Articles tagged as "Gender"

Finding out at home: community members’ and healthcare workers’ views on the use of oral HIV self-testing in Kayelitsha, South Africa

'I know that I do have HIV but nobody saw me': oral HIV self-testing in an informal settlement in South Africa.

Martinez Perez G, Cox V, Ellman T, Moore A, Patten G, Shroufi A, Stinson K, Van Cutsem G, Ibeto M. PLoS One. 2016 Apr 4;11(4):e0152653. doi: 10.1371/journal.pone.0152653. eCollection 2016.

Reaching universal HIV-status awareness is crucial to ensure all HIV-infected patients access antiretroviral treatment (ART) and achieve virological suppression. Opportunities for HIV testing could be enhanced by offering self-testing in populations that fear stigma and discrimination when accessing conventional HIV Counselling and Testing (HCT) in health care facilities. This qualitative research aims to examine the feasibility and acceptability of unsupervised oral self-testing for home use in an informal settlement of South Africa. Eleven in-depth interviews, two couple interviews, and two focus group discussions were conducted with seven healthcare workers and thirteen community members. Thematic analysis was done concurrently with data collection. Acceptability to offer home self-testing was demonstrated in this research. Home self-testing might help this population overcome barriers to accepting HCT; this was particularly expressed in the male and youth groups. Nevertheless, pilot interventions must provide evidence of potential harm related to home self-testing, intensify efforts to offer quality counselling, and ensure linkage to HIV/ART-care following a positive self-test result.

 Abstract Full-text [free] access

Editor’s notes: This is a qualitative study with services users and healthcare workers from an HIV testing service ran by Médecins Sans Frontières (MSF) in Kayelitsha, South Africa. Couple and individual interviews and focus group discussions were conducted with 20 people. The participants discussed preferences of types of HIV testing and acceptability of HIV home-testing. The aim was to inform the pilot of an activity for the use of an oral HIV self-testing device (OraQuick). OraQuick is self-administered as an oral swab and gives results straightaway. The study sample included people who had previously refused an HIV test in the clinic, people who had received an HIV test in the clinic and agreed to a couple interview with their partners. Key reasons for refusing an HIV test in the clinic included: fear of finding out one’s status, fear of HIV-treated discrimination and concerns about confidentiality in testing services. Clinics were seen by male participants as ‘women’s places’.  Men thought visiting a service for an HIV test could harm one’s reputation. Home-testing was seen as preferable because it afforded more privacy. However, not wanting to know one’s status remains a barrier even with home-testing. There were concerns that partners (of both sexes) could pressure one another to test with OraQuick and tensions could arise in case of serodiscordant results. There were concerns that some users could get confused by a test that detects the presence of HIV in the mouth. This would contradict current awareness that HIV cannot be passed through kissing. False-negative tests could encourage unsafe sex. Participants worried that some people may not link into care and treatment after finding out they are HIV positive with a home-test. The study concludes that home-testing could reach populations (especially male partners of women living with HIV and young people) that do not come forward for testing through other services, including clinic-based and voluntary community testing. Many of the disadvantages of home-testing could be mitigated with appropriate education and pre-test counselling. The pilot study continues.  It is expected that the study will be able to address questions of linkage to care for people who test HIV-positive. 

Africa
South Africa
  • share
0 comments.

Intimate partner violence among female sex workers living with HIV must be addressed to improve their wellbeing and reduce onward transmission of HIV

A prospective cohort study of intimate partner violence and unprotected sex in HIV-positive female sex workers in Mombasa, Kenya.

