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Behaviour

Is increasing gonorrhoea resistance in MSM is a result of more treatment, rather than greater sexual activity?

20 Jul, 16 | by Leslie Goode, Blogmaster

Emerging antibiotic resistance to the last-ditch treatment of Neisseria gonorrhoeae compels health policy-makers to balance opposing concerns.  On the one hand, successfully combating spread of the infection requires targeted treatment of core-group individuals.  On the other, a focus on the core-group causes a rebound in core-group incidence, with maximal dissemination of resistance (Chan & McCabe/STIs (C&M); Chan & Fisman/STIs).

Recent public health orthodoxy has tended to favour the more intensive screening of core-group individuals (Ison & Unemo (STI); Giguere & Alary/STIs; Lewis/STIs).  However Fingerhut & Althaus (F&A), in a recent modelling study, seek to shift the balance in the opposite direction.  They claim their model demonstrates that the wide disparity in the spread of resistance spread as between populations of MSM and of HMW (heterosexual men and women) reflects differing levels of treatment rather than differences in sexual behaviour (‘more sexual partners’).

So far as concerns the first part of the claim (‘gonorrhoea spreads faster with more treatment’), F&A’s findings corroborate those of C&M.  However, in coupling this with the claim that gonorrhoea spread is not the result of sexual behaviour (‘gonorrhoea (does not) spread faster with more sexual partners’) they place the balance of responsibility for spread with the prevailing policy of treatment.  This is presumably intended to push policy makers in the direction of a more conservative attitude to targeting testing and screening.

But can F&A really justify this  change of emphasis by differentiating the respective contributions of ‘more treatment’ as against ‘greater sexual activity’ to the difference in resistance between MSM and MSW popultions ?  We are wrong, the authors argue, to assume that ‘more partners’ amongst the MSM population necessarily entails more transmissions (p. 11) – and their model apparently demonstrates this.   A common sense response, however, would be to object that ‘more partners’ presumably implies ‘more sex acts with more partners’ – and that, even if ‘more partners’ does not in itself entail more transmissions, ‘more sex acts with more partners’ might certainly be expected to do so.

Interestingly, Althaus in another paper (see Althaus & Alizon) – admittedly, in connection with heterosexual groups – corroborates our common sense expectation by showing that the number of partners displays, if not a proportional, then at least a linear, relation  to number of sex acts. So can it really be the case that there is not a greater number of transmissions amongst the MSM population, given the greater number of partners? The authors evidently believe not.

Nevertheless, it would be interesting – as well as pertinent, I suspect, to the goals of the study – to have a more satisfying explanation of why, here, as elsewhere, common sense turns out to be wrong.

 

 

 

Inadequacy of ‘treatment as prevention’ strategy for combating HIV in young US MSM

23 Feb, 16 | by Leslie Goode, Blogmaster

The secret of containing the HIV epidemic is the successful engagement of key populations, we are told. In the case of the US that evidently includes young MSM (YMSM), amongst others.  The scale of the task that confronts public health interventions aimed at prevention in this group is brought out in a recent study by Wilson & Hightow-Weidmann  (W&H) who investigate the behavioural and social correlates of not achieving virological suppression.

If we take the HIV-infected population of the US as a whole, the relative impact on HIV onward transmission of the segment of the population that is infected, but not virologically suppressed (VL+), is critical to the control of the epidemic.  This is on account of the large proportion of total transmissions attributable to it.  One recent modeling study discussed in this blog (Skarbinski & Mermin {STI/blogs) (S&M)) has estimated the proportion of onward transmission attributable to VL+ at 61.3%, as against to 30.2% attributable to the undiagnosed.  (This model also takes account of the greater HIV infectivity of the non-virologically suppressed, through the impact of this is debated (Increased HIV infectivity (STIs/blog)).

So one can imagine the impact on onward transmission of failure to achieve virological suppression among YMSM, given that the proportion of HIV diagnosed who are VL+ is estimated by W&H at c.70%.  Further to this, W&H consider a factor that contributes an additional importance to the low level of viral suppression.  The headline statistic of their study is that the VL+ are considerably more likely to engage in risky sexual behavior than the rest.  Data obtained from the 20 US adolescent clinics that feature in the study show rates of condomless anal intercourse (CAI) for VL+ at 54.7%, as against 44.4% for VL-, and rates of serodiscordant CAI at 34.9%, as against 25%.  Other correlates of being VL+ are drug abuse, daily alcohol use and unemployment, suggesting a pattern or relative social marginalization that would tend to make this group harder to engage.

