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C-Channel Issue 20

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Depending on your geographical location, visit Developing World or Industrialized World.

C-Channel header  May 2010

Dear Colleagues,

C-Channel 20 highlights HIV prevention. Four articles describe HIV and risky behaviors in diverse settings, including an interview method that may improve reporting of high risk behaviors. Three articles examine the relationship between male circumcision and HIV/STI prevention. The last three articles explore the sexual behaviors of HIV-positive individuals in the context of HIV prevention and treatment. Research for these articles was conducted in Botswana, India, Indonesia, Kenya, Slovenia, Uganda, and Zimbabwe.

Kenyan government efforts to recommit to family planning and maternal health took a leap forward with the April 22 release of the Kenya National Reproductive Health Strategy. C-Change is providing broad support to this effort. With funding from the President’s Malaria Initiative (PMI), C-Change/Ethiopia staff with SBCC expertise traveled for 41 days in the PMI Malaria Mobile Van from Addis Ababa north to Tigray providing malaria prevention education to communities and disseminating the Essential Malaria Actions (EMA) scorecards and leaflets developed by C-Change. This activity culminated in the April 25 World Malaria Day celebration in Tigray State. For additional information, see www.c-changeprogram.org.

Thank you,
The C-Change KM Team


To view archived issues, visit www.c-changeprogram.org/c-channel


HIV AND RISKY BEHAVIORS

1. HIV decline in Zimbabwe due to reductions in risky sex
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2. Computer-assisted self-interview of sex workers in Kenya
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3. Sexual risk taking and HIV prevalence among "high-risk" Indonesian men

4. Sexual behaviour and STI risk behaviours in Slovenia
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MALE CIRCUMCISION

5. Male circumcision and female partners' genital tract symptoms - Uganda
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6. Male circumcision for preventing STIs - Uganda
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7. Acceptability of infant male circumcision for HIV prevention in Botswana

HIV AND PREVENTION WITH POSITIVES

8. Sexual partnerships of HIV-infected Ugandans taking ART

9. Context, gender norms, and sexual risk-taking with ART in Kenya

10. Inconsistent condom use among Indians living with HIV

 


HIV AND RISKY BEHAVIORS

1. HIV decline in Zimbabwe due to reductions in risky sex? Evidence from a comprehensive epidemiological review

Authors: Gregson S 1,2; Gonese E 3; Hallett TB 1; Taruberekera N 4; Hargrove JW 5; Lopman B 1; Corbett EL 6; Dorrington R 7; Dube S 1; Dehne K 8; Mugurungi O 3
Institutions: 1 Department of Infectious Disease Epidemiology, Imperial College London, London, UK; 2 Biomedical Research and Training Institute, Harare, Zimbabwe; 3 AIDS and TB Unit, Zimbabwe Ministry of Health and Child Welfare, Harare, Zimbabwe; 4 Population Services International, Harare, Zimbabwe; 5 ZVITAMBO Project, Harare, Zimbabwe; 6 Clinical Research Unit, London School of Hygiene and Tropical Medicine, London, UK; 7 Centre for Actuarial Research, University of Cape Town, Cape Town, South Africa; 8 UNAIDS, Geneva, Switzerland
Source:International Journal of Epidemiology 20 Apr 2010; doi:10.1093/ije/dyq055. [Epub ahead of print; Open Access]

ABSTRACT

BACKGROUND: Recent data from antenatal clinic (ANC) surveillance and general population surveys suggest substantial declines in human immunodeficiency virus (HIV) prevalence in Zimbabwe. We assessed the contributions of rising mortality, falling HIV incidence and sexual behaviour change to the decline in HIV prevalence.

METHODS: Comprehensive review and secondary analysis of national and local sources on trends in HIV prevalence, HIV incidence, mortality and sexual behaviour covering the period 1985-2007.

