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Purpose Trust is an essential component of romantic relationships. It is not understood how youth respond to a relationship stressor, which may impact trust, such as perceiving to be at risk for a sexually transmitted infection or their partner has other sex partners. We used a system science approach to examine feedback between trust and prorelationship behaviors within adolescent relationships. Methods A prospective cohort of clinic-recruited young women (N = 122), aged 16–19 years, completed daily questionnaires on partner-specific feelings and risk perceptions for 18 months. Relationship stressor defined as either perceiving the risk of sexually transmitted infection from a partner or partner had other sex partners. Prorelationship behaviors were more time spent with partner, sex with partner, and/or gift from partner. Time-lagged generalized estimating equation models were used to examine whether a relationship stressor is associated with a decrease in trust and whether prorelationship behaviors changed following the stressor. Results Experiencing a stressor was associated with threefold increased odds of having a decrease in trust in the same week (odds ratio [OR] = 3.30, 95% confidence interval [CI]: 2.30–4.72). Trust increased significantly the week following the stressor (OR = 2.09, 95% CI: 1.54–2.85). An increase in trust relative to the week of the stressor was associated with a 65% increase in prorelationship behavior in the week following the stressor (OR = 1.65, 95% CI: 1.20–2.26). Conclusions Data uniquely show that trust is impacted following a relationship stressor and that youth increase prorelationship behaviors following a drop in trust. The findings suggest that adolescents prioritize maintaining trust, which may impact engagement in protective health behaviors.

Current pelvic inflammatory disease (PID) treatment effectively treats Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT). However, coverage may be inadequate for Mycoplasma genitalium (MG)/Trichomonas vaginalis (TV) infections. We compared the longitudinal MG and TV outcomes with NG/CT outcomes for women enrolled in a longitudinal randomized controlled trial to optimize outcomes after PID. The prevalences of CT and NG were lower at 30- and 90-day follow-up compared with the prevalence at the time of diagnosis. No significant difference was observed for MG (odds ratio, 0.95; 0.86-1.04; P = 0.265) and TV (odds ratio, 0.89; 0.75-1.04; P = 0.146) over time for both treatment groups, showing that persistence and/or reinfection with MG and TV occurs more frequently than with CT or NG after treatment of PID using current national treatment guidelines.

Background In Cystic Fibrosis (CF), adherence to pulmonary medications is about 50% and decreases during adolescence. Effective interventions have not been integrated into CF care. This effectiveness study tested a brief, clinic-based behavioral intervention to improve adherence. Methods iCARE (I Change Adherence and Raise Expectations) was a pragmatic, clustered, 2-arm randomized controlled trial at 18 CF Centers. 607 adolescents with CF, ages 11–20 years, participated. Centers were randomized to IMPACT (n = 9; 300 adolescents), a brief problem-solving + education intervention, or standard care (SC; n = 9; 307 adolescents). IMPACT was delivered during a regularly scheduled clinic visit by a member of the clinical care team. The primary outcome was composite pulmonary medication possession ratio (cMPR); secondary endpoints were lung function, Body Mass Index percentile, courses of IV antibiotics, and health-related quality of life at 12 months. Results Effectiveness of the intervention was tested using mixed models, generalized estimating equations comparing IMPACT to SC. Fifty-eight percent of problem-solving sessions targeted barriers to airway clearance, exercise or nutrition, while 18% addressed pulmonary medications. Average intervention fidelity score was 67% (SD = 14%; Range = 25–100%). No significant intervention effects were found for cMPR or any of the secondary outcomes compared to SC. Conclusions The IMPACT intervention did not improve medication adherence or health outcomes over 12 months. Challenges to implementing the intervention as intended during busy clinic visits were identified. Trial Registry ClinicalTrials.gov; No.: NCT01232478; URL: www.clinicaltrials.gov.

OBJECTIVE: Asthma disproportionately affects minority groups, low income populations, and young children under 5. Head Start (HS) programs predominantly serve this high-risk population, yet staff are not trained on asthma management. The objective of this study was to assess a 5-year, multicomponent HS staff asthma education program in Baltimore City HS programs. METHODS: All HS programs were offered annual staff asthma education by a medical research team that included didactic lectures and hands-on training. Attendees received continuing education credits. HS staff were anonymously surveyed on asthma knowledge and skills and asthma medication management practices in Year 1 (preimplementation) and Year 5. RESULTS: There was an estimated response rate of 94% for Year 1 and 82% for Year 5. Compared to staff in Year 1, Year 5 staff were significantly more likely to report they had very good knowledge and skills related to asthma [odds ratio (OR) 1.63; p < 0.05] and were engaged in asthma care activities (OR 2.02; p < 0.05). Self-reported presence of asthma action plans for all children with asthma was 82% at Year 1 and increased to 89% in Year 5 (p = 0.064). CONCLUSIONS: Year 5 HS staff reported higher self-assessed knowledge and skills, self-reports of asthma medication management practices, and self-reports of asthma activities compared to Year 1 staff. HS serves high-risk children with asthma, and a multicomponent program can adequately prepare staff to manage asthma in the child care setting. Our results indicate the feasibility of providing efficacious health skill education into child care provider training to reduce asthma knowledge gaps.

