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Learn More. The datasets analysed during the current study are available from the corresponding author on reasonable request. There is a need for valid approaches to measure sexual interactions to assess the impact of behavioural interventions and to predict the impact of behaviour changes.
Different methods of asking about sexual behaviour often yield conflicting answers and men often report higher levels of heterosexual activity than women. To better understand self-reported sexual behaviour data and how best to collect it, we analyzed data collected as part of a larger project ST IMPACTS on the social and behavioural impact of introducing community-level HIV self-testing HIVST with counseling semi-supervised with pre- and generic post-test counseling provided on delivery or collection of test kits in an urban Malawian setting.
Information on sexual behaviour was collected from HIV self-testers over a three-month period. Both retrospective instruments were used before and after the three-month study period. Frequency and cross-tabulation, as well as scatterplots, were used for exploratory analyses. Chi-square tests were used to test for differences in proportions. There was reasonable agreement between the two retrospective methods although both yielded inconsistent answers e.
The diary method elicited higher reported levels of sex with multiple partners than both retrospective instruments which may be due to inadequate recall. Over the study period There was no clear relationship between reported sexual behaviour and HIV status prevalence 9.
Sex partners in Liverpool may therefore have higher validity for sensitive behaviour reporting and thus be the preferred method in similar African contexts in measuring sexual behaviours. The online version of this article Nevertheless, HIV morbidity and mortality are still having devastating effects on affected populations [ 1 ]. Although the roll-out of Antiretroviral Therapy ART during the last decade has dramatically reduced HIV-related morbidity and mortality, our ultimate goal should still be elimination of the virus, at least as a generalized epidemic [ 2 ] which requires substantial reductions in transmission [ 3 ].
Still, difficulties in identifying all HIV infected individuals and maintaining them on treatment suggest that without behaviour change, the prospects of elimination may be limited [ 5 ]. There is an increase in the of interventions that target uninfected individuals, such as Pre-Exposure Prophylaxis PrEPand microbicidal vaginal gels; but limited availability and poor adherence limit their Sex partners in Liverpool [ 6 ].
An important goal of HIV prevention remains reducing sexual risk behaviours in both HIV-infected and uninfected individuals. Both the of sexual contacts between HIV positive and negative individuals, and behaviours that affect the risk of transmission during such contacts, such as consistent condom use, ART use, or male circumcision determine this risk [ 7 ].
There is a need for valid approaches to monitor and measure sexual interactions in order to assess the impact of behavioural interventions and to predict the impact of behaviour changes - either as the consequence of interventions, autonomous changes, or because of selection for lower risk behaviour. Sexual behaviour however, is a private activity, surrounded by gender norms, societal proscriptions and prescriptions, and notoriously challenging to measure.
While asking people about their sexual behaviour may sound easy in principle, it can be difficult in practice. Different methods of asking about sexual behaviour often yield conflicting answers and men often report higher levels of heterosexual activity, such as s of partners or of sexual acts with a partner, than women, which is improbable [ Sex partners in Liverpool ].
It has been suggested that this is mostly due to underreporting by women rather than over-reporting by men [ 11 ]. Another methodological problem is that the validity of instruments, e. Validation of instruments should therefore, preferably, be replicated in each study population. To understand better self-reported sexual data and how best to collect it, we analyzed data from a larger project ST IMPACTS on the social and behavioural Sex partners in Liverpool of introducing community-level HIV self-testing HIVST with counseling semi-supervised with pre and generic post-test counseling provided on delivery or collection of test kits in an urban Malawian setting.
The parent project focused specifically on gender-based violence, sexual risk taking, and risk-compensation in the context of self-testing. In this sub-study, we estimate levels of multiple partner sex over a three-month period, using three different instruments: an Audio Computer Assisted Self Interview ACASIa Face to Face Interview FTFI with a specially trained field worker, both retrospective over the past 3 months, and a prospective self-completed pictorial diary. By comparing from these methods, we aim to obtain better information on sexual behaviours relevant for HIV transmission and validate these instruments for this setting.
The best instrument could then be further validated for its suitability to monitor behaviour change within urban Malawian and other contexts. Of these were re-contacted at home by counselors to discuss whether they would participate in our sub study on sexual behaviour and gender-based violence. Among these 16 dropped out between initial verbal agreement to participate and formal enrolment in the study and were replaced.