RESULTS: HIV prevalence fell in Zimbabwe over the past decade (national estimates: from 29.3% in 1997 to 15.6% in 2007). National census and survey estimates, vital registration data from Harare and Bulawayo, and prospective local population survey data from eastern Zimbabwe showed substantial rises in mortality during the 1990s levelling off after 2000. Direct estimates of HIV incidence in male factory workers and women attending pre- and post-natal clinics, trends in HIV prevalence in 15-24-year-olds, and back-calculation estimates based on the vital registration data from Harare indicated that HIV incidence may have peaked in the early 1990s and fallen during the 1990s. Household survey data showed reductions in numbers reporting casual partners from the late 1990s and high condom use in non-regular partnerships between 1998 and 2007.

CONCLUSIONS: These findings provide the first convincing evidence of an HIV decline accelerated by changes in sexual behaviour in a southern African country. However, in 2007, one in every seven adults in Zimbabwe was still infected with a life-threatening virus and mortality rates remained at crisis level.

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2. Is audio computer-assisted self-interview (ACASI) useful in risk behaviour assessment of female and male sex workers, Mombasa, Kenya?

Authors: van der Elst EM 1; Okuku HS 1; Nakamya P 1; Muhaari A 1; Davies A 1; McClelland RS 2; Price MA 3; Smith AD 4; Graham SM 1,5; Sanders EJ 1,6
Institutions: 1 Centre for Geographic Medicine Research-Coast, Kenya Medical Research Institute (KEMRI), Kilifi, Kenya; 2 Departments of Medicine and Epidemiology, University of Washington, Seattle, WA; 3 International AIDS Vaccine Initiative, New York, NY; 4 Department of Public Health & Primary Care, University of Oxford, Headington, UK; 5 Departments of Medicine, University of Washington, Seattle, WA; 6 Centre for Clinical Vaccinology and Tropical Medicine, University of Oxford, Headington, UK
Source: PLoS One 1 May 2009; 4(5): e5340. [Epub before print]

ABSTRACT

BACKGROUND: Audio computer-assisted self-interview (ACASI) may elicit more frequent reporting of socially sensitive behaviours than face-to-face (FtF)-interview. However, no study compared responses to both methods in female and male sex workers (FSW; MSW) in Africa.

METHODOLOGY/PRINCIPAL FINDINGS: We sequentially enrolled adults recruited for an HIV-1 intervention trial into a comparative study of ACASI and FtF-interview, in a clinic near Mombasa, Kenya. Feasibility and acceptability of ACASI, and a comparative analysis of enrolment responses between ACASI and FtF on an identical risk assessment questionnaire were evaluated. In total, 139 women and 259 men, 81% of eligible cohort participants, completed both interviews. ACASI captured a higher median number of regular (2 vs. 1, p<0.001, both genders) and casual partners in the last week (3 vs. 2, p = 0.04 in women; 2 vs. 1, p<0.001 in men). Group sex (21.6 vs. 13.5%, p<0.001, in men), intravenous drug use (IDU; 10.8 vs. 2.3%, p<0.001 in men; 4.4 vs. 0%, p = 0.03 in women), and rape (8.9 vs. 3.9%, p = 0.002, in men) were reported more frequently in ACASI. A surprisingly high number of women reported in ACASI that they had paid for sex (49.3 vs. 5.8%, p<0.001). Behaviours for recruitment (i.e. anal sex, sex work, sex between males) were reported less frequently in ACASI. The majority of women (79.2%) and men (69.7%) felt that answers given in ACASI were more honest. Volunteers who were not able to take ACASI (84 men, and 37 women) mostly lacked reading skills.

CONCLUSIONS/SIGNIFICANCE: About 1 in 5 cohort participants was not able to complete ACASI, mostly for lack of reading skills. Participants who completed ACASI were more likely to report IDU, rape, group sex, and payment for sex by women than when asked in FtF interview. ACASI appears to be a useful tool for high risk behaviour assessments in the African context.

