Articles tagged as "Eliminate gender inequalities"

Violence experience of women living with HIV: a global study

Violence. Enough already: findings from a global participatory survey among women living with HIV.

Orza L, Bewley S, Chung C, Crone ET, Nagadya H, Vazquez M, Welbourn A. J Int AIDS Soc. 2015 Dec 1;18(6 Suppl 5):20285. doi: 10.7448/IAS.18.6.20285. eCollection 2015.

Introduction: Women living with HIV are vulnerable to gender-based violence (GBV) before and after diagnosis, in multiple settings. This study's aim was to explore how GBV is experienced by women living with HIV, how this affects women's sexual and reproductive health (SRH) and human rights (HR), and the implications for policymakers.

Methods: A community-based, participatory, user-led, mixed-methods study was conducted, with women living with HIV from key affected populations. Simple descriptive frequencies were used for quantitative data. Thematic coding of open qualitative responses was performed and validated with key respondents.

Results: In total, 945 women living with HIV from 94 countries participated in the study. Eighty-nine percent of 480 respondents to an optional section on GBV reported having experienced or feared violence, either before, since and/or because of their HIV diagnosis. GBV reporting was higher after HIV diagnosis (intimate partner, family/neighbours, community and health settings). Women described a complex and iterative relationship between GBV and HIV occurring throughout their lives, including breaches of confidentiality and lack of SRH choice in healthcare settings, forced/coerced treatments, HR abuses, moralistic and judgemental attitudes (including towards women from key populations), and fear of losing child custody. Respondents recommended healthcare practitioners and policymakers address stigma and discrimination, training, awareness-raising, and HR abuses in healthcare settings.

Conclusions: Respondents reported increased GBV with partners and in families, communities and healthcare settings after their HIV diagnosis and across the life-cycle. Measures of GBV must be sought and monitored, particularly within healthcare settings that should be safe. Respondents offered policymakers a comprehensive range of recommendations to achieve their SRH and HR goals. Global guidance documents and policies are more likely to succeed for the end-users if lived experiences are used.

Abstract  Full-text [free] access

Editor’s notes: Violence against women who are living with HIV is common globally. This paper reports on a study of 832 women living with HIV from 94 countries who participated in an online survey, recruited through a non-random snowball sampling model. The survey comprised quantitative and qualitative (free text) components. Participants included women who had ever or were currently using injection drugs (14%), who had ever or were currently selling sex (14%), and who had ever or were currently homeless (14%). Lifetime experience of violence among respondents was high (86%). Perpetrators included: intimate partner (59%), family member / neighbour (45%), community member (53%), health care workers (53%) and police, military, prison or detention services (17%). Findings suggest that violence is not a one off occurrence and cannot easily be packaged as a cause or a consequence of HIV. Instead violence occurs throughout women’s lives, takes multiple forms, and has a complex and iterative relationship with HIV.

The study population did not represent all women living with HIV, and was biased towards women with internet access who have an activist interest. Nonetheless, the study provides further evidence of the breadth and frequency of gender based violence experienced by women living with HIV. Key recommendations for policy makers include training of health care workers working in sexual and reproductive services to offer non-discriminatory services to women living with HIV and to effectively respond to disclosures of gender based violence (such as intimate partner violence) as part of the package of care.

Algeria, Angola, Argentina, Armenia, Australia, Austria, Azerbaijan, Belarus, Belgium, Belize, Bolivarian Republic of Venezuela, Bolivia, Botswana, Burkina Faso, Burundi, Cambodia, Cameroon, Canada, Chile, China, Colombia, Costa Rica, Côte d'Ivoire, Czech Republic, Democratic Republic of the Congo, Denmark, Dominican Republic, Ecuador, El Salvador, Estonia, Ethiopia, France, Gabon, Germany, Ghana, Greece, Guatemala, Honduras, Hungary, India, Indonesia, Ireland, Italy, Jamaica, Kazakhstan, Kenya, Kyrgyzstan, Lesotho, Malawi, Mali, Mexico, Moldova, Morocco, Mozambique, Myanmar, Namibia, Nepal, Netherlands, New Zealand, Nicaragua, Nigeria, Norway, Panama, Paraguay, Peru, Poland, Republic of the Congo, Romania, Russian Federation, Rwanda, Serbia, South Africa, Spain, Sri Lanka, Sudan, Swaziland, Switzerland, Tajikistan, Togo, Transdniestria, Turkey, Uganda, Ukraine, United Kingdom, United Republic of Tanzania, United States of America, Uruguay, Uzbekistan, Viet Nam, Zambia, Zimbabwe
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Client violence against female sex workers in Mexico

Prevalence and correlates of client-perpetrated violence against female sex workers in 13 Mexican cities.

