Articles tagged as "Structural determinants and vulnerability"

Rape and ARV uptake/adherence

Impact of sexual trauma on HIV care engagement: perspectives of female patients with trauma histories in Cape Town, South Africa.

Watt MH, Dennis AC, Choi KW, Ciya N, Joska JA, Robertson C, Sikkema KJ. AIDS Behav. 2016 Nov 19. [Epub ahead of print]

South African women have disproportionately high rates of both sexual trauma and HIV. To understand how sexual trauma impacts HIV care engagement, we conducted in-depth qualitative interviews with 15 HIV-infected women with sexual trauma histories, recruited from a public clinic in Cape Town. Interviews explored trauma narratives, coping behaviors and care engagement, and transcripts were analyzed using a constant comparison method. Participants reported multiple and complex traumas across their lifetimes. Sexual trauma hindered HIV care engagement, especially immediately following HIV diagnosis, and there were indications that sexual trauma may interfere with future care engagement, via traumatic stress symptoms including avoidance. Disclosure of sexual trauma was limited; no woman had disclosed to an HIV provider. Routine screening for sexual trauma in HIV care settings may help to identify individuals at risk of poor care engagement. Efficacious treatments are needed to address the psychological and behavioral sequelae of trauma.

Abstract access  

Editor’s notes: Few studies have examined the impact of violence exposure on ART uptake and adherence. There is also a paucity of studies from low- and middle-income countries. South African women face a dual burden of HIV and violence risk, especially in areas characterized by extreme poverty, substance abuse and gender inequality. This study used qualitative interviews with 15 women living with HIV with histories of sexual trauma and attending an HIV-treatment clinic. The authors explore the intersections between sexual trauma experience, HIV infection and engagement with HIV care services.

Women reported complex sexual trauma histories, with repeated abuse from childhood into adulthood. This abuse was usually from family members or ‘lovers’. Sexual violence was usually accompanied by physical and emotional abuse. Women described symptoms of post-traumatic stress disorder and depression. Many associated their HIV infection with their sexual trauma / abusive relationship(s). For some, the HIV diagnosis and taking treatment reminded them of their rape and triggered feelings of shame. Women described their sexual violence experience as more stressful and shameful than their HIV status. None had disclosed their trauma history to their HIV care provider. The findings from this study suggest that women with a sexual trauma history may have poorer uptake and adherence to ARVs than women without. Additional research is necessary in low- and middle-income countries to explore this further. There is insufficient support and counselling services for women who have experienced sexual trauma and other abuse. Implementing such services may relieve symptoms of post-traumatic stress disorder and depression and support ART uptake and adherence. 

Africa
South Africa
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Conditional cash transfers had no effect on HIV in high school attendance setting

The effect of a conditional cash transfer on HIV incidence in young women in rural South Africa (HPTN 068): a phase 3, randomised controlled trial.

Pettifor A, MacPhail C, Hughes JP, Selin A, Wang J, Gomez-Olive FX, Eshleman SH, Wagner RG, Mabuza W, Khoza N, Suchindran C, Mokoena I, Twine R, Andrew P, Townley E, Laeyendecker O, Agyei Y, Tollman S, Kahn K. Lancet Glob Health. 2016 Dec;4(12):e978-e988. doi: 10.1016/S2214-109X(16)30253-4. Epub 2016 Nov 1.

Background: Cash transfers have been proposed as an intervention to reduce HIV-infection risk for young women in sub-Saharan Africa. However, scarce evidence is available about their effect on reducing HIV acquisition. We aimed to assess the effect of a conditional cash transfer on HIV incidence among young women in rural South Africa.

Methods: We did a phase 3, randomised controlled trial (HPTN 068) in the rural Bushbuckridge subdistrict in Mpumalanga province, South Africa. We included girls aged 13-20 years if they were enrolled in school grades 8-11, not married or pregnant, able to read, they and their parent or guardian both had the necessary documentation necessary to open a bank account, and were residing in the study area and intending to remain until trial completion. Young women (and their parents or guardians) were randomly assigned (1:1), by use of numbered sealed envelopes containing a randomisation assignment card which were numerically ordered with block randomisation, to receive a monthly cash transfer conditional on school attendance (≥80% of school days per month) versus no cash transfer. Participants completed an Audio Computer-Assisted Self-Interview (ACASI), before test HIV counselling, HIV and herpes simplex virus (HSV)-2 testing, and post-test counselling at baseline, then at annual follow-up visits at 12, 24, and 36 months. Parents or guardians completed a Computer-Assisted Personal Interview at baseline and each follow-up visit. A stratified proportional hazards model was used in an intention-to-treat analysis of the primary outcome, HIV incidence, to compare the intervention and control groups. This study is registered at ClinicalTrials.gov (NCT01233531).