Adolescent and young adult women disproportionately experience Pelvic Inflammatory Disease (PID) as a complication of Sexually Transmitted Infections (STIs). This study seeks to understand the relationship context, changes in sexual behavior, and impact of partner sexual behavior on recurrent STI diagnoses at 3-months post-diagnosis. Adolescents and young adult women 13-25 were recruited from an outpatient disposition from an outpatient clinic, and pediatric and adult emergency rooms. Participants received treatment at baseline and follow-up at 2-weeks, 1-month and 3-month post-diagnosis, including interviews about personal and partner sexual behaviors and STI screening (n = 94). At the 2-week interview, 53% of participants (50/94) believed they could acquire an STI from their current partner if they did not use a condom. However, at 3-month follow-up only 35% reported condom usage at last sex. At 3-month follow-up, 55% (50/91) of participants were still in a sexual relationship with the previously reported partner and 38% of participants who reported they could get an STI from their partner were diagnosed with an STI; compared with 25% of participants who predicted that they could not get an STI (OR 1.85; 95% CI: 0.67-5.30). There was no association between maintaining the same partner and having an STI at 3-months (OR 0.5; 95% CI: 0.27-1.96). Most young women diagnosed with PID report exclusive relationships, but are simultaneously aware of their risk for recurrent STIs. Given the short-term stability of many relationships, couples interventions are an unexplored opportunity for prevention of recurrent STIs after PID.

While HIV is prevalent among adolescents and young adults, testing levels remain low and little is known about gender differences in HIV testing. The objectives of this study were to describe the prevalence of past-year HIV testing and evaluate associations between HIV testing and individual- and partner-level factors by gender among heterosexually experienced youth (15-24 years) in Baltimore, Maryland (N = 352). Past-year HIV testing was prevalent (60.1%) and differed by gender (69.4% among women vs. 49.6% among men, p = 0.005). For women, African-American race (AOR 3.09) and recent older partner by ≤2 years (AOR 4.04) were significantly associated with testing. Among men, only African-American race was associated with testing (OR 4.23), with no patterns identified based on risk behavior or perceived partner risk. HIV testing among adolescent and young adults was prevalent in this highly affected urban area. Findings emphasize the value of a gender lens, and provide direction for optimizing engagement in HIV testing.

ObjectivesFeelings of intimacy, perceptions of partner concurrency (PPC) and perceptions of risk for an STD (PRSTD) are meaningful and dynamic attributes of adolescent sexual relationships. Our objective was to examine whether variations in these STI-associated feelings and perceptions predicted incident Chlamydia trachomatis and/or Neisseriagonorrhoeae infection within a prospective cohort of urban adolescent women.MethodsA cohort of clinic-recruited women aged 16–19 completed daily surveys on feelings and risk perceptions about each current sex partner on a smartphone continuously for up to 18 months. Urine was tested for C. trachomatis and N. gonorrhoeae every 3 months. Daily responses were averaged across the week. As overall means for trust, closeness and commitment were high, data were coded to indicate any decrease in feelings from the previous week. PRSTD and PPC were reverse coded to indicate any increase from the previous week. An index was created to examine the cumulative effect of variation in these feelings and perceptions. Generalised linear models were used to account for correlation among repeated measures within relationships.ResultsFor each week that there was a decrease in trust, there was a 45% increase in the risk of being infected with an STI at follow-up (relative risk (RR) 1.45, 95% CI 1.18 to 1.78, P=0.004). Neither a decrease in closeness or commitment, nor an increase in PRSTD or PPC was associated with an STI outcome. Cumulatively, the index measure indicated that a change in an additional feeling or perception over the week increased the odds of an STI by 14% (RR 1.14, 95% CI 1.02 to 1.29, P=0.026).ConclusionsA decrease in feelings of trust towards a main partner may be a more sensitive indicator of STI risk than PRSTD, PPC or commitment. The next generation of behavioural interventions for youth will need strategies to address feelings of intimacy within adolescent romantic relationships.

Beliefs about medication have been associated with adherence in other diseases but there are no existing disease-specific medication beliefs questionnaires for CF. This mixed-methods validated the Cystic Fibrosis Medication Belief Questionnaire (CF-MBQ), based on social cognitive theory.Based on previous research, items were developed for five domains: motivation, self-efficacy, perceived importance, and decisional balance to take or miss medications. Cognitive interviews were conducted with 15 adult patients with CF to refine item development. 128 patients with CF completed an online survey and objective medication adherence was measured using pharmacy refill data.The five subscales demonstrated strong psychometric properties, with adequate-to-good internal consistency scores. More importantly, each domain demonstrated construct validity with adherence.These theoretically-derived measures may be important for clinical purposes to provide guidance on appropriate interventions to improve adherence and for research to provide enhanced understanding on patient determinants of medication adherence.

Objective. To evaluate the longitudinal impact of a 9-month text message intervention on participant adherence beyond the intervention to highly effective contraceptive methods among urban adolescent and young adult women enrolled in the DepoText randomized control trial (RCT). Study Design. Retrospective longitudinal cohort study of long-term follow-up data from the DepoText RCT. Sixty-seven female participants (aged 13-21 years) using depot medroxyprogesterone acetate (DMPA) were recruited from an urban academic adolescent practice in Baltimore, Maryland. The principal outcome measured was a comparison of contraceptive method choice between the control and intervention groups during the 20 months postintervention. Results. Intervention participants were 3.65 times more likely to continue using DMPA or a more efficacious method at the 20-month postintervention evaluation (odds ratio 3.65, 95% CI 1.26-10.08; P = .015). Conclusion. Participation in the DepoText trial was associated with continued use of DMPA or a more effective contraceptive method almost 20 months after the intervention exposure ended.