All individuals who accepted HIV self-test kits were eligible, whether or not they actually tested following the acceptance of the kits. We finally recruited participants see Fig. Participants included both individuals and couples normally resident in poor, high density, areas of urban Blantyre, the second largest city of Malawi with high levels of in- and out migration.
Confirmatory HIV testing and onward referral were offered to all participants. Nic, the s appear inconsistent. If the 16 were replaced thn the recruited are not Please check. The diary tool was developed through a collaborative and iterative process with an artist and community groups to optimize comprehension and acceptability. Following a short pilot study to assess whether the instruments were understood and testing feasibility of the study, and following information sharing and written consent, all participants were requested to complete a short enrolment questionnaire using ACASI with both oral and visual presentation of questions to address literacy issues [ 15 — 18 ].
In all cases this was followed later that day by an FTFI carried out by field workers gender matched to the participant using a questionnaire with visual recall aides. Information was elicited consistently across FTFI and ACASI on socio-demographic variables such as age, sex, marital status, surviving children, and also on HIV testing behaviour, disclosure of HIV to partners, any incidents of gender-based violence GBVSex partners in Liverpool testing, and history of sexual behaviour cf.
Sexual behaviour questions asked about life-time sexual partners, sexual partners in the past 3 months, and type of partner, e. Participants were then asked to complete a daily pictorial diary for a three-month study period each diary covered a period of 2 weeks with a total of 6 diaries per participant for the 12 week diary study period. Those who agreed received full training before taking the diary home. This diary included data on, sexual behaviour, household dynamics, disclosure and incidents of gender-based violence as well as coercive testing.
Diary completion was monitored and supported through regular, formal visits every 2 weeks to collect the diary and informal visits on an ad hoc basis to participants to address any concerns and ensure that the diary was being completed daily [ 19 — 21 ].
Data on the three sources of reported behaviour were then compared and triangulated. Continuous and ordinal variables were generally reported as median and interquartile range IQR. HIV positive participants were on average 1. With one exception atheistall others reported to be Muslims. Marital status was classified in baseline FTFI. Table 1 shows the marital status at the two time points reported by each of the two Sex partners in Liverpool instruments.
For one participant, the difference was the other way around. We do not know what has caused these differences between the two instruments. Self-reported marital status and sexual behaviour, both at baseline pre and after 3 months post. As expected there was some fluidity in household arrangements.
After 3 months, five participants reported having separated FTFIwhile nine participants had reportedly entered into a cohabiting arrangement. The mean reported of living children was 2. As a measure of current and recent sexual activity, we looked at the self-reported of partners in the past 3 months.
Through the FTFI, women and men reported a mean of sex partners during the last 3 months of 1. Over the three-month period 4. For FTFI these proportions were 2. These percentages were both lower than those reported by the diary method. By ACASI, 5 of the women one of them HIV-positive and 7 of the men reported never having had sex at baseline which declined to 2 and 3 respectively after 3 months.
These kinds of inconsistencies in response have also been observed in other contexts e. Ugandaand thus do not seem to be confined to this Malawian population [ 22 ]. We therefore considered it not possible to reliably estimate the rate of acquisition of new partners from the increase in reported life-time sex partners or to reliably estimate the of life time sexual partners.
Participants were not asked explicitly whether they practiced transactional sex.
In many African cultures, including within Malawi, gifts, often some money, from men to women are an accepted — even desirable - practice and do not have the same association with sex work as it perhaps would in Western cultures [ 2324 ].
Many sexual partners, however, suggests that money may have been an important motivation for engaging in sex. Only one woman voluntarily disclosed being a sex worker at the time of the study. Table 2 presents several key sexual behaviour parameters reported by 3-month coital diaries. Women reported a median of Married participants reported a median of There was a large gender discrepancy in the reported of sex acts with cohabiting partners.
While women including those reporting no sex with a cohabiting partner reported a median of In men For women these percentages were There was no discrepancy in the of sex acts with the cohabiting partner in individuals in recruited couples. s of sex acts reported by both partners within a couple appear to be in reasonable agreement as shown in the figure below Fig.Sex partners in Liverpool
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