***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Based on qualitative research undertaken during a phase-three microbicide gel trial , this paper explores female participants ' experiences and perceptions of gel and condom use and the opinions of their male partners and community members . Participants were aware that condoms were effective in preventing HIV infection and that the efficacy of the microbicide was unproven . Yet , in narratives about gel and condom use , participants ascribed improvements to their reproductive health and intimate relationships with men to gel use . In contrast , condoms were believed to prevent disease , yet also embodied mistrust , were believed to contain dangerous substances and were felt to block the womb . These apparently contradictory views about condoms and gels are explored in the light of conceptions of flow and blockage . Health is achieved by maintaining a steady balance of substances within the body , while preventing fluid flow results in illness . We argue that women enrolled in the trial broadened the meaning of the gel beyond its primary intended effect of preventing HIV . Through their accounts of gel use , women ‘ reinvented ’ the gel as a substance that transformed their bodies and sexual relations . This has implication s for underst and ing how local knowledge of health and illness intersects with biomedical knowledge In sub-Saharan Africa more women are infected with HIV/AIDS than men and new prevention methods are urgently needed . One major attribute of female-initiated HIV prevention methods is that they can be used covertly , without a male partner 's knowledge . Using mixed methods , we explored the predictors and dimensions of covert use of the diaphragm in a r and omized controlled trial that tested its effectiveness for HIV prevention . The Methods for Improving Reproductive Health in Africa ( MIRA ) trial was conducted in Zimbabwe and South Africa , and data collection took place between September 2003 and January 2007 . This study is a secondary analysis of quantitative and qualitative data from participants r and omized to the intervention group , and their male partners . It includes survey data from 2316 women ( mean age=28.3 ) , 14 focus group discussion s ( FGD ) conducted with 104 women , and 7 FGD and 10 in-depth interviews with 37 male partners . The median follow-up for trial participation was 21 months ( range : 12 - 24 ) . At their final visit , approximately 9 % of women had never disclosed to their primary partners that they were using the diaphragm  ( covert use ) . In multivariate analysis , predictors of covert use included being older , not co-habiting with the partner , having a partner who did not use condoms , and being from South Africa . Qualitative analysis revealed that covert use was not dichotomous , but ranged along a continuum , which we categorized into five levels ( i.e. full disclosure ; mostly open use ; occasional covert use ; mostly covert use ; and completely covert use ) . We discuss the critical role of the option of covert use for many women in the context of an HIV prevention trial , as well as gender power dynamics which may influence women 's decisions about disclosure Introduction Risk perception is a core construct in many behaviour change theories in public health . Individuals who believe they are at risk of acquiring an illness may be more likely to engage in behaviours to reduce that risk ; those who do not feel at risk may be unlikely to engage in risk reduction behaviours . Among participants who seroconverted in two FEM-PrEP sites – Bondo , Kenya , and Pretoria , South Africa – we explored perceived HIV risk and worry about acquiring HIV prior to HIV infection . Methods FEM-PrEP was a phase III clinical trial of once-daily , oral emtricitabine and tenofovir disoproxil fumarate for HIV prevention among women in sub-Saharan Africa . We asked all participants about their perceived HIV risk in the next four weeks , prior to HIV testing , during a quantitative face-to-face interview at enrolment and at quarterly follow-up visits . Among participants who seroconverted , we calculated the frequencies of their responses from the visit conducted closest to , but before , HIV acquisition . Also among women who seroconverted , we conducted qualitative , semi-structured interviews ( SSIs ) at weeks 1 , 4 and 8 after participants ’ HIV diagnosis visit to retrospectively explore feelings of HIV worry . Applied thematic analysis was used to analyse the SSI data . Results Among participants who seroconverted in Bondo and Pretoria , 52 % reported in the quantitative interview that they had no chance of acquiring HIV in the next four weeks . We identified four processes of risk rationalization from the SSI narratives . In “ protective behaviour , ” participants described at least one risk reduction behaviour they used to reduce their HIV risk ; these actions made them feel not vulnerable to HIV , and therefore they did not worry about acquiring the virus . In “ protective reasoning , ” participants considered their HIV risk but rationalized , based on certain events or beliefs , that they were not vulnerable and therefore did not worry about getting HIV . In “ recognition of vulnerability , ” participants described reasons for being worried about getting HIV but said no or limited action was taken to reduce their perceived vulnerability . Participants with “ no rationalization or action ” did not describe any HIV worry or did not engage in HIV risk reduction behaviours . Conclusions Women who are at substantial risk of acquiring HIV may underestimate their actual risk . Yet , others who accurately underst and their HIV risk may be unable to act on their concerns . Perceived HIV risk and risk rationalization are important concepts to explore in risk reduction counselling to increase the use of HIV prevention strategies among women at risk of HIV 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 females ' main relationships . Methods A clinical sample of African – American women aged 14–19 years at enrolment were followed prospect ively for 3 years . At each semiannual interview , participants reported their partner-specific PRSTD , feelings of intimacy , perceptions of partner 's 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 adolescents ' expectations about intimate relationships The diaphragm is receiving renewed attention as a promising female‐controlled method of preventing HIV and other sexually‐transmitted infections . It is anticipated that female‐controlled technologies will reduce women 's biological susceptibility and assist in counteracting their sociocultural vulnerability to HIV . Underst and ing the subjective experiences of diaphragm users in