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3. Sexual risk taking, sexually transmitted infections and HIV prevalence among four "high-risk" occupational groups of Indonesian men

Authors: Mustikawati DE 1; Morineau G 2; Nurhayati 2; Irmaningrum Y 3; Riono P 2; Priohutomo S 1; Magnani R 2
Institutions: 1 Ministry of Health, Jakarta, Republic of Indonesia; 2 Family Health International, Jakarta, Republic of Indonesia; 3 Central Statistics Bureau, Jakarta, Republic of Indonesia
Source: Sexually Transmitted Infections Sep 2009; 85(5): 391-6. [Epub before print]

ABSTRACT

OBJECTIVES: This article reports new surveillance data on the prevalence of sexual risk taking, HIV and other sexually transmitted infections (STI) among four occupational groups of Indonesian men thought to be at elevated risk of infection.

METHODS: Behavioural survey data were collected from 3008 men in 11 cities, among whom 2158 men were tested for HIV and syphilis and 1950 for gonorrhoea and chlamydia. Risk factors for STI were assessed using multivariable logistic regression.

RESULTS: Thirty-six per cent of men had sex with a female sex worker (FSW) in the previous year and 20% with non-marital female partners. Consistent condom use was low with both sex workers (17%) and other non-marital partners (13%). HIV prevalence was 2% in Papua and less than 1% elsewhere, but was for the first time detectable in a non-core transmitter male population outside of Papua. STI rates were high for a non-core transmitter group, especially syphilis. Truck drivers were the most at risk. Multivariable analyses revealed exposure to FSW and inconsistent condom use, along with geographical location (Papua vs non-Papua) and unobserved factors associated with certain occupational groups, to be key risk factors for STI infection.

CONCLUSIONS: The results confirm that men in the four occupational groups are reasonable proxies for "high-risk men" for surveillance purposes in Indonesia. Although HIV prevalence was low, the extent of sexual risk taking and the moderately high levels of STI among these men, along with rising HIV rates among FSW, indicate the potential for HIV/AIDS transmission in Indonesia to accelerate.

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4. Sexual behaviour and HIV/sexually transmitted infection risk behaviours in the general population of Slovenia, a low HIV prevalence country in central Europe

Authors: Klavs I 1; Rodrigues LC 2; Wellings K 2; Weiss HA 2; Hayes R 2
Institutions: 1 Institute of Public Health of the Republic of Slovenia, Ljubljana, Slovenia; 2 London School of Hygiene and Tropical Medicine, London, UK
Source: Sexually Transmitted Infections Apr2009; 85(2): 132-8. [Epub before print]

ABSTRACT

OBJECTIVES: To describe sexual and HIV/sexually transmitted infection (STI) risk behaviours in Slovenia.

METHODS: A nationally representative cross-sectional survey of the general population aged 18-49 years in 1999-2001 was conducted. The data were collected by face-to-face interviews and anonymous self-administered questionnaires. Statistical methods for complex survey data were used.

RESULTS: 849 men and 903 women were interviewed. In the past 5 years, both men and women reported a median of one heterosexual partner (means 3.2, 1.5, respectively), concurrent heterosexual partnerships were reported by 24.4% of men and 8.2% of women, heterosexual sex with non-Slovenian partners by 12.6% of men and 12.2% of women, forced sex by 4.8% of women, paid heterosexual sex by 2.6% of men, sex with another man by 0.6% of men and heterosexual sex with an injecting drug user by 1.2% of men and 1.3% of women. In the past year, 22.7% of men and 9.5% of women reported forming at least one new heterosexual partnership. The mean numbers of episodes of heterosexual sex in the previous 4 weeks were 6.1 for men and 6.0 for women. Consistent and inconsistent condom use was reported more frequently among men reporting multiple female partners and those not married or cohabiting.

CONCLUSIONS: Recent patterns of reported sexual behaviour are consistent with a low risk of HIV and STI transmission in Slovenia. The results will inform Slovenian sexual health policies including HIV/STI prevention, and are particularly valuable because population-based data on HIV/STI risk behaviour have not previously been available in low HIV prevalence countries of central Europe.

