Articles tagged as "Gender"

The need for improved services for minors who sell sex in West Africa

Structural determinants of health among women who started selling sex as minors in Burkina Faso.

Grosso AL, Ketende S, Dam K, Papworth E, Ouedraogo HG, Ky-Zerbo O, Baral S. J Acquir Immune Defic Syndr. 2015 Mar 1;68 Suppl 2:S162-70. doi: 10.1097/QAI.0000000000000447.

Objectives: To explore the prevalence of and factors associated with initiation of selling sex as a minor.

Design: Data were drawn from cross-sectional studies of adult female sex workers (FSW) recruited through respondent-driven sampling in Ouagadougou and Bobo-Dioulasso, Burkina Faso.

Methods: FSW completed a questionnaire that included a retrospective question regarding the age at which they started selling sex. Separate multivariate logistic regression analyses were conducted for each city to examine associations with initiation of selling sex as a minor (<18 year old), controlling for current age.

Results: Of study participants, 27.8% (194/698) reported selling sex as a minor, ranging from 24.4% (85/349) in Bobo-Dioulasso to 31.2% (85/349) in Ouagadougou. In Ouagadougou, early initiates were more than twice as likely to report someone ever forced them to have sex [age-adjusted odds ratio (aaOR): 2.54, 95% confidence interval (CI): 1.53 to 4.23]. In Bobo-Dioulasso, those who started as minors were more likely to report someone ever tortured them (aaOR: 2.29, 95% CI: 1.28 to 4.10). In both cities, early initiates were more likely to not use a condom with a client if offered more money (Ouagadougou aaOR: 2.34, 95% CI: 1.23 to 4.47; Bobo-Dioulasso aaOR: 2.37, 95% CI: 1.29 to 4.36). In Ouagadougou, women who had started selling sex at a young age were half as likely to have been tested for HIV more than once ever (aaOR: 0.50, 95% CI: 0.26 to 0.94). In Bobo-Dioulasso, early initiates were less likely to attend HIV-related talks or meetings (aaOR: 0.56, 95% CI: 0.33 to 0.97).

Conclusions: A substantial proportion of FSW in Burkina Faso started selling sex as minors. The findings show that there are heightened vulnerabilities associated with selling sex below age 18 years, including physical and sexual violence, client-related barriers to condom use, and lower access to HIV-related services.

Abstract access 

Editor’s notes: Young girls in sub-Saharan Africa are at increased risk of acquiring HIV compared with their male peers. Studies have identified both individual-level and structural-level risks for HIV infection among young girls, including inconsistent condom use and violence. Female sex workers who start selling sex as minors are particularly vulnerable to these risks. In West and central Africa, HIV infection is concentrated among key populations, such as female sex workers, with pooled HIV prevalence estimated to be 34.9%. Despite this, there have been relatively few studies of girls who sell sex in sub-Saharan Africa compared to multiple studies that have been conducted in Asia and the Americas. This is one of the first studies comparing early and later initiation of selling sex in West Africa. This study, using data from cross-sectional studies, investigated the structural determinants of health associated with the start of selling sex as a minor among female sex workers in Burkina Faso. The investigators found that almost a third of female sex workers had started selling sex as minors, and early initiation of selling sex was associated with a range of behavioural risk factors. In addition these women were more likely to experience social and structural vulnerabilities including limited access to health services, and violence. The study highlights the need to provide HIV services for minors who sell sex in sub-Saharan Africa, and to prevent sexual exploitation of children.

Africa
Burkina Faso
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High levels of unmet contraceptive needs among women living with HIV in Malawi

Pregnancy prevention and condom use practices among HIV-infected women on antiretroviral therapy seeking family planning in Lilongwe, Malawi.

Haddad LB, Feldacker C, Jamieson DJ, Tweya H, Cwiak C, Chaweza T, Mlundira L, Chiwoko J, Samala B, Kachale F, Bryant AG, Hosseinipour MC, Stuart GS, Hoffman I, Phiri S. PLoS One. 2015 Mar 26;10(3):e0121039. doi: 10.1371/journal.pone.0121039. eCollection 2015.

Background: Programs for integration of family planning into HIV care must recognize current practices and desires among clients to appropriately target and tailor interventions. We sought to evaluate fertility intentions, unintended pregnancy, contraceptive and condom use among a cohort of HIV-infected women seeking family planning services within an antiretroviral therapy (ART) clinic.

