Articles tagged as "Gender"

Integration of reproductive health and rights

Editor’s notes: Integration of reproductive health services and rights needs to be well coordinated with HIV services, so a randomized trial of integration of family planning services into HIV care clinics in Kenya by Cohen CR and colleagues is encouraging.  In their initial randomized trial, 12 clinics were randomly selected for early integration using resources from the study team, while six were delayed.  Subsequently the Ministry of Health took over the integration and provision of “one stop shop” services at all 18 clinics.  The improvements in contraceptive uptake and decreased pregnancy rates that had been observed in the first phase were maintained during the second phase giving more confidence that it was truly the integrated nature of the services rather than the presence of special study team that had led to the difference.

Another major push for integration or coordination between HIV and sexual and reproductive health and rights services is around the prevention of cervical cancer.  Cervical cancer is caused by long-term infection with specific types of human papilloma virus.  Women living with HIV are at considerably increased risk of cervical cancer compared to their HIV-negative peers.  A large cohort study by Kelly HA et al. in Burkina Faso and South Africa has shown that women living with HIV, attending clinical care services have a high prevalence (59-79% at baseline), incidence (48%) and persistence (up to 70% for some types) of HR-HPV and correspondingly a high prevalence and incidence of cervical neoplasia. There are two HPV vaccines currently available, the first prevents HPV types 16 and 18 (the causes of around 70% of cervical cancer) while the newer (and currently more expensive) vaccine prevents nine types (that cause at least 90% of cervical cancer).  HPV vaccination is recommended to be given before sexual debut, as it gives high protection against the specific types of HPV prior to acquisition.  The dynamics of the many different types of HPV after acquisition is less clear.  The virus is often acquired and they may be cleared or may persist.  So this study provides important background data for understanding the possible role of vaccination and also which types are most associated with pre-cancers (cervical Intra-epithelial neoplasia [CIN]) that can be treated and cured relatively easily.  In particular, in this study, HPV58, which is in the same (alpha-9) family as HPV16 showed the greatest association with CIN2+.  HPV58 is included in the newer nonavalent vaccine, but not the current bi- or quadrivalent vaccine.  Overall this is an area where we need more research on the impact of vaccination and screening programmes for women living with HIV, but in the meantime, HPV vaccination for school girls (and boys) is an investment in the future, since these vaccines are effective ways to stop people dying of cervical (and other HPV-related) cancers.

One of the challenges for integrated reproductive services is to continue to emphasize the importance of condoms for protection against HIV and sexually transmitted infections even if other methods are being used for contraception.  Such “dual protection” is particularly hard to achieve in married or cohabiting couples despite evidence of ongoing risk of HIV infection.  A study in 2388 urban 18-24 year old individuals in Zambia (69% female; 35% married) shows that condom use is still much too low with only 45% reporting that they had used a condom in the last 12 months. As might be anticipated, the study found that the poorest and people who were married were least likely to use condoms while people who discussed contraception and agreed to use condoms were more likely to do so [Pinchoff J et al.] The importance of dual protection, and of promoting broader HIV prevention messages to women through integrated (or at least coordinated) reproductive health and rights services is made even more important given the possibility that depot medroxyprogesterone acetate (DMPA) as a long acting reversible contraceptive may increase the risk of HIV acquisition.  WHO has recently changed their guidance to make such contraceptives grade 2 in the Medical Eligibility for Contraceptives (MEC) guidelines.

Integration of family planning services into HIV care clinics: Results one year after a cluster randomized controlled trial in Kenya.

Cohen CR, Grossman D, Onono M, Blat C, Newmann SJ, Burger RL, Shade SB, Bett N, Bukusi EA. PLoS One. 2017 Mar 22;12(3):e0172992. doi: 10.1371/journal.pone.0172992.eCollection 2017.

Objectives: To determine if integration of family planning (FP) and HIV services led to increased use of more effective contraception (i.e. hormonal and permanent methods, and intrauterine devices) and decreased pregnancy rates.

Design: Cohort analysis following cluster randomized trial, when the Kenya Ministry of Health led integration of the remaining control (delayed integration) sites and oversaw integrated services at the original intervention (early integration) sites.

Setting: Eighteen health facilities in Kenya.

Subjects: Women aged 18-45 receiving care: 5682 encounters at baseline, and 11 628 encounters during the fourth quarter of year 2.

Intervention: "One-stop shop" approach to integrating FP and HIV services.

Main outcome measures: Use of more effective contraceptive methods and incident pregnancy across two years of follow-up.

Results: Following integration of FP and HIV services at the six delayed integration clinics, use of more effective contraception increased from 31.7% to 44.2% of encounters (+12.5%; Prevalence ratio (PR) = 1.39 (1.19-1.63). Among the twelve early integration sites, the proportion of encounters at which women used more effective contraceptive methods was sustained from the end of the first to the second year of follow-up (37.5% vs. 37.0%). Pregnancy incidence including all 18 integrated sites in year two declined in comparison to the control arm in year one (rate ratio: 0.72; 95% CI 0.60-0.87).