In their conclusions, W&H highlight the inadequacies of treatment as prevention as the sole risk reduction method.  A more underlying issue would seem to be retention in care and engagement with services, for socially marginalized populations.

Sherer (STIs) analyses the structural factors which make this particularly a problem for the US.  Access to sexual health services has been improved by the Affordable Care Act.  However, there remains considerable debate about how this will affect publically funded STD clinics which seem to have been financially squeezed in recent years.  Also about what role, if any, these clinics will continue to play in the US health system and what the implications of this will be for the accessibility of sexual health services for the socially marginalized (Mettenbrink & Cornelis (STIs); Stephens & Berstein (STIs); Hoover & Gift; Bocour & Shepard).

Where next for HIV prevention in New Zealand?

29 Jan, 16 | by Leslie Goode, Blogmaster

A recent issue of the New Zealand Medical Journal (NZMJ) (128: vol. 1426) gives pride of place to a series of papers that reconsider the way forward for HIV prevention in New Zealand (NZ) against the background of the past thirty years.  Recent contributions to STI journal by these authors analyse the behavioural surveillance data from NZ (Saxton & Hughes (STIs); Lachowsky & Summerlee (STIs); Lachowsky & Dewey (STIs)); the papers in NZMJ set these findings against a broader background (Saxton & Giola; Hughes & Saxton; Dickson & Saxton; Saxton & Ludlam).

Broadly speaking, the situation in NZ resembles, both in nature and scale, what we find in Western European countries: namely, persistent but relatively low-level epidemics concentrated in the MSM population (above all, in Auckland), and among heterosexual individuals of foreign extraction (Dickson & Saxton).

The distinctiveness of the NZ epidemics, as against those of Western Europe, lies primarily in geo-political factors: such as migration from sub-Saharan Africa, which reached a peak in 2006 before abruptly declining – or the changing demography of Auckland with its large populations of South Asians and people of Pacific origin (Dickson & Saxton: Lachowsky & Summerlee (STIs)).  The main emphasis of the NZMJ papers, however, is on issues that will have a familiar ring to West European readers – such as the importance of achieving a balance between public health and clinic-based approaches to HIV control.

Overall, their account suggests some considerable degree of success on the part of health interventions – but in the face of a public health challenge that is constantly evolving and may yet prove intractable.  As regards the success, some behavioural surveillance data indicate levels of condom use with casual partners of 85% (Hughes & Saxton; Saxton & Hughes (STIs));  The challenge is represented by the growing minority who do not perceive HIV as a threat on account of new treatments (Hughes & Saxton; Saxton & Ludlam). There also remain, as elsewhere, the problems of high levels of undiagnosed HIV (c. 20%) and relatively late presentation to health services (over a third of MSM at CD4=<350/mm3).  A things stand, the worst kind of scenarios seen amongst gay communities in Thailand or the US would appear to have been averted.  Nevertheless, the epidemics show every sign of persisting, and, given a level of diagnosis that it is marginally higher than seen hitherto, may still turn out to be on an upward trajectory.

A key focus of the NZMJ editorial (Saxton & Giola) is on the continued importance of behaviour-based interventions in a world where the momentum seems to have shifted to clinic based control involving pharmaceuticals.  They highlight the danger that the medicalization of HIV prevention could lead to a disinvestment in behaviour-based interventions, which, they imply, would not be conducive to controlling the epidemic.   In this regard, the authors cite Phillips & Cambiano who argue that a mere 10% reduction in condom use would, without improvements in testing levels and ART initiation, result in a doubling of HIV incidence over 15 years.

PrEP highly effective against HIV in MSM and has limited impact on risk compensation

22 Oct, 15 | by Leslie Goode, Blogmaster

The year 2015 is likely to turn out a decisive one for the story of PrEP (pre-exposure prophylaxis for HIV).  After a slow and faltering beginning, with trials in sub-Saharan Africa dogged by problems of poor adherence (Haberer & Bangsburg/STI/blog; VOICE D/STI/blog; Hendrix & Bumpus/STI/blog), this intervention appears at last to have proved its worth – at least in high-risk populations such as MSM in Europe and America.  This is to be seen in a succession of results from recent or still ongoing trials.

