Articles tagged as "Reduce sexual transmission"

Using Facebook to increase uptake of HIV testing among MSM in Peru

The HOPE social media intervention for global HIV prevention in Peru: a cluster randomised controlled trial.

Young SD, Cumberland WG, Nianogo R, Menacho LA, Galea JT, Coates T. The Lancet HIV 2.1 (2015): e27-e32.

Background: Social media technologies offer new approaches to HIV prevention and promotion of testing. We examined the efficacy of the Harnessing Online Peer Education (HOPE) social media intervention to increase HIV testing among men who have sex with men (MSM) in Peru.

Methods: In this cluster randomised controlled trial, Peruvian MSM from Greater Lima (including Callao) who had sex with a man in the past 12 months, were 18 years of age or older, were HIV negative or serostatus unknown, and had a Facebook account or were willing to create one (N=556) were randomly assigned (1:1) by concealed allocation to join intervention or control groups on Facebook for 12 weeks. For the intervention, Peruvian MSM were trained and assigned to be HIV prevention mentors (peer-leaders) to participants in Facebook groups. The interventions period lasted 12 weeks. Participants in control groups received an enhanced standard of care, including standard offline HIV prevention available in Peru and participation in Facebook groups (without peer leaders) that provided study updates and HIV testing information. After accepting a request to join the groups, continued participation was voluntary. Participants also completed questionnaires on HIV risk behaviours and social media use at baseline and 12 week follow-up. The primary outcome was the number of participants who received a free HIV test at a local community clinic. The facebook groups were analysed as clusters to account for intracluster correlations. This trial is registered with ClinicalTrials.gov, number NCT01701206.

Findings: Of 49 peer-leaders recruited, 34 completed training and were assigned at random to the intervention Facebook groups. Between March 19, 2012, and June 11, 2012, and Sept 26, 2012, and Dec 19, 2012, 556 participants were randomly assigned to intervention groups (N=278) or control groups (N=278); we analyse data for 252 and 246. 43 participants (17%) in the intervention group and 16 (7%) in the control groups got tested for HIV (adjusted odds ratio 2·61, 95% CI 1·55–4·38). No adverse events were reported.

Interpretation: Development of peer-mentored social media communities seemed to be an efficacious method to increase HIV testing among high-risk populations in Peru. Results suggest that the HOPE social media intervention could improve HIV testing rates among MSM in Peru.

Abstract access

Editor’s notes: Community peer-led HIV programmes aim to increase behaviours by changing social norms and attitudes. They have led to increased condom use and decreased unprotected anal intercourse. In this study, a peer-led social media activity was shown to increase HIV testing among men who have sex with men in Peru. The programme involved belonging to a closed Facebook group, with a peer-leader providing posts and chats about the importance of HIV testing and prevention. Further, the communities remained highly engaged in group discussions, suggesting that the activity may also work on improving linkage to care, although this was not an outcome in this trial. This study is the first social media-based randomised controlled trial assessing HIV testing and suggests the efficacy of using social media and other innovative low-cost technologies for HIV prevention and treatment in other settings.

Latin America
Peru
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Awareness of HIV status of self and partner – levels still too low

Who knows their partner's HIV status? Results from a nationally representative survey in Uganda.

Kenyon CR, Kirungi W, Kaharuza F, Buyze J, Bunnell R. J Acquir Immune Defic Syndr. 2015 Jan 23. [Epub ahead of print]

Objective: We examine the extent to which Ugandans accurately know their HIV status and that of their partners.

Methods: The 2011 Uganda AIDS Indicator Survey (UAIS) was a nationally representative study of 15-59 year olds that tested 21 366 individuals for HIV. We compared self-reported with UAIS determined HIV status for respondents. We were able to link 3285 couples in the survey and in this group we compared the reported HIV status of partners with that determined by UAIS. Multiple logistic regression analysis was used to identify factors associated with inaccurate knowledge of HIV status.