Conclusions: Integration of FP services into HIV clinics led to a sustained increase in the use of more effective contraceptives and decrease in pregnancy incidence 24 months following implementation of the integrated service model.

Trial registration: ClinicalTrials.gov NCT01001507.

Abstract  Full-text [free] access

Associations of human papillomavirus (HPV) genotypes with high-grade cervical neoplasia (CIN2+) in a cohort of women living with HIV in Burkina Faso and South Africa.

Kelly HA, Ngou J, Chikandiwa A, Sawadogo B, Gilham C, Omar T, Lompo O, Doutre S), Meda N, Weiss HA, Delany-Moretlwe S, Segondy M, Mayaud P; HARP Study Group. PLoS One. 2017 Mar 23;12(3):e0174117. doi: 10.1371/journal.pone.0174117.eCollection 2017.

Objective: To describe associations of high-risk human papillomavirus (HR-HPV) with high-grade cervical intraepithelial neoplasia (CIN2+) in women living with HIV (WLHIV) in Burkina Faso (BF) and South Africa (SA).

Methods: Prospective cohort of WLHIV attending HIV outpatient clinics and treatment centres. Recruitment was stratified by ART status. Cervical HPV genotyping using INNO-LiPA and histological assessment of 4-quadrant cervical biopsies at enrolment and 16 months later.

Results: Among women with CIN2+ at baseline, the prevalence of any HR-HPV genotypes included in the bi/quadrivalent (HPV16/18) or nonavalent (HPV16/18/31/35/45/52/58) HPV vaccines ranged from 37% to 90%. HPV58 was most strongly associated with CIN2+ (aOR = 5.40, 95%CI: 2.77-10.53). At 16-months follow-up, persistence of any HR-HPV was strongly associated with incident CIN2+ (aOR = 7.90, 95%CI: 3.11-20.07), as was persistence of HPV16/18 (aOR = 5.25,95%CI: 2.14-12.91) and the additional HR types in the nonavalent vaccine (aOR =3.23, 95%CI: 1.23-8.54).

Conclusion: HR-HPV persistence is very common among African WLHIV and is linked to incident CIN2+. HPV vaccines could prevent between 37-90% of CIN2+ among African WLHIV.

Abstract  Full-text [free] access

Why don't urban youth in Zambia use condoms? The influence of gender and marriage on non-use of male condoms among young adults.

Pinchoff J, Boyer CB, Mutombo N, Chowdhuri RN, Ngo TD. PLoS One. 2017 Mar 23;12(3):e0172062. doi: 10.1371/journal.pone.0172062.eCollection 2017.

Background: Zambia experiences high unmet need for family planning and high rates of HIV, particularly among youth. While male condoms are widely available and 95%of adults have heard of them, self-reported use in the past 12 months is low among young adults (45%). This study describes factors associated with non-use of male condoms among urban young adults in Zambia.

Methods: A household cross-sectional survey in four urban districts was conducted from November 2015 to January 2016 among sexually active young adults ages 18-24 years. A random walk strategy was implemented in urban areas; eligible, enrolled participants were administered a survey on household characteristics, health access, and knowledge, attitudes and practices related to contraception. Relative risk regression models were built to determine factors associated with the decision to not use a male condom (non-use) at most recent sexual intercourse.

Results: A total of 2388 individuals were interviewed; 69% were female, 35% were married, and average lifetime sex partners was 3.45 (SD±6.15). Non-use of male condoms was 59% at most recent sexual intercourse. In a multivariate model, women were more likely to report non-use of a male condom compared with men (aRR = 1.24[95% CI: 1.11, 1.38]), married individuals were more likely to report non-use compared with unmarried individuals (aRR = 1.59 [1.46, 1.73]), and those residing in the highest poverty wards were more likely to report non-use compared with those in the lowest poverty wards (aRR = 1.31 [1.16, 1.48]). Those with more negative perceptions of male condom use were 6% more likely to report non-use (aRR = 1.06 [1.03, 1.09]). Discussion regarding contraception with a partner decreased non-use 13% (aRR = 0.87 [0.80, 0.95]) and agreement regarding male condom use with a partner decreased non-use 16% (aRR = 0.84 [0.77, 0.91)]).

Discussion: Non-use of male condoms is high among young, married adults, particularly women, who may be interested in contraception for family planning but remain at risk of STI infection. Effective marketing strategy of dual protection methods to this population is critical.

Abstract  Full-text [free] access

Africa
Burkina Faso, Kenya, South Africa, Zambia
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Gender and sexuality are central considerations in voluntary medical male circumcision campaigns

Discourses of masculinity, femininity and sexuality in Uganda's Stand Proud, Get Circumcised campaign.

Rudrum S, Oliffe JL, Benoit C. Cult Health Sex. 2017 Feb;19(2):225-239. doi: 10.1080/13691058.2016.1214748. Epub 2016 Aug 11.

