Articles tagged as "Gender"

Assessing the risk of HIV in older age in South Africa

HIV after 40 in rural South Africa: a life course approach to HIV vulnerability among middle aged and older adults.

Mojola SA, Williams J, Angotti N, Gomez-Olive FX. Soc Sci Med. 2015 Oct;143:204-12. doi: 10.1016/j.socscimed.2015.08.023. Epub 2015 Aug 17.

South Africa has the highest number of people living with HIV in the world (over 6 million) as well as a rapidly aging population, with 15% of the population aged 50 and over. High HIV prevalence in rural former apartheid homeland areas suggests substantial aging with HIV and acquisition of HIV at older ages. We develop a life course approach to HIV vulnerability, highlighting the rise and fall of risk and protection as people age, as well as the role of contextual density in shaping HIV vulnerability. Using this approach, we draw on an innovative multi-method data set collected within the Agincourt Health and Demographic Surveillance System in South Africa, combining survey data with 60 nested life history interviews and 9 community focus group interviews. We examine HIV risk and protective factors among adults aged 40-80, as well as how and why these factors vary among people at older ages.

Abstract access

Editor’s notes: A growing body of work is documenting the importance of HIV in older age in East and southern Africa. This paper is a valuable addition to the literature. The authors look at how the risk of HIV infection, and the impact of living with HIV, affects women and men aged 40-80 years old. Forty is a relatively young age for a study of older people, but the age span covered by this paper does allow the authors to trace HIV vulnerability for people actively engaged in migrant labour to when they settle, as they age into their 60s and 70s. The finding that risk of HIV-infection and vulnerability to the impact of HIV vary across the life course, is not new. But the findings presented in this paper provide a compelling picture of changing risk. Indeed, the possibility that men in their 60s might be at particular risk of acquiring HIV because of their wives diminishing interest in sex highlights the importance of not assuming only people under 50 are ‘sexually active’. The authors also illustrate the risk that older women face who may prefer to remain celibate but cannot always refuse to have sexual intercourse with their husbands. One notable finding is that older men with a pension are attractive partners for younger women in what the authors describe as a poverty stricken area. The mixture of quantitative and qualitative data the authors use provide both breadth and depth to the findings presented making this both an interesting and informative paper.

Africa
South Africa
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Childhood sexual violence and HIV risk in Tanzania

HIV and childhood sexual violence: implications for sexual risk behaviors and HIV testing in Tanzania.

Chiang LF, Chen J, Gladden MR, Mercy JA, Kwesigabo G, Mrisho F, Dahlberg LL, Nyunt MZ, Brookmeyer KA, Vagi K. AIDS Educ Prev. 2015 Oct;27(5):474-87. doi: 10.1521/aeap.2015.27.5.474

Prior research has established an association between sexual violence and HIV. Exposure to sexual violence during childhood can profoundly impact brain architecture and stress regulatory response. As a result, individuals who have experienced such trauma may engage in sexual risk-taking behavior and could benefit from targeted interventions. In 2009, nationally representative data were collected on violence against children in Tanzania from 13-24 year old respondents (n = 3739). Analyses show that females aged 19-24 (n = 579) who experienced childhood sexual violence, were more likely to report no/infrequent condom use in the past 12 months (AOR = 3.0, CI [1.5, 6.1], p = 0.0017) and multiple sex partners in the past 12 months (AOR = 2.3, CI [1.0, 5.1], p = 0.0491), but no more likely to know where to get HIV testing or to have ever been tested. Victims of childhood sexual violence could benefit from targeted interventions to mitigate impacts of violence and prevent HIV.

Abstract access

Editor’s notes: A growing body of evidence has established an association between sexual violence and increased vulnerability to HIV infection. Childhood sexual violence may increase HIV risk both directly (e.g. forced sex) and indirectly (e.g. through high-risk sex behaviours later in life). This paper examined two questions: is childhood violence exposure associated with (i) high-risk sexual behaviour in early adulthood and (ii) increased/decreased knowledge and uptake of HIV testing services.

A nationally representative sample of females aged 19-24 years were surveyed. Women were excluded from the analyses if they were not sexually active. Some 26.1% of 579 women reported childhood sexual violence (answering yes to one of four questions around unwanted touch / attempted rape / unwanted / coercive sexual intercourse before age 18 years). Childhood sexual violence was associated with (i) low / no condom use with someone other than husband / live in partner and (ii) >1 sexual partner, past 12 months. There was no association with knowledge or uptake of HIV testing services. These findings are consistent with research done elsewhere and suggest childhood sexual violence is associated with increased sexual risk taking behaviours in early adulthood. These findings present evidence for the importance of programmes to reduce childhood exposure to violence and focussed, adolescent-friendly sexual health services.