Results: An estimated 55.8% of adult Ugandans reported having had an HIV test. Of 1495 HIV-infected Ugandans, 59.1% were unaware of their HIV-infection. Among 3285 linked couples in this analysis, 273 (8.3%) couples had at least one infected partner; with 96 (2.9%) couples having both members infected and the remaining 177 couples (5.4%) being HIV discordant. This meant that 369 persons in the linked couple group had an HIV-infected partner. 110 (29.8%) of this group knew their partner was HIV infected. In multiple logistic regression analysis, accurately knowing that one’s partner was HIV infected was strongly associated with couple HIV testing (AOR 4.3, CI: 2.2-8.4) and reporting oneself to be HIV-positive, versus reporting HIV-negative (AOR 7.3, CI 3.8-14.3) or HIV status unknown (AOR 30.6, CI 3.8-263.4).

Conclusions: Respondents may be reporting the HIV status of their partners based on their own HIV status. Campaigns to inform people about the prevalence of serodiscordance in conjunction with further promotion of couple counseling may help increase the proportion of Ugandans who know their own HIV status and that of their partners.

Abstract access

Editor’s notes: It is important for people to know their own HIV status, and that of their partners, if HIV transmission reduction strategies are to be effective. In this large, nationally-representative survey in Uganda, self-reported HIV status was compared with laboratory-confirmed results. The proportion of women and men reporting to know their HIV status has increased considerably since the last survey. Yet over half of adults living with HIV were unaware of their HIV status. Less than a third of people with a partner living with HIV were aware of their partner’s status. There was a strong association between self-reported HIV status and reported partners’ HIV status. The authors suggest that one explanation may be that people are reporting the HIV status of their partners based on their own HIV status. This argument is supported by previous studies suggesting that concordance of HIV test results is often assumed. This study indicates a need for education strategies about the prevalence and consequences of discordance. These could be combined with couple testing and antiretroviral therapy as prevention, for discordant couples, to address the generalized HIV epidemic in Uganda and more widely. 

Africa
Uganda
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Does a protective effect against herpes simplex virus-2 increase the cost-effectiveness of PrEP?

Estimating the cost-effectiveness of pre-exposure prophylaxis to reduce HIV-1 and HSV-2 incidence in HIV-serodiscordant couples in South Africa.

Jewell BL, Cremin I, Pickles M, Celum C, Baeten JM, Delany-Moretlwe S, Hallett TB. PLoS One. 2015 Jan 23;10(1):e0115511. doi: 10.1371/journal.pone.0115511. eCollection 2015.

Objective: To estimate the cost-effectiveness of daily oral tenofovir-based PrEP, with a protective effect against HSV-2 as well as HIV-1, among HIV-1 serodiscordant couples in South Africa.

Methods: We incorporated HSV-2 acquisition, transmission, and interaction with HIV-1 into a microsimulation model of heterosexual HIV-1 serodiscordant couples in South Africa, with use of PrEP for the HIV-1 uninfected partner prior to ART initiation for the HIV-1 1infected partner, and for one year thereafter.

Results: We estimate the cost per disability-adjusted life-year (DALY) averted for two scenarios, one in which PrEP has no effect on reducing HSV-2 acquisition, and one in which there is a 33% reduction. After a twenty-year intervention, the cost per DALY averted is estimated to be $10 383 and $9757, respectively - a 6% reduction, given the additional benefit of reduced HSV-2 acquisition. If all couples are discordant for both HIV-1 and HSV-2, the cost per DALY averted falls to $1445, which shows that the impact is limited by HSV-2 concordance in couples.

Conclusion: After a 20-year PrEP intervention, the cost per DALY averted with a reduction in HSV-2 is estimated to be modestly lower than without any effect, providing an increase of health benefits in addition to HIV-1 prevention at no extra cost. The small degree of the effect is in part due to a high prevalence of HSV-2 infection in HIV-1 serodiscordant couples in South Africa.

