Prevalence and Attitudes Regarding Withdrawal Use for Pregnancy and HIV Prevention Among HIV-Positive Youth.

W ithdrawal (coitus interruptus) has been fairly well studied for pregnancy prevention, but its use for HIV transmission prevention has not been fully explored, particularly among sexually active youth. Potential concerns arise from the fact that semen and other genital fluids may represent an independent HIV reservoir: pre-ejaculate has been shown to contain CD4 lymphocytes, macrophages, as well as cell-free HIV virions. The presence of HIV virions in genital secretions may explain incidence of HIV transmission even in the setting of an undetectable plasma viral load. Withdrawal before ejaculation has been shown to reduce the risk of HIV-1 transmission in the context of penile–vaginal intercourse. Prevalence of withdrawal use among sexually active youth is widely variable, with higher rates reported in the literature if study participants report ever use or use concurrent with another method. Sexual risk taking among youth is high, and this additionally holds true for those living with HIV. Our objective was to determine the prevalence of withdrawal use as both a method for HIV transmission prevention and contraceptive option in a population of 18to 25-year-old youth living with HIV. The study design was a prospective observational study approved by the Medical University of South Carolina’s IRB (No. 44763). Youth living with HIV of ages 18–25 years were eligible for the study if they presented to a clinic visit and had not previously participated. Individuals were not eligible if they were not primarily literate in English. Eligible individuals were approached for study enrollment during a routine HIV care appointment for participation in an online survey after verbal consent. Survey responses were collected and stored in REDCap, a secure electronic data capture tool. Study participants were enrolled between 2014 and 2017. A sample size of 88 participants was needed to have 80% power to demonstrate a 3.5-fold difference in self-reported withdrawal use among HIV-infected male youth compared with female youth (a = 0.05). Survey questions were developed on the basis of a survey administered by Higgins and Wang, with assistance of a qualitative researcher with expertise in survey design and instrument development for primary data collection (B.S.). Survey questions aimed to assess sexual activity, contraceptive use, and self-knowledge of HIV. Data analysis was performed using SAS software version 9.4 (Cary, NC) and HyperRESEARCH 3.7. 3. Open-ended text responses were analyzed using thematic analysis methodology. Participant characteristics and HIV-related variables were compared between male and female participants, as well as between withdrawal users (WU) and nonusers. Shapiro–Wilk analysis was used to evaluate continuous variables for normal distribution. Normally distributed continuous variables were described as means with standard deviation, and non-normally distributed continuous variables were described as medians with a corresponding interquartile range. Continuous variables were analyzed using Wilcoxon rank sum tests, whereas categorical variables were analyzed by Fisher’s exact or chi-square test. A total of 88 youth of 18–25 years of age living with HIV were surveyed for the study; 89 youth were approached, 1 female declined participation. Thirty-eight males and 36 females completed the survey (response rate = 84%; Table 1). Among the 41 (55%) respondents reporting any withdrawal use, WU were 54% male [59% men having sex with men (MSM), 41% men having sex with women (MSW)] and 46% female [89.5% women having sex with men (WSM), 10.5% women having sex with women (WSW)]. WU were more likely to report monogamous sex (44.7% vs. 25%, p = 0.02), sex partner with unknown HIV status (30% vs. 9.1%, p = 0.005), oral contraceptives use (22% vs. 6%, p = 0.04), and report that condoms decreased sexual pleasure (24.4% vs. 3%, p = 0.009). Respondents were asked about withdrawal use for HIV and pregnancy prevention: 17 (40%) reported using withdrawal for both HIV and pregnancy prevention, 4 (9.5%) reported exclusively using withdrawal for HIV prevention, and 20 (48%) reported only using withdrawal for pregnancy prevention. Among the four respondents exclusively reporting withdrawal for HIV prevention, there were three males and one female; compared with non-WU, WU for HIV prevention (n = 4) were more likely to report sexual education from family (100% vs. 27%, p = 0.01.) Respondents exclusively using withdrawal for HIV prevention (n = 4) were grouped with those reporting withdrawal