Findings: Between March 5, 2011, and Dec 17, 2012, we recruited 10 134 young women and enrolled 2537 and their parents or guardians to receive a cash transfer programme (n=1225) or not (control group; n=1223). At baseline, the median age of girls was 15 years (IQR 14-17) and 672 (27%) had reported to have ever had sex. 107 incident HIV infections were recorded during the study: 59 cases in 3048 person-years in the intervention group and 48 cases in 2830 person-years in the control group. HIV incidence was not significantly different between those who received a cash transfer (1.94% per person-years) and those who did not (1.70% per person-years; hazard ratio 1.17, 95% CI 0.80-1.72, p=0.42).

Interpretation: Cash transfers conditional on school attendance did not reduce HIV incidence in young women. School attendance significantly reduced risk of HIV acquisition, irrespective of study group. Keeping girls in school is important to reduce their HIV-infection risk. 

Abstract  Full-text [free] access 

Editor’s notes: Cash transfers to vulnerable household and/or individuals have been used successfully in a variety of settings as a means to reduce poverty, improve health and achieve other development-associated outcomes. Cash transfers can help address structural drivers of HIV, such as economic and gender inequalities and low levels of education, and have been proposed as a potentially important addition to HIV prevention efforts. However, the evidence of their effectiveness in the context of HIV prevention is mixed. This study is the first randomized controlled trial to examine the effect of cash transfers conditional on school attendance with HIV incidence in adolescent girls and young women in sub-Saharan Africa. The trial found no evidence that receipt of the conditional cash transfer reduced HIV or HSV-2 incidence.

Staying in education has been highlighted as a key factor for reducing the risk of HIV infection in girls and young women. In this setting, school attendance based on attendance registers was high in both trial arms (95%). This is much higher than in South Africa overall, and higher than in Mpumalanga Province (the study area). Eligibility for the trial was restricted to girls and young women who were currently enrolled in school, so the trial participants may have been more motivated to attend school than those who were not eligible. Interestingly, 75% of individuals who were screened for the trial were found to be ineligible, although the reasons for their exclusion are not given, and it is difficult to know how generalizable the results are. South Africa has a strong social protection system for poor families, and 80% of the study participants were from households that were receiving child support grants. The benefits of additional cash transfers in areas with high coverage of social protection may be minimal. Cash transfers to girls and young women for HIV prevention are likely to have a greater effect in settings with low school attendance and more limited social protection coverage.

Consistent with other studies, the trial found that staying in school was associated with a reduced risk of HIV, irrespective of trial arm. The cash transfer was also associated with a strongly reduced risk of intimate partner violence, and a small effect on reducing some sexual risk behaviours. Cash transfers may work both directly and indirectly, through a variety of different pathways that are likely to vary between settings and between populations. The high-recorded school attendance in both trial arms will have limited the ability to examine education as a pathway through which the cash transfer may have influenced HIV risk. A better understanding of these pathways and how they are affected by the setting may help inform the conditions under which cash transfers may be an effective component of an HIV prevention programme.

Africa
South Africa
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‘I wish I could have a life like others’: mental health challenges for young people living with HIV in Tanzania

A qualitative exploration of the mental health and psychosocial contexts of HIV-positive adolescents in Tanzania.

Ramaiya MK, Sullivan KA, K OD, Cunningham CK, Shayo AM, Mmbaga BT, Dow DE. PLoS One. 2016 Nov 16;11(11):e0165936. doi: 10.1371/journal.pone.0165936. eCollection 2016.