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MALE CIRCUMCISION

5. The effects of male circumcision on female partners' genital tract symptoms and vaginal infections in a randomized trial in Rakai, Uganda

Authors: Gray RH 1; Kigozi G 2; Serwadda D 3; Makumbi F 2; Nalugoda F 2; Watya S 4; Moulton L 1; Chen MZ 1; Sewankambo NK 2,5; Kiwanuka N 2,3; Sempijja V 2; Lutalo T 2; Kagayii J 2; Wabwire-Mangen F 2,3; Ridzon R 6; Bacon M 7; Williams C 7; Wawer MJ 1
Institutions: 1 Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD; 2 Rakai Health Sciences Program, Entebbe, Uganda; 3 Makerere University, School of Public Health, Kampala, Uganda; 4 Mulago Hospital/Makerere University, Department of Urology, Kampala, Uganda; 5 Makerere University, School of Medicine, Kampala, Uganda; 6 Bill & Melinda gates Foundation, Seattle, WA; 7 National Institutes of Health, National Institutes of Allergy and Infectious Diseases, Division of AIDS, Bethesda, MD
Source: American Journal of Obstetrics and Gynecology Jan 2009; 200(1): 42.e1-7. [PubMed Central]

ABSTRACT

OBJECTIVE: The objective of the study was to assess effects of male circumcision on female genital symptoms and vaginal infections.

STUDY DESIGN: Human immunodeficiency virus (HIV)-negative men enrolled in a trial were randomized to immediate or delayed circumcision (control arm). Genital symptoms, bacterial vaginosis (BV), and trichomonas were assessed in HIV-negative wives of married participants. Adjusted prevalence risk ratios (adjPRR) and 95% confidence intervals (CIs) were assessed by multivariable log-binomial regression, intent-to-treat analyses.

RESULTS: A total of 783 wives of control and 825 wives of intervention arm men were comparable at enrollment. BV at enrollment was higher in control (38.3%) than intervention arm spouses (30.5%, P = .001). At 1 year follow-up, intervention arm wives reported lower rates of genital ulceration (adjPRR, 0.78; 95% CI, 0.63-0.97), but there were no differences in vaginal discharge or dysuria. The risk of trichomonas was reduced in intervention arm wives (adjPRR, 0.52; 95% CI, 0.05-0.98), as were the risks of any BV (adjPRR, 0.60; 95% CI, 0.38-0.94) and severe BV (prevalence risk ratios, 0.39; 95% CI, 0.24-0.64).

CONCLUSION: Male circumcision reduces the risk of ulceration, trichomonas, and BV in female partners.

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6. Male circumcision for the prevention of HSV-2 and HPV infections and syphilis

Authors: Tobian AA 1; Serwadda D 6; Quinn TC 2,8; Kigozi G 7; Gravitt PE 3; Laeyendecker O 2,8; Charvat B 4; Ssempijja V 7; Riedesel M 8; Oliver AE 2; Nowak RG 3; Moulton LH 5; Chen MZ 4; Reynolds SJ 2,8; Wawer MJ 4; Gray RH 4
Institutions: 1 Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD; 2 Department of Medicine, School of Medicine, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; 3 Department of Epidemiology and Molecular Microbiology and Immunology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; 4 Department of Population, Family, and Reproductive Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; 5 International Health and Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; 6 Institute of Public Health, Makerere University, Kampala Uganda; 7 Rakai Health Sciences Program, Entebbe, Uganda; 8 Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
Source: New England Journal of Medicine 26 Mar 2009; 360(13): 1298-309.

ABSTRACT

BACKGROUND: Male circumcision significantly reduced the incidence of human immunodeficiency virus (HIV) infection among men in three clinical trials. We assessed the efficacy of male circumcision for the prevention of herpes simplex virus type 2 (HSV-2) and human papillomavirus (HPV) infections and syphilis in HIV-negative adolescent boys and men.