Methods: 200 women completed an interviewer-administered questionnaire during enrollment into a prospective contraceptive study at the Lighthouse Clinic, an HIV/ART clinic in Lilongwe, Malawi, between August and December 2010.

Results: Most women (95%) did not desire future pregnancy. Prior reported unintended pregnancy rates were high (69% unplanned and 61% unhappy with timing of last pregnancy). Condom use was inconsistent, even among couples with discordant HIV status, with lack of use often attributed to partner's refusal. Higher education, older age, lower parity and having an HIV negative partner were factors associated with consistent condom usage.

Discussion: High rates of unintended pregnancy among these women underscore the need for integrating family planning, sexually transmitted infection (STI) prevention, and HIV services. Contraceptive access and use, including condoms, must be improved with specific efforts to enlist partner support. Messages regarding the importance of condom usage in conjunction with more effective modern contraceptive methods for both infection and pregnancy prevention must continue to be reinforced over the course of ongoing ART treatment.

Abstract  Full-text [free] access

Editor’s notes: This paper highlights the high rate of unmet contraceptive need in sub-Saharan Africa. Almost all of the women living with HIV included in this study in Malawi reported that they did not desire future fertility. Most stated that their partners also did not desire more children.  Despite this, levels of consistent condom use were low. To ensure appropriate delivery of HIV and family planning services, it is important to understand the specific needs of women living with HIV. The study has a number of limitations, such as subjective retrospective reporting by the participants. However, the high rate of unintended pregnancies highlights the continued need to integrate family planning into HIV care. Despite the biases associated with self-reported condom use, the inconsistent condom use reported by women in this study emphasises the need for additional efforts to increase access to and uptake of effective contraceptive services to couples living with HIV, in addition to other HIV prevention and treatment services.

Africa
Malawi
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Does having an older male partner actually protect women over 30 in KwaZulu-Natal?

Partner age-disparity and HIV incidence risk for older women in rural South Africa.

Harling G, Newell ML, Tanser F, Barnighausen T. AIDS Behav. 2015 Feb 11. [Epub ahead of print]

While sexual partner age disparity is frequently considered as a potential risk factor for HIV among young women in Africa, no research has addressed this question among older women. Our aim was thus to determine whether sex partner age disparity was associated with subsequent HIV acquisition in women over 30 years of age. To achieve this aim we conducted a quantitative analysis of a population-based, open cohort of women in rural KwaZulu-Natal, South Africa (n = 1737) using Cox proportional hazards models. As partner age rose, HIV acquisition risk fell significantly: compared to a same-aged partner, a 5-year older partner was associated with a one-third reduction [hazard ratio (HR) 0.63, 95 % CI 0.52-0.76] and a 10-year older partner with a one-half reduction (HR 0.48, 95 % CI 0.35-0.67) in acquisition risk. This result was neither confounded nor effect-modified by women's age or socio-demographic factors. These findings suggest that existing HIV risk-reduction campaigns warning young women about partnering with older men may be inappropriate for older women. HIV prevention strategies interventions specifically tailored to older women are needed.

Abstract access

Editor’s notes: The effect of partner age disparity is important for the dynamics of HIV transmission. This is because of the potential of transmission across generations, and also that it may reflect power imbalances with associated vulnerabilities and risks. This study is the first to assess HIV risk and partner age disparity in women between the ages of 30 and 50 years. As might be expected, the associations are different to those generally found in young women where having an older partner typically increases HIV risk. In this study, having a partner five years older reduces HIV risk by one third, and having a partner 10 years older reduces HIV risk by half. This is not surprising for several reasons, including that HIV prevalence decreases with older age. But it highlights the need for HIV prevention campaigns that advocate for women to avoid older men, to be nuanced by the age of the woman.  However, it is also notable that in this population, a previous paper showed no evidence of an association of partner age disparity and HIV risk for women aged 15-29. The results illustrate the need to continue to broaden and improve HIV prevention programming and to tailor prevention messages for different age groups, as the traditional ‘risky behaviours’ for young women may not be appropriate for older ages.

Africa
South Africa
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Expectations and experiences of disclosing HIV status to sexual partners in Ghana

The 'fears' of disclosing HIV status to sexual partners: a mixed methods study in a counseling setting in Ghana.  