Wilson KS, Deya R, Yuhas K, Simoni J, Vander Stoep A, Shafi J, Jaoko W, Hughes JP, Richardson BA, McClelland RS. AIDS Behav. 2016 Apr 19. [Epub ahead of print]

We conducted a prospective cohort study to test the hypothesis that intimate partner violence (IPV) is associated with unprotected sex in HIV-positive female sex workers in Mombasa, Kenya. Women completed monthly visits and quarterly examinations. Any IPV in the past year was defined as ≥1 act of physical, sexual, or emotional violence by the current or most recent emotional partner ('index partner'). Unprotected sex with any partner was measured by self-report and prostate specific antigen (PSA) test. Recent IPV was associated with significantly higher risk of unprotected sex (adjusted relative risk [aRR] 1.91, 95 % CI 1.32, 2.78, p = 0.001) and PSA (aRR 1.54, 95 % CI 1.17, 2.04, p = 0.002) after adjusting for age, alcohol use, and sexual violence by someone besides the index partner. Addressing IPV in comprehensive HIV programs for HIV-positive women in this key population is important to improve wellbeing and reduce risk of sexual transmission of HIV.

Abstract access  

Editor’s notes: Intimate partner violence (IPV) is the most common form of gender-based violence globally. A recent systematic review reported high prevalence of IPV in sub-Saharan Africa, ranging from 30% to 66% among ever partnered women. Negative outcomes associated with IPV include increased risk of HIV infection and there are multiple pathways through which IPV may increase the risk of HIV infection in women. These include reduced sexual relationship power and ability to negotiate condom, and more risky sexual behaviour. Furthermore, IPV may be a marker of relationships with men who have a history of violent behaviour and may be at increased risk of HIV themselves. Women living with HIV are also at increased risk of IPV, which in turn can increase the risk of condomless sex and onward transmission of HIV.

Female sex workers are a key population disproportionately affected by violence, substance abuse and HIV. This longitudinal study of female sex workers in Kenya found a significant association between IPV and condomless sex. It highlights the value of using both self-reported behavioural and biological markers of sexual behaviour to gain a more complete understanding of the relationship between IPV and risky sexual behaviour. Comprehensive HIV programmes must address IPV to improve both the health and well-being of women living with HIV and to reduce sexual transmission of HIV. 

Africa
Kenya
  • share
0 comments.

The right kind of sex

The feminine ideal and transactional sex: navigating respectability and risk in Swaziland.

Fielding-Miller R, Dunkle KL, Jama-Shai N, Windle M, Hadley C, Cooper HL. Soc Sci Med. 2016 Apr 7;158:24-33. doi: 10.1016/j.socscimed.2016.04.005. [Epub ahead of print]

Women who engage in transactional sex are not only at increased risk of HIV and intimate partner violence, but also face social risks including gossip and ostracism. These social and physical risks may be dependent on both what a woman expects and needs from her partner and how her community perceives the relationship. Gender theory suggests that some of these social risks may hinge on whether or not a woman's relationship threatens dominant masculinity. We conducted a qualitative study in Swaziland from September 2013 to October 2014 to explore transactional sex and respectable femininity through the lens of hegemonic gender theory. Using cultural consensus modeling, we identified cultural models of transactional sex and conducted 16 in-depth interviews with model key informants and 3 focus group discussions, for a total of 41 participants. We identified 4 main models of transactional relationships: One typified by marriage and high social respectability, a second in which women aspire towards marriage, a third particular to University students, and a fourth "sugar daddy" model. Women in all models expected and received significant financial support from their male partners. However, women in less respectable relationships risked social censure and stigma if they were discovered, in part because aspects of their relationship threatened hegemonic masculinity. Conversely, women who received male support in respectable relationships had to carefully select HIV risk reduction strategies that did not threaten their relationship and associated social status. Research and programming efforts typically focus only on the less socially respectable forms of transactional sex. This risks reinforcing stigma for women in relationships that are already considered socially unacceptable while ignoring the unique HIV risks faced by women in more respectable relationships.