This paper analyses discourses of masculinity, femininity and sexuality in Stand Proud, Get Circumcised, a public health campaign promoting circumcision as an HIV-prevention strategy in Uganda. The campaign includes posters highlighting the positive reactions of women to circumcised men, and is intended to support the national rollout of voluntary medical male circumcision. We offer a critical discourse analysis of representations of masculinity, femininity and sexuality in relation to HIV prevention. The campaign materials have a playful feel and, in contrast to ABC (Abstain, Be faithful, Use condoms) campaigns, acknowledge the potential for pre-marital and extra-marital sex. However, these posters exploit male anxieties about appearance and performance, drawing on hegemonic masculinity to promote circumcision as an idealised body aesthetic. Positioning women as the campaign's face reasserts a message that women are the custodians of family health and simultaneously perpetuates a norm of estrangement between men and their health. The wives' slogan, 'we have less chance of getting HIV', is misleading, because circumcision only directly prevents female-to-male HIV transmission. Reaffirming hegemonic notions of appearance- and performance-based heterosexual masculinity reproduces existing unsafe norms about masculinity, femininity and sexuality. In selling male circumcision, the posters fail to promote an overall HIV-prevention message.

Abstract access  

Editor’s notes: In this article, the authors provide a feminist, critical discourse analysis of Uganda’s 2012 ‘Stand Proud, Get Circumcised’ campaign. The campaign promoted voluntary medical male circumcision as an HIV prevention strategy. The authors look at how masculinity, femininity, gender relations and acceptable sexuality are configured.

The authors note that even within this prevention strategy that is male-only, men were largely absent with women representing the campaign’s public face. They argue that this is in keeping with widespread messages about gender and HIV in the region that position women as the central actors. That said, messages about normative masculinity were evident and focussed on anxieties about men’s penises as a site for the physical assessment of masculine sexual prowess or failure. Together with a lack of reference to gay men, this positioning affirms dominant ideals of what a ‘man’ is: straight, circumcised, sexually active. The authors also observe that discourses of femininity, while departing from women-as-victims and introducing sexual pleasure, were relevant only for women’s ability to impose conditions for sex, thereby influencing men to circumcise. The authors therefore argue that the discourses around gender and sexuality, rather than being socially transformative, were instead positioned to produce existing norms around sex. This positioning offers little hope for creating structural changes to gender relations that might hinder HIV transmission. The authors also express concern that the posters sell circumcision, but neglect to highlight the evidence that women are not directly protected, or that other tools of prevention including condoms remain important. 

Africa
Uganda
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Sexual risk behaviour, HIV prevalence unchanged in Kenya as more men are circumcised

Changes in male circumcision prevalence and risk compensation in the Kisumu, Kenya population, 2008-2013.

Westercamp M, Jaoko W, Mehta S, Abuor P, Siambe P, Bailey RC. J Acquir Immune Defic Syndr. 2017 Feb 1;74(2):e30-e37. doi: 10.1097/QAI.0000000000001180.

Background: Three randomized controlled trials showed that voluntary medical male circumcision (VMMC) reduces the risk of female-to-male HIV transmission by approximately 60%. However, data from communities where VMMC programs have been implemented are needed to assess changes in circumcision prevalence and whether men and women compensate for perceived reductions in risk by increasing their HIV risk behaviors.

Methods: Scale-up of free VMMC began in Kisumu, Kenya in 2008. Between 2009 and 2013, a sequence of 3 unlinked cross-sectional surveys were conducted. All individuals 15-49 years of age residing in randomly selected households were interviewed and offered HIV testing. Male circumcision status was confirmed by examination. Design-adjusted bivariate comparisons and multivariable analyses were used for statistical inference.

Results: The prevalence of male circumcision increased from 32% (95% CI: 26% to 38%) in 2009 to 60% (95% CI: 56% to 63%) in 2013. The adjusted prevalence ratio of HIV and genital ulcer disease in circumcised compared with uncircumcised men was 0.48 (95% CI: 0.36 to 0.66) and 0.51 (95% CI: 0.37 to 0.69), respectively. There was no association between circumcision status and sexual behaviors, HIV knowledge, or indicators of risk perception.

Conclusions: The conditions necessary for the VMMC program to have a significant public health impact are present in Kisumu, Kenya. Between 2009 and 2013, circumcision prevalence increased from 30% to 60%; HIV prevalence in circumcised men was half that of uncircumcised men, and there was no or minimal sexual risk compensation.