Following the report of encouraging headline figures at last February’s Conference on Retroviruses and Opportunistic Infections (CROI), the UK PROUD study (Pre-exposure Option for reducing HIV in the UK immediate or Deferred) has published its results (McCormack & Gill; PROUD/STI/blog).  As stated in my earlier blog, this study, based in 13 UK clinics, aimed, in its design, to replicate real-life conditions in being an ‘open-label’, as opposed to a blind placebo controlled, randomized study.  September also saw the publication of a brief report of a San Francisco based study (Volk & Hare) investigating HIV and STI incidence amongst a comparable number of patients (650) referred for PrEP over 2 and a half year period in a clinical practice under the health insurance provider Kaiser Permanente.  Finally, the PROUD study refers to the still ongoing IPERGAY study run by French and Canadian researchers (IPERGAY; Molina & Delfraissy).  The latter differs from the PROUD study, first in respect to the PrEP regime followed, which is ‘on demand’ (i.e. before and after sex) rather than daily; second, in having a blind placebo controlled, rather than an ‘open-label’, design.

The three studies investigate relatively high-risk, largely MSM, populations – to judge by the high rates (c. 34%-50% within a year of follow-up) of STIs and especially (18%-32%) of rectal STIs.   Rates of HIV transmission, however, were, in all cases, similarly low.  As indicated in my blog (PROUD/STI/blog), the PROUD study headlined an HIV incidence of 1-2 per 100 person years (py) in the immediate initiation, as against 9 per 100 py in the ‘deferred initiation’ arm.  The IPERGAY study saw rates of 0.94 as against 6.75.  The San Francisco study was without a control arm, but saw zero cases of HIV among PrEP users over the two and a half year study period.  All this would suggest that amongst self-selecting high-risk MSM, PrEP interventions can be successful in preventing HIV transmission.  It would, however, be reassuring to know more about the impact of PrEP on risk compensation – always the supposed ‘Achilles heel’ of MSM PrEP (Cassell & Halperin) – especially as rates of STI incidence following PrEP initiation were very high in all studies.  Here the published version of the PROUD study has the advantage of being able to compare incidence of other STIs between the intervention and the control arm of the study.  No significant difference between the two arms was observed.  This was particularly encouraging as the PROUD study was designed to replicate the conditions of a real-life intervention in that those in the intervention arm knew they were taking PrEP, and could have adjusted their behaviour on the basis of this knowledge.

A final issue that PROUD and IPERGAY may begin to help health professionals to address is that of cost effectiveness.  The PROUD researchers calculate that ‘thirteen men in a similar population would need access to 1 year of PrEP to avert 1 HIV infection’.  This would make PrEP targeted at this group cost-effective at current prices if the cost of tenofovir and emtricitibine were halved.  It could also be achieved if the proposed intervention were to adopt the ‘on demand’ regimen trialled by IPERGAY:  namely, two tablets 2-24 hrs before sex, one taken 24hr, and a further tablet 48 hrs. after.  IPERGAY, it will be remembered, demonstrated the same 86% reduction in HIV incidence that was observed by PROUD.

Living dangerously in the Dominican Republic and Mexico City: can cash transfer payments be used to counteract the “risk premium”?

17 Dec, 14 | by Leslie Goode, Blogmaster

The Caribbean has the highest levels of HIV outside sub-Saharan Africa – and the Dominican Republic (DR), which together with Haiti accounts for 70% of all people living with HIV in the Caribbean region, is a hotspot.  While there has been a 73% reduction in the rate of new infections in the DR between 2001 and 2011, prevalence of HIV remains high among key populations of MSM (6%) and female sex-workers (3%).  A recent qualitative study has sought to investigate the relations between the drug trade, sex tourism, and risk taking which may hold the secret of the obstinately high-levels of HIV in these key populations (Guillamo-Ramos & Robles).  In-depth interviews, along with drug screening, were conducted with 30 local drug users in Sosua, known for its tourist sex industry.

Three major themes emerge.  First, drugs are freely available as a result of diversion from the major drug routes running from N to S America through the DR.  Second, they have become integral to the local tourist industry – specifically as a vital component of sex work.  Third, the engagement of locals, along with tourists, in commercial sex fuelled by drug use gives rise to the kind high-risk behaviours that sustain the spread of HIV in the local population.