Abstract access

Editor’s notes: Adolescent girls and young women are at a disproportionate risk of HIV infection when compared to their male counterparts. Transactional sex is associated with gendered HIV vulnerability in sub-Saharan Africa and is also associated with intimate partner violence. While economic exchange is present in many relationships, adolescent girls and young women are required to navigate a line between acceptable and unacceptable economic dependence. This line is further complicated by the fact that in much of the world, the notion of ‘men as providers’ is considered the norm. 

The findings illustrate, as with previous research, that women’s economic dependence in relationships was seen to be a risk. So too was social pressure. Women whose relationships manifested an emphasised femininity used health protection strategies that did not jeopardise their relationship (for example always being sexually available) so as to maintain their social and economic stability. Health protection strategies of women, whose relationship was deemed less acceptable, were more mixed.  They may have been less able to negotiate condom use or sexual encounters if they were financially dependent on their partners. But they may also have been more willing to leave a partner or demand condom use. Women who were ‘too independent’ were condemned and stigmatised by community members because of their threat to male dominance.  Programmes designed to reduce risk associated with transactional sex may have greater impact if they focus on the power dynamics created by gender norms. This may be more effective than focusing on the exchange of gifts or money within a relationship. It is important to pay careful attention to local understandings and interpretation of women’s financial, sexual and romantic obligations. We also need to understand women’s motivations for entering or remaining in sexual relationships.

Africa
Swaziland
  • share
0 comments.

Risky young love

Perspectives on intimate relationships among young people in rural South Africa: the logic of risk. 

Edin K, Nilsson B, Ivarsson A, Kinsman J, Norris SA, Kahn K. Cult Health Sex. 2016 Mar 17:1-15. [Epub ahead of print]

This paper explores how young people in rural South Africa understand gender, dating, sexuality and risk-taking in adolescence. The empirical material drawn upon consists of 20 interviews with young men and women (aged 18-19) and reflects normative gender patterns characterised by compulsory heterosexuality and dating as obligatory, and representing key symbols of normality. However, different meanings of heterosexual relationships are articulated in the interviews, for example in the recurring concept of 'passing time', and these meanings show that a relationship can be something arbitrary: a way to reduce boredom and have casual sex. Such a rationale for engaging in a relationship reflects one of several other normative gender patterns, which relate to the trivialisation of dating and sexual risk-taking, and which entail making compromises and legitimising deviations from the 'ideal' life-script and the hope of a better future. However, risks do not exclusively represent something bad, dangerous or immoral, because they are also used as excuses to avoid sex, HIV acquisition and early pregnancy. In conclusion, various interrelated issues can both undermine and/or reinforce risk awareness and subsequent risk behaviour. Recognition of this tension is essential when framing policies to support young people to reduce sexual risk-taking behaviour.

Abstract access

Editor’s notes: This article explores how young people in a poor, rural area in South Africa articulate and understand gender, dating, sexuality, and risk-taking.  Twenty young people (10 female, 10 male) aged between 18 and 19 years of age were randomly selected from three villages that participate in the Health and Socio-Demographic Surveillance System in Mpumalanga Province in north-eastern South Africa. 

Participants’ narratives highlight how normative gender patterns characterised by compulsory heterosexuality and dating as obligatory represent key symbols of normality. The authors highlight how two themes, early pregnancy and HIV, are central to understanding practices of dating and heterosexual relationships. They are also important for understanding ideas about the consequences of a dissolute lifestyle and the risk it exerts on plans and hopes for a better future. This risk was perceived to be particularly acute by, and for, young women who are seen to bear the brunt of negative outcomes, particularly relating to early school dropout.

The findings of this study have important implications for HIV prevention programmes, particularly for adolescent girls and young women. Where intimate relationships are trivialised as guided by normative gender patterns and pressure to have heterosexual relationships, young people risk becoming infected with HIV, becoming parents too early, and interrupting their education. The findings highlight the potential for context-sensitive programmes which play careful attention to local norms and young people’s internalised relationship discourses. These could usefully include opportunities for critical reflection in order to support young people to reduce their exposure to risks.  It is also important to recognise young people’s aspirations, and the perceived benefits they derive from relationships.