Africa
United Republic of Tanzania
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Invitation plus tracing increases male partner testing during pregnancy

Recruiting male partners for couple HIV testing and counselling in Malawi's option B+ programme: an unblinded randomised controlled trial.

Rosenberg NE, Mtande TK, Saidi F, Stanley C, Jere E, Paile L, Kumwenda K, Mofolo I, Ng'ambi W, Miller WC, Hoffman I, Hosseinipour M. Lancet HIV. 2015 Nov;2(11):e483-91. doi: 10.1016/S2352-3018(15)00182-4. Epub 2015 Oct 22.

Background: Couples HIV testing and counselling (CHTC) is encouraged but is not widely done in sub-Saharan Africa. We aimed to compare two strategies for recruiting male partners for CHTC in Malawi's option B+ prevention of mother-to-child transmission programme: invitation only versus invitation plus tracing and postulated that invitation plus tracing would be more effective.

Methods: We did an unblinded, randomised, controlled trial assessing uptake of CHTC in the antenatal unit at Bwaila District Hospital, a maternity hospital in Lilongwe, Malawi. Women were eligible if they were pregnant, had just tested HIV-positive and therefore could initiate antiretroviral therapy, had not yet had CHTC, were older than 18 years or 16-17 years and married, reported a male sex partner in Lilongwe, and intended to remain in Lilongwe for at least 1 month. Women were randomly assigned (1:1) to either the invitation only group or the invitation plus tracing group with block randomisation (block size=4). In the invitation only group, women were provided with an invitation for male partners to present to the antenatal clinic. In the invitation plus tracing group, women were provided with the same invitation, and partners were traced if they did not present. When couples presented they were offered pregnancy information and CHTC. Women were asked to attend a follow-up visit 1 month after enrolment to assess social harms and sexual behaviour. The primary outcome was the proportion of couples who presented to the clinic together and received CHTC during the study period and was assessed in all randomly assigned participants. This study is registered with ClinicalTrials.gov, number NCT02139176.

Findings: Between March 4, 2014, and Oct 3, 2014, 200 HIV-positive pregnant women were enrolled and randomly assigned to either the invitation only group (n=100) or the invitation plus tracing group (n=100). 74 couples in the invitation plus tracing group and 52 in the invitation only group presented to the clinic and had CHTC (risk difference 22%, 95% CI 9-35; p=0.001) during the 10 month study period. Of 181 women with follow-up data, two reported union dissolution, one reported emotional distress, and none reported intimate partner violence. One male partner, when traced, was confused about which of his sex partners was enrolled in the study. No other adverse events were reported.

Interpretation: An invitation plus tracing strategy was highly effective at increasing CHTC uptake. Invitation plus tracing with CHTC could have many substantial benefits if brought to scale.

Abstract access

Editor’s notes: A major challenge to the Option B+ prevention of mother-to-child-transmission programme is retaining women in HIV care. Lack of male partner support may be an important barrier to retention. Couples HIV testing and counselling (CHTC) can increase mutual disclosure, enhance behavioural HIV prevention, and ultimately improve maternal, child and male partner health outcomes.  However, uptake of CHTC in antenatal settings remains low throughout most of sub-Saharan Africa. This randomised controlled trial illustrates that combining an invitation for the male partner to present to the antenatal clinic with active tracing of the partner by the study team greatly increased uptake of CHTC. A unique feature of the programme was that the invitation and tracing messages focused on general health during pregnancy, rather than on HIV, which may have improved acceptability. Even in the invitation alone arm, over half of the male partners presented for CHTC. Both strategies found that over half the men who tested were HIV positive, and the majority were unaware of their status. Women in the invitation plus tracing arm had higher retention in the Option B+ programme at one month than individuals in the invitation alone arm, and were more likely to report safer sex behaviour. 

Although provider-based strategies for increasing couples testing are more expensive than patient-based strategies, they may be very cost-effective in settings of high HIV prevalence where few men are aware of their HIV status. Interestingly, most gains in partner uptake from tracing were a result of telephone contact, which is relatively low cost. Longer term follow-up is necessary to assess whether increases in retention are maintained over time but the results demonstrate the potential for provider-based strategies for increasing CHTC to help achieve UNAIDS 90-90-90 targets.