Improved survival after cardiac arrest has placed greater emphasis on neurologic resuscitation. The purpose of this pilot study was to evaluate the relationship between cerebrovascular autoregulation and neurologic outcomes after pediatric cardiac arrest.Children resuscitated from cardiac arrest had autoregulation monitoring during the first 72h after return of circulation with an index derived from near-infrared spectroscopy in a pilot study. The range of mean arterial blood pressure (MAP) with optimal vasoreactivity (MAPOPT) was identified. The area under the curve (AUC) of the time spent with MAP below MAPOPT and MAP deviation below MAPOPT was calculated. Neurologic outcome measures included placement of a new tracheostomy or gastrostomy, death from a primary neurologic etiology (brain death or withdrawal of support for neurologic futility), and change in the Pediatric Cerebral Performance Category score (ΔPCPC).Thirty-six children were monitored. Among children who did not require extracorporeal membrane oxygenation (ECMO), children who received a tracheostomy/gastrostomy had greater AUC during the second 24h after resuscitation than those who did not (P=0.04; n=19). Children without ECMO who died from a neurologic etiology had greater AUC during the first 48h than did those who lived or died from cardiovascular failure (P=0.04; n=19). AUC below MAPOPT was not associated with ΔPCPC when children with or without ECMO were analyzed separately.Deviation from the blood pressure with optimal autoregulatory vasoreactivity may predict poor neurologic outcomes after pediatric cardiac arrest. This experimental autoregulation monitoring technique may help individualize blood pressure management goals after resuscitation.

This research examined the association between a novel measure of perceived partner availability and discordance between ideal and actual partner characteristics as well as trajectories of ideal partner preferences and perceptions of partner availability over time.A clinic-recruited cohort of adolescent females (N = 92), aged 1619 years, were interviewed quarterly for 12 months using audio computer-assisted self-interview. Participants ranked the importance of characteristics for their ideal main sex partner and then reported on these characteristics for their current main partner. Participants reported on perceptions of availability of ideal sex partners in their neighborhood. Paired t-tests examined discordance between ideal and actual partner characteristics. Random-intercept regression models examined repeated measures.Actual partner ratings were lower than ideal partner preferences for fidelity, equaled ideal preferences for emotional support and exceeded ideal preferences for social/economic status and physical attractiveness. Discordance on emotional support and social/economic status was associated with sex partner concurrency. Participants perceived low availability of ideal sex partners. Those who perceived more availability were less likely to be ideal/actual discordant on fidelity [OR = .88, 95% CI: .78, 1.0]. Neither ideal partner preferences nor perceptions of partner availability changed over 12 months.Current main sex partners met or exceeded ideal partner preferences in all domains except fidelity. If emotional needs are met, adolescents may tolerate partner concurrency in areas of limited partner pools. Urban adolescent females who perceive low availability may be at increased risk for sexually transmitted infection (STI) because they may be more likely to have nonmonogamous partners.

Objective. To determine the level of nurse case management and outreach required to notify young women with sexually transmitted infection (STI) positive test results after pelvic inflammatory disease (PID) and percent seeking treatment. Methods. Participants (N = 153) were enrolled in a clinical trial of young women diagnosed with PID and followed for 3 months for recurrent STIs. Vaginal swabs were obtained at 1 and 3 months. All participants were notified of positive STIs at 1 and 3 months and treatment arranged. Data were analyzed with logistic regression for comparison of treatment status by number of nurse contacts. Results. Over the 3-month period, 59 participants (38.6%) tested positive for one or more STIs and all received notification. Only 50% (19/38) of participants with STI at 1 month and 43% (16/37) at 3 months received treatment. Conclusions. Despite the high notification rate of positive test results for young adults with recurrent STIs, many failed to seek treatment.

Objectives A core construct targeted by behavioural interventions is the perception that one is at risk for acquiring a sexually transmitted disease (STD). The objective of this analysis was to examine the role of intimacy on perceptions of risk for an STD (PRSTD) and condom use within late adolescent females9 main relationships. Methods A clinical sample of African–American women aged 14–19 years at enrolment were followed prospectively for 3 years. At each semiannual interview, participants reported their partner-specific PRSTD, feelings of intimacy, perceptions of partner9s concurrency and condom use at last sex for each of their main sex partners. Results A total of 285 individuals reported 724 main relationships. Using generalised estimating equations, intimacy was negatively associated with risk perception, after adjusting for perceptions of partner concurrency (OR: 0.68; 95% CI 0.60 to 0.76). PRSTD was no longer associated with condom use after adjusting for intimacy (OR: 1.30; 95% CI 0.83 to 2.02. Conclusions Intimacy was found to be associated with risk perception and condom use within adolescent main relationships. Adolescents may not view their intimate partners as sources of infection. The success of individual-level STD prevention efforts, such as condom promotion, might be limited as condoms may be in conflict with adolescents9 expectations about intimate relationships.

Purpose Epidemic levels of sexually transmitted infections (STIs) among urban youth have drawn attention to the potential role of sex partner selection in creating risk for STIs. The objectives of this study were to describe the ideal preferences and real selection of sex partners, to evaluate sex partner ideal versus real discordance using quantitative methods, and to determine the association between discordance and STI risk behaviors. Methods Data are obtained from an urban, household sample of 429 individuals aged 15–24 years. Trait clusters were developed for participants' ratings of their real and ideal sex partners and tested for reliability. Discordance between the ratings of real and ideal partners was measured. Logistic regression was used to assess associations between sex partner discordance and STI risk behaviors. Results Ratings of the real sex partners were often lower than participants' ideal sex partner ratings. A total of 33% of male adolescents and young men and 66% of female adolescents and young women were discordant on at least one trait cluster. Male adolescents and young men who were discordant on the emotional support they expected of their partner were more likely to report more than two sex partners in the past 90 days (odds ratio=2.13, 95% confidence interval: 1.06–4.26) and perceived partner concurrency (odds ratio=3.85, 95% confidence interval: 1.53–9.72). For female adolescents and young women, discordance on fidelity or emotional support significantly increased the odds of all risk behaviors. Conclusion Male and female adolescents with discordant real and ideal sex partner ratings were more likely to report STI-related risk behaviors. Further steps should involve identification of factors associated with ideal versus real sex partner discordance, such as features of the social context.