Africa
South Africa
  • share
0 comments.

Programme planning must take into account diversity of sex worker populations - Pakistan

Heterogeneity among sex workers in overlapping HIV risk interactions with people who inject drugs: a cross-sectional study from 8 major cities in Pakistan. 

Melesse DY, Shafer LA, Shaw SY, Thompson LH, Achakzai BK, Furqan S, Reza T, Emmanuel F, Blanchard JF. Medicine (Baltimore). 2016 Mar;95(12):e3085. doi: 10.1097/MD.0000000000003085.

Concerns remain regarding the heterogeneity in overlapping human immunodeficiency virus (HIV) risk behaviors among sex workers (SWs) in Pakistan; specifically, the degree to which SWs interact with people who inject drugs (PWID) through sex and/or needle sharing. Following an in-depth mapping performed in 2011 to determine the size and distribution of key populations at highest risk of HIV acquisition in Pakistan, a cross-sectional biological and behavioral survey was conducted among PWID, female (FSWs), male (MSWs), and hijra/transgender (HSWs) sex workers, and data from 8 major cities were used for analyses. Logistic regression was used to identify factors, including city of residence and mode of SW-client solicitation, contributing to the overlapping risks of drug injection and sexual interaction with PWID. The study comprised 8483 SWs (34.5% FSWs, 32.4% HSWs, and 33.1% MSWs). Among SWs who had sex with PWID, HSWs were 2.61 (95% confidence interval [CI], 1.19-5.74) and 1.99 (95% CI, 0.94-4.22) times more likely to inject drugs than MSWs and FSWs, respectively. There was up to a 3-fold difference in drug injecting probability, dependent on where and/or how the SW solicited clients. Compared with SWs in Larkana, the highest likelihood of drug injection use was among SWs in Multan (OR = 4.52; 95% CI: 3.27-6.26), followed by those in Lahore, Quetta, and Faisalabad. Heterogeneity exists in the overlapping patterns of HIV risk behaviors of SWs. The risk of drug injection among SWs also varies by city. Some means of sexual client solicitation may be along the pathway to overlapping HIV risk vulnerability due to increased likelihood of drug injection among SWs. There is a need to closely monitor the mixing patterns between SWs and PWID and underlying structural factors, such as means of sexual client solicitation, that mediate HIV risk, and implement prevention programs customized to local sub-epidemics.

Abstract  Full-text [free] access

Editor’s notes: This is an important paper reporting findings of an HIV prevalence and risk behaviour survey among sex workers and people who inject drugs. The paper describes the diversity of sex work, including male and transgender sex workers that are often neglected in research and service planning. It also examines injecting drug use among sex workers, a behaviour that can increase sex workers’ vulnerability to HIV, violence and other health harms. The finding that among sex workers who had a sex partner who also injected drugs, transgender sex workers had higher odds of injecting than male or female sex workers is important. This finding highlights the differences in vulnerability among the three sex worker populations, whose diversity is often not taken into account in programme planning. Other international evidence suggests increased stigma experienced by transgender sex workers on account of their gender. For example, with increased arrest and harassment administered by police and higher levels of poor emotional health. These are factors that might explain use of injecting drugs as a coping strategy. The study illustrates a clear need to target harm reduction services among this population, to ensure they have access to needle-syringe programmes.  Advice on safe injecting practices and how to manage injecting drug use alongside sex work are also necessary. Findings also clearly illustrate the need to understand better the underlying determinants of drug use and address those. Understanding why prevalence of drug use varies by city is vital. So too, is understanding how the way in which clients are engaged increases risk of injecting, in order to create enabling environments to minimise harms associated with injecting. 

Asia
Pakistan
  • share
0 comments.

ART reduces fertility differences by HIV status among women living in sub-Saharan Africa

Measuring the impact of antiretroviral therapy roll-out on population level fertility in three African countries. 