Semple SJ, Stockman JK, Pitpitan EV, Strathdee SA, Chavarin CV, Mendoza DV, Aarons GA, Patterson TL. PLoS One. 2015 Nov 23;10(11):e0143317. doi: 10.1371/journal.pone.0143317. eCollection 2015.

Background: Globally, client-perpetrated violence against female sex workers (FSWs) has been associated with multiple health-related harms, including high-risk sexual behavior and increased exposure to HIV/STIs. This study examined correlates of client-perpetrated sexual, physical, and economic violence (e.g., robbery) against FSWs in 13 cities throughout Mexico.

Methods: FSWs (N = 1089) who were enrolled in a brief, evidence-based, sexual risk reduction intervention for FSWs (Mujer Segura) were interviewed about their work context, including experiences of violence perpetrated by clients, sexual risk and substance use practices, financial need, and social supports. Three broad categories of factors (sociodemographic, work context, behavioral and social characteristics of FSWs) were examined as correlates of sexual, physical, and economic violence.

Results: The prevalence of different types of client-perpetrated violence against FSWs in the past 6 months was: sexual (11.7%), physical (11.8%), economic (16.9%), and any violence (22.6%). Greater financial need, self-identification as a street worker, and lower perceived emotional support were independently associated with all three types of violence. Alcohol use before or during sex with clients in the past month was associated with physical and sexual violence. Using drugs before or during sex with clients, injection drug use in the past month, and population size of city were associated with sexual violence only, and FSWs' alcohol use score (AUDIT-C) was associated with economic violence only.

Conclusions: Correlates of client-perpetrated violence encompassed sociodemographic, work context, and behavioral and social factors, suggesting that approaches to violence prevention for FSWs must be multi-dimensional. Prevention could involve teaching FSWs strategies for risk avoidance in the workplace (e.g., avoiding use of alcohol with clients), enhancement of FSWs' community-based supports, development of interventions that deliver an anti-violence curriculum to clients, and programs to address FSWs' financial need by increasing their economic opportunities outside of the sex trade.

Abstract Full-text [free] access

Editor’s notes: Violence against women who sell sex is receiving increasing attention. Perpetrators include clients, police, strangers, local thugs and husbands or intimate (non-paying) partners. This study from Mexico examined physical, sexual and emotional violence by clients among female sex workers in 13 cities in Mexico. Violence by clients was common (22.6% any violence, past six months) and similar to rates reported in other countries. Violence exposure was associated with greater financial need, street sex work, and lower perceived emotional support. Sexual and physical violence were also associated with alcohol use. Alcohol use, street sex work and debt have been associated with violence exposure among female sex workers in other low and middle income settings. This research supports a growing body of evidence which suggests that violence prevention should be a key element in services designed for and with female sex workers. Successful violence and HIV prevention programming will need to address the broader structural determinants of vulnerability such as poverty, sex work structure (typology), stigma and discrimination, and associated alcohol and drug use.  

Latin America
Mexico
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Justification of PrEP use as protection from rape

Negotiating the use of female-initiated HIV prevention methods in a context of gender-based violence: the narrative of rape.