Although 85% of HIV-positive adolescents reside in sub-Saharan Africa, little is known about the psychosocial and mental health factors affecting their daily well-being. Identifying these contextual variables is key to development of culturally appropriate and effective interventions for this understudied and high-risk population. The purpose of this study was to identify salient psychosocial and mental health challenges confronted by HIV-positive youth in a resource-poor Tanzanian setting. A total of 24 qualitative interviews were conducted with a convenience sample of adolescents aged 12-24 receiving outpatient HIV care at a medical center in Moshi, Tanzania. All interviews were audio-recorded, transcribed, and coded using thematic analysis. Psychosocial challenges identified included loss of one or more parents, chronic domestic abuse, financial stressors restricting access to medical care and education, and high levels of internalized and community stigma among peers and other social contacts. Over half of youth (56%) reported difficulties coming to terms with their HIV diagnosis and espoused related feelings of self-blame. These findings highlight the urgent need to develop culturally proficient programs aimed at helping adolescents cope with these manifold challenges. Results from this study guided the development of Sauti ya Vijana (The Voice of Youth), a 10-session group mental health intervention designed to address the psychosocial and mental health needs of HIV-positive Tanzanian youth.

Abstract  Full-text [free] access 

Editor’s notes: This article presents the findings of a mixed-methods study with young people living with HIV and accessing care in Moshi, Tanzania. The study was conducted as part of a larger study assessing mental health needs in this population. The article reports on themes from individual qualitative interviews with 24 young people (aged 13-23) who had mental health difficulties that were previously assessed with the scales used in the larger project. Young people reported a wide range of psychosocial issues leading to ongoing mental health challenges.  These were challenges for which they had received little or no psychological support. Issues included internalized, feared and experienced HIV stigma, loss and bereavement from being orphaned.  Additional challenges were stress from poverty and insecurity in the household, isolation and difficulties with disclosure of their HIV status, and direct and vicarious experiences of violence and abuse. Young people also discussed finding strength in spirituality, friendships and especially peer-support from other young people living with HIV. Findings from the overall study are being used to inform the development of a mental health activity model that, if effective, could be scaled up in other low-income settings. 

Africa
United Republic of Tanzania
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Migrations, even over short distances, substantially increase the risk of HIV acquisition in rural South Africa

Space-time migration patterns and risk of HIV acquisition in rural South Africa: a population-based cohort study.

Dobra A, Barnighausen T, Vandormael A, Tanser F. AIDS. 2016 Oct 14. [Epub ahead of print]

Objective: To quantify the space-time dimensions of human mobility in relationship to the risk of HIV acquisition.

Methods: We used data from the population cohort located in a high HIV-prevalence, rural population in KwaZulu-Natal, South Africa (2000 - 2014). We geolocated 8006 migration events (representing 1 028 782 km travelled) for 17 743 individuals (≥15 years of age) who were HIV-negative at baseline and followed-up these individuals for HIV acquisition (70 395 person-years). Based on the complete geolocated residential history of every individual in this cohort, we constructed two detailed time-varying migration indices. We then used interval-censored Cox proportional hazards models to quantify the relationship between the migration indices and the risk of HIV acquisition.

Results: 17.4% of participants migrated at least once outside the rural study community during the period of observation (median migration distance = 107.1 km, IQR 18.9-387.5). The two migration indices were highly predictive of hazard of HIV acquisition (p < 0.01) in both men and women. Holding other factors equal, the risk of acquiring HIV infection increased by 50% for migration distances of 40 km (men) and 109 km (women). HIV acquisition risk also increased by 50% when participants spent 44% (men) and 90% (women) of their respective time outside the rural study community.

Conclusion: This in-depth analysis of a population cohort in a rural sub-Saharan African population has revealed a clear non-linear relationship between distance migrated and HIV acquisition. Our findings show that even relatively short distance migration events confer substantial additional risk of acquisition.