Africa
Malawi
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How many people have really died of HIV/AIDS in South Africa?

HIV/AIDS in South Africa: how many people died from the disease between 1997 and 2010?

Bradshaw D, Msemburi W, Dorrington R, Pillay-van Wyk V, Laubscher R, Groenewald P, team SN. AIDS. 2015 Oct 27. [Epub ahead of print]

Objectives: Empirical estimates of the number of HIV/AIDS deaths are important for planning, budgeting, and calibrating models. However, there is an extensive misattribution of HIV/AIDS as an underlying cause-of-death. This study estimates the true numbers of AIDS deaths from South African vital statistics between 1997 and 2010.

Methods: Individual-level cause-of-death data were grouped according to a local burden of disease list and source causes (i.e. causes under which AIDS deaths are misclassified) that recorded a rapid increase. After adjusting for completeness of registration, mortality rate of the source causes, by age and sex, was regressed on lagged HIV prevalence to estimate the rate of increase correlated with HIV. Background trends in the source-cause mortality rates were estimated from the trend experienced among 75-84 year olds.

Results: Of 214 causes considered, 19 were identified as potential sources for cause misattribution. High proportions of deaths from tuberculosis, lower respiratory infections (mostly pneumonia), diarrhoeal diseases, and ill-defined natural causes were estimated to be HIV-related, with only 7% of the estimated AIDS deaths being recorded as HIV. Estimated HIV/AIDS deaths increased rapidly, then reversed after 2006, totalling 2.8 million deaths over the whole period. The number was lower than model estimates from UNAIDS and the Global Burden of Disease Study.

Conclusion: Empirically based estimates confirm the considerable loss of life from HIV/AIDS and should be used for calibrating models of the AIDS epidemic which generally appear too low for infants but too high for other ages. Doctors are urged to specify HIV on death notifications to provide reliable cause-of-death statistics.

Abstract access 

Editor’s notesIn many countries, the true number of HIV-associated deaths is significantly under-reported in national vital registration data making it difficult to monitor the epidemic trends from this source. This study describes new estimates of HIV-associated mortality based on empirical vital registration data which aimed to provide accurate estimates of the numbers of HIV-associated deaths in South Africa. The study estimates that, from 1997-2010, 2.86 million deaths in South Africa were due to HIV – over one-third of all deaths. However, relatively few deaths, 7%, were registered as HIV-associated. At the peak of the epidemic in 2006 the vital registration derived estimates show lower trends than other models. All models estimated a decline in the number of HIV-associated deaths post-2008, a finding which is consistent with the extensive roll-out of antiretroviral therapy in South Africa, and with trends reported from verbal autopsy data for all deaths in rural South African demographic surveillance sites. This paper highlights the importance of reporting accurate causes for HIV-associated deaths in the death registration process - however, without de-stigmatisation of HIV, this is going to be difficult to achieve.

Africa
South Africa
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Condoms or PrEP? Women’s decision-making for the prevention of HIV-transmission in Kenya and South Africa

Motivations for reducing other HIV risk-reduction practices if taking pre-exposure prophylaxis: findings from a qualitative study among women in Kenya and South Africa.

Corneli A, Namey E, Ahmed K, Agot K, Skhosana J, Odhiambo J, Guest G. AIDS Patient Care STDS. 2015 Sep;29(9):503-9. doi: 10.1089/apc.2015.0038. Epub 2015 Jul 21.

Findings from a survey conducted among women at high risk for HIV in Bondo, Kenya, and Pretoria, South Africa, demonstrated that a substantial proportion would be inclined to reduce their use of other HIV risk-reduction practices if they were taking pre-exposure prophylaxis (PrEP). To explore the motivations for their anticipated behavior change, we conducted qualitative interviews with 60 women whose survey responses suggested they would be more likely to reduce condom use or have sex with a new partner if they were taking PrEP compared to if they were not taking PrEP. Three interrelated themes were identified: (1) "PrEP protects"-PrEP was perceived as an effective HIV prevention method that replaced the need for condoms; (2) condoms were a source of conflict in relationships, and PrEP would provide an opportunity to resolve or avoid this conflict; and (3) having sex without a condom or having sex with a new partner was necessary for receiving material goods and financial assistance-PrEP would provide reassurance in these situations. Many believed that PrEP alone would be a sufficient HIV risk-reduction strategy. These findings suggest that participants' HIV risk-reduction intentions, if they were to use PrEP, were based predominately on their understanding of the high efficacy of PrEP and their experiences with the limitations of condoms. Enhanced counseling is needed to promote informed decision making and to ensure overall sexual health for women using PrEP for HIV prevention, particularly with respect to the prevention of pregnancy and other sexually transmitted infections when PrEP is used alone.