Hartmann M, Montgomery E, Stadler J, Laborde N, Magazi B, Mathebula F, van der Straten A. Cult Health Sex. 2015 Nov 9:1-14. [Epub ahead of print]

Female-initiated methods of HIV prevention are needed to address barriers to HIV prevention rooted in gender inequalities. Understanding the sociocultural context of pre-exposure prophylaxis (PrEP) trials, including gender-based violence, is thus critical. MTN-003C (VOICE-C), a qualitative sub-study of the larger MTN-003 (VOICE) trial, examined sociocultural barriers and facilitators to PrEP amongst women in Johannesburg. We conducted focus-group discussions, in-depth interviews and ethnographic interviews with 102 trial participants, 22 male partners, 17 community advisory board members and 23 community stakeholders. We analysed how discussions of rape are emblematic of the gendered context in which HIV risk occurs. Rape emerged spontaneously in half of discussions with community advisory board members, two-thirds with stakeholders and among one-fifth of interviews/discussions with trial participants. Rape was used to reframe HIV risk as external to women's or partner's behaviour and to justify the importance of PrEP. Our research illustrates how women, in contexts of high levels of sexual violence, may use existing gender inequalities to negotiate PrEP use. This suggests that future interventions should simultaneously address harmful gender attitudes, as well as equip women with alternative means to negotiate product use, in order to more effectively empower women to protect themselves from HIV.

Abstract access 

Editor’s notes: This paper presents qualitative research which explored the broader context of gender-based violence surrounding PrEP use. The study was an ancillary study alongside the VOICE trial at the South Africa site, which evaluated daily oral and vaginal PrEP. Participants in the ancillary study included women participants, male partners and community stakeholders. The authors found that the issue of rape was spontaneously mentioned by the majority of participants, with the exception of male partners. From these discussions of rape, issues of gender norms emerged, which revealed a continuum from what was called gender exploitative and gender accommodating. The context of gender exploitative was expressed as rape as a reflection of women’s vulnerability. In this context women’s vulnerability to rape and HIV provides a rationale for the use of PrEP. This includes protecting them against sexual violence victimisation. The study highlights that rape provides justification for the use of PrEP but reveals that such justification is complex in that women are seen as both vulnerable to rape but also blamed for rape through unacceptable behaviours including drinking alcohol. The authors conclude that the focus on rape by strangers hides women’s vulnerability to sexual violence from partners and argue that any move to legitimise PrEP for the threat of rape may undermine its use in consensual sex and reinforces negative gender norms about women’s vulnerability to strangers. They suggest that initiatives surrounding PrEP need to recognise and challenge harmful gender norms. This study has highlighted that while PrEP has not been imagined as a gendered HIV prevention tool, in contrast to microbicides, it does in fact emerge as a tool that will be gendered in potentially harmful ways. 

Africa
South Africa
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HIV and sexuality curricula programmes that address gender or power are five times more effective than those that do not

The case for addressing gender and power in sexuality and HIV education: a comprehensive review of evaluation studies.

Haberland NA. Int Perspect Sex Reprod Health. 2015 Mar;41(1):31-42. doi: 10.1363/4103115.

Context: Curriculum-based sexuality and HIV education is a mainstay of interventions to prevent STIs, HIV and unintended pregnancy among young people. Evidence links traditional gender norms, unequal power in sexual relationships and intimate partner violence with negative sexual and reproductive health outcomes. However, little attention has been paid to analyzing whether addressing gender and power in sexuality education curricula is associated with better outcomes.

Methods: To explore whether the inclusion of content on gender and power matters for program efficacy, electronic and hand searches were conducted to identify rigorous sexuality and HIV education evaluations from developed and developing countries published between 1990 and 2012. Intervention and study design characteristics of the included interventions were disaggregated by whether they addressed issues of gender and power.

Results: Of the 22 interventions that met the inclusion criteria, 10 addressed gender or power, and 12 did not. The programs that addressed gender or power were five times as likely to be effective as those that did not; fully 80% of them were associated with a significantly lower rate of STIs or unintended pregnancy. In contrast, among the programs that did not address gender or power, only 17% had such an association.

Conclusions: Addressing gender and power should be considered a key characteristic of effective sexuality and HIV education programs.

Abstract  Full-text [free] access

Editor’s notes: Curriculum-based sexuality and HIV education plays a central role in the prevention of sexually transmitted infections (STI), HIV and unintended pregnancy among young people. This paper synthesizes current evidence from 22 rigorous evaluation studies that assessed the impacts of different curricula based programmes on HIV, STI or pregnancy risk. The nearly opposite outcomes of programmes that address gender and power compared to those that do not, was striking, with programmes that addressed gender or power being five times as likely to be effective as those that did not.