Obiri-Yeboah D, Amoako-Sakyi D, Baidoo I, Adu-Oppong A, Rheinlander T. AIDS Behav. 2015 Feb 26. [Epub ahead of print]

Encouraging disclosure within a trusting and supportive environment is imperative in dealing with HIV/AIDS related stigma. However, disclosure rates and the factors that influence it are vaguely understood in African societies. This study aimed at determining the disclosure rate and factors that influence disclosure in Cape Coast, Ghana. In-depth interviews of 15 peer educators and a survey of 510 PLHIV were used in a mixed methods study design. Majority of the study participants (78.6 %) had disclosed their HIV positive status to their sexual partners. Although peer educators in this study portrayed the overall outcome of disclosure to be negative, 84.0 % of disclosers were accepted by their partners without negative consequences after disclosure. This study suggests that the existing support services ill prepares newly diagnosed HIV positive clients and hampers disclosure initiatives. Providing comprehensive support services and re-training peer educators may be crucial in creating a safe disclosure environment in Ghana.

Abstract access

Editor’s notes: This mixed methods study explores the important issue of disclosure to sexual partners. Supporting increased rates of disclosure to partners is crucial for effective prevention efforts. But it may also be valuable in influencing the support that people living with HIV can receive from their sexual partner to manage their condition. This is pertinent because other research has illustrated that keeping their status a secret from partners and household members can impede adherence and sustained access to care. The initial data analysis of the 15 in-depth interviews with peer educators was used to inform the design of the questionnaire which was then completed by 510 people living with HIV in Cape Coast, Ghana. The findings from the formative qualitative research are also used to explain some of the subsequent quantitative findings.  

There are two particularly striking findings reported in the paper. The first is that among individuals who have disclosed their status, a significant majority, some 82%, did so within the first week of having been diagnosed. This suggests that there is a crucial, but short, window in which individuals may be more willing to disclose to partners. This is important for programme design and ensuring that pre- and post-test counselling includes discussion and support to disclose to partners. The second key finding is that while the survey data illustrates that the experience of disclosers was predominately positive, the 15 peer educators captured in the qualitative study portrayed a far more negative expectation about the risks involved in disclosure to partners. The time that had passed since individuals were diagnosed was not presented for either the quantitative or qualitative samples. Given the changing meaning of HIV within the context of antiretroviral therapy, the time since participants’ diagnosis and subsequent disclosure to partners may be an important factor in shaping individuals’ experiences and thus their expectations of the impact of disclosure. The evidence presented in this paper illustrates the importance not only of examining the experiences and expectations of disclosure by people living with HIV, but also in considering what may be influencing their expectations. The peer educator’s role may limit, as well as support, peoples’ readiness to disclose to partners. 

Africa
Ghana
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Don’t ask, don’t tell: concealment as a stigma management strategy in India

'I am doing fine only because I have not told anyone': the necessity of concealment in the lives of people living with HIV in India.

George MS, Lambert H. Cult Health Sex. 2015 Feb 23:1-14. [Epub ahead of print]

In HIV prevention and care programmes, disclosure of status by HIV-positive individuals is generally encouraged to contain the infection and provide adequate support to the person concerned. Lack of disclosure is generally framed as a barrier to preventive behaviours and accessing support. The assumption that disclosure is beneficial is also reflected in studies that aim to identify determinants of disclosure and recommend individual-level measures to promote disclosure. However, in contexts where HIV infection is stigmatised and there is fear of rejection and discrimination among those living with HIV, concealment of status becomes a way to try and regain as much as possible the life that was disrupted by the discovery of HIV infection. In this study of HIV-positive women and children in India, concealment was considered essential by individuals and families of those living with HIV to re-establish and maintain their normal lives in an environment where stigma and discrimination were prevalent. This paper describes why women and care givers of children felt the need to conceal HIV status, the various ways in which people tried to do so and the implications for treatment of people living with HIV. We found that while women were generally willing to disclose their status to their husband or partner, they were very keen to conceal their status from all others, including family members. Parents and carers with an HIV-positive child were not willing to disclose this status to the child or to others. Understanding the different rationales for concealment would help policy makers and programme managers to develop more appropriate care management strategies and train care providers to assist clients in accessing care and support without disrupting their lives.

