OBJECTIVES: This study sought to estimate the size and direction of the human immunodeficiency virus (HIV) epidemic in US metropolitan statistical areas (MSAs) with populations greater than 500,000. METHODS: A "components model" from review of more than 350 documents, several large datasets, and information from 220 public health personnel was used. Data review focused on injection drug users, men who have sex with men, and high-risk heterosexual men and women. RESULTS: In the 96 MSAs, there are, broadly, an estimated 1.5 million injection drug users, 1.7 million gay and bisexual men, and 2.1 million at-risk heterosexuals, and, among them, an estimated 565,000 prevalent and 38,000 incident HIV infections. This implies about 700,000 prevalent and 41,000 new HIV infections yearly in the United States. Roughly half of all estimated new infections are occurring among injection drug users, most of them in northeastern cities, Miami, and San Juan. Gay and bisexual men still represent most prevalent HIV infectio...

The estimated prevalence and incidence of HIV in 96 large US metropolitan areas

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(05)67732-X.pdf

Sex-work harm reduction

Biomedical interventions to prevent HIV infection: evidence, challenges, and way forward

The aim of this study was to examine the association between type of sexual partnership and condom use consistency It is a prospective follow-up study of women attending two urban clinics for sexually transmitted diseases Sexual diaries recording barrier method partner initials and partner type for each act of intercourse were kept by 869 women Condom use by partner type was evaluated in three ways in the entire group: among women who encountered multiple partners during months in which women encountered multiple partners and within sexual partnerships that changed status during the study Consistency of condom use was higher with new and casual partners than with regular partners in the entire group and among women who encountered multiple partners In months in which partners of different types were encountered condom-use consistency was higher with new and casual partners than with regular partners Consistent condom use decreased in partnerships that changed status from new to regular The female condom was used more often with regular partners than with new or casual partners in the entire study group among women who encountered multiple partners and during months in which a woman achieved consistent use with her regular partner This study provides strong evidence that condom use behavior is modified by partner type Observations about condom use and partner type made in cross-sectional or retrospective surveys also hold in the present longitudinal analyses of individual women and of partnerships that change status The female condom may be an important option for achieving consistent protection within stable partnerships (authors)

Partner type and condom use.

Biomedical interventions to prevent HIV infection: Evidence, challenges, and way forward [Electronic version]

The male condom is the most effective barrier method available for protection against sexually transmitted diseases (STDs) including HIV infection. There is an urgent need to develop and evaluate other prevention methods such as the female condom. This study estimated the additional protection against STDs offered to sex workers by giving them the option of using the female condom when clients refused to use a male condom. Sex establishments in four cities in Thailand were randomized into two study groups: one in which sex workers were instructed to use male condoms consistently (male condom group); and one in which sex workers had the option of using the female condom if clients refused or were not able to use male condoms (male/female condom group). Randomization was done by sex establishments and not by individuals to minimize sharing of female condoms across study groups. The proportion of unprotected sexual acts (defined as sexual acts in which condoms were not used tore or slipped in or out) and incidence rate of STDs (gonorrhoea chlamydial infection trichomoniasis and genital ulcer disease) were measured over a 24-week period and compared between the two study groups. Results are available from 34 sex establishments (249 women) in the male/female condom group and 37 sex establishments (255 women) in the male condom group. Condom use was very high in both groups (97.9 and 97.3 % of all sexual acts respectively P > 0.05). Male condom use was lower in the male/female condom group when compared with the male condom group (88.2 and 97.5% respectively P < 0.001). However this reduction in male condom use was counterbalanced by the use of female condoms in 12.0% of all sexual acts in the male/female condom group contributing to a 17% reduction in the proportion of unprotected sexual acts in this group when compared to the male condom group (5.9 versus 7.1% respectively P = 0.16). Female condom use was sustained over the entire study period. There was also a 24% reduction in the weighted geometric mean incidence rate of STDs in the sex establishments of the male/female condom group compared to the male condom group (2.81 versus 3.69 per 100 person-weeks P = 0.18). The replacement of male condoms by female condoms in a proportion of sexual acts in the male/female condom group suggests that some sex workers and/or their clients preferred using the female condom. This switch in barrier method was accompanied by non-significant reductions in the proportion of unprotected sexual acts and in the incidence rate of STDs in the women of the male/female condom group. Special attention should be paid to a potential risk of slippage of the female condom in inexperienced users. (authors)

Protection against sexually transmitted diseases by granting sex workers in Thailand the choice of using the male or female condom: results from a randomized controlled trial.