Several common characteristics of effective programmes were identified. In addition to having interactive and learner-centered pedagogical approaches, effective programmes tended to give explicit attention to gender or power in relationships. Effective programmes fostered critical thinking about how gender norms or inequalities in power manifest and operate and influence life, sexual relationships or health. The programmes also support participants to value themselves and recognize their ability to effect change in their life, relationship or community.

The review findings are consistent with broader theory and evidence that links gender, power and intimate partner violence with sexual and reproductive health outcomes, including HIV. The findings illustrate the value of addressing gender in sexual health programming, illustrating that this is not a luxury for programmes, but rather a critical component of successful programming. 

Africa, Northern America
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SHARE trial impacts on intimate partner violence and HIV incidence

Effectiveness of an integrated intimate partner violence and HIV prevention intervention in Rakai, Uganda: analysis of an intervention in an existing cluster randomised cohort.

Wagman JA, Gray RH, Campbell JC, Thoma M, Ndyanabo A, Ssekasanvu J, Nalugoda F, Kagaayi J, Nakigozi G, Serwadda D, Brahmbhatt H. Lancet Glob Health. 2015 Jan;3(1):e23-33. doi: 10.1016/S2214-109X(14)70344-4. Epub 2014 Nov 28.

Background: Intimate partner violence (IPV) is associated with HIV infection. We aimed to assess whether provision of a combination of IPV prevention and HIV services would reduce IPV and HIV incidence in individuals enrolled in the Rakai Community Cohort Study (RCCS), Rakai, Uganda.

Methods: We used pre-existing clusters of communities randomised as part of a previous family planning trial in this cohort. Four intervention group clusters from the previous trial were provided standard of care HIV services plus a community-level mobilisation intervention to change attitudes, social norms, and behaviours related to IPV, and a screening and brief intervention to promote safe HIV disclosure and risk reduction in women seeking HIV counselling and testing services (the Safe Homes and Respect for Everyone [SHARE] Project). Seven control group clusters (including two intervention groups from the original trial) received only standard of care HIV services. Investigators for the RCCS did a baseline survey between February, 2005, and June, 2006, and two follow-up surveys between August, 2006, and April, 2008, and June, 2008, and December, 2009. Our primary endpoints were self-reported experience and perpetration of past year IPV (emotional, physical, and sexual) and laboratory-based diagnosis of HIV incidence in the study population. We used Poisson multivariable regression to estimate adjusted prevalence risk ratios (aPRR) of IPV, and adjusted incidence rate ratios (aIRR) of HIV acquisition. This study was registered with ClinicalTrials.gov, number NCT02050763.

Findings: Between Feb 15, 2005, and June 30, 2006, we enrolled 11 448 individuals aged 15-49 years. 5337 individuals (in four intervention clusters) were allocated into the SHARE plus HIV services group and 6111 individuals (in seven control clusters) were allocated into the HIV services only group. Compared with control groups, individuals in the SHARE intervention groups had fewer self-reports of past-year physical IPV (346 [16%] of 2127 responders in control groups vs 217 [12%] of 1812 responders in intervention groups; aPRR 0.79, 95% CI 0.67-0.92) and sexual IPV (261 [13%] of 2038 vs 167 [10%] of 1737; 0.80, 0.67-0.97). Incidence of emotional IPV did not differ (409 [20%] of 2039 vs 311 [18%] of 1737; 0.91, 0.79-1.04). SHARE had no effect on male-reported IPV perpetration. At follow-up 2 (after about 35 months) the intervention was associated with a reduction in HIV incidence (1.15 cases per 100 person-years in control vs 0.87 cases per 100 person-years in intervention group; aIRR 0.67, 95% CI 0.46-0.97, p=0.0362).

Interpretation: SHARE could reduce some forms of IPV towards women and overall HIV incidence, possibly through a reduction in forced sex and increased disclosure of HIV results. Findings from this study should inform future work toward HIV prevention, treatment, and care, and SHARE's ecological approach could be adopted, at least partly, as a standard of care for other HIV programmes in sub-Saharan Africa.