Marston M, Nakiyingi-Miiro J, Hosegood V, Lutalo T, Mtenga B, Zaba B, and on behalf of the ALPHA network. PLoS One. 2016 Mar 25;11(3):e0151877. doi: 10.1371/journal.pone.0151877. eCollection 2016.

Background: UNAIDS official estimates of national HIV prevalence are based on trends observed in antenatal clinic surveillance, after adjustment for the reduced fertility of HIV positive women. Uptake of ART may impact on the fertility of HIV positive women, implying a need to re-estimate the adjustment factors used in these calculations. We analyse the effect of antiretroviral therapy (ART) provision on population-level fertility in Southern and East Africa, comparing trends in HIV infected women against the secular trends observed in uninfected women.

Methods: We used fertility data from four community-based demographic and HIV surveillance sites: Kisesa (Tanzania), Masaka and Rakai (Uganda) and uMkhanyakude (South Africa). All births to women aged 15-44 years old were included in the analysis, classified by mother's age and HIV status at time of birth, and ART availability in the community. Calendar time period of data availability relative to ART introduction varied across the sites, from 5 years prior to ART roll-out, to 9 years after. Calendar time was classified according to ART availability, grouped into pre ART, ART introduction (available in at least one health facility serving study site) and ART available (available in all designated health facilities serving study site). We used Poisson regression to calculate age adjusted fertility rate ratios over time by HIV status, and investigated the interaction between ART period and HIV status to ascertain whether trends over time were different for HIV positive and negative women.

Results: Age-adjusted fertility rates declined significantly over time for HIV negative women in all four studies. However HIV positives either had no change in fertility (Masaka, Rakai) or experienced a significant increase over the same period (Kisesa, uMkhanyakude). HIV positive fertility was significantly lower than negative in both the pre ART period (age adjusted fertility rate ratio (FRR) range 0.51 95%CI 0.42-0.61 to 0.73 95%CI 0.64-0.83) and when ART was widely available (FRR range 0.57 95%CI 0.52-0.62 to 0.83 95%CI 0.78-0.87), but the difference has narrowed. The interaction terms describing the difference in trends between HIV positives and negatives are generally significant.

Conclusions: Differences in fertility between HIV positive and HIV negative women are narrowing over time as ART becomes more widely available in these communities. Routine adjustment of ANC data for estimating national HIV prevalence will need to allow for the impact of treatment.

Abstract  Full-text [free] access 

Editor’s notes: Antenatal care (ANC) clinics records on demographic characteristics and HIV status of attenders are a major component of primary data used to estimate HIV prevalence in sub-Saharan Africa. Prior to scale-up of antiretroviral therapy (ART), the fertility of women living with HIV was lower than that for people without HIV. This means that prevalence estimates from ANC data were adjusted to avoid underestimating the true population fertility rates.

This paper analyses the changing fertility patterns in four longitudinal community-based cohorts in eastern and southern Africa. The study finds that differences in fertility rates between women living with HIV and women without HIV are narrowing as ART is scaled-up, although substantial differences still exist. There was considerable variation in the patterns between the sites reflecting the differing local epidemic profiles. The authors explain this variation as being due to various factors including biological (increased fertility associated with viral suppression), or behavioural (increased fertility among women experiencing widowhood and then forming new partnerships). The impact of treatment on fertility needs to be incorporated into models of HIV prevalence estimated from ANC data, to inform national policy makers measuring their progress towards HIV elimination targets.

Africa
  • share
0 comments.

Couples talking about prevention and supporting each other on PrEP and ART: lessons from Kenya

I knew I would be safer. Experiences of Kenyan HIV serodiscordant couples soon after pre-exposure prophylaxis (PrEP) initiation.

Ngure K, Heffron R, Curran K, Vusha S, Ngutu M, Mugo N, Celum C, Baeten JM. AIDS Patient Care STDS. 2016 Feb;30(2):78-83. doi: 10.1089/apc.2015.0259.

