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Sexual Behavior Research

Sexual Behavior Research. Thomas J. Coates PhD Professor of Infectious Diseases David Geffen School of Medicine University of California, Los Angeles Professor of Medicine University of California, San Francisco. Worthwhile? Useful?.

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Sexual Behavior Research

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  1. Sexual Behavior Research Thomas J. Coates PhD Professor of Infectious Diseases David Geffen School of Medicine University of California, Los Angeles Professor of Medicine University of California, San Francisco Worthwhile? Useful?

  2. Congress to Dr. ZerhouniIs sex research?--Good use of taxpayer monies?--Scientifically valid?--Ethically appropriate?--Review process followed?--Is funding disproportionate to disease burden?

  3. The Burden is Easy to Demonstrate--18.9 STIs annually--9.1m among 15-24 year olds--42m people with HIV worldwide--$6.5b annual costWeinstock et al; Chesson et alPerspectives on Sexual and Reproductive HealthJan/Feb, 2004

  4. But Has Sexual Behavior Research Given Us Any Tools To Reduce HIV/STI Transmission? YES: • Evidence sources: • The very best health journals in the world • NIH’s Consensus Development Conference • CDC’s Prevention Research Synthesis Project • Variety of UNAIDS documents • Gates Foundation Global HIV Prevention Working Group

  5. At-risk MSM One-session group 12-session group Peer-lead community-level At-risk MSW/M Video-based, 1-session intervention Condom social marketing Outreach-based services 7-session group At-risk women Condom social marketing Outreach-based services 5-session group Injection drug users Needle & syringe exchange Multi-session group Drug treatment STD clinic clients HIV counseling and testing, referral and partner notification Effective and Cost-Effective Interventions(Pinkerton et al., AIDS 2001; Kahn review chapter, 1998)

  6. Levels of HIV Prevention Interventions • Individual • Dyad/Family • Venue/Network • Community • Biomedical/Surgical • Structural • Laws & policies • Environment • Societal determinants Waldo & Coates, AIDS, 2000, 14: S18-S26 Auerbach & Coates, AJPH, 2000, 90: 1-4

  7. Case Study #1 Continued High Risk Behavior Following a Diagnosis of HIV

  8. Interesting Solution—Wrong Diagnosis and Therefore Wrong Solution It is time to abandon this ethnocentric Western rhetoric … that led to the “V” in V.C.T….We propose redesignating Voluntary Counseling and Testing as something like “Confidential and Recommended [or routine] Counseling and Testing or C.R.C.T.” Richard Holbrooke and Richard Furman NY Times, Feb 10, 2004

  9. Sexual Behavior Research Tells Us • Reasons for not being tested previously were logistical • inconvenient hours (25.6%) • inconvenient location (20.7%) • high cost (8%)

  10. Nairobi Slums

  11. Nairobi Slums

  12. Will they be infected within the next 5 years?

  13. 1563 HIV VCT 1557 Health Ed R Interventions to prevent and treat HIVHIV VCT • 2N= 3120 individuals • randomized to VCT or health education • Conducted in Kenya, Tanzania, and Trinidad • HIV+’s • -Unprotected intercourse with primary partner: • reduced by 40% • -Unprotected intercourse with non-primary partner • HIV+ Men: reduced by 80% • HIV+ Women: reduced by 10% • Lancet, 2000, 356: 103-112; 113-121

  14. Continued High Risk Behavior in Kenya and Tanzania • (N=250 HIV+ Men) • Married (OR = 3.1) • Relationships <1 year (OR=1.8) • No HIV-related Sxs (OR=.50) • Alcohol prior to sex (OR=2.3) • Not concerned about HIV (OR=.70)

  15. Levels of HIV Prevention Interventions • Individual • Dyad/Family • Venue/Network • Community • Biomedical/Surgical • Structural • Laws & policies • Environment • Societal determinants Waldo & Coates, AIDS, 2000, 14: S18-S26 Auerbach & Coates, AJPH, 2000, 90: 1-4

  16. Case Study #2 ABC Abstain til Marriage Be Faithful Condoms

  17. Marriage and Risk for HIV Infection • Studies in Kisumu, Kenya • Ndola, Zambia • Teenage brides are more likely to be infected with HIV than sexually active same-age peers • NY Times, February 29, 2004

  18. Case Study #3 Sexual Violence Unwanted sexual body contact prior to age 18

  19. Violence as Risk Factor for HIV Infection • HIV positive women were significantly more likely than HIV negative women to report having had at least one physically violent event with their current partner (52% vs. 28%, p=.001) • HIV positive women were also significantly more likely than HIV negative women to report having had at least one physically abusive partner in their lifetime (53.45% vs. 31.97, p=.002)

  20. Childhood Sexual Abuse Dynamics Powerless over sexuality, commuinication, decision-making Difficulties forming attachments and long-term relationships Dissociation from feelings Alcohol and drug use Sexual re-victimization

  21. Levels of HIV Prevention Interventions • Individual • Dyad/Family • Venue/Network • Community • Biomedical/Surgical • Structural • Laws & policies • Environment • Societal determinants Waldo & Coates, AIDS, 2000, 14: S18-S26 Auerbach & Coates, AJPH, 2000, 90: 1-4

  22. Case Study #4 Abstinence Only And Abstinence Plus Sex Education

  23. About 14 000 new HIV infections a day in 2003 • More than 95% are in low and middle income countries • Almost 2000 are in children under 15 years of age • About 12 000 are in persons aged 15 to 49 years, of whom: • almost 50% are women • about 50% are 15–24 year olds

  24. Sex Education Works • Published in peer review journal • Used experimental design • Collected baseline and post-intervention data on intervention and control groups • Two beneficial sexual behavior changes • Reduced pregnancy, HIV, or STI acquisition www.advocatesforyouth.org/programsthatwork