In this study we explore associations between child and adult victimization and sexual risk behavior in 118 young, HIV positive women. Prior research has demonstrated associations between victimization and engagement in sexual risk behavior. Victimization sequelae can include disrupted assertiveness and communication, as well as increased association with risky partners, both of which are also linked with engagement in sexual risk behavior. Thus, we propose a model wherein victimization is linked to sexual risk behavior through two mediating pathways, sexual communication and affiliation with risky partners. We also examine the moderating effects of the presence of an anxiety or depressive disorder on the path from child to adult victimization. Results suggested that adult victimization was associated with unprotected sex with a main partner; however, this association was mediated by less sexual communication and having a risky partner. Trends toward significance were found for depression and anxiety as a moderator of the relationship between child and adult victimization. Child victimization did not have direct effects on unprotected sex. Implications for secondary prevention of HIV and healthy intimate relationships are discussed.

Objective To describe a pilot programme that consisted of identifying, contacting and providing HIV testing to members of social and sexual networks of HIV-infected youth patients as a part of routine clinical care at an adolescent HIV clinic in Baltimore, Maryland, USA. Methods Forty-nine sexually active HIV-infected adolescent patients were interviewed about their social and sexual contacts at a routine HIV clinic visit. A trained community health worker located these referred social and sexual contacts, and encouraged them to make an appointment for HIV counselling, testing and referral (CTR) services. Results During a period of 18 months, 26 index youths provided locating information on 53 first-generation contacts and these 53 contacts provided information on 16 second-generation contacts. A total of 32 contacts received counselling services and 25 were tested for HIV infection, yielding three new HIV-positive individuals. Conclusion As a part of standard care for regular visits of HIV-infected youth patients, interviewing about their social and sexual contacts could be a viable strategy in identifying high-risk youths for HIV infection and subsequent CTR services.

Objective The objective of this research was to examine the effectiveness of a brief behavioral intervention, provided at the time of diagnosis of pelvic inflammatory disease, on subsequent behaviors by patients who were urban adolescents in a community in which sexually transmitted infection was prevalent. Methods 121 adolescents aged 15 to 21 years with mild to moderate pelvic inflammatory disease were enrolled in a randomized trial. All participants received standardized care, completed baseline audio computerized self-interviews, received full courses of medication at discharge, and were interviewed after the 2-week treatment course. The intervention group also watched a 6-minute intervention video. Main Outcome Measures Medication completion, temporary sexual abstinence during the 14-day treatment period, partner notification, partner treatment, and return for 72-hour follow-up were studied. Data were evaluated using multivariate regression analysis. Results Of the participants, 61% were located and could participate in the 2-week interview by the disease intervention specialist. The intervention participants had higher rates of 72-hour follow-up (32% vs. 16%) and partner treatment (71% vs. 53%) in bivariate analyses at a P = 0.1 level. There were no differences in medication completion (66% vs. 66%), sexual abstinence (78% vs. 89%), or partner notification (88% vs. 92%). Only the partner-treatment finding persisted in multivariate models (AOR = 3.10; 95% CI, 1.03-9.39, P = .045). Conclusions Adolescent girls randomized to a community-specific video intervention at diagnosis of pelvic inflammatory disease were three times more likely to have their partners treated than those in the control group. Given the value of partner treatment in secondary prevention of sexually transmitted diseases, this video may be an essential component of discharge programming in urgent care settings. Additional structural supports may be necessary to facilitate improved adherence to other key adherence behaviors.

Objectives Mindfulness-based stress reduction (MBSR) has been shown to improve mental health and reduce stress in a variety of adult populations. Here, we explore the effects of a school-based MBSR program for young urban males. Participants and methods In fall 2009, 7th and 8th graders at a small school for low-income urban boys were randomly assigned to 12-session programs of MBSR or health education (Healthy Topics—HT). Data were collected at baseline, post-program, and three-month follow-up on psychological functioning; sleep; and salivary cortisol, a physiologic measure of stress. Results Forty-one (22 MBSR and 19 HT) of the 42 eligible boys participated, of whom 95% were African American, with a mean age of 12.5 years. Following the programs, MBSR boys had less anxiety (p = 0.01), less rumination (p = 0.02), and showed a trend for less negative coping (p = 0.06) than HT boys. Comparing baseline with post-program, cortisol levels increased during the academic terms for HT participants at a trend level (p = 0.07) but remained constant for MBSR participants (p = 0.33). Conclusions In this study, MBSR participants showed less anxiety, improved coping, and a possible attenuation of cortisol response to academic stress, when compared with HT participants. These results suggest that MBSR improves psychological functioning among urban male youth.

Stigma in HIV positive persons has been associated with numerous negative sequelae, including decreased social support, depressive symptoms, and engagement in risk behaviors. Few studies examined the interrelationships of these factors to facilitate understanding of the mechanisms by which HIV stigma influences risk behavior, thus the current study focuses on identifying pathways between HIV-related stigma and risk behavior in 147 young HIV positive women. Depression and social support were hypothesized to mediate between HIV-related stigma and risk behavior. Structural equation modeling was used to test these hypothesized pathways, results suggested that depression was a significant mediator between HIV-related stigma and risk behavior. Implications for interventions with young HIV positive women who report high levels of HIV-related stigma include a focus on depression as a method of reducing engagement in risk behavior and improving mental health and health behaviors in persons living with HIV.

