Sexual Behaviour Research

							Sexual Behavior Research
Worthwhile? Useful?
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

Congress to Dr. Zerhouni

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

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 cost
Weinstock et al; Chesson et al Perspectives on Sexual and Reproductive Health Jan/Feb, 2004

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

Effective and Cost-Effective Interventions
(Pinkerton et al., AIDS 2001; Kahn review chapter, 1998)

• At-risk MSM
– One-session group – 12-session group – Peer-lead communitylevel

• At-risk women
– Condom social marketing – Outreach-based services – 5-session group

• Injection drug users
– Needle & syringe exchange – Multi-session group – Drug treatment

• At-risk MSW/M
– Video-based, 1-session intervention – Condom social marketing – Outreach-based services – 7-session group

• STD clinic clients
– HIV counseling and testing, referral and partner notification

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

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

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

Sexual Behavior Research Tells Us
 Reasons

for not being tested previously were logistical

 inconvenient hours (25.6%)  inconvenient location (20.7%)  high cost (8%)

Nairobi Slums

Nairobi Slums

Will they be infected within the next 5 years?

Interventions to prevent and treat HIV HIV VCT
R
1563 HIV VCT 1557 Health Ed

• 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

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)

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,

Case Study #2
ABC Abstain til Marriage Be Faithful Condoms

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

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

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)

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

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,

Case Study #4
Abstinence Only And Abstinence Plus Sex Education

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

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

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

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

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

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

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

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,

Case Study #5
Male Circumcision

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

• Structural

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

Needle and Syringe Exchange
(Strathdee & Vlahov, AIDScience, 2001)

• 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%

Interventions to prevent and treat HIV
mucosal surface to surface blood to blood

Infectious person

Susceptible person

mother to child

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.

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)

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)

Case Study #7
Targeting Prevention Resources

A Final Note
• ―Don’t gerrymander a fire line.‖
– Marilyn Chase, Wall Street Journal

Population Profiles
_______________________________________________________________________

Males Females Total (1096=91%) (109=9%) (1205) _______________________________________________________________________ Married/living with partner With 7+ years of education Any non-marital unprotected sex in last 3 mo Positive for Chlamydia Positive for Gonorrhea Positive for HSV-2 Positive for Trichomonas Positive for Syphilis Positive for HIV Any positive test Any positive non-viral test 25% 87% 60% 5.6% 0.5% 28.5% -5.6% 1.7% 36% 18.5% 2.8% 43.5% 6.5% 4.6% 0.0% 58% 6.8% 0.8% 29.9% -5.5% 1.5% 36.5% 12.8%

Variable

Population Profile
_______________________________________________________________________

Variable

MSoM (N=172)

Esquineros (N=922)

Gen Pop (N=668)

___________________________________________________________________

Any non-marital unprotected sex in last 3 mo Positive for Chlamydia Positive for Gonorrhea Positive for HSV-2 Positive for Syphilis Positive for HIV

67% 2.4% 0% 72.5% 28.7% 9.6%

77% 6.2% 6.0% 20.7% 1.4% 0.2%

28% 4.7% 0% 7.1% 0.8% 0%