Pre-exposure prophylaxis (PrEP) for HIV-uninfected persons is highly efficacious for HIV prevention. Understanding how people at risk for HIV will use PrEP is important to inform PrEP scale-up and implementation. We used qualitative methods to gather insights into couples' early experiences with PrEP use within the Partners Demonstration Project, an open-label implementation study evaluating integrated delivery of PrEP and antiretroviral therapy (ART). PrEP is offered to HIV uninfected partners until the HIV-infected partner initiates and sustains ART use (i.e., PrEP as a "bridge" to ART initiation and viral suppression). From August 2013 to March 2014 we conducted 20 in-depth dyadic interviews (n = 40) with heterosexual HIV serodiscordant couples participating at the Thika, Kenya study site, exploring how couples make decisions about using PrEP for HIV prevention. We developed and applied deductive and inductive codes to identify key themes related to experiences of PrEP initiation and use of time-limited PrEP. Couples reported that PrEP offered them an additional strategy to reduce the risk of HIV transmission, meet their fertility desires, and cope with HIV serodiscordance. Remaining HIV negative at follow-up visits reinforced couples' decisions and motivated continued adherence to PrEP. In addition, confidence in their provider's advice and client-friendly services were critical to their decisions to initiate and continue use of PrEP. Strategies for wide-scale PrEP delivery for HIV serodiscordant couples in low resource settings may include building capacity of health providers to counsel on PrEP adoption while addressing couples' concerns and barriers to adoption and continued use.

Abstract access

Editor’s notes: This paper is based on findings from the Partners Demonstration Project. This project evaluated the implementation of ART and PrEP for HIV-1 prevention in African heterosexual HIV-1 serodiscordant couples in Uganda and Kenya. As has been reported elsewhere, the research achieved impressive reductions in HIV-incidence. The strategy adopted in the project was to provide PrEP to the HIV-negative partner until the HIV-positive partner had sustained their use of ART for six months. Using data from Kenya, the authors describe in this paper the value placed by couples on PrEP, which underpinned the study success. Couples wanted to use PrEP because PrEP (and ART) provided the possibility of reduced HIV transmission. In addition to the findings on reasons for PrEP use, this paper also offers insights into couple dynamics. The research was conducted with mutually disclosed HIV serodiscordant couples. The authors illustrated through their analysis and the excerpts from interviews used in the text, the importance of communication between partners. They also, importantly, illustrate differences between couples. The authors describe the use of both verbal and non-verbal communication in discussions about PrEP and ART. Through the data in this paper a picture is built up on the importance of open and frank communication in decisions about using and sustaining the use of PrEP and ART. In a study setting, couples could be afforded support which might be scarce in public health settings. Even so, the findings underline the value of being sensitive to context and individual needs, in supporting PrEP and ART roll-out.

Africa
Kenya
  • share
0 comments.

Multifaceted approaches necessary to reduce HIV risk among orphaned and vulnerable adolescents

Psychological and behavioral interventions to reduce HIV risk: evidence from a randomized control trial among orphaned and vulnerable adolescents in South Africa.

Thurman TR, Kidman R, Carton TW, Chiroro P. AIDS Care. 2016 Feb 17:1-8. [Epub ahead of print]

Evidence-based approaches are needed to address the high levels of sexual risk behavior and associated HIV infection among orphaned and vulnerable adolescents. This study recruited adolescents from a support program for HIV-affected families and randomly assigned them by cluster to receive one of the following: (1) a structured group-based behavioral health intervention; (2) interpersonal psychotherapy group sessions; (3) both interventions; or (4) no new interventions. With 95% retention, 1014 adolescents were interviewed three times over a 22-month period. Intent-to-treat analyses, applying multivariate difference-in-difference probit regressions, were performed separately for boys and girls to assess intervention impacts on sexual risk behaviors. Exposure to a single intervention did not impact behaviors. Exposure to both interventions was associated with risk-reduction behaviors, but the outcomes varied by gender: boys reported fewer risky sexual partnerships (beta = -.48, p = .05) and girls reported more consistent condom (beta = 1.37, p = .02). There was no difference in the likelihood of sexual debut for either gender. Providing both psychological and behavioral interventions resulted in long-term changes in sexual behavior that were not present when either intervention was provided in isolation. Multifaceted approaches for reducing sexual risk behaviors among vulnerable adolescents hold significant promise for mitigating the HIV epidemic among this priority population.