METHODS: We enrolled 5534 HIV-negative, uncircumcised male subjects between the ages of 15 and 49 years in two trials of male circumcision for the prevention of HIV and other sexually transmitted infections. Of these subjects, 3393 (61.3%) were HSV-2-seronegative at enrollment. Of the seronegative subjects, 1684 had been randomly assigned to undergo immediate circumcision (intervention group) and 1709 to undergo circumcision after 24 months (control group). At baseline and at 6, 12, and 24 months, we tested subjects for HSV-2 and HIV infection and syphilis, along with performing physical examinations and conducting interviews. In addition, we evaluated a subgroup of subjects for HPV infection at baseline and at 24 months.

RESULTS: At 24 months, the cumulative probability of HSV-2 seroconversion was 7.8% in the intervention group and 10.3% in the control group (adjusted hazard ratio in the intervention group, 0.72; 95% confidence interval [CI], 0.56 to 0.92; P=0.008). The prevalence of high-risk HPV genotypes was 18.0% in the intervention group and 27.9% in the control group (adjusted risk ratio, 0.65; 95% CI, 0.46 to 0.90; P=0.009). However, no significant difference between the two study groups was observed in the incidence of syphilis (adjusted hazard ratio, 1.10; 95% CI, 0.75 to 1.65; P=0.44).

CONCLUSIONS: In addition to decreasing the incidence of HIV infection, male circumcision significantly reduced the incidence of HSV-2 infection and the prevalence of HPV infection, findings that underscore the potential public health benefits of the procedure. (ClinicalTrials.gov numbers, NCT00425984 and NCT00124878.) 2009 Massachusetts Medical Society

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7. Acceptability of infant male circumcision as part of HIV prevention and male reproductive health efforts in Gaborone, Botswana, and surrounding areas

Authors: Plank RM 1,2,3; Makhema J 2; Kebaabetswe P 4; Hussein F 5; Lesetedi C 5,6; Halperin D 7; Bassil B 8; Shapiro R 2,3,9; Lockman S 1,2,3
Institutions: 1 Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA; 2 Botswana-Harvard School of Public Health AIDS Initiative for HIV Research and Education, Gaborone, Botswana; 3 Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, MA; 4 Centers for Disease Control and Prevention Botswana, USA (BOTUSA), Gaborone, Botswana; 5 Botswana National Ministry of Health, Gaborone, Botswana; 6 Princess Marina Hospital Department of Surgery, Gaborone, Botswana; 7 Department of Global Health and Population, Harvard School of Public Health, Boston, MA; 8 Boston, MA; 9 Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA
Source: AIDS and Behavior 19 Nov 2009; doi: 10.1007/s10461-009-9632-0. [Epub ahead of print]

ABSTRACT

Adult male circumcision reduces a man's risk for heterosexual HIV acquisition. Infant circumcision is safer, easier and less costly but not widespread in southern Africa. Questionnaires were administered to sixty mothers of newborn boys in Botswana: 92% responded they would circumcise if the procedure were available in a clinical setting, primarily to prevent future HIV infection, and 85% stated the infant's father must participate in the decision. Neonatal male circumcision appears to be acceptable in Botswana and deserves urgent attention in resource-limited regions with high HIV prevalence, with the aim to expand services in safe, culturally acceptable and sustainable ways.

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HIV AND PREVENTION WITH POSITIVES

8. Sex after ART: Sexual partnerships established by HIV-infected persons taking anti-retroviral therapy in Eastern Uganda

Authors: Seeley J a; Russell S a; Khana K b; Ezati E b; King R b; Bunnell R b
Institutions: a School of Development Studies, University of East Anglia, Norwich, UK; b Global AIDS Program, Centers for Disease Control and Prevention-Entebbe, Uganda
Source: Culture Health & Sexuality Oct 2009; 11(7): 703-16. [PubMed]

ABSTRACT

This paper explores the social contexts that influence the formation and nature of sexual partnerships among people on anti-retroviral therapy (ART). We draw on the findings of a qualitative, longitudinal study of 70 people (36 women and 34 men) who have been participating in a home-based ART programme for over three years in Eastern Uganda. Since initiating ART, 32 (18 men and 14 women) participants reported having had a new partner. Five participants (4 men and 1 woman) renewed relationships with spouses with whom they had been prior to starting ART. Overall, 37 of the 70 participants had had a sexual partner after starting ART. Companionship, material support, social and cultural norms, as well as a desire for sex and children, are drivers of new relationships. The opportunity that ART brings for people to get on with their lives brings with it a reinstatement into a social world that places a value on marriage and child-bearing. The sexual rights of those living with HIV and on ART need to be taken seriously and safer sex facilitated.