Abstract access  

Editor’s notes: Evidence of the protective effect of male circumcision on HIV incidence has led many countries in sub-Saharan Africa to promote voluntary medical male circumcision (VMMC). Mathematical models have illustrated that VMMC programmes will reduce HIV prevalence over time when VMMC uptake is high, and when men who have had VMMC do not substantially increase their sexual risk behaviours. In Kenya, the VMMC programme has exceeded its targets, with over 1.1 million procedures conducted between 2008 and 2015. In this paper, the authors assessed the assumptions behind the models, using data from three population-based cross-sectional surveys conducted among male and female adult residents of Kisumu, Kenya between 2009 and 2013. During this time, VMMC prevalence among men almost doubled from 32% to 60%, yet, HIV prevalence did not change for men or women. In addition, men who had VMMC reported the same levels of sexual risk behaviours as men who were not circumcised, yet had half the prevalence of HIV and genital ulcer disease. This study re-confirms the individual benefit of VMMC in a non-trial population, while demonstrating no evidence for sexual risk compensation. This study is notable for its large sample size, population-based sampling design, visual confirmation of circumcision status, and HIV testing protocol. Studies of longer duration are required to confirm the population-level impacts of VMMC– i.e. a protection benefit beyond men who had VMMC - on HIV prevalence, and to monitor the longer-term trend in sexual risk behaviours.

Africa
Kenya
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How did SASA! reduce violence against women?

Exploring couples' processes of change in the context of SASA!, a violence against women and HIV prevention intervention in Uganda.

Starmann E, Collumbien M, Kyegombe N, Devries K, Michau L, Musuya T, Watts C, Heise L. Prev Sci. 2017 Feb; 18(2): 233–244. doi:  10.1007/s11121-016-0716-6. Epub 2016 Sep 29. 

There is now a growing body of research indicating that prevention interventions can reduce intimate partner violence (IPV); much less is known, however, about how couples exposed to these interventions experience the change process, particularly in low-income countries. Understanding the dynamic process that brings about the cessation of IPV is essential for understanding how interventions work (or don't) to reduce IPV. This study aimed to provide a better understanding of how couples' involvement with SASA!-a violence against women and HIV-related community mobilisation intervention developed by Raising Voices in Uganda-influenced processes of change in relationships. Qualitative data were collected from each partner in separate in-depth interviews following the intervention. Dyadic analysis was conducted using framework analysis methods. Study findings suggest that engagement with SASA! contributed to varied experiences and degrees of change at the individual and relationship levels. Reflection around healthy relationships and communication skills learned through SASA! activities or community activists led to more positive interaction among many couples, which reduced conflict and IPV. This nurtured a growing trust and respect between many partners, facilitating change in longstanding conflicts and generating greater intimacy and love as well as increased partnership among couples to manage economic challenges. This study draws attention to the value of researching and working with both women, men and couples to prevent IPV and suggests IPV prevention interventions may benefit from the inclusion of relationship skills building and support within the context of community mobilisation interventions.

Abstract  Full-text [free] access 

Editor’s notes: Evidence from sub-Saharan Africa suggests community mobilization approaches work at many different levels to prevent intimate partner violence. However it is unclear how they work. This study interviewed ten couples (men and women interviewed separately) who participated in the SASA! activities and reported reductions in intimate partner violence over time. Findings suggest that engagement with SASA! by one or both members of the couple resulted in a range of change processes at the individual and relational levels. The biggest changes were seen in couples with severe intimate partner violence and in couples where one or both partners experienced high-intensity exposure to SASA! Changes were not usually universal or rapid but often uneven and slow. Overall, greater awareness of healthy relationship values and increased relational resources – communication and self-regulation skills – led to improved relationships.

Of interest to people involved in programmes on intimate partner violence, is that focusing on promoting positive relationship values and dynamics - such as love, respect and trust are effective.  Indeed, they were far more effective, than focusing on gender roles such as sharing of household tasks – which created conflict. The findings suggest intimate partner violence programmes should consider mixed-sex approaches that work with both men and women. These programmes should include promoting love and intimacy as a mechanism to achieve more balanced power in relationships and reduce violence. 

 

Africa
Uganda
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Community mobilization programme to increase HIV testing – more work is necessary

Community mobilization for HIV testing uptake: results from a community randomized trial of a theory-based intervention in rural South Africa.

Lippman SA, Neilands TB, MacPhail C, Peacock D, Maman S, Rebombo D, Twine R, Selin A, Leslie HH, Kahn K, Pettifor A. J Acquir Immune Defic Syndr. 2017 Jan 1;74 Suppl 1:S44-S51.

Background: HIV testing uptake in South Africa is below optimal levels. Community mobilization (CM) may increase and sustain demand for HIV testing, however, little rigorous evidence exists regarding the effect of CM interventions on HIV testing and the mechanisms of action.

Methods: We implemented a theory-driven CM intervention in 11 of 22 randomly-selected villages in rural Mpumalanga Province. Cross-sectional surveys including a community mobilization measure were conducted before (n = 1181) and after (n = 1175) a 2-year intervention (2012-2014). We assessed community-level intervention effects on reported HIV testing using multilevel logistic models. We used structural equation models to explore individual-level effects, specifically whether intervention assignment and individual intervention exposure were associated with HIV testing through community mobilization.

Results: Reported testing increased equally in both control and intervention sites: the intervention effect was null in primary analyses. However, the hypothesized pathway, CM, was associated with higher HIV testing in the intervention communities. Every standard deviation increase in village CM score was associated with increased odds of reported HIV testing in intervention village participants (odds ratio: 2.6, P = <0.001) but not control village participants (odds ratio: 1.2, P = 0.53). Structural equation models demonstrate that the intervention affected HIV testing uptake through the individual intervention exposure received and higher personal mobilization scores.