Abstract access  

Editor’s notes: Many studies in sub-Saharan African settings have illustrated that migrants have a greater risk of HIV infection and subsequent HIV-associated mortality than their non-migrant peers. The causal mechanisms underlying this enhanced risk and the temporal sequence of the migration and HIV acquisition events are less well understood. This study conducted in rural KwaZulu-Natal in South Africa is a longitudinal analysis linking data on migration episodes and the results of repeated HIV tests for individuals who were HIV negative at baseline. The two places of residence associated with the migration event were geo-coded, enabling the associations between spatiotemporal aspects of the migration and the risk of HIV acquisition to be explored. Two migration indices were calculated - one measuring the length of time spent outside the home residence and the other measuring the sum of the distances associated with the migrations. Both migration indices were significantly associated the risk of HIV acquisition. The association with distance was non-linear, with the risk of acquisition increasing by 50% at relatively short distances (approximately 55km), and the rates of increase of risk declined as the distance of migration increased further. The magnitude of this effect was similar for both sexes. By contrast the effect of time spent away from home on the risk of acquisition of HIV was significantly greater for men than women.

There are likely to be a number of mechanisms explaining the increased risks for migrants. These include an increase in the number of sexual partners, adoption of higher risk sexual behaviour and a detachment from the social support networks that exist in the home community. Further qualitative studies are necessary to explore these more fully. The authors also recommend that such studies are replicated in other settings to assess the generalisability of the findings. Having established these causal pathways, novel HIV prevention approaches focused towards these highly vulnerable migrant populations will need to be developed as part of efforts to achieve the UNAIDS 90:90:90 treatment target.

Africa
South Africa
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Violence and HIV among poor urban women in the USA

Physical and sexual violence predictors: 20 years of the women's interagency HIV study cohort.

Decker MR, Benning L, Weber KM, Sherman SG, Adedimeji A, Wilson TE, Cohen J, Plankey MW, Cohen MH, Golub ET. Am J Prev Med. 2016 Nov;51(5):731-742. pii: S0749-3797(16)30253-7. doi: 10.1016/j.amepre.2016.07.005. [Epub 2016 Aug 29]. 

Introduction: Gender-based violence (GBV) threatens women's health and safety. Few prospective studies examine physical and sexual violence predictors. Baseline/index GBV history and polyvictimization (intimate partner violence, non-partner sexual assault, and childhood sexual abuse) were characterized. Predictors of physical and sexual violence were evaluated over follow-up.

Methods: HIV-infected and uninfected participants (n=2838) in the Women's Interagency HIV Study provided GBV history; 2669 participants contributed 26 363 person years of follow-up from 1994 to 2014. In 2015-2016, multivariate log-binomial/Poisson regression models examined violence predictors, including GBV history, substance use, HIV status, and transactional sex.

Results: Overall, 61% reported index GBV history; over follow-up, 10% reported sexual and 21% reported physical violence. Having experienced all three forms of past GBV posed the greatest risk (adjusted incidence rate ratio [AIRR]physical=2.23, 95% CI=1.57, 3.19; AIRRsexual=3.17, 95% CI=1.89, 5.31). Time-varying risk factors included recent transactional sex (AIRRphysical=1.29, 95% CI=1.03, 1.61; AIRRsexual=2.98, 95% CI=2.12, 4.19), low income (AIRRphysical=1.22, 95% CI=1.01, 1.45; AIRRsexual=1.38, 95% CI=1.03, 1.85), and marijuana use (AIRRphysical=1.43, 95% CI=1.22, 1.68; AIRRsexual=1.57, 95% CI=1.19, 2.08). For physical violence, time-varying risk factors additionally included housing instability (AIRR=1.37, 95% CI=1.15, 1.62); unemployment (AIRR=1.38, 95% CI=1.14, 1.67); exceeding seven drinks/week (AIRR=1.44, 95% CI=1.21, 1.71); and use of crack, cocaine, or heroin (AIRR=1.76, 95% CI=1.46, 2.11).

Conclusions: Urban women living with HIV and their uninfected counterparts face sustained GBV risk. Past experiences of violence create sustained risk. Trauma-informed care, and addressing polyvictimization, structural inequality, transactional sex, and substance use treatment, can improve women's safety.

Abstract access  

Editor’s notes: Gender-based violence results in physical, sexual and mental health morbidities, including HIV risk behaviours and HIV infection. There is limited prospective research on risk factors for physical and sexual violence. This study characterised leading violence forms – that is, intimate partner violence, non-partner sexual assault and childhood sexual assault – among a cohort of low-income women living in six American cities, some of whom are living with HIV. It also examined predictors of violence experience during follow-up. This study found extensive gender-based violence of all types, listed above, among this cohort of 2838 HIV positive and HIV negative women. Lifetime gender-based violence history was highly prevalent among white women (72%), non-heterosexual women (74%), homeless / unstably housed women (80%) and among women with a sex work history (81%). Experience of different types of gender-based violence by baseline conferred significant risk for subsequent physical and sexual violence. HIV status did not confer risk for violence victimisation indicating that low-income women in this setting are at considerable risk for violence, regardless of their HIV status.