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9. Changes in sexual risk taking with antiretroviral treatment: Influence of context and gender norms in Mombasa, Kenya

Authors: Sarna A a; Chersich M b; Okal J b; Luchters SM c; Mandaliya KN d; Rutenberg N e; Temmerman M c
Institutions: a Population Council, New Delhi, India; b International Centre for Reproductive Health, Mombasa, Kenya; c International Centre for Reproductive Health, Ghent University, Belgium; d Coast Provincial General Hospital, Mombasa, Kenya; e Population Council, New York, NY
Source: Culture Health & Sexuality Nov 2009; 11(8): 783-97. [PubMed]

ABSTRACT

In-depth interviews were conducted with 23 sexually-active adults receiving antiretroviral treatment (ART) in Mombasa Kenya to understand changes in sexual behaviour after treatment initiation and factors influencing condom use. Advanced HIV disease had previously led to marked decreases in sexual desire and function. After HIV testing, numbers of partners reduced and monogamous relationships began to predominate. Receipt of ART strengthened these changes, while improving sexual health. However, concurrent sexual partnerships continue within polygamous marriage and unprotected sex occurs with regular partners, even those who are HIV-negative. Those who used condoms inconsistently prior to ART often remained inconsistent users thereafter. While disclosure of HIV status appeared to support condom use, this does not always predict protected sex. In addition to classic perceptions about condom's effect on intimacy and trust, traditional gender roles, misconceptions about potential harm from condoms and fertility desires hinder condom use.

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10. Prevalence and contexts of inconsistent condom use among heterosexual men and women living with HIV in India: Implications for prevention

Authors: Chakrapani V 1; Newman PA 2; Shunmugam M 1; Dubrow R 3
Institutions: 1 Indian Network for People Living with HIV/AIDS (INP+), Chennai, India; 2 University of Toronto Faculty of Social Work/Centre for Applied Social Research, Toronto, Ontario, Canada; 3 Yale School of Public Health, Yale School of Medicine, New Haven, CT
Source: AIDS Patient Care and STDS Jan 2010; 24(1): 49-58.

ABSTRACT

This investigation examined sexual behaviors among heterosexual persons living with HIV (PLHIV) in India. Study participants (mostly married) were interviewed during August to November 2006 in five Indian states using a quantitative survey (n = 100 men and 100 women), eight focus groups (n = 58 participants), and in-depth interviews (n = 31). One third of men and one fourth of women reported inconsistent condom use with regular sexual partners. Facilitators of condom use with regular partners included a feeling of personal responsibility to protect the health of the partner, desire to prevent acquisition and/or transmission of sexually transmitted infections, and the belief that condoms are needed for antiretroviral therapy to be effective. Barriers to consistent condom use with regular partners included the belief that condoms are unnecessary in HIV-positive seroconcordant relationships; lack of sexual satisfaction with condoms; the desire to have a child; husband's alcohol use, depression, and anxiety; fear that disclosure of HIV status will bring marital discord and family shame; and inadequate counseling by health care providers. Positive prevention programs should include counseling about benefits of safer sex in HIV-positive seroconcordant relationships, counseling about integrating condom use with sexual satisfaction and intimacy, condom use self-efficacy and negotiation skills-building, family planning counseling, mental health and alcohol dependence treatment, and counseling and skills-building about disclosure. Health care providers must be trained to provide these services. Furthermore, efforts are needed to promote tolerance for family planning choices made by couples and to counter the stigma associated with HIV/AIDS and condoms in the broader society.

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