Conclusions: There was no evidence of community-wide gains in HIV testing due to the intervention. However, a significant intervention effect on HIV testing was noted in residents who were personally exposed to the intervention and who evidenced higher community mobilization. Research is needed to understand whether CM interventions can be diffused within communities over time.

Abstract  Full-text [free] access 

Editor’s notes: HIV testing is an integral component of HIV prevention strategies, and essential for achieving the UNAIDS 90-90-90 treatment target. However, testing coverage in many parts of sub-Saharan Africa remains low, particularly among men. Stigma, gender norms, and lack of ‘buy in’ about the benefits of early testing and treatment remain major barriers to testing. 

This cluster-randomised trial of a community mobilization (CM) approach for HIV prevention in South Africa is one of the first to be based around an explicit theoretical model of community change. CM is designed to engage community members and motivate people to achieve a common goal, and has been used successfully in some HIV prevention programmes. The programme focused on young men aged 18-35 years, with an aim to build community support for normative changes that are necessary to tackle social barriers to HIV testing and care. Trial outcomes included gender norms, sexual behaviour and HIV testing uptake. The trial found no overall effect on the uptake of HIV testing – self-reported HIV testing increased significantly in both arms over the two year observation period, with no difference between the programme and control communities. However, CM scores, used to quantify the degree of community engagement, were higher in the programme communities. In addition, individuals with greater exposure to the programme were more likely to report HIV testing. These findings suggest that although the CM programme did have an impact on the individuals exposed to it, the effect did not filter through to the wider community.  

CM strategies are used increasingly in public health programmes, and can be a powerful tool for increasing community awareness and engagement with HIV prevention. The benefit of CM is its ability to diffuse beyond the immediate participants to the community as a whole, to bring about the greatest possible change. However, little is known about why and how these approaches work. As this study illustrates, there is a need to understand more about the underlying mechanisms of change associated with CM, and the factors that contribute to its success.

Africa
South Africa
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Violence and sex work in Uganda

Policing the epidemic: high burden of workplace violence among female sex workers in conflict-affected northern Uganda.

Muldoon KA, Akello M, Muzaaya G, Simo A, Shoveller J, Shannon K. Glob Public Health. 2017 Jan;12(1):84-97. Epub 2015 Oct 27.

Sex workers in sub-Saharan Africa experience a high burden of HIV with a paucity of data on violence and links to HIV risk among sex workers, and even less within conflict-affected environments. Data are from a cross-sectional survey of female sex workers in Gulu, northern Uganda (n = 400). Logistic regression was used to determine the specific association between policing and recent physical/sexual violence from clients. A total of 196 (49.0%) sex workers experienced physical/sexual violence by a client. From those who experienced client violence the most common forms included physical assault (58.7%), rape (38.3%), and gang rape (15.8%) Police harassment was very common, a total of 149 (37.3%) reported rushing negotiations with clients because of police presence, a practice that was significantly associated with increased odds of client violence (adjusted odds ratio: 1.61, 95% confidence intervals: 1.03-2.52). Inconsistent condom use with clients, servicing clients in a bar, and working for a manager/pimp were also independently associated with recent client violence. Structural and community-led responses, including decriminalisation, and engagement with police and policy stakeholders, remain critical to addressing violence, both a human rights and public health imperative.

Abstract access  

Editor’s notes: Sex workers are at increased risk of HIV and of violence from multiple perpetrators. There is a paucity of research examining violence among sex workers in conflict-affected areas. Sex work in Uganda is illegal. A police presence can reduce sex workers ability to screen for dangerous clients, negotiate sex acts, price and condom use. This study is from northern Uganda. The site, now at peace, has experienced 20 years of war. A quarter of sex workers are living with HIV. The paper examines the prevalence of client violence, police arrest and other factors, and how they interrelate.

Participants in the study were usually young (median age 21 years), poorly educated and had ≥1 child. One third had been abducted into the Lord’s Resistance Army and two thirds had lived in an Internal Displacement Camp. Some 49% had experienced recent physical or sexual violence from clients.  Eight percent had been gang raped in the past six months. Policing, inconsistent condom use, having sex in a bar and working for a manager or pimp were significantly associated with client violence. Sex workers in this survey face a high prevalence of violence and HIV. Decriminalisation of sex work is vital if sex workers are to access labour and human rights protection and to reduce the high prevalence of violence and HIV

Africa
Uganda
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ART has dramatically improved life expectancy for people living with HIV in KwaZulu-Natal, South Africa

Trends in the burden of HIV mortality after roll-out of antiretroviral therapy in KwaZulu-Natal, South Africa: an observational community cohort study.