Abstract access

Editor’s notes: New HIV-prevention methods and messages may be understood differently by different people. For example, the protection from HIV infection for men ‘at about 60%’ that is afforded by medical male circumcision is not always well understood. Some men assume higher protection levels. The authors of this paper describe women’s HIV-prevention method intentions, should pre-exposure prophylaxis (PrEP) be available.  The study is of women’s intention, not actual behaviour, but the findings provide useful insights into the way in which prevention messages are interpreted. In this case, the new method is seen to offer an alternative to using condoms. The authors describe the reasons women give for not using condoms based on their belief that PrEP would protect them from infection. The authors suggest that counselling to inform women of the other benefits of condoms, beyond HIV-infection, is necessary where PrEP is introduced as a HIV-prevention method. This may be so, but underlying the reasons the women gave for not wanting to use condoms was inequitable relationships with their partners. The decision to use condoms often rests mainly with the man. While some women actively disliked condoms because of a reduction in sexual pleasure, many saw not using condoms as a way to sustain their relationship. The authors note that prevention strategies not only need to support women’s choices; but they also need to engage with women who lack choice.  

Africa
Kenya, South Africa
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Intimate partner violence and uptake and adherence of HIV treatment

Intimate partner violence and engagement in HIV care and treatment among women: a systematic review and meta-analysis.

Hatcher AM, Smout EM, Turan JM, Christofides N, Stockl H. AIDS. 2015 Sep 5. [Epub ahead of print]

Objective: We aimed to estimate the odds of engagement in HIV care and treatment among HIV-positive women reporting intimate partner violence (IPV).

Design: We systematically reviewed the literature on the association between IPV and engagement in care. Data sources included searches of electronic databases (PubMed, Web of Science, CINAHL and PsychoInfo), hand searches and citation tracking.

Methods: Two reviewers screened 757 full-text articles, extracted data and independently appraised study quality. Included studies were peer-reviewed and assessed IPV alongside engagement in care outcomes: antiretroviral treatment (ART) use; self-reported ART adherence; viral suppression; retention in HIV care. Odds ratios (ORs) were pooled using random effects meta-analysis.

Results: Thirteen cross-sectional studies among HIV-positive women were included. Measurement of IPV varied, with most studies defining a 'case' as any history of physical and/or sexual IPV. Meta-analysis of five studies showed IPV to be significantly associated with lower ART use [OR 0.79, 95% confidence interval (95% CI) 0.64-0.97]. IPV was associated with poorer self-reported ART adherence in seven studies (OR 0.48, 95% CI 0.30-0.75) and lower odds of viral load suppression in seven studies (OR 0.64, 95% CI 0.46-0.90). Lack of longitudinal data and measurement considerations should temper interpretation of these results.

Conclusion: IPV is associated with lower ART use, half the odds of self-reported ART adherence and significantly worsened viral suppression among women. To ensure the health of HIV-positive women, it is essential for clinical programmes to address conditions that impact engagement in care and treatment. IPV is one such condition, and its association with declines in ART use and adherence requires urgent attention.

Abstract access 

Editor’s notes: Intimate partner violence (IPV) is prevalent globally (30%). It has been associated with HIV infection and also with progression to AIDS among women living with HIV. However it is unclear how intimate partner violence may impact on HIV-associated health. This study examined associations between violence exposure and uptake of HIV treatment and care services. The authors conducted a systematic review and meta-analyses. From an initial search of 621 studies, 13 were included in these analyses: 12 were conducted in the United States of America and one in Haiti. All were cross-sectional. Measurement of intimate partner violence varied from a single question to validated scales. Some 11 measured lifetime IPV and two measured recent intimate partner violence, in the past 12 months.