Abstract  Full-text [free] access

Editor’s notes: There are a very limited number of programme trials that have illustrated impacts on HIV incidence. This trial adds to the evidence base. The Safe Homes and Respect for Everyone (SHARE) project, incorporates both community programming elements, to shift social norms on gender inequality and violence, along with a clinic based screening and brief activity, to promote safe HIV disclosure and risk reduction. This study showed that the SHARE project had an impact on women's experience of violence and HIV incidence. The findings suggest that, when compared with the provision of standard HIV treatment alone, SHARE plus HIV treatment had a significant impact on HIV incidence and women’s experiences of physical and sexual partner violence. The findings complement previous trials, that illustrate that intimate partner violence can be prevented, and strengthen the case for the need to invest in programmes to address gender inequality and violence as part of the HIV response. Further research is needed to better understand the pathways through which HIV incidence may have been reduced, especially given that the study did not document impacts on reported numbers of sexual partners or condom use.

Africa
Uganda
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Addressing gender inequality through a community mobilisation programme

The impact of SASA!, a community mobilization intervention, on reported HIV-related risk behaviours and relationship dynamics in Kampala, Uganda.

Kyegombe N, Abramsky T, Devries KM, Starmann E, Michau L, Nakuti J, Musuya T, Heise L, Watts C. J Int AIDS Soc. 2014 Nov 5;17(1):19232. doi: 10.7448/IAS.17.1.19232. eCollection 2014.

Introduction: Intimate partner violence (IPV) violates women's human rights, and it is a serious public health concern associated with increased HIV risk. SASA!, a phased community mobilization intervention, engages communities to prevent IPV and promote gender equity. The SASA! study assessed the community-level impact of SASA! on reported HIV-related risk behaviours and relationship dynamics.

Methods: Data were collected as part of a cluster randomized controlled trial conducted between 2007 and 2012 in eight communities in Kampala. An adjusted cluster-level intention to treat analysis, compares secondary outcomes in intervention and control communities at follow-up. The qualitative evaluation explored participants' subjective experience of SASA!. A total of 82 in-depth interviews were audio recorded at follow-up, transcribed verbatim and analyzed using thematic analysis.

Results: Men in intervention communities were significantly more likely than controls to report a broad range of HIV-protective behaviours, including higher levels of condom use (aRR 2.03, 95% CI 1.22-3.39), HIV testing (aRR 1.50, 95% CI 1.13-2.00) and fewer concurrent partners (aRR 0.60, 95% CI 0.37-0.97). They were also more likely to report increased joint decision-making (aRR 1.92, 95% CI 1.27-2.91), greater male participation in household tasks (aRR 1.48, 95% CI 1.09-2.01), more open communication and greater appreciation of their partner's work inside (aRR 1.31, 95% CI 1.04-1.66) and outside (aRR 1.49, 95% CI 1.08-2.06) the home. For women, all outcomes were in the hypothesized direction, but effect sizes were smaller. Only some achieved statistical significance. Women in intervention communities were significantly more likely to report being able to refuse sex with their partners (aRR 1.16, 95% CI 1.00-1.35), joint decision-making (aRR 1.37, 95% CI 1.06-1.78) and more open communication on a number of indicators. Qualitative interviews suggest that shifts operated through broader improvements in relationships, including increased trust and cooperation, participants' greater awareness of the connections between HIV and IPV and their resultant desire to improve their relationships. Barriers to change include partial uptake of SASA!, partner resistance, fear and entrenched previous beliefs.

Conclusions: SASA! impacted positively on reported HIV-related risk behaviours and relationship dynamics at a community level, especially among men. Social change programmes focusing on IPV and gender equity could play an important role in HIV prevention efforts.