  25. Sex Education Works • 16/19 programs contain information about abstinence and contraception • 12/19 programs demonstrated delay in onset of intercourse • 17/19 demonstrated reduction in risk taking behavior • 8/19 demonstrated reduction in pregnancy, HIV, or STI acquistion www.advocatesforyouth.org/programsthatwork

  26. 10 Characteristics of Effective Sex Education Programs • Focus on sexual behaviors • Theory-based • Consistent and clear message about abstinence and importance of protection • Basic and accurate information • Addresses social pressures to have sex

  27. 10 Characteristics of Effective Sex Education Programs • Examples and practice of communication, negotiation, and refusal skills • Teaching methods that involve students • Age-appropriate • Last a sufficient amount of time • Select teachers or peer leaders and trains them well

  28. Federal Gov’t Role in Sex Education • 1981: Adolescent Family Life Act $12m annually • 1996: Personal Responsibility and Work Opportunity Reconciliation Act $437.5m • 2000: SPRANS $40m as part of the maternal and child health block grant Kaiser Family Foundation Issue Update, October 2002 www.kff.org

  29. Does Abstinence-Only Education Work? The short answer is that we still do not have good evidence that any specific abstinence-only program has changed behavior. A partial exception is one abstinence media program in Monroe Country New York,but it has rather weak evidence. This does not mean that abstinence-only programs do not work (I suspectsome, but not all of them do). However, it does mean that relativelyfew good research studies have been conducted on abstinence-onlyprograms and that we cannot point to any abstinence-only program, know that it works, and then replicate it Doug Kirby PhD, personal communication

  30. Levels of HIV Prevention Interventions • Individual • Dyad/Family • Venue/Network • Community • Biomedical/Surgical • Structural • Laws & policies • Environment • Societal determinants Waldo & Coates, AIDS, 2000, 14: S18-S26 Auerbach & Coates, AJPH, 2000, 90: 1-4

  31. Case Study #5 Male Circumcision

  32. Levels of HIV Prevention Interventions • Individual • Dyad/Family • Venue/Network • Community • Biomedical/Surgical • Structural • Laws & policies • Environment • Societal determinants Waldo & Coates, AIDS, 2000, 14: S18-S26 Auerbach & Coates, AJPH, 2000, 90: 1-4

  33. Case Study #6 Transmission of HIV among IDU Sharing of Injection Drug Equipment or Unprotected Intercourse?

  34. Governmental documents summarizing NSE effectiveness 1991, National Commission on AIDS 1993, GAO 1993, CDC and UCSF report 1995, NAS 1997, NIH Consensus Development Conference Statement Some estimates of HIV incidence reductions associated with NSE attendance New Haven, 33% Amsterdam, 50% (hybrid of NSE, HIV CT, and methadone treatment) New York, 70% Needle and Syringe Exchange(Strathdee & Vlahov, AIDScience, 2001)

  35. Interventions to prevent and treat HIV mucosal surface to surface blood to blood Infectious person Susceptible person mother to child

  36. Why Hasn’t HIV Prevention Been More Effective Globally? • Insufficient resources (US$1.2 billion in 2002 – only 25% of what is needed) • Insufficient depth and breadth (10-20% coverage for sexual prevention interventions, 1-10% coverage for VCT/PMTCT) • Insufficient strategic focus • Insufficient political support • Insufficient focus on community and societal level intervention Sources: Gates Foundation Blueprint for Action; 2002; Jha et al., 2002; UNAIDS, 2002; Schwartlander et al., 2001.

  37. Needed Global Funding for HIV/AIDS • $6.3b – 2003 • $8.3b – 2004 • $10.7b – 2005 • $12.7b – 2006 • $14.9b -- 2007 • Summers and Kates, Global Funding for HIV/AIDS in Resource Poor Settings, • Henry J. Kaiser Family Foundation, 2003 (www.kff.org)

  38. Global Funding for HIV/AIDS • $4.232b in 2003 • $852m—US government bilateral • $1.163b—other governments bilateral • $350m—UN agencies • $120m—World Bank • $200m—Foundations and NGOs • $1b—Affected country governments • Summers and Kates, Global Funding for HIV/AIDS in Resource Poor Settings, Henry J. Kaiser Family Foundation, 2003 (www.kff.org)

  39. Case Study #7 Targeting Prevention Resources

  40. A Final Note • “Don’t gerrymander a fire line.” • Marilyn Chase, Wall Street Journal

  41. Population Profiles _______________________________________________________________________Variable Males Females Total (1096=91%) (109=9%) (1205) _______________________________________________________________________ Married/living with partner 25% With 7+ years of education 87% Any non-marital unprotected sex in last 3 mo 60% 36% 58% Positive for Chlamydia 5.6% 18.5% 6.8% Positive for Gonorrhea 0.5% 2.8% 0.8% Positive for HSV-2 28.5% 43.5% 29.9% Positive for Trichomonas -- 6.5% -- Positive for Syphilis 5.6% 4.6% 5.5% Positive for HIV 1.7% 0.0% 1.5% Any positive test36.5% Any positive non-viral test 12.8%

  42. Population Profile _______________________________________________________________________Variable MSoM Esquineros Gen Pop(N=172) (N=922) (N=668) ___________________________________________________________________ Any non-marital unprotected sex in last 3 mo 67% 77% 28% Positive for Chlamydia 2.4% 6.2% 4.7% Positive for Gonorrhea 0% 6.0% 0% Positive for HSV-2 72.5% 20.7% 7.1% Positive for Syphilis 28.7% 1.4% 0.8% Positive for HIV 9.6% 0.2% 0%

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