Abstract  Full-text [free] access

Editor’s notes: Herpes simplex virus-2 (HSV-2) is a risk factor for HIV, and can also have serious consequences for pregnant women if contracted during pregnancy. It is also difficult to prevent outside of condom use, and highly prevalent in sub-Saharan Africa. It is unsurprising then, that a great deal of enthusiasm came out of findings from the Partners pre-exposure prophylaxis (PrEP) Study, which found that daily oral emtricitabine/ tenofovir disoproxil fumarate (TDF/FTC) decreased acquisition of HSV-2 by 33%. It also decreased the risk of HIV acquisition by some 75%. This article evaluates the cost-effectiveness of oral tenofovir-based PrEP. It focuses on the incremental cost-effectiveness of reduction of HSV-2 incidence, an increased health benefit with no extra cost. 

Surprisingly, the authors found that over a 20 year period, the efficacy of TDF/FTC PrEP to prevent HSV-2 infections will not materially affect the cost-effectiveness of PrEP. Although the simulated PrEP programme, with a 33% reduction in HSV-2 acquisition was more effective, it only had a minimal effect on the cost per DALY averted. This was compared to PrEP with 0% reduction in HSV-2 ($9757 as compared to $10 383/DALY averted). This is due to the relatively mild health consequences of HSV-2 in comparison with HIV. The vast majority of DALYs averted from the programme originate from preventing new HIV infections, rather than HSV-2 prevention.  Nonetheless, the authors argue that this added health benefit may be appealing, particularly for dually discordant couples; one partner having both HIV and HSV-2. The authors also argue for further investigation of the impact of this combination for other populations, such as young women.

Africa
South Africa
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Savings-led microfinance programme leads to lower sexual risk among sex workers in Mongolia

Efficacy of a savings-led microfinance intervention to reduce sexual risk for HIV among women engaged in sex work: a randomized clinical trial.

Witte SS, Aira T, Tsai L, Riedel M, Offringa R, Chang M, El-Bassel N, Ssewamala F. Am J Public Health. 2015 Mar;105(3):e95-e102. doi: 10.2105/AJPH.2014.302291. Epub 2015 Jan 20.

Objectives: We tested whether a structural intervention combining savings-led microfinance and HIV prevention components would achieve enhanced reductions in sexual risk among women engaging in street-based sex work in Ulaanbaatar, Mongolia, compared with an HIV prevention intervention alone.

Methods: Between November 2011 and August 2012, we randomized 107 eligible women who completed baseline assessments to either a 4-session HIV sexual risk reduction intervention (HIVSRR) alone (n = 50) or a 34-session HIVSRR plus a savings-led microfinance intervention (n = 57). At 3- and 6-month follow-up assessments, participants reported unprotected acts of vaginal intercourse with paying partners and number of paying partners with whom they engaged in sexual intercourse in the previous 90 days. Using Poisson and zero-inflated Poisson model regressions, we examined the effects of assignment to treatment versus control condition on outcomes.

Results: At 6-month follow-up, the HIVSRR plus microfinance participants reported significantly fewer paying sexual partners and were more likely to report zero unprotected vaginal sex acts with paying sexual partners.

Conclusions: Findings advance the HIV prevention repertoire for women, demonstrating that risk reduction may be achieved through a structural intervention that relies on asset building, including savings, and alternatives to income from sex work.

Abstract access

Editor’s notes: This study on sexual risk among sex workers in Ulaanbaatar, Mongolia, contributes to evidence that economic empowerment reduces HIV risk. Mongolia has a low prevalence of HIV. But it is considered highly vulnerable to the spread of HIV. This suggests that such programmes should be implemented to prevent concentrated epidemics becoming generalised epidemics. The authors acknowledge that while microfinance might be economically empowering it may represent “saving down”, which can keep women in debt and in a cycle of poverty and a reliance on sex work. The trial tested whether increasing financial literacy, business development knowledge and skills and personal savings would lead to more significant reductions in sexual risk behaviours than a sexual risk reduction programme alone. Groups of sex workers were randomised to receive either a four session HIV sexual risk reduction programme (HIVSRR) or HIVSRR plus a savings-led microfinance programme. The HIVSRR alone involved the delivery of two sessions per week for two weeks and focused on skills to develop self-efficacy for risk reduction. The HIVSRR plus savings-led microfinance programme involved the four sessions on self-efficacy for risk reduction, followed by 12 financial literacy sessions three times a week and then 12 sessions of business development training three times a week. The activities were tested at three months and six months to explore the short time impact on sexual risk. The authors found that women who received the HIVSSRR plus savings-led microfinance programme reported greater reductions in number of paying sexual partners and fewer sexual partners at six months follow up. These women were also more likely to report no unprotected vaginal sex acts at six months follow up. This study is important in illustrating that as a structural programme, the provision of microfinance is more effective if women are provided with skills to manage finances and to save money instead of ending up in a cycle of debt repayment. This has important implications for other microfinance programmes, such as programmes to reduce gender-based violence.