Abstract Full-text [free] access

Editor’s notes: This cluster randomised trial adds to the increasing evidence that participatory, gender transformative violence prevention programmes can impact intimate partner violence and HIV-related risk behaviour. The trial evaluated the impact of SASA !, a phased community mobilisation programme that seeks to prevent intimate partner violence and to reduce HIV-related behaviours at the community level. Results illustrated that SASA! was associated with lower, past year experience of physical and sexual intimate partner violence among women and lower levels of sexual concurrency among men. In this paper, the authors report the secondary outcomes of the trial relating to HIV-related risk behaviours and several indicators of relationship dynamics. They also report findings from the qualitative evaluation which suggest that SASA! has the potential to improve relationship dynamics and to reduce HIV-related risk behaviours within intimate partnerships. The impact was greater in men, which may reflect respondent bias. However, given its context, in which patriarchy is dominant, the results of this study are encouraging. SASA! may make men more cognisant of what they should or could be doing to foster more equitable relationships. Changes in male behaviour have the potential to improve relationship dynamics and reduce HIV-related risk behaviours.

Africa
Uganda
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High levels of suicide ideation among women living with HIV, with a history of gender violence

Women with HIV: gender violence and suicidal ideation

Ceccon RF, Meneghel SN, Hirakata VN. Rev Saude Publica. 2014 Oct;48(5):758-65.

Objective: To analyze the relationship between gender violence and suicidal ideation in women with HIV.

Methods: A cross-sectional study with 161 users of specialized HIV/AIDS care services. The study investigated the presence of gender violence through the Brazilian version of the World Health Organization Violence against Women instrument, and suicidal ideation through the Suicidal Ideation Questionnaire. Statistical analyses were performed with the SPSS software, using the Chi-square test and Poisson multiple regression model.

Results: Eighty-two women with HIV reported suicidal ideation (50.0%), 78 (95.0%) of whom had suffered gender violence. Age at first sexual intercourse < 15 years old, high number of children, poverty, living with HIV for long, and presence of violence were statistically associated with suicidal ideation. Women who suffered gender violence showed 5.7 times more risk of manifesting suicidal ideation.

Conclusions: Women with HIV showed a high prevalence to gender violence and suicidal ideation. Understanding the relationship between these two grievances may contribute to the comprehensive care of these women and implementation of actions to prevent violence and suicide.

Abstract Full-text [free] access

Editor’s notes: The HIV epidemic in Brazil is becoming increasingly feminized. The male to female ratio of HIV infections has decreased from 26 to 1.5 men for every woman, over the past 10 years. Within the HIV field, there has been growing recognition of the mental health impacts of HIV infection, and the importance of considering how best to address this issue, as part of service provision. Similarly, there has been growing recognition within the violence field, that experiences of violence from a partner has both short and long term mental health impacts. Women who have violent partners may be at greater risk of contracting HIV, and be at risk of violence following disclosure. This paper illustrates the ways in which these issues cluster. The study finds that women living with HIV who had a history of violence are far more likely to report being HIV positive. The findings illustrate the need for HIV services to be able to both support women with mental health support needs, and support women who have a history of violence. The findings suggests that HIV counsellors need to be able to discuss issues of depression, suicidal ideation and violence, and potentially facilitate referral to specialized services in each area.

Latin America
Brazil
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Engaging with men about microbicides

Engaging male partners in women's microbicide use: evidence from clinical trials and implications for future research and microbicide introduction.

Lanham M, Wilcher R, Montgomery ET, Pool R, Schuler S, Lenzi R, Friedland B. J Int AIDS Soc. 2014 Sep 8;17(3 Suppl 2):19159. doi: 10.7448/IAS.17.3.19159. eCollection 2014.

Introduction: Constructively engaging male partners in women-centred health programs such as family planning and prevention of mother-to-child HIV transmission has resulted in both improved health outcomes and stronger relationships. Concerted efforts to engage men in microbicide use could make it easier for women to access and use microbicides in the future. This paper synthesizes findings from studies that investigated men's role in their partners' microbicide use during clinical trials to inform recommendations for male engagement in women's microbicide use.

Methods: We conducted primary and secondary analyses of data from six qualitative studies implemented in conjunction with microbicide clinical trials in South Africa, Kenya, and Tanzania. The analyses included data from 535 interviews and 107 focus groups with trial participants, male partners, and community members to answer research questions on partner communication about microbicides, men's role in women's microbicide use, and potential strategies for engaging men in future microbicide introduction. We synthesized the findings across the studies and developed recommendations.

