multivariable analysis, having a steady partner (aOR 4.1, 95% CI 1.6–10.5) was associated with unprotected sex. HIV-infected participants were less likely to report unprotected sex (aOR 0.07, 95% CI 0.02–0.37).ConclusionsHIV incidence and injection risk behaviour declined from 1986 onwards. STI prevalence is low; unprotected sex is associated with steady partners and is less common among HIV-infected participants. These findings indicate a low transmission risk of HIV and STI, which suggests that DU do not play a significant role in the current spread of HIV in Amsterdam.

Transmission Patterns of HIV-Subtypes A/AE versus B: Inferring Risk-Behavior Trends and Treatment-Efficacy Limitations from Viral Genotypic Data Obtained Prior to and during Antiretroviral Therapy

BackgroundHIV subtypes A and CRF01_AE (A/AE) became prevalent in Israel, first through immigration of infected people, mostly intravenous-drug users (IVDU), from Former Soviet-Union (FSU) countries and then also by local spreading. We retrospectively studied virus-transmission patterns of these subtypes in comparison to the longer-established subtype B, evaluating in particular risk-group related differences. We also examined to what extent distinct drug-resistance patterns in subtypes A/AE versus B reflected differences in patient behavior and drug-treatment history.MethodsReverse-transcriptase (RT) and protease sequences were retrospectively analyzed along with clinical and epidemiological data. MEGA, ClusalX, and Beast programs were used in a phylogenetic analysis to identify transmission networks.Results318 drug-naive individuals with A/AE or patients failing combination antiretroviral therapy (cART) were identified. 61% were IVDU. Compared to infected homosexuals, IVDU transmitted HIV infrequently and, typically, only to a single partner. 6.8% of drug-naive patients had drug resistance. Treatment-failing, regimen-stratified subtype-A/AE- and B-patients differed from each other significantly in the frequencies of the major resistance-conferring mutations T215FY, K219QE and several secondary mutations. Notably, failing boosted protease-inhibitors (PI) treatment was not significantly associated with protease or RT mutations in either subtype.ConclusionsWhile sizable transmission networks occur in infected homosexuals, continued HIV transmission among IVDU in Israel is largely sporadic and the rate is relatively modest, as is that of drug-resistance transmission. Deviation of drug-naive A/AE sequences from subtype-B consensus sequence, documented here, may subtly affect drug-resistance pathways. Conspicuous differences in overall drug-resistance that are manifest before regimen stratification can be largely explained in terms of treatment history, by the different efficacy/adherence limitations of older versus newer regimens. The phenomenon of treatment failure in boosted-PI-including regimens in the apparent absence of drug-resistance to any of the drugs, and its relation to adherence, require further investigation.

Trends in risk behaviors among female sex workers in south India: Priorities for sustaining the reversal of HIV epidemic

HIV epidemic in India is predominantly concentrated in subgroups of population, such as female sex workers (FSWs) and their clients, whose behavior exposes them to a higher risk of acquiring HIV infection. This paper aims to present the changing patterns of socio-demographic characteristics, behaviors, reported sexually transmitted infections (STIs), and associated factors among FSWs over 11 years. Multistage cluster sampling with probability-proportional-to-size (PPS) method was used in the surveys. A sample of 400 FSWs was studied every year. The mean age and literacy at the baseline level increased significantly over the years. House-based sex increased by 40% from 43.3% in 1997 to 83% in 2008 (p<0.001). Condom use at last sex with one-time clients; consistent condom use (CCU) with one-time and regular clients indicated increasing trends. FSWs reported low levels of condom use at last sex (14.5% in 1997 to 5% in 2008; p<0.001) and CCU (12.6% in 2004 to 3.6% in 2008; p<0.01) with regular partners. FSWs who used condom with one-time clients at last sex reported significantly less STI symptoms. A two-third reduction in genital ulcers was found from 13.1% in 1997 to 4.5% in 2008 (p<0.001). Nonliterate and hotel-based sex workers were 1.6 (1.0–2.5; 95% CI) and 2.2(1.3–3.7; 95% CI) times more likely to have reported STI symptoms. The percentage of FSWs who underwent HIV testing increased (p<0.001); similarly, a 20% increase was found in FSWs who availed counseling services from 65.2% in 1997 to 85.4% in 2008 (p<0.001). Poor, illiterate, and marginalized were more likely to get involved in risky behaviors which suggest the need for structural interventions as part of HIV prevention strategy.

PEPFAR's Evolving HIV Prevention Approaches for Key Populations—People Who Inject Drugs, Men Who Have Sex With Men, and Sex Workers

In most countries, the burden of HIV among people who inject drugs, men who have sex with men, and sex workers is disproportionately high compared with that in the general population. Meanwhile, coverage rates of effective interventions among those key populations (KPs) are extremely low, despite a strong evidence base about the effectiveness of currently available interventions. In its first decade, President's Emergency Plan for AIDS Relief (PEPFAR) is making progress in responding to HIV/AIDS, its risk factors, and the needs of KPs. Recent surveillance, surveys, and size estimation activities are helping PEPFAR country programs better estimate the HIV disease burden, understand risk behavior trends, and determine coverage and resources required for appropriate scale-up of services for KPs. To expand country planning of programs to further reduce HIV burden and increase coverage among KPs, PEPFAR has developed a strategy consisting of technical documents on the prevention of HIV among people who inject drugs (July 2010) and prevention of HIV among men who have sex with men (May 2011), linked with regional meetings and assistance visits to guide the adoption and scale-up of comprehensive packages of evidence-based prevention services for KPs. The implementation and scaling up of available and targeted interventions adapted for KPs are important steps in gaining better control over the spread and impact of HIV/AIDS among these populations.

HIV prevention through sport: the case of the Mathare Youth Sport Association in Kenya

Sport has become a popular tool for HIV prevention, based on claims that it can foster life skills that are necessary to translate knowledge, attitudes and behavioural intentions into actual behaviour. Empirical evidence of the effectiveness of sport-based HIV prevention programmes is, however, sorely lacking. We therefore conducted a cross-sectional survey assessing sexual behaviour and the determinants thereof among 454 youth of the Mathare Youth Sport Association (MYSA) in Kenya and a control group of 318 non-MYSA members. Multiple (ordinal) logistic regression models were applied to measure the association between MYSA membership and attitudes, subjective norms and self-efficacy related to condom use as well as sexual experience, age at sexual debut, condom use, history of concurrent relationships and number of partners in the last year. MYSA members were more likely to use condoms during the first sex act (odds ratio (OR)=2.10; 95% CI: 1.10–3.99). Consistent condom use with the current/last partner was 23.2% (36/155) among MYSA members vs. 17.2% (17/99) among the control group. Even after adjusting for media exposure – a factor associated with both MYSA membership and higher frequency of condom use – MYSA members were still found to use condoms more frequently with their current/last partner (adjusted OR=1.64; 95% CI: 1.01–2.68). Nevertheless, levels of condom use remain disturbingly low. More rigorous evaluations of sport programmes for HIV prevention are needed. When possible, programmes should be preceded by baseline assessments, trends in risk behaviour of the intervention group should be compared with those of a control group, and protocols for data collection and analysis should include measuring of and adjusting for potentially confounding factors.