Significant numbers of adolescents are initiating sexual activity at age 13 and younger. Little is known about this younger population of adolescents. This includes risk or protective factors for sexual activity and sexually transmitted infection (STI) acquisition. To safeguard all adolescents from the consequences of risky sexual behaviors, and to insure age appropriate and effective interventions, further study is critical to address risky behaviors specific to early adolescents.This study was a retrospective chart review of 155 sexually active adolescent girls enrolled in 3 inner city school-based health centers. Students were divided into those who never had a documented STI and those who had 1 or more STIs. Data were collected from a sexual history questionnaire and the Guidelines for Adolescent Preventive Services questionnaire. These data were grouped into risk or protective Guidelines for Adolescent Preventive Services domains. Domains were made up of 5 items of protective factors, 3 items of peer risks, 2 items of family risks, and 7 items of individual risks. STI outcomes were compared to these characteristics.One hundred fifty-five sexually active black adolescents were studied. A univariate and multivariate analysis of risk and protective factors for testing positive for an STI demonstrated that high levels of protective factors reduced the risk of STIs.Increased levels of protective factors were associated with a decrease in STI risk. This suggests that STI prevention programs should focus on increasing protective factors among young adolescents in addition to reducing risk factors.

OBJECTIVE. The goal was to assess the impact of a mentor-implemented, violence prevention intervention in reducing aggression, fighting, and reinjury among assault-injured youths.METHODS. In a randomized, controlled trial performed in the emergency departments of 2 large urban hospitals, 10- to 15-year-old youths who presented with peer assault injuries were recruited and randomly assigned to intervention and comparison groups. In the intervention group, youths received a mentor, who implemented a 6-session problem-solving curriculum, and parents received 3 home visits with a health educator, to discuss family needs and to facilitate service use and parental monitoring. The comparison group received a list of community resources, with 2 follow-up telephone calls to facilitate service use. Youths and parents were interviewed at baseline and at 6 months, for assessment of attitudes about violence, risk factors, fighting, and repeat injury.RESULTS. A total of 227 families were recruited, with 23% refusing participation and 4% providing partial interview completion. A total of 166 families were enrolled, with 87 assigned to the intervention group and 79 to the comparison group; 118 (71%) completed both youth and parent follow-up interviews, and 113 had usable data. The intervention and comparison groups were not significantly different at baseline with respect to demographic features or risk factors, except for increased knife-carrying and fewer deviant peers in the intervention group. After adjustment for baseline differences, there was a trend toward significant program effects, including reduced misdemeanor activity and youth-reported aggression scores and increased youth self-efficacy. Program impact was associated with the number of intervention sessions received.CONCLUSIONS. A community-based, mentor-implemented program with assault-injured youths who presented to the emergency department trended in the direction of decreased violence, with reduced misdemeanors and increased self-efficacy.

The importance of gender within HIV/STI prevention has become widely recognized. However, gender ideologies associated with vulnerability to HIV/STI are often examined and addressed without sufficient attention to the larger socioeconomic context within which they arise and evolve. We conducted a cross-sectional survey with 155 female, African-American adolescents recruited from two health clinics in Baltimore, Maryland. Multivariate logistic regression was utilized to assess the relationships between HIV/STI vulnerability resulting from male partner concurrency, adherence to traditional female gender norms, using a measure of hyperfemininity, and perceived socioeconomic opportunity structures. The likelihood of reported partner concurrency increased significantly among participants reporting higher levels of hyperfemininity (OR = 2.08; 95%CI = 1.01–4.30). Hyperfeminine thinking and behavior was significantly lower in the context of higher perceived socioeconomic opportunity structures (OR = 0.87; 95%CI = 0.79–0.95). Interventions seeking to promote gender equity and reduce HIV/STI may be more effective when the socioeconomic context of gender ideologies is assessed and addressed. Programs and policies to increase educational and professional opportunity structures, particularly among marginalized communities, should be actively integrated into HIV/STI prevention planning.

Qualitative research suggests that young women's relationships with the biological fathers of their children (BFRs), known colloquially as 'baby daddy' relationships, enable risk for pregnancy and STI/HIV. Our study compared partner characteristics and sexual risk within dyads based on BFR, among a sample of young women in Baltimore, Maryland, USA.We conducted secondary analysis of survey data collected in 2011-2013 from heterosexually experienced youth ages 15-24 in Baltimore, Maryland, USA. Analyses are limited to women with at least one recent (past 6 months) sex partner (n=171 participants, reporting on 271 relationships). Using generalised estimating equations with logit function for correlated binary responses, we evaluate associations of BFR with partner characteristics, sexual risk behaviour and contraceptive non-use.At least one BFR partner was reported by 25.2%. Male partners in BFRs were more likely to have been incarcerated or arrested. BFRs were more often characterised by women as 'main' versus 'casual' partners (adjusted OR (AOR) 3.92, 95% CI 1.19 to 12.9). In adjusted analyses, BFR was associated with condom non-use for vaginal (AOR 12.3, 95% CI 3.92 to 38.7) and anal (AOR 3.32, 95% CI 1.34 to 8.22) intercourse. While BFR was associated with contraceptive non-use (AOR 2.21, 95% CI 1.01 to 4.84), this association attenuated to non-significance after adjusting for partnership type (AOR 2.06, 95% CI 0.91 to 4.67).While few differences in BFR partner characteristics emerged, significantly greater risk for unprotected intercourse was identified within BFR relationships. Findings suggest that the relationship context of a shared child heightens sexual risk for the young women most affected by STI.