different setting s has the potential to inform the development and promotion of such methods . This paper explores the perspectives of female sex workers and women attending sexual and reproductive health services in Mombasa , Kenya . Data are reported from focus group discussion s and in‐depth interviews with women and men , following a prospect i ve study investigating diaphragm continuation rates over six months . Discussion s highlighted covert use of the diaphragm , during sex work or with casual partners , and coital independence as favourable attributes . These features were especially pronounced compared with male condoms . Few difficulties with diaphragm use were reported , although its insertion and removal occasionally presented problems . Many women — especially those in long term partnerships — wished to disclose its use but found the disclosure process highly problematic . Accidental discovery often result ed in partner conflict . Although future uptake of the diaphragm may be high in this setting , its use may be limited to certain types of relationships and relationship context The aim of the study was to examine and describe the individual and structural-environmental factors that shape the vulnerability of brothel-based female sex workers ( FSWs ) in Ibadan , southwest Nigeria to HIV infection . A descriptive qualitative research design was utilised to elicit data , using in-depth interviews and focus group discussion s , from 60 r and omly selected participants in four brothels . A thematic analysis of data was undertaken following transcription and validation of interviews . Five themes emerged from the data : ( i ) flawed knowledge and fatalistic attitudes ; ( ii ) the psychosocial and economic context of sex work ; ( iii ) religious beliefs , stigma and risk taking ; ( iv ) barriers to HIV testing ; and ( v ) legal and policy constraints to sex work . We describe the complex interaction between these themes and how they combine to increase the risk of HIV infection among FSWs . The impact of previous interventions to reduce the risk of HIV infection among FSWs has been limited by personal and structural factors ; hence we recommend that new strategies that recognise the practical constraints to HIV prevention among FSWs are urgently needed to make the environment of commercial work safer for FSWs , their clients , and by extension the general population Male circumcision has been shown to reduce the risk of heterosexual transmission of HIV infection in men by up to 60 % in three r and omized controlled trials . Less is known , however , about sexual behavior change in men who have been circumcised and whether male circumcision 's protective effect leads to riskier sexual behaviors . This study used qualitative in-depth interviews to underst and men 's  sexual behavior after circumcision  and to determine whether and how men participated in riskier sexual behaviors  following male circumcision . Men in urban Swazil and , circumcised in the previous 12 months , were recruited and asked about their perceptions of sexual risk and sexual behavior  post-circumcision .  Results showed that following circumcision , men experience changes in both their sexual attitudes and behavior , which can be considered both protective and risky for HIV transmission . Most of them described protective changes ( e.g. , more responsible attitudes towards safe sex , reducing sexual temptation and partners , easier condom use ) . A minority , however , experienced increased sexual risk-taking , typically during a brief period of sexual experimentation shortly after circumcision . HIV counseling and counseling throughout the circumcision process is shown to be critical in influencing protective behaviors . Findings in this study confirm the existence of risk compensation following circumcision ; however , this study adds important context ual insight about precisely when and why such risk-taking occurs . Nevertheless this study suggests that male circumcision scale-up as an HIV prevention strategy is likely to foster protective behavior change among men . The integration of HIV counseling with circumcision provision remains critical for effectively mitigating HIV risk behavior as male circumcision gains momentum as a viable HIV prevention tool Objective : Adherence may be the “ Achilles heel ” of pre-exposure prophylaxis ( PrEP ) , a promising biomedical approach to HIV prevention . This article presents an explanation of PrEP adherence for African serodiscordant couples derived from qualitative data . Design : Explaining quantitative findings is one way qualitative investigation contributes to research in medicine and public health . This qualitative interview study was nested in the Partners PrEP Study , a phase III r and omized trial evaluating oral tenofovir and emtricitabine/tenofovir PrEP to prevent HIV acquisition by HIV-uninfected partners in serodiscordant heterosexual couples . Methods : In-depth qualitative interviews were provided by 60 Partners PrEP Study participants in Ug and a. Interviews used open-ended questions eliciting information on adherence experiences , barriers , and facilitators . An inductive approach informed by grounded theory methodology was used to analyze study data . Results : The proposed explanation may be summarized as follows . Serodiscordance destabilizes couples , as the HIV-negative partner reacts with anger , fear , and sadness to the implication of infidelity represented by HIV infection . A “ discordance dilemma ” ensues , as the desire to avoid acquiring HIV and the advantages of preserving the relationship become competing priorities . PrEP is seen as a solution — a means of safeguarding health without ending the relationship . PrEP users benefit from the support of partners , who reinforce adherence . Where discord in the relationship persists , adherence suffers . Conclusions : PrEP adherence in serodiscordant couples may be understood as a function of the desire to reduce risk although preserving a partnered relationship . PrEP use in stable couples may be associated with improved adherence and thus , greater effectiveness 
    Output:
    
Among the themes identified , a particularly salient one was the potential of HIV prevention interventions to threaten the stability of a relationship and impact on how and when people may — or may not — choose to use prevention interventions .
Conclusions and implication s When considering the risk of HIV acquisition , it is insufficient to examine biological risk in isolation from the personal , relational and economic costs associated with intervention use .
This loss of emotional , physical , or material support may be perceived as more consequential than the prevention of a potential infection