Accurate estimates of HIV incidence that reflect the effect of non-vaccine interventions (education counseling condom promotion and possibly sexually transmitted disease treatment) and that may be provided in a Phase III vaccine efficacy trial are needed so that vaccine trial population sample sizes can be accurately determined. In order to avoid delays in the implementation of clinical trials well characterized cohorts must also be developed and available to participate in such trials. The authors reviewed the potential study populations the epidemiologic methods for the determination of HIV incidence (using open cohort closed cohort and seroprevalence data methods) and the need for the development of population cohorts in preparation for Phase III HIV vaccine efficacy trials. These Phase III trials in developed and developing countries looked at a comparison of open and closed cohorts and those using seroprevalence data to estimate HIV incidence. Open and closed cohorts each have disadvantages. However the open cohort may be more suitable for determining estimates of HIV incidence that reflect non-vaccine interventions and for the development of a well-characterized cohort available to participate in efficacy trials. Careful preparation of research infrastructures and population cohorts will help ensure the successful conduct of scientifically and ethically sound HIV vaccine efficacy trials in the future. (authors)

Preparation for phase III HIV vaccine efficacy trials: methods for the determination of HIV incidence.

The female condom may provide women with the first female- controlled barrier method that is effective against sexually transmitted diseases including HIV infection. This study evaluated the acceptability of the female condom among sex workers in Thailand. Data on use and acceptability of the female condom were collected using a structured questionnaire during an 8-week follow-up. Analyses included 148 women who were still in follow- up at week 8. Sex workers used on average 2.8 female condoms per week. The overall satisfaction rate with the female condom was 68% although among users 31% had difficulties in device insertion 37% had pain from the inner ring and 22% reported itching sensations. The main reason for using the female condom in the future was its perceived safety and the main reason for not using it would be the clients refusal. Two-thirds of the sex workers were satisfied with the female condom. Difficulties at insertion discomfort during use and clients attitude were potential obstacles to the use of the female condom in the future. (authors)

Acceptability of the female condom among sex workers in Thailand. Results from a prospective study.

One hundred and ninety five (195) brothel-based commercial sex workers (CSW) in
Chiang Mai, Thailand, were screened for sexually transmitted diseases (STD) between October
1994 and April 1995, prior to their enrollment in a multi-center comparative trial of the effectiveness
of two strategies using male and female condoms. These CSW had a mean age of 22.2
(SD 4.3) years. Forty-seven per cent were Thai and 57.4 per cent had no formal education. Median
duration of prostitution was 16 months and median cost for sexual service was 50 baht (US$ 2) per
client. Ninety-four per cent of CSW reported always using condoms with clients. There were 63
(32.3%) CSW infected with at least one type of the STD screened. The prevalence of STD
included chlamydia! infection (16.9%), gonococcal infection (14.4%), condyloma accuminata
( 4.6% ), moluscum contagiosum (2.6%) and trichomoniasis ( 1.0% ). There was no statistically
significant risk factor for STD found in this study. Despite an active programme for prevention
of STD in CSW and the provision of free condoms, STD were diagnosed in one-third of the
screened CSW in Chiang Mai. The programme needs to be strengthened by more intensive education
and practice in the correct and consistent use of condoms and integrated with other STD
prevention programmes.

Joseph Saba

Papers

Protection against sexually transmitted diseases by granting sex workers in Thailand the choice of using the male or female condom: results from a randomized controlled trial.

Preparation for phase III HIV vaccine efficacy trials: methods for the determination of HIV incidence.

Acceptability of the female condom among sex workers in Thailand. Results from a prospective study.

Sexually transmitted disease prevalence in brothel-based commercial sex workers in Chiang Mai, Thailand: impact of the condom use campaign.