Asia
Mongolia
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Refocussing on sex workers in Swaziland - even in generalized epidemics

Reconceptualizing the HIV epidemiology and prevention needs of female sex workers (FSW) in Swaziland.

Baral S, Ketende S, Green JL, Chen PA, Grosso A, Sithole B, Ntshangase C, Yam E, Kerrigan D, Kennedy CE, Adams D. PLoS One. 2014 Dec 22;9(12):e115465. doi: 10.1371/journal.pone.0115465. eCollection 2014

Background: HIV is hyperendemic in Swaziland with a prevalence of over 25% among those between the ages of 15 and 49 years old. The HIV response in Swaziland has traditionally focused on decreasing HIV acquisition and transmission risks in the general population through interventions such as male circumcision, increasing treatment uptake and adherence, and risk-reduction counseling. There is emerging data from Southern Africa that key populations such as female sex workers (FSW) carry a disproportionate burden of HIV even in generalized epidemics such as Swaziland. The burden of HIV and prevention needs among FSW remains unstudied in Swaziland.

Methods: A respondent-driven-sampling survey was completed between August-October, 2011 of 328 FSW in Swaziland. Each participant completed a structured survey instrument and biological HIV and syphilis testing according to Swazi Guidelines.

Results: Unadjusted HIV prevalence was 70.3% (n = 223/317) among a sample of women predominantly from Swaziland (95.2%, n = 300/316) with a mean age of 21 (median 25) which was significantly higher than the general population of women. Approximately one-half of the FSW (53.4%, n = 167/313) had received HIV prevention information related to sex work in the previous year, and about one-in-ten had been part of a previous research project (n = 38/313). Rape was common with nearly 40% (n = 123/314) reporting at least one rape; 17.4% (n = 23/314) reported being raped 6 or more times. Reporting blackmail (34.8%, n = 113/314) and torture (53.2%, n = 173/314) was prevalent.

Conclusions: While Swaziland has a highly generalized HIV epidemic, reconceptualizing the needs of key populations such as FSW suggests that these women represent a distinct population with specific vulnerabilities and a high burden of HIV compared to other women. These women are understudied and underserved resulting in a limited characterization of their HIV prevention, treatment, and care needs and only sparse specific and competent programming. FSW are an important population for further investigation and rapid scale-up of combination HIV prevention including biomedical, behavioral, and structural interventions.

Abstract  Full-text [free] access

Editor’s notes: In countries with high prevalence generalised epidemics, research and resources often focus on the general population, and the role of key populations is often ignored. This study, from Swaziland, illustrates how the sex worker population in Swaziland suffer from a concentrated epidemic within a generalized one. The study highlights the need for focused services to address the very high HIV prevalence, some 70%, in this population. The study further highlights the lack of services, education and support reaching sex workers in this setting. Given large sexual networks, high prevalence of HIV and limited condom use, this vulnerable population is likely to be contributing substantially to the widespread epidemic in Swaziland. In this and similar settings, HIV treatment and prevention services specifically for sex workers are necessary and should be a central plank of service delivery programming, and policy making. 

Africa
Swaziland
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Promising results from a combination HIV prevention strategy for MSM in Central America

Effectiveness of a combination prevention strategy for HIV risk reduction with men who have sex with men in Central America: a mid-term evaluation.