This study presents data from the largest ongoing prospective cohort study among American women living with HIV and includes a demographically matched HIV negative comparison group. The key limitation of this study was the non-probability sample, which limits generalisability of these results. The results are best generalised to urban American women in high-HIV prevalence settings. Additional cohort studies are necessary in other settings and contexts. However, the findings demonstrate the need to understand and address different forms of violence experienced by the same woman for violence prevention and health promotion. They support the USA 2015 National HIV/AIDS strategy recommendations to address violence and trauma for women both at risk for and living with HIV. 

Northern America
United States of America
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The limits of HIV disclosure for women in 27 countries

The association between HIV disclosure status and perceived barriers to care faced by women living with HIV in Latin America, China, central/eastern Europe, and western Europe/Canada.

Loutfy M, Johnson M, Walmsley S, Samarina A, Vasquez P, Hao-Lan H, Madihlaba T, Martinez-Tristani M, van Wyk J. AIDS Patient Care STDS. 2016 Sep;30(9):435-44. doi: 10.1089/apc.2016.0049. Epub 2016 Aug 23.

Generally, women are less likely than men to disclose their HIV status. This analysis examined the relationship between HIV disclosure and (1) perceived barriers to care and (2) quality of life (QoL) for women with HIV. The ELLA (EpidemioLogical study to investigate the popuLation and disease characteristics, barriers to care, and quAlity of life for women living with HIV) study enrolled HIV-positive women aged ≥18 years. Women completed the 12-item Barriers to Care Scale (BACS) questionnaire. QoL was assessed using the Health Status Assessment. BACS and QoL were stratified by dichotomized HIV disclosure status (to anyone outside the healthcare system). Multilevel logistic regression analysis was used to identify factors associated with disclosure. Of 1945 patients enrolled from Latin America, China, central/eastern Europe, and western Europe/Canada between July 2012 and September 2013, 1929 were included in the analysis (disclosed, n = 1724; nondisclosed, n = 205). Overall, 55% of patients lived with a husband/partner, 53% were employed, and 88% were receiving antiretroviral therapy. Patients who were with a serodiscordant partner were more likely to disclose (p = 0.0003). China had a disproportionately higher percentage of participants who did not disclose at all (nearly 30% vs. <15% for other regions). Mean BACS severity scores for medical/psychological service barriers and most personal resource barriers were significantly lower for the disclosed group compared with the nondisclosed group (p ≤ 0.02 for all). Compared with the disclosed group, the nondisclosed group reported statistically significantly higher (p ≤ 0.03) BACS item severity scores for 8 of the 12 potential barriers to care. The disclosed group reported better QoL. Overall, HIV nondisclosure was associated with more severe barriers to accessing healthcare by women with HIV.

Abstract Full-text [free] access

Editor’s notes: This study drew women participants from Latin America, China, central and eastern Europe and from western Europe and Canada.  China was the only Asian country included and no African countries were included. This is important background information since the first sentence of the abstract ‘women are less likely than men to disclose HIV status’ is less likely to be true for, for example, parts of Africa. The study did not include men. So, no comparison can therefore be made with men’s disclosure behaviour. Nevertheless, the paper draws on data from 27 countries. Most women in the study did have access to ‘efficacious, well-tolerated’ antiretroviral therapy. A number of women, most notably in China, did not disclose their HIV status outside the health care system. Many women disclosed their status to a limited extent (only to some family and close friends). Non-disclosure affected access to health care as well as more general support. This pattern of non- or limited disclosure and barriers to access to care is replicated in many other places. The findings in this paper point to the importance globally of tackling stigma and providing a supportive health care and social setting for people living with HIV, so they can benefit fully from the treatment and care that is available.

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Preventing intimate partner violence for HIV positive women

Relationship power and sexual violence among HIV-positive women in rural Uganda.