Abstract   Ful-text [free] access

Editor’s notes: HIV infection is the leading cause of mortality among adolescents in sub-Saharan Africa and this age group is a priority group for programmes. Within this age-group, orphaned adolescents are particularly vulnerable, and a major risk factor for HIV infection in this population is psychological distress, which is a key factor in sexual decision-making. This study suggests that a multifaceted approach that addresses both psychological well-being and sexual risk taking behaviour may reduce risky sexual behaviour. Such activities are more likely to be successful if other more basic needs, such as economic security, are already being met. However, the strength of the findings is limited by the reliance on self-reported behaviours rather than biological endpoints. The authors highlight a number of issues that could improve the efficacy of programmes, including introducing gender specific sessions and activities and supplemental school-based programmes.    

Africa
South Africa
  • share
0 comments.

The effects of trauma follow people on the move

A systematic review of HIV risk behaviors and trauma among forced and unforced migrant populations from low and middle-income countries: state of the literature and future directions.

Michalopoulos LM, Aifah A, El-Bassel N. AIDS Behav. 2016 Feb;20(2):243-61. doi: 10.1007/s10461-015-1014-1.

The aim of the current systematic review is to examine the relationship between trauma and HIV risk behaviors among both forced and unforced migrant populations from low and middle income countries (LMIC). We conducted a review of studies published from 1995 to 2014. Data were extracted related to (1) the relationship between trauma and HIV risk behaviors, (2) methodological approach, (3) assessment methods, and (4) differences noted between forced and unforced migrants. A total of 340 records were retrieved with 24 studies meeting inclusion criteria. Our review demonstrated an overall relationship between trauma and HIV risk behaviors among migrant populations in LMIC, specifically with sexual violence and sexual risk behavior. However, findings from 10 studies were not in full support of the relationship. Findings from the review suggest that additional research using more rigorous methods is critically needed to understand the nature of the relationship experienced by this key-affected population.

Abstract access

Editor’s notes: The number of forced and unforced migrants is growing globally. Refugees, asylum seekers, and internally displaced persons (IDP) are forced migrants who often migrate due to political violence or conflict. Labour migrants are seen as unforced migrants who choose to emigrate for economic reasons. About half of labour migrants worldwide are women who are increasingly migrating on their own being the sole income provider for their families. With respect to trauma exposure and HIV risk in settings of long-term political violence and conflict, the distinction between war migrant, non-war migrant, and long-term resident is blurred. This in-depth review of 24 studies related to low-and middle-income countries (LMIC), mostly from sub-Saharan Africa, found findings similar to those from non-migrant populations in high-income countries. These linked traumatic experiences among migrant populations with HIV risk behaviours. Sexual violence was consistently associated with HIV sexual risk behaviours and HIV infection across the studies. But there are big gaps in the scientific literature. For example, the relationship between trauma and HIV risks has been explored for female labour migrants who are sex workers but not among women who have other occupations. Most studies addressed sexual risk and alcohol dependence, but injecting drug risk behaviours and use of any illicit drugs were virtually ignored by most studies. Few studies examined a possible link for trauma that occurred pre-migration and post-migration. Three qualitative studies examined male migrants who have sex with men, finding that violent experiences and discrimination and stigma associated with homophobia, combined with other migrant-associated traumas, can compound their mental health outcomes and subsequent HIV risk behaviours – but all were only conducted in the last four years. No studies were found that focused on HIV prevention programmes to address trauma and HIV risks among migrant workers in LMIC. However, the studies do reveal important factors that prevention programmes would have to consider. For example, concerns among labour migrants about dangerous working conditions may take precedence over HIV risk perceptions and the need for safer sex. This systematic review presents a wealth of information while highlighting the need to improve the quality of scientific research examining the link between HIV and trauma among both forced and unforced migrants in LMIC. 