Purpose Places are an important determinant of risk for sexually transmitted infection (STI) acquisition and transmission. We sought to identify social places that are critical for targeted STI control activities. The objective of this study was to determine whether sex partner meeting places characterized by drug markets, sex markets, and separately, drug and/or sex markets were more likely to have potential core transmitters as compared with other sex partner meeting places in one urban setting. Methods In 2008–2009, heterosexual sex partner places or venues were identified in Baltimore, MD using a venue-based study approach. Results A total of 1334 participants aged 18 to 35 years were enrolled at 85 venues. In those participants, 39 potential core transmitters were identified and 31% of venues had at least one potential core transmitter. In final age-adjusted and gender-adjusted models, core transmitters were significantly more likely to be identified at drug markets (OR = 1.37; 95% CI = 1.23–1.53), sex markets (OR = 1.27; 95% CI = 1.14–1.41), and drug and/or sex markets (OR = 1.49; 95% CI = 1.32–1.68). Conclusions This study identified key characteristics of venues, such as drug and sex market activity, that may be important in identifying places for the targeted control of STI transmission.

Background: Although physical attributes have been shown to be associated with sexually transmitted disease (SD) rates, there is little information about the association between social attributes and STD rates. Goal: The objective of this study was to determine the association between gonorrhea prevalence and perceptions of social cohesion in impoverished, urban neighborhoods. Study Design: We conducted a street-based survey of 18- to 24year-olds residing in selected census block groups in Baltimore City, Maryland. Census block groups eligible for selection were defined as impoverished (greater than 20% in poverty) and unstable (lowest 25th percentile for stability). From the eligible census block groups, 5 from high gonorrhea rate (greater than the 75th percentile) census block groups and 5 from the lower gonorrhea rate (lowest 25th percentile to equal or greater than the 75th percentile) census block groups were randomly selected. Participants within the 10 selected census block groups were recruited using a street-intercept method. Participants were asked about perceived social cohesion and control. Results: Results showed that for young adults 18 to 24 years of age residing in high gonorrhea census block groups, the mean social cohesion index scores were 1.7 points lower than mean social cohesion index scores of the participants residing in the low gonorrhea census block groups (P

BACKGROUND It is not well understood whether characteristics of adolescent main partnerships differ categorically from one relationship to the next or whether observed differences in sexually transmitted infection (STI)-related perceptions and sexual behaviors between main partnerships results from a failure to capture variability within adolescent main partnerships. The objective of this study was to examine the extent to which female adolescents' STI-related feelings, perceptions, and sexual behavior associated with main sex partners varied over the course of their relationship. METHODS A cohort of adolescent women aged 16 to 19 years at baseline, recruited from health clinics or community venues, completed daily diaries on a Smartphone continuously for 18 months. Participants reported daily on their partner-specific feelings of closeness, trust, commitment, perceived risk for acquiring a sexually transmitted disease (PRSTD), perception of partner concurrency (PPC), and condom use for their main sexual partners. RESULTS Relationships from 49 participants were used to examine variability over time in STI-related feelings, perceptions, and behavior. Overall, relationships were characterized by high levels of trust, closeness, and commitment and low levels of PPC, PRSTD, and condom use. However, for all but PRSTD, there was more variation (>50%) within than between relationships for each of these measures, although variability of PRSTD was high (47.1%). Residual variability for all perceptions and behaviors remained significant after controlling for trends over time. CONCLUSIONS Diary data illustrate wide day-to-day fluctuations in feelings of intimacy, PPCs, PRSTDs, and condom use indicating that these are dynamic attributes of adolescent romantic relationships.

Study Objective To describe a model of how interactions between positive and negative childbearing motivations affect the use of condoms for contraceptive purposes and test hypotheses based on that model. Design Psychological and behavioral data were collected during a study that sampled randomly selected census block groups. Setting Respondents were household residents of Baltimore City, Maryland, between 2004 and 2007. Participants English-speaking, sexually active African-American women between the ages of 15 and 24 who had completed a reliable and valid measure of both positive and negative childbearing motivations. Main Outcome Measures Regularity of condom use during the past 90 days and contraceptive method at last sex. Results The results of regression analyses with the total sample confirm that antinatal childbearing motivations predicted more regular condom use and that ambivalent, pronatal, and indifferent childbearing motivations acting together each predicted less regular condom use. The results with a subgroup using condom and not hormonal contraception confirmed that ambivalent childbearing motivation alone predicted less regular condom use. Conclusions Our findings demonstrate how positive and negative childbearing motivations interact to create a dynamic effect on contraceptive behavior that transcends the effect of either positive or negative motivation acting alone. We conclude that the dynamics of these motivational interactions have important implications for further research on contraceptive decision-making, for augmenting the understanding of caretakers and providers, and for the formation of new policies that focus on the prevention of unplanned pregnancy among youth.

Summary To determine effectiveness of alternate venue testing (AVT), social network strategy (SNS) and provider referral (PR) for identifying previously undiagnosed HIV-infected 18–64-year-old African American men who have sex with men (AA MSM) by a health department. For AVT, staff used a mobile clinic to conduct HIV testing. For PR, staff solicited contact information from HIV-infected AA MSM, located contacts and offered HIV testing. For SNS, HIV-positive AA MSM recruited network associates for HIV testing. Two hundred and eighteen self-identified AA MSM were tested through AVT (25.2% HIV positivity) of whom 20 were newly identified HIV-positive. Fourteen HIV-positive men participated in SNS; 22 AA MSM contacts were recruited through SNS, eight (36.4%) were HIV positive and none were new positives. Two HIV-infected men participated in the PR strategy, yielding two AA MSM sex partners (one previously positive). The results suggest the need for health departments to consider using several complimentary strategies for identifying previously undiagnosed HIV infections in AA MSM in urban environments such as Baltimore.