Meta-analysis suggests intimate partner violence is associated with significantly lower odds of (i) current ART use (ii) self-reported adherence and (iii) worsened viral load suppression. There was insufficient data to measure retention in HIV care. These analyses suggest that uptake and adherence to ART is a key pathway through which intimate partner violence may negatively influence HIV-associated health of women. Further research is necessary, in low and middle income settings, and among key populations. Future studies should develop and test programmes to address intimate partner violence within HIV clinical care. 

Latin America, Northern America
Haiti, United States of America
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Contraception for young girls living with HIV: barriers and facilitators to service provision in western Kenya

Barriers and facilitators adolescent females living with HIV face in accessing contraceptive services: a qualitative assessment of providers' perceptions in western Kenya.

Hagey JM, Akama E, Ayieko J, Bukusi EA, Cohen CR, Patel RC. J Int AIDS Soc. 2015 Sep 16;18(1):20123. doi: 10.7448/IAS.18.1.20123. eCollection 2015.

Introduction: Avoiding unintended pregnancies is important for the health of adolescents living with HIV and has the additional benefit of preventing potential vertical HIV transmission. Health facility providers represent an untapped resource in understanding the barriers and facilitators adolescents living with HIV face when accessing contraception. By understanding these barriers and facilitators to contraceptive use among adolescent females living with HIV, this study aimed to understand how best to promote contraception within this marginalized population.

Methods: We conducted structured in-depth interviews with 40 providers at 21 Family AIDS Care & Education Services - supported clinics in Homabay, Kisumu and Migori counties in western Kenya from July to August 2014. Our interview guide explored the providers' perspectives on contraceptive service provision to adolescent females living with HIV with the following specific domains: contraception screening and counselling, service provision, commodity security and clinic structure. Transcripts from the interviews were analyzed using inductive content analysis.

Results: According to providers, interpersonal factors dominated the barriers adolescent females living with HIV face in accessing contraception. Providers felt that adolescent females fear disclosing their sexual activity to parents, peers and providers, because of repercussions of perceived promiscuity. Furthermore, providers mentioned that adolescents find seeking contraceptive services without a male partner challenging, because some providers and community members view adolescents unaccompanied by their partners as not being serious about their relationships or having multiple concurrent relationships. On the other hand, providers noted that institutional factors best facilitated contraception for these adolescents. Integration of contraception and HIV care allows easier access to contraceptives by removing the stigma of coming to a clinic solely for contraceptive services. Youth-friendly services, including serving youth on days separate from adults, also create a more comfortable setting for adolescents seeking contraceptive services.

Conclusions: Providers at these facilities identified attitudes of equating seeking contraceptive services with promiscuity by parents, peers and providers as barriers preventing adolescent females living with HIV from accessing contraceptive services. Health facilities should provide services for adolescent females in a youth-friendly manner and integrate HIV and contraceptive services.

Abstract  Full-text [free] access

Editor’s notes: The article offers a clear picture of barriers and facilitators to access and uptake of contraceptive services for young girls living with HIV. It provides valuable evidence of providers’ views regarding integrated HIV and contraceptive services. The study was carried out with HIV care providers in different areas of western Kenya. The authors found that young girls find it difficult to access services, especially on their own, for fear of being seen as sexually active and/or promiscuous. Parental presence during consultations in HIV services can be a barrier to requesting contraceptives. But some parents are supportive and wish to prevent unintended pregnancies for their daughters. Young girls living with HIV might find it challenging to manage questions from their peers about their HIV medication and contraceptives. Providers’ themselves prioritise abstinence and condoms over offering hormonal contraceptives. Providers can feel protective towards the patients, whom they may see as ‘children’. The authors suggest that further involvement of parents, young boys and male partners can facilitate uptake of contraceptives for young girls living with HIV. The integration of HIV and contraceptive services for young girls can provide a crucial platform to reduce sexually transmitted infections, unintended pregnancies and vertical HIV transmission.

Africa
Kenya
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In the market for drugs and alcohol: characterising a risk environment in Malawi

Substance use and risky sexual behaviors among young men working at a rural roadside market in Malawi.