Abstract access 

Editor’s notes: This paper provides a powerful illustration of the persistence of stigma in the lives of many people living with HIV in India. Using data collected in 2012, the authors illustrate how prejudice and discrimination shape the lives of the women and children included in this study. While access to antiretroviral therapy (ART) provided a way for participants to regain and maintain what is described as ‘normal life’, that same treatment could result in unintended disclosure. Participants spoke of the fear of being seen carrying ART, since illustrations of the pills were widely available at clinics. They described the challenges of disclosing to their children as well as other relatives. Disclosure to wider social networks posed a reputational threat because of the association of HIV with moral laxity. All these are challenges that many people face in other settings too, providing further evidence of the persistence of HIV-associated stigma. The authors also illustrate the unintended consequences of well-meaning policies. One striking illustration came from a participant who was using a free travel pass, available to people living with HIV to collect their treatment. The pass included the word ‘AIDS’ and a ticket collector ridiculed the woman and her husband in front of other passengers because of this evidence of infection. The authors make the point that encouraging disclosure may overlook the importance of concealment as a way to cope with stigma. 

Asia
India
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Further evidence of an association with the injectable contraceptive, depot-medroxyprogesterone acetate with risk of HIV

Hormonal contraception and the risk of HIV acquisition: an individual participant data meta-analysis.

Morrison CS, Chen PL, Kwok C, Baeten JM, Brown J, Crook AM, Van Damme L, Delany-Moretlwe S, Francis SC, Friedland BA, Hayes RJ, Heffron R, Kapiga S, Karim QA, Karpoff S, Kaul R, McClelland RS, McCormack S, McGrath N, Myer L, Rees H, van der Straten A, Watson-Jones D, van de Wijgert JH, Stalter R, Low N. PLoS Med. 2015 Jan 22;12(1):e1001778. doi: 10.1371/journal.pmed.1001778. eCollection 2015.

Background: Observational studies of a putative association between hormonal contraception (HC) and HIV acquisition have produced conflicting results. We conducted an individual participant data (IPD) meta-analysis of studies from sub-Saharan Africa to compare the incidence of HIV infection in women using combined oral contraceptives (COCs) or the injectable progestins depot-medroxyprogesterone acetate (DMPA) or norethisterone enanthate (NET-EN) with women not using HC.

Methods and findings: Eligible studies measured HC exposure and incident HIV infection prospectively using standardized measures, enrolled women aged 15-49 y, recorded ≥15 incident HIV infections, and measured prespecified covariates. Our primary analysis estimated the adjusted hazard ratio (aHR) using two-stage random effects meta-analysis, controlling for region, marital status, age, number of sex partners, and condom use. We included 18 studies, including 37 124 women (43 613 woman-years) and 1830 incident HIV infections. Relative to no HC use, the aHR for HIV acquisition was 1.50 (95% CI 1.24-1.83) for DMPA use, 1.24 (95% CI 0.84-1.82) for NET-EN use, and 1.03 (95% CI 0.88-1.20) for COC use. Between-study heterogeneity was mild (I2 < 50%). DMPA use was associated with increased HIV acquisition compared with COC use (aHR 1.43, 95% CI 1.23-1.67) and NET-EN use (aHR 1.32, 95% CI 1.08-1.61). Effect estimates were attenuated for studies at lower risk of methodological bias (compared with no HC use, aHR for DMPA use 1.22, 95% CI 0.99-1.50; for NET-EN use 0.67, 95% CI 0.47-0.96; and for COC use 0.91, 95% CI 0.73-1.41) compared to those at higher risk of bias (pinteraction = 0.003). Neither age nor herpes simplex virus type 2 infection status modified the HC-HIV relationship.

Conclusions: This IPD meta-analysis found no evidence that COC or NET-EN use increases women's risk of HIV but adds to the evidence that DMPA may increase HIV risk, underscoring the need for additional safe and effective contraceptive options for women at high HIV risk. A randomized controlled trial would provide more definitive evidence about the effects of hormonal contraception, particularly DMPA, on HIV risk.

Abstract  Full-text [free] access

Editor’s notes: As seen in the paper published this month by Ralph et al, observational studies have reported that hormonal contraception, in particular injectable progestins depot-medroxyprogesterone acetate (DMPA), may increase risk of HIV infection. This individual patient data meta-analysis adds further to the evidence. A major strength of the study is the large sample size. It provides sufficient power to examine associations between specific contraceptives and HIV risk and to investigate effect modification in pre-specified sub-group analyses. Furthermore, using individual-level data allowed a consistent approach to coding and adjustment for confounding. If the association is real, this has important implications for sexual and reproductive health in areas of sub-Saharan Africa where the incidence of HIV acquisition and unintended pregnancy is high.