What, from the public health angle, seems particularly challenging in this situation is that the element of risk-taking isn’t merely an incidental effect of the sexual activity; it is precisely the element that makes that activity attractive, and – from the locals’ point of view – lucrative.  Participants associate sex work and drug use with improved livelihood, and describe how risk behaviours are part of the economic negotiating process.

This is the same general kind of problem described in the reported base-line study of a pilot trial of an intervention among male sex workers in Mexico City (STI/Galarraga & Sosa-Rubi).  These male sex-workers are at particular risk of infection because they receive market-based inducements from clients to engage in condomless sex.  It is not simply that MSW are neglecting to take precautions; the average price for a sex transaction is 35% higher for condomless sex – and, given MSW may be unemployed (16%), or dependent for their income on sex work (37%), the economic pressures to engage in unsafe practices are considerable.

The Punto Seguro pilot trial, based at the Clinica Condesa, an HIV centre in Mexico City, is considering as a potential solution the idea of a conditional cash transfer (CCT) whereby MSW are rewarded for keeping themselves free of curable STIs over a six-month period.  Within Mexico CCT has been employed, since the 1990s to provide incentives for poor people to keep their children in school, and to attend preventative check-ups, though not apparently in the sphere of HIV.  In the US, however, it has been used to prevent persistent STIs and pregnancy amongst the Latino population (STI/Minnis & Padian), in Pakistan to encourage infected men to disclose to their wives, and have them tested (STI/Khan & Khan).

The paper sets out the procedures and the baseline data for investigating the effectiveness of a form of this kind of intervention.  The 267 participants have been randomized to four groups: control; medium conditional incentive ($50); high conditional incentive ($75); unconditional incentive ($50). Previous formative work established the incentive levels necessary for behaviour change ($156 per year).  It is also hoped that CCT interventions may benefit participants by helping to link them into care – since of the participants in the trial who knew they were infected with HIV, only 40% were on treated, and of these, only 61% had achieved viral suppression.

Should bisexuals be considered a population with specific sexual health needs?

28 Jul, 14 | by Leslie Goode, Blogmaster

Across many cultural contexts, men who have sex with both men and women (MSMW) have levels of STIs/HIV comparable to those we find in men who have sex only with men (MSM); but MSMW have often proved particularly hard for health services to access.  Mercer & Cassell (M&C) (UK) and STIs/Beyrer & Baral (B&B) (South Africa) refer to poor rates of HIV testing as compared to MSM (RR 0.31 and 0.62 respectively). Both studies stress the need to find ways of targeting safe-sex messages for MSMW who do not identify as gay.

In an intriguingly entitled reivew of the literature on MSMW sexual health in the US 2008-2013 (“Beyond the bisexual bridge”)  Jeffries  corroborates this general picture of high STI risk and poor accessibility.  But he seeks to get beyond what he considers an obsession on the part of researchers with the role of MSMW as a “bridging” population with women.  He claims this “characterization” is not justified by the research – at least where the US is concerned (Chu & Curran; Satcher & Dean; Kahn & Catania).  He also views it as ultimately detrimental to the sexual health of MSMW, which needs to be founded on the “recognition of MSMW’s unique sexual and social experiences”.

The article reviews both the sexual health, and socio-cultural challenges to MSMW’s health.  Sexual health challenges include: levels of STIs other than HIV equalling and exceeding MSM levels, alongside levels of HIV lower than MSM, yet higher than MSW (as in the UK (see M&C)); also enormously higher levels of injection drug use, sex in exchange for money or drugs, and drug and alcohol use during sex than in MSM; also sex within female networks (as well as male) that imperil sexual health, with a high proportion of female partners having injected drugs, being under influence of drugs during sex, and having concurrent partners.  Socio-cultural challenges include biphobia in society at large, and fairly extreme socio-economic marginalization, as indicated by lack of education, poverty, homelessness and incarceration.

Some corroboration of the role that Jeffries attributes to settled identities in moderating at risk behaviour is provided by the success of a number of ongoing initiatives aimed at black or Latino MSMW.  These all appear to address MSMW’s masculinity concerns and heterosexual identities in a non-judgmental and culturally sensitive manner.  Men of African American Legacy Empowering Self (MAALES) has been evaluated in a RCT discussed in an earlier blog (STI/blog/Are bisexuals well served by interventions that assume gay identity?).  Jeffries also mentions: Hombres Sanos; the Bruthas Project; the Enhanced Sexual health Intervention for Men (ES-HIM).