Firestone R, Rivas J, Lungo S, Cabrera A, Ruether S, Wheeler J, Vu L. BMC Public Health. 2014 Dec 4;14:1244. doi: 10.1186/1471-2458-14-1244.

Background: Despite over a decade of research and programming, little evidence is available on effective strategies to reduce HIV risks among Central American men who have sex with men (MSM). The Pan-American Social Marketing Organization (PASMO) and partners are implementing a HIV Combination Prevention Program to provide key populations with an essential package of prevention interventions and services: 1) behavioral, including interpersonal communications, and online outreach; 2) biomedical services including HIV testing and counseling and screening for STIs; and 3) complementary support, including legal support and treatment for substance abuse. Two years into implementation, we evaluated this program's effectiveness for MSM by testing whether exposure to any or a combination of program components could reduce HIV risks.

Methods: PASMO surveyed MSM in 10 cities across Guatemala, El Salvador, Nicaragua, Costa Rica, and Panama in 2012 using respondent-driven sampling. We used coarsened exact matching to create statistically equivalent groups of men exposed and non-exposed to the program, matching on education, measures of social interaction, and exposure to other HIV prevention programs. We estimated average treatment effects of each component and all combined to assess HIV testing and condom use outcomes, using multivariable logistic regression. We also linked survey data to routine service data to assess program coverage.

Results: Exposure to any program component was 32% in the study area (n = 3531). Only 2.8% of men received all components. Men exposed to both behavioral and biomedical components were more likely to use condoms and lubricant at last sex (AOR 3.05, 95% CI 1.08, 8.64), and those exposed to behavioral interventions were more likely to have tested for HIV in the past year (AOR 1.76, 95% CI 1.01, 3.10).

Conclusions: PASMO's strategies to reach MSM with HIV prevention programming are still achieving low levels of population coverage, and few men are receiving the complete essential package. However, those reached are able to practice HIV prevention. Combination prevention is a promising approach in Central America, requiring expansion in coverage and intensity.

Abstract  Full-text [free] access

Editor’s notes: In countries where same-sex behaviour is criminalised and/or highly stigmatised, men who have sex with men (MSM) often find it very difficult to obtain appropriate sexual health services.  Such difficulties contribute to the continued high prevalence of HIV among MSM in some settings.  Strategies to prevent HIV transmission, increasingly favour a combination of activities which aim to reflect specific social conditions. It is important that these complex prevention programmes are systematically evaluated. This paper discusses one of the first evaluations of a combined HIV prevention strategy including behavioural, biomedical and psychosocial components. The strategy is aimed specifically at MSM in Central America, among whom the authors note that HIV prevalence ranges from 7.5% to 11.1%. About one-third of MSM participants in respondent-driven samples, reported exposure to at least one component of the programme during the two years of implementation. But few, three percent, received all three components, reflecting the hard-to-reach nature of the population as well as programmatic issues. Despite the modest coverage, there was some evidence that the programme was associated with reported risk reduction and HIV testing uptake. The study provides promising results, but highlights the need to tackle stigmatisation and social exclusion of MSM in this region, to enable prevention strategies to be effective at scale.

Latin America
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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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How can HIV resources be best used to avert as many infections as possible?

Using geospatial modelling to optimize the rollout of antiretroviral-based pre-exposure HIV interventions in sub-Saharan Africa.

Gerberry DJ, Wagner BG, Garcia-Lerma JG, Heneine W, Blower S. Nat Commun. 2014 Dec 2;5:5454. doi: 10.1038/ncomms6454.