 


 

Hormonal contraceptive use and women's risk of HIV acquisition: a meta-analysis of observational studies.

Ralph LJ, McCoy SI, Shiu K, Padian NS. Lancet Infect Dis. 2015 Jan 8. pii: S1473-3099(14)71052-7. doi: 10.1016/S1473-3099(14)71052-7. [Epub ahead of print]

Background: The evidence from epidemiological research into whether use of hormonal contraception increases women's risk of HIV acquisition is inconsistent. We did a robust meta-analysis of existing data to provide summary estimates by hormonal contraceptive method which can be used to inform contraceptive guidelines, models, and future studies.

Methods: We updated a recent systematic review to identify and describe studies that met inclusion criteria. To ensure inclusion of more recent research, we searched PubMed for articles published after December, 2011, using the terms "hormonal contraception", "HIV/acquisition", "injectables", "progestin", and "oral contraceptive pills". We assessed statistical heterogeneity for these studies, and, when appropriate, combined point estimates by hormonal contraception formulation using random-effects models. We assessed publication bias and investigated heterogeneity through subgroup and stratified analyses according to study population and design features.

Findings: We identified 26 studies, 12 of which met inclusion criteria. There was evidence of an increase in HIV risk in the ten studies of depot medroxyprogesterone acetate (pooled hazard ratio [HR] 1.40, 95% CI 1.16-1.69). This risk was lower in the eight studies done in women in the general population (pooled HR 1.31, 95% CI 1.10-1.57). There was substantial between-study heterogeneity in secondary analyses of trials (n=7, I2 51.1%, 95% CI 0-79.3). Although individual study estimates suggested an increased risk, substantial heterogeneity between two studies done in women at high risk of HIV infection (I2 54%, 0-88.7) precluded pooling estimates. There was no evidence of an increased HIV risk in ten studies of oral contraceptive pills (pooled HR 1.00, 0.86-1.16) or five studies of norethisterone enanthate (pooled HR 1.10, 0.88-1.37).

Interpretation: Our findings show a moderate increased risk of HIV acquisition for all women using depot medroxyprogesterone acetate, with a smaller increase in risk for women in the general population. Whether the risks of HIV observed in our study would merit complete withdrawal of depot medroxyprogesterone acetate needs to be balanced against the known benefits of a highly effective contraceptive.

Abstract access

Editor’s notes: This meta-analysis has similar findings to the individual patient data (IPD) meta-analysis by Morrison et al, also published this month. The study finds that depot medroxyprogesterone (DMPA) is associated with a moderate increase in HIV risk, and little evidence of a risk associated with combined oral contraceptives or norethisterone enanthate (NET-EN). The policy implications of this finding are unclear. As with the IPD analysis, this meta-analysis is based on observational studies and does not provide conclusive evidence that DMPA causes the increased risk of HIV. However, it does provide refined estimates for modelling studies to assess the implications of possible withdrawal of DMPA on maternal and HIV-associated mortality, so that context-specific contraceptive policies can be considered.

Africa
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Incentives for orphans to stay in school: a structural programme for HIV prevention in Zimbabwe

The impact of school subsidies on HIV-related outcomes among adolescent female orphans.

Hallfors DD, Cho H, Rusakaniko S, Mapfumo J, Iritani B, Zhang L, Luseno W, Miller T. J Adolesc Health. 2015 Jan;56(1):79-84. doi: 10.1016/j.jadohealth.2014.09.004.

Purpose: We examine effects of school support as a structural HIV prevention intervention for adolescent female orphans in Zimbabwe after 5 years.

Methods: Three hundred twenty-eight orphan adolescent girls were followed in a clustered randomized controlled trial from 2007 to 2010. The experimental group received school fees, uniforms, and school supplies and were assigned a school-based "helper." In 2011-2012, the control group received delayed partial treatment of school fees only. At the final data point in 2012, survey, HIV, and Herpes Simplex Virus Type 2 (HSV-2) biomarker data were collected from approximately 88% of the sample. Bivariate and multivariate analyses were conducted on end point outcomes, controlling for age, religious affiliation, and baseline socioeconomic status.

Results: The two groups did not differ on HIV or HSV-2 biomarkers. The comprehensive 5-year intervention continued to reduce the likelihood of marriage, improve school retention, improve socioeconomic status (food security), and marginally maintain gains in quality of life, even after providing school fees to the control group.