Results: The majority of women in steady partnerships wanted agreement from their partners to use microbicides. Women used various strategies to obtain their agreement, including using the product for a while before telling their partners, giving men information gradually, and continuing to bring up microbicides until resistant partners acquiesced. Among men who were aware their partners were participating in a trial and using microbicides, involvement ranged from opposition to agreement/non-interference to active support. Both men and women expressed a desire for men to have access to information about microbicides and to be able to talk with a healthcare provider about microbicides.

Conclusions: We recommend counselling women on whether and how to involve their partners including strategies for gaining partner approval; providing couples' counselling on microbicides so men have the opportunity to talk with providers; and targeting men with community education and mass media to increase their awareness and acceptance of microbicides. These strategies should be tested in microbicide trials, open-label studies, and demonstration projects to identify effective male engagement approaches to include in eventual microbicide introduction. Efforts to engage men must take care not to diminish women's agency to decide whether to use the product and inform their partners.

Abstract  Full-text [free] access

Editor’s notes: Microbicides were initially conceived as being products that would enable women to protect themselves from HIV without prior negotiation with their partners. However, the experience from microbicide trials shows that in general, male partners play an important role in women’s microbicide use. This paper synthesizes the findings from qualitative research conducted as part of trials in east and southern Africa. The findings highlight that men’s responses to products vary widely, and that women use a range of strategies to obtain men’s agreement. The findings show that no one strategy will fit all women’s needs; and that the priority should be to support women’s agency to decide whether to use microbicides, how to introduce the subject with their partners, and ultimately gain their support. Currently different strategies of male engagement are being used within trials. But the positive and negative effects of different approaches – including their effect on partner communication, relationship quality and intimate partner violence - are not being routinely measured. The paper shows the need for further research in microbicide trials, open-label studies, and demonstration projects, not only on how to support women’s ability to access and use products, but to also to help ensure consistent product use, which is crucial to the overall effectiveness of products.

Africa
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Violence against men – by women

Male victims of sexual violence in rural Malawi: the overlooked association with HIV infection.

Conroy AA, Chilungo A. AIDS Care. 2014 Jul 3:1-5. [Epub ahead of print]

In sub-Saharan Africa, research on intimate partner violence (IPV) has largely failed to consider men's experiences as victims by female perpetrators - particularly within ongoing heterosexual relationships such as marriage. The objectives of this study were to document the prevalence of sexual coercion among men, to describe the characteristics of male victims, and to test for an association between sexual coercion and HIV positivity. In 2010, cross-sectional data on HIV risk behaviors, HIV status, and IPV were collected from a sample of 684 mostly married men in rural Malawi. Bivariate analyses were used to examine differences in HIV risk characteristics between victims and nonvictims of sexual coercion. Multivariate logistic regression was used to determine the association between sexual coercion and HIV positivity. Over one-tenth (10.4%) of men reported being a victim of sexual coercion. Male victims of sexual coercion were more likely to be married (p < 0.05), older than 24 years (p < 0.05), physically abused by a female partner (p < 0.001), believed their partners were at higher risk for HIV (p < 0.05), and had consumed alcohol in the past month (p < 0.01). After controlling for potential confounders, the odds of being HIV positive were 7.2 times higher among men who had experienced sexual coercion (p < 0.000). In sub-Saharan Africa, research on men's experience of violence as victims is long overdue. More formative research is needed to understand the mechanisms through which men experience violence and how to appropriately measure IPV among male victims. While the data are cross-sectional and cannot evaluate causality, the strength of the association with HIV positivity merits further attention.

Abstract access

Editor’s notes: Research on intimate partner violence (IPV), in which a man is the victim, is rare in sub-Saharan Africa.  This paper, based on data collected over the course of a longitudinal study on reproduction and AIDS in Malawi, is therefore a welcome addition to the literature on IPV.  While the findings show associations between sexual coercion and alcohol use, age and HIV-status, there is much that is not known.  Might the woman also have been subject to IPV? Was she intoxicated at the time of the violence or coercion? Is IPV against a man habitual in some relationships? This is an uncomfortable topic to investigate in settings where the man is expected to be `in charge’, but given the associated risk factors, more needs to be known.  The call by the authors for more research should be heeded.