Jere DL, Norr KF, Bell CC, Corte C, Dancy BL, Kaponda CP, Levy JA. J Assoc Nurses AIDS Care. 2015 Jul 13. pii: S1055-3290(15)00147-8. doi: 10.1016/j.jana.2015.07.003. [Epub ahead of print]

Using an ecological model, we describe substance use and sexual risk behaviors of young male laborers at a roadside market in Malawi. Data included observations and interviews with 18 key market leaders and 15 laborers (ages 18-25 years). Alcohol, marijuana, and commercial sex workers (CSWs) were widely available. We identified three patterns of substance use: 6 young men currently used, 6 formerly used, and 3 never used. Substance use was linked to risky sex, including sex with CSWs. The market supported risky behaviors through availability of resources; supportive norms, including beliefs that substance use enhanced strength; and lack of restraints. Community-level poverty, cultural support for alcohol, interpersonal family/peer influences, early substance use, and school dropout also contributed to risky behaviors. Parental guidance was protective but not often reported. Local programs addressing substance use and risky sex simultaneously and better national substance use policies and mental health services are needed.

Abstract access

Editor’s notes: There has been a global focus on how substance use and associated risk behaviours contribute to HIV acquisition. Over the last decade there has been emerging evidence to suggest that substance use is increasing in the sub-Saharan African region, which is leading people to engage in risky sexual behaviour associated with HIV transmission. Despite this, there is a continued absence of research which focuses on the causes and practices of substance use, the associated impact and the opportunities to ameliorate the associated harms. This has led to a considerable knowledge gap. This paper provides a case study which offers insights into the factors which promote and sustain the relatively heavy use of marijuana and alcohol in a rural Malawian roadside market among young male labourers.

Adopting Scribener’s ecological model framework, the authors start from the premise that there are multiple level factors (societal, neighbourhood, interpersonal and individual) which shape the behaviour of men working in these markets. Using an ethnographic approach, they provide a rich description of how these multiple levels of risk factors operate and interact to facilitate men’s substance use.

The study found that the availability and use of alcohol and marijuana within the market by young men was widespread and that this was known about and broadly tolerated by key actors and groups involved in the market. The environment of the market is characterised by an ease of opportunity to consume these substances. The environment exhibited cultural norms which appeared to promote the acceptability of this behaviour and the absence of protective mechanisms to minimise the harms. There were two novel findings in the study. The first was how the perceived benefits of alcohol and marijuana use was integrated into expectations that it would help people to gain work and then do their jobs better. The second was that participants often justified their own behaviour by illustrating that it was endorsed by Ngoni culture, predominately in the area where the market was located. As such drinking alcohol was a means to perform young masculinity. This thoughtful research provides valuable evidence to support the need for programmes to include a focus on structural changes, such as availability and regulation of substance use but also in engaging with the presumed cultural norms. These should be considered alongside a more individual orientated approach in order to design a programme that is likely to be successful in reducing the harm of these behaviours. 

Gender, Substance use
Africa
Malawi
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Antiretroviral therapy coverage associated with reduced HIV incidence in Kenya

Impact of community antiretroviral therapy coverage on HIV incidence in Kenyan female sex workers: a 15-year prospective cohort study.

McClelland RS, Richardson BA, Cherutich P, Mandaliya K, John-Stewart G, Miregwa B, Odem-Davis K, Jaoko W, Kimanga D, Overbaugh J. AIDS. 2015 Jul 31. [Epub ahead of print]

Objective: To test the hypothesis that increasing community antiretroviral therapy (ART) coverage would be associated with lower HIV incidence in female sex workers (FSWs) in Mombasa District, Kenya.

Design: Prospective cohort study.

Methods: From 1998 to 2012, HIV-negative FSWs were asked to return monthly for an interview regarding risk behavior and testing for sexually transmitted infections including HIV. We evaluated the association between community ART coverage and FSW's risk of becoming HIV infected using Cox proportional hazards models adjusted for potential confounding factors.

Results: One thousand four hundred four FSWs contributed 4335 woman-years of follow-up, with 145 acquiring HIV infection (incidence 3.35/100 woman-years). The ART rollout began in 2003. By 2012, an estimated 52% of HIV-positive individuals were receiving treatment. Community ART coverage was inversely associated with HIV incidence (adjusted hazard ratio 0.77; 95% confidence interval 0.61-0.98; P = 0.03), suggesting that each 10% increase in coverage was associated with a 23% reduction in FSWs' risk of HIV acquisition. Community ART coverage had no impact on herpes simplex virus type-2 incidence (adjusted hazard ratio 0.97; 95% confidence interval 0.79-1.20; P = 0.8).