Conclusions: Paying school fees and expenses resulted in significant improvements in life outcomes for orphan adolescent girls. Biological evidence of HIV infection prevention, however, was not observed. Our study adds to the growing body of research on school support as HIV prevention for girls in sub-Saharan Africa, but as yet, no clear picture of effectiveness has emerged.

Abstract access

Editor’s notes: Structural programmes for HIV prevention potentially offer a means to mitigate the risk factors which are thought to drive the substantially higher rates of HIV observed among adolescent women in low-income settings. In Zimbabwe, female orphans in the programme arm of this randomized control trial were offered a package of school support. This included payment of their school fees. There was low power to assess differences in HIV or HSV-2 prevalence by arm, but there were promising impacts on several important mediating factors for HIV infection. These included sexual debut, marriage, school drop-out, and socioeconomic status. The long follow-up period of five years and the high rate of retention in the study, 88%, are major strengths of this study. The study joins a limited evidence base on structural programmes for adolescent women in sub-Saharan Africa. Future research must re-consider the pathways by which structural determinants of HIV infection operate.

Africa
Zimbabwe
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Negotiating the price for safe sex: A study among rural sex workers in Zimbabwe

The price of sex: condom use and the determinants of the price of sex among female sex workers in eastern Zimbabwe.

Elmes J, Nhongo K, Ward H, Hallett T, Nyamukapa C, White PJ, Gregson S. J Infect Dis. 2014 Dec 1;210 Suppl 2:S569-78. doi: 10.1093/infdis/jiu493.

Background: Higher prices for unprotected sex threaten the high levels of condom use that contributed to the decline in Zimbabwe's human immunodeficiency virus (HIV) epidemic. To improve understanding of financial pressures competing against safer sex, we explore factors associated with the price of commercial sex in rural eastern Zimbabwe.

Methods: We collected and analyzed cross-sectional data on 311 women, recruited during October-December 2010, who reported that they received payment for their most-recent or second-most-recent sex acts in the past year. Zero-inflated negative binomial models with robust standard errors clustered on female sex worker (FSW) were used to explore social and behavioral determinants of price.

Results: The median price of sex was $10 (interquartile range [IQR], $5-$20) per night and $10 (IQR, $5-$15) per act. Amounts paid in cash and commodities did not differ significantly. At the most-recent sex act, more-educated FSWs received 30%-74% higher payments. Client requests for condom use significantly predicted protected sex (P < .01), but clients paid on average 42.9% more for unprotected sex.

Conclusions: Within a work environment where clients' preferences determine condom use, FSWs effectively use their individual capital to negotiate the terms of condom use. Strengthening FSWs' preferences for protected sex could help maintain high levels of condom use.

Abstract  Full-text [free] access

Editor’s notes: This study addresses a relatively neglected issue of how payments for commercial sex among rural sex workers are determined, and which factors are important to price negotiations. In this study from Zimbabwe, the participants were grouped into “more professional”, both the last two clients were commercial, (FSW2) and “less professional”, one of the last two clients was commercial (FSW1). The “more professional” sex workers effectively negotiated transactions, with unprotected sex increasing the mean payment by almost a half, compared with protected sex. This differential pricing was not seen for the “less professional” sex workers, perhaps reflecting limited capacity to negotiate with clients. This study demonstrates the importance of strengthening preferences for protected sex, among female sex workers, including among less visible sex workers. Such strategies may include enhancing social capital and collective action, e.g. collective price-fixing to reduce competitive pressure to engage in unsafe sex. 

Africa
Zimbabwe
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Associations between HIV and intimate partner violence in ten African countries

Intimate partner violence and HIV in ten sub-Saharan African countries: what do the Demographic and Health Surveys tell us?

Durevall D, Lindskog A. Lancet Glob Health. 2015 Jan;3(1):e34-43. doi: 10.1016/S2214-109X(14)70343-2. Epub 2014 Nov 21.

Background: Many studies have identified a significant positive relation between intimate partner violence and HIV in women, but adjusted analyses have produced inconsistent results. We systematically assessed the association, and under what condition it holds, using nationally representative data from ten sub-Saharan African countries, focusing on physical, sexual, and emotional violence, and on the role of male controlling behaviour.