Conroy AA, Tsai AC, Clark GM, Boum Y, Hatcher AM, Kawuma A, Hunt PW, Martin JN, Bangsberg DR, Weiser SD. AIDS Behav. 2016 Sep;20(9):2045-53. doi: 10.1007/s10461-016-1385-y.

Gender-based power imbalances place women at significant risk for sexual violence, however, little research has examined this association among women living with HIV/AIDS. We performed a cross-sectional analysis of relationship power and sexual violence among HIV-positive women on antiretroviral therapy in rural Uganda. Relationship power was measured using the Sexual Relationship Power Scale (SRPS), a validated measure consisting of two subscales: relationship control (RC) and decision-making dominance. We used multivariable logistic regression to test for associations between the SRPS and two dependent variables: recent forced sex and transactional sex. Higher relationship power (full SRPS) was associated with reduced odds of forced sex (AOR = 0.24; 95 % CI 0.07-0.80; p = 0.020). The association between higher relationship power and transactional sex was strong and in the expected direction, but not statistically significant (AOR = 0.47; 95 % CI 0.18-1.22; p = 0.119). Higher RC was associated with reduced odds of both forced sex (AOR = 0.18; 95 % CI 0.06-0.59; p < 0.01) and transactional sex (AOR = 0.38; 95 % CI 0.15-0.99; p = 0.048). Violence prevention interventions with HIV-positive women should consider approaches that increase women's power in their relationships.

Abstract access 

Editor’s notes: This paper addresses the lack of research into relationship power and sexual violence among women living with HIV. The authors report on analysis of data, collected as part of an ongoing prospective cohort study on HIV medication adherence (Uganda AIDS Rural Treatment Outcomes (UARTO) study). The authors examined the association between relationship power and forced and transactional sex, based on their hypothesis that higher relationship power would be protective against both.

Participants for the main study were recruited from the Mbarara Regional Referral Hospital Immune Suppression Syndrome (ISS) Clinic, and in August 2007, the survey was modified for this sub-study to include measures on relationship power, intimate partner violence, stigma, social support, health behaviours, and food security. For the survey, relationship power was measured using the Sexual Relationship Power Scale (SRPS), which contains two subscales: relationship control (RC) and decision-making dominance (DMD).

The authors found a strong protective effect of relationship power on recent experience of forced sex and transactional sex among the participants. They also found that the association between RC and transactional sex was consistent with the association between RC and forced sex, which they suggest reveals that transactional sex, for these women, is associated with male dominance and control. That is, HIV-positive women with low relationship power may be more likely to engage in transactional sex due to poverty and food insecurity rather than for empowering reasons associated with agency.

The authors conclude with a call to consider the multiplicity of issues that need to be addressed for women living with HIV, including access to HIV care and treatment, social support, stigma and discrimination, disclosure, poverty and food security, and skills to negotiate safer sex and resolve conflict. In relationship to violence prevention they argue that anti-violence programmes should be integrated within HIV healthcare services as well as addressing structural factors through economic empowerment and gender transformative programmes.

Africa
Uganda
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Migration and HIV – a double synergy

Migration and HIV infection in Malawi.

Anglewicz P, VanLandingham M, Manda-Taylor L, Kohler HP. AIDS. 2016 Aug 24;30(13):2099-105. doi: 10.1097/QAD.0000000000001150.

Objective: To evaluate the assumption that moving heightens HIV infection by examining the time-order between migration and HIV infection and investigate differences in HIV infection by migration destination and permanence.

Methods: We employ four waves of longitudinal data (2004-2010) for 4265 men and women from a household-based study in rural Malawi and a follow-up of migrants (2013). Using these data, we examine HIV status prior to migration. Migrants are disaggregated by destination (rural, town, and urban) and duration (return and permanent); all compared with individuals who consistently resided in the rural origin ('nonmigrants').