Africa
Malawi
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Widow cleansing and inheritance practices amongst the Luo limit women’s options to use current HIV prevention methods

 

Widow cleansing and inheritance among the Luo in Kenya: the need for additional women-centred HIV prevention options.  

Perry B, Oluoch L, Agot K, Taylor J, Onyango J, Ouma L, Otieno C, Wong C, Corneli A J Int AIDS Soc. 2014; 17(1): 19010. Epub Jun 26, 2014.  doi:  10.7448/IAS.17.1.19010

Introduction: The customs of widow cleansing and widow inheritance are practiced in several communities throughout sub-Saharan Africa. In the Nyanza Province of Kenya, according to tradition, Luo widows are expected to engage in sexual intercourse with a "cleanser," without the use of a condom, in order to remove the impurity ascribed to her after her husband's death. Luo couples, including widows, are also expected to engage in sex preceding specific agricultural activities, building homes, funerals, weddings, and other significant cultural and social events. Widows who are inherited for the purpose of fulfilling cultural obligation have a higher prevalence of HIV than those who remain un-inherited or are inherited for the purpose of companionship.

Methods: As part of a larger descriptive qualitative study to inform study procedures for FEM-PrEP, an HIV prevention pre-exposure prophylaxis clinical trial, we conducted 15 semi-structured interviews (SSIs) with widows, 15 SSIs with inheritors, and four focus group discussions with widows in the Bondo and Rarieda districts in Nyanza Province to explore the HIV risk context within widow cleansing and inheritance practices. Thematic qualitative analysis was used to analyze the data.

Results: The majority of widows reported in the demographic questionnaire being inherited, and most widows in the SSIs described participating in the cleansing ritual. We identified two main themes related to HIV prevention within the context of widow cleansing and inheritance: 1) widows must balance limiting their risk for HIV infection with meeting cultural expectations and ensuring that their livelihood needs are met, and 2) sexual abstinence undermines cultural expectations in widowhood while the use of condoms is deemed inappropriate in fulfilling culturally prescribed sexual rituals, and is often beyond the widow's ability to negotiate.

Conclusions: Women-controlled HIV prevention methods such as antiretroviral-based oral pre-exposure prophylaxis, vaginal gels, and vaginal rings are needed for HIV-negative widows who engage in sexual rituals related to widowhood.

Abstract  Full-text [free] access  

Editor’s notes: This paper provides an in-depth insight into the practice of widow cleansing and its implications for widows’ vulnerability to contracting HIV. The paper describes the practice of widow cleansing by the Luo in Kenya. This entails the requirement for widows to have sexual intercourse with a non-relative of her deceased husband to “cleanse” the impurity she has acquired from the death of her husband. Following this practice widows are “inherited”, traditionally by an in-law but more recently by a professional inheritor who inherits widows for money. Relationships with professional inheritors commonly entail sexual intercourse and financial and emotional support for the widow. These relationships can be ended if not fulfilled to expectation. Alongside this, there are other expectations for widows to perform sexual intercourse with other men as part of ceremonies.

To understand the sexual risk-taking behaviours of Luo widows and inheritors, in-depth interviews and focus groups were conducted with widows and inheritors. This was part of a larger qualitative study during the FEM-PrEP trial. The findings revealed that widows were aware of their risk of HIV infection through cleansing and inheritance practices, which often entailed sexual intercourse without a condom. However, women’s concerns about this were outweighed by the need to fulfil cultural expectations to avoid being ostracised, and importantly to receive financial support. Whilst some women were able to use condoms with inheritors, this only occurred in new relationships or during menstruation or pregnancy. Widows and inheritors reported that condoms were rarely used during “cleansing” practices as the mixing of semen and vaginal fluids is essential to remove impurities.

Whilst this study reveals similar constraints on condom use for women in long-term relationships it highlights the additional complexity for Luo widows in relation to cleansing and inheritance practices. These practices legitimise multiple concurrent relationships and sex without a condom. Importantly, as a strongly embedded practice this gives widows limited options to use condoms or abstinence to prevent HIV infection. The authors suggest that Luo widows would benefit from access to biomedical HIV prevention methods, including PrEP and microbicides.

Africa
Kenya
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