BACKGROUND Sex partner concurrency is an important risk factor for sexually transmitted infection transmission. Understanding how adolescents conceptualize the length of their relationships when they break up and get back together is essential to the assessment of concurrency. METHODS A prospective cohort of 392 late adolescents and emerging adults, aged 14 to 19 years at baseline, were recruited from 2 clinics in Baltimore, MD and interviewed semiannually for 3 years. At each interview, participants were asked to report on all of their sexual partners in the previous 6 months, the length of relationship, and whether they thought their partner had other sex partners. For relationships that had broken up and gotten back together, reports of length of the relationship were compared before and after the breakup. Random effects logistic regression was used to examine the association between length of relationship and both breakup and partner concurrency. RESULTS For relationships that ended and subsequently got back together, participants considered the length of relationship to include the period when they were broken up. Longer relationships were at increased odds of both having broken up and gotten back together (odds ratio [OR] = 1.04, 95% confidence interval [CI]: 1.02, 1.05) and of partner concurrency (OR = 1.03, 95% CI: 1.02, 1.04). The magnitude of the odds of concurrency was greater for relationships that had broken up and gotten back together (OR = 1.07, 95% CI: 1.02, 1.11). CONCLUSIONS Findings from this study emphasize the need for an improved understanding of the association between the temporal dynamics of late adolescent and emerging adult romantic relationships and concurrency.

Objectives To examine the effect of retaliatory attitudes on subsequent violent behavior and fight-related injuries among youth who presented to the emergency department with assault injuries. Design Assault-injured youth were interviewed at baseline, 6 months, and 18 months to assess fighting behavior, retaliatory attitudes, weapon carrying, and injury history as part of a larger randomized control trial. Setting Two emergency departments in urban areas were selected for the study. Participants A total of 129 adolescents aged 10–15 years were included in the study. Outcome measures Fighting behavior, assault injury, weapon carrying, and aggressive behavior. Results Higher retaliatory attitudes at baseline were associated with more aggression and a higher frequency of fighting over time. Conclusions Retaliatory attitudes may fuel cycles of violence among youth. Medical professionals in acute care settings have an opportunity to identify youths at risk of future assault injury by assessing retaliation, providing anticipatory guidance, and referring to intervention programs.

Identify factors associated with appointment-keeping among HIV-infected adolescents and young adults.HIV-infected adolescent and young adult females in five U.S. cities were followed for a period of 18 months to examine adherence to scheduled clinic visits with their HIV care provider. Psychosocial and behavioral factors that have been shown in other populations to influence appointment adherence were measured at baseline and follow-up visits using an audio computer-assisted self-interview questionnaire. These factors included mood disorder, depressive symptoms, social network support, healthcare satisfaction, disease acceptance, HIV stigma, alcohol use, and marijuana use. CD4 count and prescription of antiretroviral therapy medication were also monitored to understand the influence of health status on appointment- keeping.Participants included 178 youth with a mean age of 20.6 years. Forty-two percent had clinically significant depressive symptoms, 10% had a diagnosable mood disorder, 37% reported marijuana use in the last 90 days, and 47% reported alcohol use. Overall, participants attended 67.3% of their scheduled visits. Controlling for age and health status, marijuana use was the only variable that was associated with appointment-keeping behavior.Considering the importance of appointment-keeping for maintaining personal health and preventing further transmission, screening HIV-infected adolescents for marijuana use could help alert providers of this specific barrier to visit compliance.

Objective To determine the frequency of recurrent sexually transmitted infections (STIs) and/or pelvic inflammatory disease (PID), the average time until subsequent infection following a baseline PID diagnosis, and age- and insurance-related associations with subsequent diagnoses. Design This study used prospective longitudinal follow-up of STI and/or PID outcome data from electronic medical records. Setting An urban academic hospital system. Participants A total of 110 adolescent girls treated for PID as outpatients in pediatric ambulatory sites. Main Exposure Electronic medical records used to assess subsequent PID diagnoses and/or infections with Neisseria gonorrhoeae or Chlamydia trachomatis during the study window. Main Outcome Measures Demographic, health care use, and STI and/or PID outcome data were examined. Incidence of an STI and/or PID was calculated as incident cases per person-months of exposure. Cox proportional hazard modeling was performed to evaluate the incidence of STI by age or insurance status. Results The mean (SD) age was 16.8 (1.9) years, 89% of patients were black, and 39% had laboratory results that were positive for N gonorrhoeae or C trachomatis at baseline. Thirty-four percent of patients had an additional diagnosis of an STI during the 48-month follow-up window (incidence, 3.1 per 100 person-months) and the mean (SD) time to a subsequent STI and/or PID was 377 (297) days. Of those patients, 67% (n = 18) had chlamydia, 11% had gonorrhoeae, and 44% had PID. There were no differences based on age or insurance status. Conclusions Adolescents treated for PID are at risk for subsequent STI and/or PID for a 48-month period. Given the need to prevent future infections in these vulnerable youths, efforts to explore the value of ongoing strategies for risk reduction after diagnosis are warranted.