Reniers G, Blom S, Calvert C, Martin-Onraet A, Herbst AJ, Eaton JW, Bor J, Slaymaker E, Li ZR, Clark SJ, Barnighausen T, Zaba B, Hosegood V Lancet HIV. 2016 Dec 9. pii: S2352-3018(16)30225-9. doi: 10.1016/S2352-3018(16)30225-9

Background: Antiretroviral therapy (ART) substantially decreases morbidity and mortality in people living with HIV. In this study, we describe population-level trends in the adult life expectancy and trends in the residual burden of HIV mortality after the roll-out of a public sector ART programme in KwaZulu-Natal, South Africa, one of the populations with the most severe HIV epidemics in the world.

Methods: Data come from the Africa Centre Demographic Information System (ACDIS), an observational community cohort study in the uMkhanyakude district in northern KwaZulu-Natal, South Africa. We used non-parametric survival analysis methods to estimate gains in the population-wide life expectancy at age 15 years since the introduction of ART, and the shortfall of the population-wide adult life expectancy compared with that of the HIV-negative population (ie, the life expectancy deficit). Life expectancy gains and deficits were further disaggregated by age and cause of death with demographic decomposition methods.

Findings: Covering the calendar years 2001 through to 2014, we obtained information on 93 903 adults who jointly contribute 535 428 person-years of observation to the analyses and 9992 deaths. Since the roll-out of ART in 2004, adult life expectancy increased by 15.2 years for men (95% CI 12.4-17.8) and 17.2 years for women (14.5-20.2). Reductions in pulmonary tuberculosis and HIV-related mortality account for 79.7% of the total life expectancy gains in men (8.4 adult life-years), and 90.7% in women (12.8 adult life-years). For men, 9.5% is the result of a decline in external injuries. By 2014, the life expectancy deficit had decreased to 1.2 years for men (-2.9 to 5.8) and to 5.3 years for women (2.6-7.8). In 2011-14, pulmonary tuberculosis and HIV were responsible for 84.9% of the life expectancy deficit in men and 80.8% in women.

Interpretation: The burden of HIV on adult mortality in this population is rapidly shrinking, but remains large for women, despite their better engagement with HIV-care services. Gains in adult life-years lived as well as the present life expectancy deficit are almost exclusively due to differences in mortality attributed to HIV and pulmonary tuberculosis.

Abstract access

Editor’s notes: Health and demographic surveillance system (HDSS) sites allow for monitoring of population health through the collection of detailed data on tens of thousands of individuals. Such sites in countries with high HIV prevalence have played an important role in measuring the effects of large-scale programmes, such as the global roll-out of antiretroviral therapy (ART). The data presented in this paper, from the Africa Centre Demographic Information System (ACDIS) in KwaZulu-Natal, South Africa, span 13 years (2001–14) and represent over 93 000 individuals living in an area with extremely high HIV prevalence (29% in adults aged 15–49 years in 2011). At least 15 000 of people studied were HIV-positive, of whom at least 2000 died. ART was first made available to people living with HIV (PLHIV) in this area in 2004.

Among adults aged 15–49 years, the authors report an overall reduction in death rate from 2001–14.  This translates into large increases in life expectancy (i.e., the expected number of years lived from age 15) of 15 and 17 years for men and women, respectively, between 2001 and 2014.  The changes in life expectancy are greater in people who were confirmed HIV-positive: 18 and 21 years for men and women, respectively, from 2007–14.  The large difference in life expectancies between the sexes that still exists (31 versus 44 years in HIV-positive men and women, respectively) are consistent with previously published estimates from Rwanda and Uganda. This study, however, illustrates that HIV-positive men are catching up to their HIV-negative counterparts faster than women are. The ‘deficit’ in 2014 - the gap in life expectancies between HIV-positive and HIV-negative individuals, was 1.2 years in men but still 5.3 years in women.

The authors propose that increased access to ART is the primary driver of the gains in life expectancy seen in this cohort. To further support this, they include data from verbal autopsies (VAs), which suggest that reductions in deaths due to HIV and pulmonary tuberculosis were responsible for 80% and 90% of the increases in life expectancy in men and women, respectively. VAs have limitations, however, particularly in areas of high HIV prevalence, but the overall mortality patterns suggested by these findings are likely to be accurate, even if the precise estimates differ.

The dramatic increases in life expectancy, in only seven years, for HIV-positive individuals in this cohort add to the encouraging observations from other low- and middle-income countries that many people receiving ART can expect to live for nearly as long as HIV-negative individuals.  Of course, people with advanced disease starting ART are still at high risk of death and there remain considerable challenges in getting treatment to all people in need of it. 

Africa
South Africa
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A step forward for HIV prevention in women

Safety and efficacy of a dapivirine vaginal ring for HIV prevention in women.

Nel A, van Niekerk N, Kapiga S, Bekker LG, Gama C, Gill K, Kamali A, Kotze P, Louw C, Mabude Z, Miti N, Kusemererwa S, Tempelman H, Carstens H, Devlin B, Isaacs M, Malherbe M, Mans W, Nuttall J, Russell M, Ntshele S, Smit M, Solai L, Spence P, Steytler J, Windle K, Borremans M, Resseler S, Van Roey J, Parys W, Vangeneugden T, Van Baelen B, Rosenberg Z; Ring Study Team. N Engl J Med. 2016 Dec;375(22):2133-2143.