A puzzle remains in the lower susceptibility of MSMW, as against MSM, to HIV – alongside equivalent or higher susceptibility to other STIs .  Jeffries discusses this, but offers no explanation.  Could the less than expected levels of HIV in MSMW be the result of an association between MSM identity and sexual networks that carry particular risk of HIV transmission?

Shared needles for Viagra injection fuel STIs among the Korean elderly

1 May, 14 | by Leslie Goode, Blogmaster

UK BBC radio’s 4’s Korean correspondent, Lucy Williamson refers in last Tuesday’s Crossing Continents to a category of STI transmission through IVDU, which is unlikely to be familiar to our readers.  A recent article in the Korea Times  gives further details.  The individuals at risk are the 16% of South Korean seniors (65+) in Seoul who pay for sex (Korea Herald).  The means of transmission are the syringes used by elderly prostitutes carrying on trade in soft drinks (Korean-style Bacchus) to inject their elderly patients with Viagra, and then “recycled” – according to the interview, “ten or twenty times, or until the needle breaks”.  No surprise, levels of STIs among these elderly partners were found by a recent survey to be as high as 40%.

The proportion of seniors in Seoul who pay for sex (16%) (half of these five times over the last two years) seems high. The percentage of individuals who use sex workers varies enormously between countries, as does the age profile of the typical user (Prostitution: the Johns Chart).  By comparison, rates of use in the US and a number of European countries stand at around 20%, in Spain and Italy nearer 40%, though the typical user is likely to be in his 30s or 40s – not his 60s and 70s.  (For the situation in the UK, see STIs/Ward & Mercer).

Prostitution is illegal in Korea, and most safe-sex counselling is aimed at young people.  “There is a great lack of instructors for sex education for senior citizens”, says a welfare professor at Baekseok University.  “We also need to create quality programs, through which senior citizens can meet friends of the opposite sex and form wholesome relationships” (Korea Herald) .

This problem may currently be local to Seoul.  Commentators  attribute it, however, to rising levels of poverty among seniors – a consequence, they argue, of a fast ageing population in a culture that once placed a high value on Confucian values of filial duty, but has now ceased do so.  If these commentators are right, one can well imagine these conditions being replicated in other Asian countries, as they follow the trajectory of Korea.  In which case, Jong-myo Park may be the shape of things to come (Korea Times).

Partners PrEP sub-study finds no evidence that PrEP use is associated with risk compensation behaviour

21 Nov, 13 | by Leslie Goode, Blogmaster

How useful is pre-exposure prophylaxis (PrEP)?  The Partners PrEP randomized control study of daily pre-exposure prophylaxis among HIV-uninfected partners of heterosexual HIV-discordant couples in Uganda and Kenya has indicated that, given adequate adherence, PrEP has high biologic efficacy.  The study itself (Baeten & Celum) demonstrates levels of risk reduction of 75%; while a spin-off sub-study from the original trial, monitoring adherence (STI blog/Haberer & Bangsberg ), has established that, with high adherence (c. 97%), levels of protection are even higher than the study might suggest (none of the 14/1,147 sub-study participants who sero-converted were from the intervention arm of the study).

These results have fed into recent attempts to model the likely effectiveness of PrEP.  The consensus hitherto seems to be that PrEP is a relatively high-cost intervention most likely to be cost-effective as an addition to ART in countries where the burden of HIV is high, and rates of male circumcision low – such as southern Africa (Verguet & WalshYing and Barnabas).

Last month saw the online publication of a second interesting spin-off sub-study of Partners PrEP (Mugwanya & Baeten).  It undertakes a longitudinal analysis of data from the original trial to address what is perhaps the greatest concern affecting the implementation of PrEP as a public health intervention (STI blog/Sugarman & Mayer), that of risk compensation – i.e. the possibility that the security promised by PrEP will itself encourage sexual risk-taking behaviour.  M&B’s results, along with those of any future studies of this issue, will no doubt serve to inform the assumptions of future models.

In July 2011 the Partners PrEP study reported its findings, and the placebo arm of the trial was closed.  However, follow-up of 3,024 participants continued.  This allowed data on their sexual activity to be collected over a period which spanned the 12 months preceding – and the 12 months following – the disclosure to participants of the results of the study.  These data included unprotected sex acts and total sex acts over this period, both within the primary relationship as registered by the study and outside that relationship.