Background: Urine-based screening for Chlamydia trachomatis using highly sensitive and specific nucleic acid amplification tests offers a unique opportunity to screen men attending school-based health centers. Methods: As part of a large multicenter chlamydia screening project in men, 1434 students were enrolled; 1090 in high schools in Baltimore and 344 middle and high-school students in Denver. Students were screened for chlamydia using urine-based nucleic acid amplification tests at well adolescent visits, acute care visits, or visits for other reasons, such as sports physicals. A self-administered survey to ascertain sexual risk behaviors was used. Data were analyzed separately for Baltimore and Denver, with univariate and multivariate logistic regression analysis. Results: The overall prevalence in asymptomatic adolescent men was 6.8% (7.5% in Baltimore and 4.7% in Denver, P = n.s.). Students in Denver were older, more racially diverse, and more likely to have had intercourse in the previous 2 months than students in Baltimore. Students in Baltimore were more likely than those in Denver to have used a condom at last intercourse with casual and main partners. Among men in Denver but not Baltimore, condom use at last intercourse with both casual (OR 0.15, 95% CI, 0.03, 0.78) and main partners (OR 0.30, 95% CI, 0.10, 0.91) was protective against infection. The only risk factor for CT infection in Baltimore students was age (OR 1.47, 95% CI, 1.23, 1.75). In multivariate analysis that included age (as a continuous variable), race, history of an STI, any sex partner in the last 2 months, > 1 sex partner in the past 12 months, a new partner in the last 2 months, and condom use with last main and last casual partner, age (adjusted odds ratio 1.34, 95% CI, 1.11, 1.62) and black race (adjusted odds ratio 2.37, 95% CI, 1.21, 4.63) were the only variables associated with testing chlamydia positive. Conclusions: School-based health centers are important venues in which to perform urine-based screening for chlamydia in sexually active, asymptomatic males, especially in high prevalence communities, and such screening provides the opportunity to identify and treat substantial numbers of chlamydia infections.

Objectives: Although the prevalence of sexually transmitted infections (STIs) among girls infected with HIV has been reported, the incidence of STI diagnoses has not been well documented. The objectives of this study were to examine (1) incident STI diagnoses and (2) the association between viral load (VL) and incident STI diagnosis among HIV-infected adolescent girls in care. Methods: This was a prospective longitudinal 18-month study of girls enrolled in the Adolescent HIV trials network. Cox proportional hazard modelling was performed to evaluate the incidence of STI by baseline viral load. Results: The mean (SD) age of participants was 20.6 (2.0) years, viral load of participants was 66 917 (165 942) copies/ml and median viral load was 7096 copies/ml. The incidence of STIs for the entire cohort was 1.4 per 100 person-months. During the 18-month follow-up period, there were no significant differences in the STI incidence between the high and low viral load groups (hazard ratio (HR) = 0.86, 95% CI 0.37 to 1.95) There was also no significant association between STI incidence and log-transformed viral load (HR = 1.10, 95% CI 0.92 to 1.3). Conclusions: Adolescent girls with HIV infection continue to acquire sexually transmitted infections after diagnosis. This analysis does not suggest that VL is a critical factor in STI acquisition over time. Additional work exploring the role of other contextual factors on STI acquisition among HIV-infected adolescent girls is warranted.

The relationship between neighborhood social dynamics and adolescent sexual behavior has not been well explored. We conducted a cross-sectional survey with 343 adolescents recruited from two health clinics in Baltimore. Multivariate logistic regression was utilized to assess the influence of perceived neighborhood social cohesion and collective monitoring of youth on condom use at last sex, controlling for family and individual factors. Condom use was significantly higher among participants who perceived their neighborhoods as high, 54.7%, versus low, 40.4%, in social cohesion. Neighborhood cohesion was significantly associated with condom use in multivariate analyses, as was parental communication, family structure, and gender. No association between perceived neighborhood collective monitoring of youth and condom use was found. We conclude that perceived neighborhood social cohesion is positively associated with condom use among adolescents vulnerable to HIV/STI and should be encouraged in the context of community-based prevention efforts.

The goal of this study was to examine the risk for repeat sexually transmitted infections (STIs) associated with reducing the number of sex partners who come from within the social networks of males 13 to 25 years old in Baltimore Maryland and Denver Colorado. Asymptomatic males diagnosed with chlamydia and/or gonorrhea as part of an asymptomatic chlamydia and gonorrhea male screening project were recruited and interviewed about their sexual behaviors and their perceptions of social characteristics and sexual behaviors of their sex partners. We characterized the sex partners of each participant as belonging to or not belonging to his social network. We examined whether a decrease in percentage of sex partners who were in the participants social network was associated with repeat infection. There were 47 participants in Baltimore and 92 in Denver. In both cities there was a trend toward a finding that decreasing the percentage of sex partners belonging to a participants social network was protective for repeat STI. These data suggest that interventions may need to be designed to reduce the prevalence of infection in the social networks of infected men. (authors)

Objective To determine whether African American adolescents, whose recent sex partners reported having another sex partner, are at increased risk for exposure to genital chlamydial infection or gonorrhea. Study design A household sample of low-income urban African American adolescents 14 to19 years of age, up to two of their close friends, and their sex partners were interviewed and tested for gonorrhea and chlamydial infection. Results Thirty-four of 145 adolescents had at least one recent sex partner infected with Neisseria gonorrhoeae and/or Chlamydia trachomatis . The adjusted model showed that adolescents, whose recent sex partners reported having another sex partner, were more likely to have a recent sex partner with gonorrhea and/or chlamydial infection. Conclusion In addition to individual factors, network factors may explain why African American adolescents are at increased risk for exposure to sexually transmitted infections (STIs). Multi-level community-based interventions may need to address network factors along with personal behaviors in order to prevent STIs among low-income urban African American adolescents.