Background: The incidence of human immunodeficiency virus (HIV) infection remains high among women in sub-Saharan Africa. We evaluated the safety and efficacy of extended use of a vaginal ring containing dapivirine for the prevention of HIV infection in 1959 healthy, sexually active women, 18 to 45 years of age, from seven communities in South Africa and Uganda.

Methods: In this randomized, double-blind, placebo-controlled, phase 3 trial, we randomly assigned participants in a 2:1 ratio to receive vaginal rings containing either 25 mg of dapivirine or placebo. Participants inserted the rings themselves every 4 weeks for up to 24 months. The primary efficacy end point was the rate of HIV type 1 (HIV-1) seroconversion.

Results: A total of 77 participants in the dapivirine group underwent HIV-1 seroconversion during 1888 person-years of follow-up (4.1 seroconversions per 100 person-years), as compared with 56 in the placebo group who underwent HIV-1 seroconversion during 917 person-years of follow-up (6.1 seroconversions per 100 person-years). The incidence of HIV-1 infection was 31% lower in the dapivirine group than in the placebo group (hazard ratio, 0.69; 95% confidence interval [CI], 0.49 to 0.99; P=0.04). There was no significant difference in efficacy of the dapivirine ring among women older than 21 years of age (hazard ratio for infection, 0.63; 95% CI, 0.41 to 0.97) and those 21 years of age or younger (hazard ratio, 0.85; 95% CI, 0.45 to 1.60; P=0.43 for treatment-by-age interaction). Among participants with HIV-1 infection, nonnucleoside reverse-transcriptase inhibitor resistance mutations were detected in 14 of 77 participants in the dapivirine group (18.2%) and in 9 of 56 (16.1%) in the placebo group. Serious adverse events occurred more often in the dapivirine group (in 38 participants [2.9%]) than in the placebo group (in 6 [0.9%]). However, no clear pattern was identified.

Conclusions: Among women in sub-Saharan Africa, the dapivirine ring was not associated with any safety concerns and was associated with a rate of acquisition of HIV-1 infection that was lower than the rate with placebo. (Funded by the International Partnership for Microbicides; ClinicalTrials.gov number, NCT01539226 .).

Abstract  Full-text [free] access

Editor’s notes: The need to develop safe, effective tools for women, particularly young women and adolescent girls, remains a high priority in sub-Saharan Africa. Self-inserted vaginal rings, which provide sustained release of antiretroviral drugs over time, offer an option that women can initiate themselves. Two large randomised trials have been conducted to assess the efficacy and safety of a vaginal ring containing dapivirine in preventing HIV infection in women. This trial is published in the same issue of the New England Journal of Medicine as the trial by Baeten et al. (reviewed by HIV This Month in March 2016). Both trials were conducted in eastern and southern Africa where the incidence of HIV remains high.

As in the Baeten trial, this trial found a moderate reduction in HIV infection (31% lower) among women using the dapivirine vaginal ring compared with placebo. In both trials, protection was higher among women older than 21 years of age, although, unlike the Baeten trial, the difference in efficacy between the two age groups in this trial was not statistically significant. Baeten et al noted that biological measurement of adherence was higher among women older than 21 years (more than 70% overall) which may partly explain the higher protection observed. The investigators of both trials note that the genital tract of younger women may make them more susceptible to HIV infection. This warrants further investigation. Differences in the frequency of vaginal and/or anal sex across different age groups may also be important. In an editorial to accompany publication of these two important trials, Adimora notes that “providers and women must ensure that the HIV interventions that women adopt match their sexual behaviours and needs. Different women – and women at different life stages – will require different types of HIV prevention.”  

Africa
South Africa, Uganda
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MSM resilience to HIV

Identifying resilience resources for HIV prevention among sexual minority men: a systematic review.

Woodward EN, Banks RJ, Marks AK, Pantalone DW. AIDS Behav. 2016 Dec 15. [Epub ahead of print]

Most HIV prevention for sexual minority men and men who have sex with men targets risk behaviors (e.g., condom use) and helps <50% of participants. Bolstering resilience might increase HIV prevention's effectiveness. This systematic review identified resilience resources (protective factors) in high-risk, HIV-negative, sexual minority men. We reviewed PsycINFO, PsycARTICLES, MEDLINE, references, and Listservs for studies including sexual minority men with 1+ HIV risk factor (syndemics): childhood sexual abuse, partner abuse, substance abuse, or mental health symptoms. From 1356 articles screened, 20 articles met inclusion criteria. Across the articles, we identified and codified 31 resilience resources: socioeconomic (e.g., employment), behavioral coping strategies (e.g., mental health treatment), cognitions/emotions (e.g., acceptance), and relationships. Resilience resources were generally associated with lower HIV risk; there were 18 low-risk associations, 4 high-risk associations, 8 non-significant associations. We generated a set of empirically based resilience variables and a hypothesis to be evaluated further to improve HIV prevention.