Africa, Asia, Europe, Latin America
  • share
0 comments.

HIV and injecting ‘krokodile’

Krokodile Injectors in Ukraine: fueling the HIV Epidemic?

Booth RE, Davis JM, Brewster JT, Lisovska O, Dvoryak S. AIDS Behav. 2016 Feb;20(2):369-76. doi: 10.1007/s10461-015-1008-z.

This study was designed to assess the characteristics of krokodile injectors, a recent phenomenon in Ukraine, and HIV-related risk factors among people who inject drugs (PWID). In three Ukraine cities, Odessa, Donetsk and Nikolayev, 550 PWID were recruited between December 2012 and October 2013 using modified targeted sampling methods. The sample averaged 31 years of age and they had been injecting for over 12 years. Overall, 39% tested positive for HIV, including 45% of krokodile injectors. In the past 30 days, 25% reported injecting krokodile. Those who injected krokodile injected more frequently (p < 0.001) and they injected more often with others (p = 0.005). Despite knowing their HIV status to be positive, krokodile users did not reduce their injection frequency, indeed, they injected as much as 85% (p = 0.016) more frequently than those who did not know their HIV status or thought they were negative. This behavior was not seen in non-krokodile using PWID. Although only a small sample of knowledgeable HIV positive krokodile users was available (N = 12), this suggests that krokodile users may disregard their HIV status more so than non-krokodile users. In spite of widespread knowledge of its harmful physical consequences, a growing number of PWID are turning to injecting krokodile in Ukraine. Given the recency of krokodile use in the country, the associated higher frequency of injecting, a propensity to inject more often with others, and what could be a unique level of disregard of HIV among krokodile users, HIV incidence could increase in future years.

Abstract access

Editor’s notes: This is an important study among a highly vulnerable population of people who inject drugs where HIV prevalence has been consistently high over the last decade. This is one of the first empirical studies to examine the role of krokodile use on HIV risk acquisition. Krokodile is a home produced drug that has become more popular among people who inject drugs in Ukraine and the Russian Federation over the last five years. There is a long history of injection with home-produced opioids and amphetamines in these countries. The key component of krokodile is codeine, an opioid, but severe side effects have been associated with its injection including tissue damage, gangrene and organ failure. This study highlights some of the characteristics and HIV risk behaviours associated with krokodile injection to inform appropriate HIV prevention programming. Findings note that people who inject krokodile are more likely to inject with others. This reflects the home-produced nature of the drug that facilitates more group injecting as people congregate at places where it is produced to buy and inject. Programmes need to focus on strategies to avoid injecting with other people’s used injecting equipment, such as marking equipment, as can happen in group injecting scenarios. This programme would ensure there are sufficient numbers of clean needles/syringes in circulation. Worryingly, a higher prevalence of HIV was observed among people who inject krokodile, most likely associated with their older age and more frequent injecting. Targeted harm reduction information is urgently needed for krokodile users to prevent further HIV transmission and prevent soft tissue damage. There is already a large network of needle-syringe programmes and opioid substitution therapy available for people who inject drugs in Ukraine. However, access is often reduced since people who inject drugs are concerned about being arrested. Registration as a person who injects drugs causes problems with employment, families and police. Collaboration with the police is necessary to increase access to opioid substitution and needle and syringe programmes. Programmes are also required to reduce the stigma associated with injection in order to address the health needs of this population. 

Europe
Ukraine
  • share
0 comments.