Results: HIV-positive individuals have significantly greater odds of migration than those who are HIV negative [odds ratio 2.75; 95% confidence interval (CI) 1.89-4.01]. Being HIV positive significantly increases the relative risk (RR) that respondent will be a rural-urban migrant [RR ratio (RRR) 6.28; 95% CI 1.77-22.26), rural-town migrant (RRR 3.62; 95% CI 1.24-10.54), and a rural-rural migrant (RRR 4.09; 95% CI 1.68-9.97), instead of a nonmigrant. Being HIV positive significantly increases the RR that a respondent will move and return to the village of origin (RRR 2.58; 95% CI 1.82-3.66) and become a permanent migrant (RRR 3.21; 95% CI 1.77-5.82) instead of not migrating.

Conclusion: HIV-positive status has a profound impact on mobility: HIV infection leads to significantly higher mobility through all forms of migration captured in our study. These findings emphasize that migration is more than just an independent risk factor for HIV infection: greater prevalence of HIV among migrants is partly due to selection of HIV-positive individuals into migration.

Abstract access  

Editor’s notes: Previous studies in sub-Saharan Africa have identified that migrants are at greater risk of living with HIV than their non-migrant counterparts. There is however a lack of knowledge of the direction of causality between migration status and HIV status. This longitudinal study enabled analysis of the direction of causality between HIV acquisition and migration.  Individuals living with HIV were significantly more likely to migrate in the future than people who were not living with HIV.  The effect was seen for all types of migration (rural to rural, rural to town (district capital) and rural to urban (regional capital).

The true association between HIV status and migration status may exceed that illustrated as some individuals who were HIV negative at baseline may have become HIV positive prior to migration. The patterns identified could be driven by better healthcare being available in an urban setting. Alternatively individuals may move to avoid HIV-associated stigma in the relative anonymity of an urban environment. Previous research in Malawi has also illustrated that marriage and migration are closely linked. Thus marital dissolution following HIV infection may in part explain the patterns seen.  Further qualitative studies are necessary to investigate such factors.

This study illustrates that an increasing emphasis needs to be placed on HIV prevention in the rural communities from which migrants originate, in addition to focusing on the risk in the urban areas. 

Africa
Malawi
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Pregnancy and intimate partner violence among women living with HIV

Intimate partner violence experienced by HIV-infected pregnant women in South Africa: a cross-sectional study.

Bernstein M, Phillips T, Zerbe A, McIntyre JA, Brittain K, Petro G, Abrams EJ, Myer L. BMJ Open. 2016 Aug 16;6(8):e011999. doi: 10.1136/bmjopen-2016-011999.

Objectives: Intimate partner violence (IPV) during pregnancy may be common in settings where HIV is prevalent but there are few data on IPV in populations of HIV-infected pregnant women in Southern Africa. We examined the prevalence and correlates of IPV among HIV-infected pregnant women.

Setting: A primary care antenatal clinic in Cape Town, South Africa.

Participants: 623 consecutive HIV-infected pregnant women initiating lifelong antiretroviral therapy.

Measures: IPV, depression, substance use and psychological distress were assessed using the 13-item WHO Violence Against Women questionnaire, the Edinburgh Postnatal Depression Scale (EPDS), Alcohol and Drug Use Disorders Identification Tests (AUDIT/DUDIT) and the Kessler 10 (K-10) scale, respectively.

Results: The median age in the sample was 28 years, 97% of women reported being in a relationship, and 70% of women reported not discussing and/or agreeing on pregnancy intentions before conception. 21% of women (n=132) reported experiencing ≥1 act of IPV in the past 12 months, including emotional (15%), physical (15%) and sexual violence (2%). Of those reporting any IPV (n=132), 48% reported experiencing 2 or more types. Emotional and physical violence was most prevalent among women aged 18-24 years, while sexual violence was most commonly reported among women aged 25-29 years. Reported IPV was less likely among married women, and women who experienced IPV were more likely to score above threshold for substance use, depression and psychological distress. In addition, women who reported not discussing and/or not agreeing on pregnancy intentions with their partner prior to conception were significantly more likely to experience violence.

Conclusions: HIV-infected pregnant women in the study reported experiencing multiple forms of IPV. While the impact of IPV on maternal and child health outcomes in the context of HIV infection requires further research attention, IPV screening and support services should be considered within the package of routine care for HIV-infected pregnant women.

Trial registration number: NCT01933477.