Within the primary relationship (i.e. with the registered HIV-infected partner), the crude average frequency of unprotected/total sex acts within the primary relationship was 59/414 per 100 person- months prior to, and 53/361 following, unmasking.  Outside that primary relationship the frequency of unprotected total sex acts was 49/62 as opposed to 67/84. So there appears to be a fall in unprotected/total sex acts with the primary sex partner as between the two halves of the period, and a small, but significant, rise in unprotected/total sex acts outside this relationship.  The latter rise (unprotected sex acts outside the primary relationship) is helpfully quantified at an average of 6.8 sex acts per year following unmasking as against an average of 6.2 acts in a predicted counterfactual scenario had patients remained unmasked.  M&B place this figure in the context of the estimated doubling of risk-behaviour, which modellers suggest would be required in order to see any attenuation in the effectiveness of PrEP.

The authors suggest – optimistically perhaps – that the small decrease in unprotected sex following enrolment indicates that PrEP delivered in the context of an HIV prevention package may be synergistic for risk reduction.  However, they also point to an earlier study (Ndase & Thomas) that finds this overall pattern of decline in sex acts with primary partner and rise in sex acts outside the primary relationship to be indicative of dissolution of the primary relationship and formation of new relationships.  They also observe that unprotected sex without outside partners was “high among the few participants who reported sex outside the primary partnership” – an observation that accords with recent study findings that a quarter of HIV infections in sero-discordant partnerships arise from non-primary partners.

The findings of the study seem reassuring.  They raise two questions, however.  The first concerns the impact of the probable gap between the HIV prevention package accompanying any real-life PrEP implementation and the package made available to the participants in Partners-PrEP.  The second concerns the impact of new partnership formation on unprotected sex over the longer term.  It is here that the findings of M&B would lead us to expect the greatest challenge to PrEP; yet the true extent of such a challenge is something of which their study can offer us only the most preliminary impression.

Are bisexuals well served by HIV interventions that assume gay identity?

30 Oct, 13 | by Leslie Goode, Blogmaster

Studies published in STI journal have examined the impact of bisexual concurrency on HIV epidemiology in South Africa (Behrer & Baral) (B&B) and China (Yun & Shang) (Y&S), where it is reckoned at 53.7% and 31.2% of the MSM population, respectively.  However, a recent randomized control study of an educational intervention in Los Angeles (Harawa & Cunningham) claims to be among the first studies addressing bisexual concurrency among black MSM in the US.

US black MSM who have sex with women (MSMW) are less likely than white MSM to identify gay, and more concerned to fulfil traditional gender expectations.  Consequently, say the authors, they may be less well served by interventions based on contemporary conceptualizations of sexual behaviour in terms of fixed sexual identities.  This raises a number of interesting questions, among them, how far the situation of US black MSM resembles that of MSM in traditional societies (e.g. South Africa or China), and how far influential contemporary conceptualizations about sexual identity, based on the cultural experience of white MSM, constitute an appropriate model for interventions outside that specific social context.   The authors see potential benefits for MSMW of interventions based on more fluid and context-dependent models of sexual behaviour.

The intervention that is the object of this study – Men of African American Legacy Empowering Self (MAALES) – is an HIV education and risk-reduction course addressed specifically to the needs of this group (Williams & Harawa).  It consists in six two-hour sessions delivered over a three week period (with booster sessions at six and 18 weeks), and aims, above all, to be “culturally congruent”.  It is conducted by black MSM facilitators, and its content is theoretically grounded in a teaching model developed in African American communities (the critical thinking model), as well as in reasoned action theory and empowerment theory.

The study itself compares sexual behaviours, at base-line and three and six months after the intervention, of 437 black MSMW randomly assigned to either the MAALES intervention or a twenty-minute HIV education and risk-reduction session based on a standard HIV test counselling approach. Adjusted results indicate the achievement of significantly less unprotected sex acts with male or female over prior ninety days at six months in the intervention arm as against the control arm (RR 0.61), significantly less unprotected sex acts with females (RR 0.5), and a near-significant reduction in sex acts with males (RR 0.63).  Given the time and resources dedicated to the MAALES as compared to the control intervention, one wonders how much of this behavioural modification is owed to the greater investment in the patients in the intervention arm of the study, and how much to the superiority of its culturally congruent methodology over the conventional alternative.