Antiretroviral (ARV)-based pre-exposure HIV interventions may soon be rolled out in resource-constrained sub-Saharan African countries, but rollout plans have yet to be designed. Here we use geospatial modelling and optimization techniques to compare two rollout plans for ARV-based microbicides in South Africa: a utilitarian plan that minimizes incidence by using geographic targeting, and an egalitarian plan that maximizes geographic equity in access to interventions. We find significant geographic variation in the efficiency of interventions in reducing HIV transmission, and that efficiency increases disproportionately with increasing incidence. The utilitarian plan would result in considerable geographic inequity in access to interventions, but (by exploiting geographic variation in incidence) could prevent ~40% more infections than the egalitarian plan. Our results show that the geographic resource allocation decisions made at the beginning of a rollout, and the location where the rollout is initiated, will be crucial in determining the success of interventions in reducing HIV epidemics.

Abstract access

Editor’s notes: With the flatlining of HIV resources, it is becoming increasingly important to identify how best to maximise the impact of HIV programmes. This study used geospatial HIV modelling and optimisation to compare two potential rollout plans for antiretroviral based microbicides. One was based on egalitarian principles, where every community has an equal chance of accessing microbicides. The other was based on the utilitarian principles, where settings at greatest risk are prioritised. Assuming a fixed amount of resources, the impact of these two different rollout plans was compared. Using data from South Africa, the authors found that the geographic focusing at provincial level could prevent more infections in the first year of the rollout. The findings illustrate how decisions made about where new prevention technologies are first introduced at the start of a programme rollout can strongly influence the scale of their impact. In particular, it highlights that roll out strategies that first focus on the most vulnerable communities could have greatest impact. The modelling approach used in this study is applicable to other settings with geographic heterogeneity in the HIV epidemic, and could be used to inform the implementation and evaluation of other HIV prevention programmes.

HIV modelling
Africa
South Africa
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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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School and family factors interact to influence sexual behaviour in adolescent girls

Multiple sexual partnerships among female adolescents in rural Uganda: the effects of family structure and school attendance.

Pilgrim NA, Ahmed S, Gray RH, Sekasanvu J, Lutalo T, Nalugoda F, Serwadda D, Wawer MJ. Int J Adolesc Med Health. 2014 Nov 21. pii: /j/ijamh.ahead-of-print/ijamh-2014-0032/ijamh-2014-0032.xml. doi: 10.1515/ijamh-2014-0032. [Epub ahead of print]

Background: A better understanding is needed of the contextual factors that influence HIV risk behaviors among female adolescents in sub-Saharan Africa. The objectives of this study were to assess the influence of family structure on lifetime sexual partners and on the number of sexual partners in the last year among female adolescents in rural Rakai, Uganda. In addition, the study assessed whether the influence of family structure on these outcomes differed by the school attendance status of the adolescents.

Methods: The sample consisted of 2337 unmarried adolescent girls, aged 15-19, enrolled in the Rakai Community Cohort Study. The last survey interview within the time period of 2001-2008 available for each girl was used. Analyses were stratified by age (15-17 year olds and 18-19 year olds) and school status. Multinomial logistic and poisson regressions were used.

Results: Living in a household with a biological father was protective against both outcomes. Family structure was not associated with the outcomes among in-school adolescents but it was significantly associated with the outcomes among out-of-school adolescents.

Conclusions: The findings suggest that understanding the familial context in which female adolescents develop, as well as its interaction with school attendance, is important for HIV prevention efforts. Both research and programmatic initiatives must consider the interplay between the family and school domains when considering ways to reduce HIV acquisition among adolescent women.

Abstract access

Editor’s notes: This study addresses the key issue of adolescent sexual behaviour among unmarried girls which itself has significant implications for HIV and other STI risk. Only about 40% of girls in this study lived in a family structure which included a biological father in the household. Living with their own father was protective against having multiple partners. The authors highlight that cultural factors may lead to reverse causality behind this finding – including the fact that girls who got pregnant were made to leave the parental home. However, the biological father’s role in protecting daughters from sexual advances and exploitation is also suggested as an underlying reason. A novel finding of this study was the fact that family structure influenced sexual behaviour of non-school going girls but did not influence school-going girls. It is unclear whether school-attendance was itself protective or whether girls who went to school came from more supportive backgrounds in the first place. The authors emphasise that more research is needed to understand the pathways underlying this finding.

Africa
Uganda
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