Abstract access  

Editor’s notes: This systematic review sought to identify why gay men and other men who have sex with men, at high-risk of HIV, remain HIV negative. HIV-negative, gay men and other men who have sex with men, with a key risk factor for HIV were identified. These risk factors were childhood sexual abuse, partner abuse, substance abuse or mental health symptoms. The authors sought to identify why such men remain HIV negative. Why they are resilient to infection. Some 20 studies met the inclusion criteria. Four broad categories of resilience were identified; socioeconomic (e.g. degree, full-time job); behavioural coping strategies (e.g. accessing mental health services), cognitions/ emotions (e.g. acceptance of a situation); and relationships (e.g. perceived sufficient social support). Of the 31 sub-categories of resilience resources identified, four were identified as protective for HIV infection: main sex partner is HIV negative, willingness to use PrEP, PrEP acceptance and condom use. Resilience resource research for HIV prevention is a sparse area of study. This study generated a set of resilience variables upon which further research can be built.

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High prevalence of gender based violence among adolescent female sex workers - need to improve access to health services

Prevalence and correlates of sexual and gender-based violence against Chinese adolescent women who are involved in commercial sex: a cross-sectional study.

Zhang XD, Myers S, Yang HJ, Li Y, Li JH, Luo W, Luchters S. BMJ Open. 2016 Dec 19;6(12):e013409. doi: 10.1136/bmjopen-2016-013409.

Objectives: Despite the vast quantity of research among Chinese female sex workers (FSWs) to address concerns regarding HIV/sexually transmitted infection (STI) risk, there is a paucity of research on issues of sexual and gender-based violence (SGBV) and the missed opportunity for sexual and reproductive health (SRH) promotion among young FSWs. Our research aimed to assess the prevalence and correlates of SGBV among Chinese adolescent FSWs, and to explore SRH service utilisation.

Design and methods: A cross-sectional study using a one-stage cluster sampling method was employed. A semistructured questionnaire was administered by trained peer educators or health workers. Multivariable logistic regression was conducted to determine individual and structural correlates of SGBV.

Setting and participants: Between July and September 2012, 310 adolescent women aged 15-20 years, and who self-reported having received money or gifts in exchange for sex in the past 6 months were recruited and completed their interview in Kunming, Yunnan Province, China.

Results: Findings confirm the high prevalence of SGBV against adolescent FSWs in China, with 38% (118/310) of participants affected in the past year. Moreover, our study demonstrated the low uptake of public health services and high rates of prior unwanted pregnancy (52%; 61/118), abortion (53%; 63/118) and self-reported STI symptoms (84%; 99/118) in participants who were exposed to SGBV. Forced sexual debut was reported by nearly a quarter of FSWs (23%; 70/310) and was independently associated with having had a drug-using intimate partner and younger age (<17 years old) at first abortion. When controlling for potential confounders, having experienced SGBV was associated with frequent alcohol use, having self-reported symptoms of STI, having an intimate partner and having an intimate partner with illicit drug use.

Conclusions: This study calls for effective and integrated interventions addressing adolescent FSWs' vulnerability to SGBV and broader SRH consequences.

Abstract  Full-text [free] access 

Editor’s notes: The paper reports a study conducted to measure the prevalence and correlates of sexual and gender-based violence among Chinese adolescent female sex workers, given the paucity of data on this. A cross-sectional survey was conducted in the Yunnan Province, which has a relatively high HIV-1 prevalence. Around 300 women aged 15-19 years, who had received money or gifts in exchange for sex in the past six months were recruited for a survey.

The survey revealed that over half the female sex workers were married or cohabiting but lived predominantly with other sex workers or friends, or alone. The majority reported that they had been a sex worker for less than six months. Over the past year, 82% of the female sex workers had an intimate partner, and most of these relationships were for less than one year. Alcohol use was common, with 83% of the female sex workers reporting drinking alcohol at least twice a week. Inconsistent condom use in the past month was reported by 57% of the female sex workers.

Around a quarter of women’s first sexual experience was forced. Thirty-eight per cent of the female sex workers reported having experienced sexual and gender-based violence in the past year, with three quarters of women reporting the perpetrator as their intimate male partner and (62%) a male paying client. The female sex workers experiencing sexual and gender-based violence in the past year were more likely to be frequent drinkers or have a drug-using intimate partner. Women who experienced sexual and gender-based violence were more likely to report unwanted pregnancy, and less likely to use public health facilities or HIV testing services.

The authors suggest that their findings reveal a missed opportunity for the public health sector to address sexual and gender-based violence and associated sexual and reproductive health issues. However, they suggested there is a need to involve women-led community-based organisations to build relationships with female sex workers to enable them to utilise such services. There is also a need for further research on integrated programmes to prevent or reduce sexual and gender-based violence against adolescent female sex workers. 

Epidemiology, Gender
Asia
China
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