Methods: We assessed cross-sectional data from 12 Demographic and Health Surveys from ten countries in sub-Saharan Africa. The data are nationally representative for women aged 15-49 years. We estimated odds ratios using logistic regression with and without controls for demographic and socioeconomic factors and survey-region fixed effects. Exposure was measured using physical, sexual, emotional violence, and male controlling behaviour, and combinations of these. The samples used were ever-married women, married women, and women in their first union. Depending on specification, the sample size varied between 11 231 and 45 550 women.

Findings: There were consistent and strong associations between HIV infection in women and physical violence, emotional violence, and male controlling behaviour (adjusted odds ratios ranged from 1.2 to 1.7; p values ranged from <0.0001 to 0.0058). The evidence for an association between sexual violence and HIV was weaker and only significant in the sample with women in their first union. The associations were dependent on the presence of controlling behaviour and a high regional HIV prevalence rate; when women were exposed to only physical, sexual, or emotional violence, and no controlling behaviour, or when HIV prevalence rates are lower than 5%, the adjusted odds ratios were, in general, close to 1 and insignificant.

Interpretation: The findings indicate that male controlling behaviour in its own right, or as an indicator of ongoing or severe violence, puts women at risk of HIV infection. HIV prevention interventions should focus on high-prevalence areas and men with controlling behaviour, in addition to violence.

Abstract  Full-text [free] access

Editor’s notes: Despite two cohort studies illustrating that exposures to intimate partner violence are associated with incident HIV infection, evidence from cross-sectional analysis of population data is more mixed. Using Demographic and Health Surveys data for women aged 15-49 years from 10 sub-Saharan countries, this paper illustrates that HIV infection is strongly associated with physical violence and/or emotional violence and controlling behaviour, with a weaker association with sexual violence. For all forms of violence, the association was strongest among women who also reported that their partner was controlling, and in settings where HIV prevalence exceeds five percent. This study adds to the growing literature on HIV and intimate partner violence that suggests that risk is not only linked to forced sex, but rather to being in a violent and controlling relationship. The paper highlights the importance of male control as a risk factor for HIV, and supports the need for HIV prevention programmes that focus on reducing intimate partner violence in higher-prevalence settings.

Africa
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Sexual health of the partners of people who inject drugs

'Women at risk': the health and social vulnerabilities of the regular female partners of men who inject drugs in Delhi, India.

Sharma V, Sarna A, Luchters S, Sebastian M, Degomme O, Saraswati LR, Madan I, Thior I, Tun W. Cult Health Sex. 2014 Dec 2:1-15. [Epub ahead of print]

Needle and syringe sharing is common among people who inject drugs and so is unprotected sex, which consequently puts their sex partners at risk of sexually transmitted infections (STIs) including HIV and other blood-borne infections, like hepatitis. We undertook a nested study with the regular female partners of men who inject drugs participating in a longitudinal HIV incidence study in Delhi, India. In-depth interviews were conducted with female partners of 32 men. The interviews aimed to gather focused and contextual knowledge of determinants of safe sex and reproductive health needs of these women. Information obtained through interviews was triangulated and linked to the baseline behavioural data of their partner (index men who injected drugs). The study findings illustrate that women in monogamous relationships have a low perception of STI- and HIV-related risk. Additionally, lack of awareness about hepatitis B and C is a cause of concern. Findings also suggest impact of male drug use on the fertility of the female partner. It is critical to empower regular female partners to build their self-risk assessment skills and self-efficacy to negotiate condom use. Future work must explore the role of drug abuse among men who inject drugs in predicting fertility and reproductive morbidity among their female partners.

Abstract access 

Editor’s notes: This is an interesting study describing the HIV and sexual health needs of female partners of people who inject drugs (PWID). The study’s strengths lie in the innovative way in which female partners of PWID were reached and recruited into the study. Female partners of PWID are a highly hidden group and there has been little research conducted among them, with research focussing mostly on PWID and their HIV risk. Therefore the approach to identifying female partners through an existing cohort of male PWID is highly innovative and provides new information on a hidden population. Findings have important implications for HIV programmes for this population. These include the need to increase uptake of HIV testing, teach the importance of condoms as a contraceptive method and for HIV prevention, as well as dispelling myths that assumed monogamy is a sufficient prevention tool. The paper clearly illustrates that addressing sexual and reproductive health needs of this population is paramount, including addressing problems with infertility and the need for contraceptives. The paper usefully highlights the impact of a male partner’s drug use on the daily lives of their female partner, including increased poverty and high levels of violence.

Asia
India
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