In their conclusions Harawa and Cunningham tend to corroborate the emphasis of Behrer and Baral, Yun and Shang and others on the influence of societal and cultural factors.  There have even been attempts to quantify the impact of psychosocial constructs on MSM sexual behaviour (Konda & Kegeles).  Yet, Harawa and Cunningham differ somewhat from these other studies in the greater stress they place on the role of participants as responsible agents.  They also recommend on the basis of the more frequent reporting of unprotected sex with females in their study, and the relatively low levels of sex with males, that interventions aiming to “responsibilise” MSMW should prioritize the reduction of risky behaviour which involves females, rather than males.

Was the “sexual revolution” triggered by the decline of syphilis?

26 Mar, 13 | by Leslie Goode, Blogmaster

The year 1939 saw total US syphilis deaths at 15 per 100,000 and syphilis deaths of black males at 72.5 per 100,000: this is a death rate comparable to that for HIV/AIDS at the height of the epidemic in 1995 when total deaths and deaths of black males stood, respectively, at 16.2 and 80.2 per 100,000.  Subsequently, in the late 40s and early 50s, incidence and mortality from syphilis were to fall precipitously – thanks to penicillin.  A recent paper in the Archives for Sexual Behavior by an economist, Andrew Francis, argues for the importance of this collapse in the “cost” of syphilis in spurring the sexual revolution (http://link.springer.com/article/10.1007%2Fs10508-012-0018-4). His exploration of this hypothesis prompts general reflection on the link between the “cost” of disease (which he equates with absence of an effective treatment) and sexual behaviour.

The paper correlates data across US states on syphilis incidence and mortality with measures of “risky non-traditional sex” – which, in the context of the poverty of relevant data for the period, is evaluated on the basis of gonorrhoea rate, illegitimate birth ratio and teen birth share.  Coefficients are given from regressions of measures of sexual behaviour on indicators for the number of years since syphilis collapse (which varies by state).  As regards illegitimate birth ratio and teen birth share, a positive correlation emerges which goes back as early as three years or less from syphilis collapse; gonorrhoea, however, continues to decline from its WW2 peak, as we might expect.

Ultimately, however, Francis’s argument rests also on the claim that his own explanation of sexual revolution fits the facts better than the alternative explanations, of which the most familiar is that “anti-conception technology”, especially the pill, played a decisive role.  Francis admits that, from the late sixties, conception technologies and measures of risky behaviour increase simultaneously.  Yet measures of risky sexual behaviour, he claims, had already been rising sharply for a decade before anti-conception technology began to make its impact.  His own data show that the two changes do not coincide.   Nor do measures of permissive values or religious observance show any discontinuous change that would coincide with the increase in risky behaviour.  So if Francis’ hypothesis is wrong, then the precise timing of the sexually revolution remains mysterious.  Francis gestures vaguely towards the possibility of the change in sexual behaviour being triggered by still less definable “economic, social and cultural changes”.

The obvious recent parallel to the syphilis collapse in our own times would be impact of the introduction of HAART on HIV/AIDS mortality.  The concern that an effective therapy might lead to disinhibition has been widely discussed in STI journal and elsewhere.  An increase in risk-taking behaviour among MSM during the late 1990s has been established:  http://sti.bmj.com/content/77/3/184.abstract?sid=5d909365-4627-4232-8ef4-a93445f5baed (Stolte & Coutinho: Amsterdam);  http://sti.bmj.com/content/80/6/451.abstract?sid=5d909365-4627-4232-8ef4-a93445f5baed (Elford & Hart: London); http://sti.bmj.com/content/80/6/518.abstract?sid=5d909365-4627-4232-8ef4-a93445f5baed(Cox & Allard: Montreal); http://sti.bmj.com/content/79/1/7.abstract?sid=5d909365-4627-4232-8ef4-a93445f5baed (Stephensen & Williams: London).  But opinions on the contribution of HAART to changing sexual behaviour seem divided, with Stolte & Coutinho supporting the hypothesis, and the others inclined to attribute it to other factors.  The probable future emergence of multi-resistant gonorrhoea (http://sti.bmj.com/content/87/Suppl_2/ii39) represents the inverse case (loss of a therapy leading to potential inhibition).  If the diminished “cost” of an STI (syphilis) can spur an increase in risky sexual behaviour, should we not expect an increased cost to have the opposite result?  Time will tell.

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