Conclusion: Increasing general population ART coverage was associated with lower HIV incidence in FSWs. The association with HIV incidence, but not herpes simplex virus type-2 incidence, suggests that the effect of community ART coverage may be specific to HIV. Interventions such as preexposure prophylaxis and antiretroviral-containing microbicides have produced disappointing results in HIV prevention trials with FSWs. These results suggest that FSWs' risk of acquiring HIV infection might be reduced through the indirect approach of increasing ART coverage in the community.

Abstract access

Editor’s notes: The individual-level benefit of antiretroviral therapy (ART) on reducing HIV transmission between serodiscordant partners is established, but less is known about a possible population-level effect of ART on key populations such as female sex workers. In this study of 1404 initially HIV-negative female sex workers in Mombasa, Kenya, increased community ART coverage was strongly associated with reduced HIV incidence. HIV incidence was 23% lower for every 10% increase in ART coverage, after adjusting for HIV prevalence and participants’ behavioural characteristics. However, the authors note that HIV incidence was already declining prior to the introduction of ART (from 11.4 cases/100 woman-years in 1998 to 7.6/100 woman-years in 2002), due to other factors including changes in risk behaviour and HIV-prevention efforts in the community. Despite this, the present study suggests that in the setting of ongoing high-quality HIV prevention services, the risk of HIV acquisition among female sex workers is likely to be reduced by increasing ART coverage in the community. Moves to increase coverage of ART in the community will potentially have a substantial HIV prevention benefit on this key population.

Africa
Kenya
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HIV and the relative perception of risk in a fishing site in Uganda

Risk denial and socio-economic factors related to high HIV transmission in a fishing community in Rakai, Uganda: a qualitative study.

Lubega M, Nakyaanjo N, Nansubuga S, Hiire E, Kigozi G, Nakigozi G, Lutalo T, Nalugoda F, Serwadda D, Gray R, Wawer M, Kennedy C, Reynolds SJ. PLoS One. 2015 Aug 26;10(8):e0132740. doi: 10.1371/journal.pone.0132740. eCollection 2015.

Background: In Kasensero fishing community, home of the first recorded case of HIV in Uganda, HIV transmission is still very high with an incidence of 4.3 and 3.1 per 100 person-years in women and men, respectively, and an HIV prevalence of 44%, reaching up to 74% among female sex workers. We explored drivers for the high HIV transmission at Kasensero from the perspective of fishermen and other community members to inform future policy and preventive interventions.

Methods: 20 in-depth interviews including both HIV positive and HIV negative respondents, and 12 focus-group discussions involving a total of 92 respondents from the Kasensero fishing community were conducted during April-September 2014. Content analysis was performed to identify recurrent themes.

Results: The socio-economic risk factors for high HIV transmission in Kasensero fishing community cited were multiple and cross-cutting and categorized into the following themes: power of money, risk denial, environmental triggers and a predisposing lifestyle and alcoholism and drug abuse. Others were: peer pressure, poor housing and the search for financial support for both the men and women which made them vulnerable to HIV exposure and or risk behavior.

Conclusions: There is a need for context specific combination prevention interventions in Kasensero that includes the fisher folk and other influential community leaders. Such groups could be empowered with the knowledge and social mobilization skills to fight the negative and risky behaviors, perceptions, beliefs, misconceptions and submission attitudes to fate that exposes the community to high HIV transmission. There is also need for government/partners to ensure effective policy implementation, life jackets for all fishermen, improve the poor housing at the community so as to reduce overcrowding and other housing related predispositions to high HIV rates at the community. Work place AIDS-competence teams have been successfully used to address high HIV transmission in similar settings.

Abstract  Full-text [free] access

Editor’s notes: In recent years policy makers and programme implementers have been urged to ‘know your epidemic’. This paper provides a striking illustration of the complexity of responding to the knowledge of a place with high prevalence and incidence. The authors describe the many factors which contribute to high HIV transmission rates. They illustrate why, for example, providing condoms and instruction on safer sex may have limited impact on a man who expresses concerns about drowning while fishing tomorrow. Drowning is a more immediate risk than dying because of AIDS-associated illnesses in the future. The information in this paper is not new. We have known about the different risk factors in fishing sites in Uganda for some time. There is also a considerable body of work on the relative perception of risk. However, what the authors do offer is a clear and well-grounded overview of the many different reasons why people in the study setting are at risk of HIV. They illustrate the vital importance of understanding the context of HIV-transmission; the value of looking beneath the prevalence and incidence figures.

Africa
Uganda
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