Abstract  Full-text [free] access 

Editor’s notes: Intimate partner violence among women in sub-Saharan Africa is >30%. There is limited research examining intimate partner violence among women living with HIV. Research is important as intimate partner violence may impact on a woman’s ability to adhere to antiretroviral therapy. Among pregnant women, this includes during pregnancy and post-partum. This study describes the prevalence of recent intimate partner violence, and examines associations between recent intimate partner violence and demographic, relationship and psychological variables.

The study was set in a township in Cape Town, South Africa, where the majority of residents have low socio-economic status and HIV infection among women is approximately 30%. Some 21% percent of 623 participants reported any recent intimate partner violence in the past 12 months.  Fifteen percent reported emotional violence, 15% physical violence (7% severe physical) and two percent sexual violence. Recent violence was associated with hazardous alcohol use, psychological distress and depression. It was more likely among unmarried women, and among women who had not discussed/agreed pregnancy prior to conception. There was no evidence to suggest intimate partner violence was elevated among women newly diagnosed with HIV.

These data suggest significant intimate partner violence experience among pregnant women living with HIV, living in this township. This study adds to the limited literature, examining intimate partner violence in the context of pregnancy and HIV. Longitudinal studies, and studies which examine the impact of intimate partner violence on ART uptake and adherence, including during pregnancy and post-partum, are necessary. 

Africa
South Africa
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‘Scared of going there’ – barriers to HIV treatment for pregnant women in Tanzania

Stigma, facility constraints, and personal disbelief: why women disengage from HIV care during and after pregnancy in Morogoro region, Tanzania.

McMahon SA, Kennedy CE, Winch PJ, Kombe M, Killewo J, Kilewo C. AIDS Behav. 2016 Aug 17. [Epub ahead of print]

Millions of children are living with HIV in sub-Saharan Africa, and the primary mode of these childhood infections is mother-to-child transmission. While existing interventions can virtually eliminate such transmission, in low- and middle-income settings, only 63% of pregnant women living with HIV accessed medicines necessary to prevent transmission. In Tanzania, HIV prevalence among pregnant women is 3.2%. Understanding why HIV-positive women disengage from care during and after pregnancy can inform efforts to reduce the impact of HIV on mothers and young children. Informed by the tenets of Grounded Theory, we conducted qualitative interviews with 40 seropositive postpartum women who had disengaged from care to prevent mother-to-child transmission (PMTCT). Nearly all women described antiretroviral treatment (ART) as ultimately beneficial but effectively inaccessible given concerns related to stigma. Many women also described how their feelings of health and vitality coupled with concerns about side effects underscored a desire to forgo ART until they deemed it immediately necessary. Relatively fewer women described not knowing or forgetting that they needed to continue their treatment regimens. We present a theory of PMTCT disengagement outlining primary and ancillary barriers. This study is among the first to examine disengagement by interviewing women who had actually discontinued care. We urge that a combination of intervention approaches such as mother-to-mother support groups, electronic medical records with same-day tracing, task shifting, and mobile technology be adapted, implemented, and evaluated within the Tanzanian setting.

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Editor’s notes: The push for universal access to antiretroviral therapy for everyone living with HIV faces many obstacles.  In many parts of the world, pregnant women are offered HIV testing as a part of antenatal care. Treatment is then offered if a woman is found to be HIV-positive. Many women accept this care, having been provided with the information that this is beneficial for their baby and also themselves. Some women who accept treatment take themselves out of care. This can be detrimental not only for the HIV status of their baby, but also for their general antenatal care. As the authors of this paper note, there is a growing body of literature that describes losses to care from the provider perspective. There are also a number of papers about women who have accepted care, who describe why others refuse treatment.  It is unusual to find detailed findings from interviews with women who have dropped out of or refused HIV treatment while pregnant. While the findings are not particularly surprising, the authors of this paper have captured the individual reasons why the 40 women interviewed in their study, left or never entered care. The reasons given underline the challenge of ‘prompt treatment’. Many women were not ready for immediate treatment.  Fears of the clinic layout ‘betraying’ a woman’s status are described. So too are the negative attitudes of health providers as well as family and community members. The authors provide an excellent example of how good qualitative research, conducted and analysed in an exemplary manner, offers valuable insights. This paper provides valuable information on an often hidden minority of women who are not ready or able ‘to test and treat’.

Africa
United Republic of Tanzania
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