Articles tagged as "Eliminate gender inequalities"

Female sex workers exposed to community mobilization less exposed to sexually transmitted infections

Community mobilization and empowerment of female sex workers in Karnataka state, south India: associations with HIV and sexually transmitted infection risk. 

Beattie TS, Mohan HL, Bhattacharjee P, Chandrashekar S, Isac S, Wheeler T, Prakash R, Ramesh BM, Blanchard JF, Heise L, Vickerman P, Moses S, Watts C. Am J Public Health. 2014 Jun 12:e1-e10. doi:10.2105/AJPH.2014.301911 [Epub ahead of print]

Objectives: We examined the impact of community mobilization (CM) on the empowerment, risk behaviors, and prevalence of HIV and sexually transmitted infection in female sex workers (FSWs) in Karnataka, India.

Methods: We conducted behavioral-biological surveys in 2008 and 2011 in 4 districts of Karnataka, India. We defined exposure to CM as low, medium (attended nongovernmental organization meeting or drop-in centre), or high (member of collective or peer group). We used regression analyses to explore whether exposure to CM was associated with the preceding outcomes. Pathway analyses explored the degree to which effects could be attributable to CM.

Results: By the final survey, FSWs with high CM exposure were more likely to have been tested for HIV (adjusted odd ratio [AOR] = 25.13; 95% confidence interval [CI] = 13.07, 48.34) and to have used a condom at last sex with occasional clients (AOR = 4.74; 95% CI = 2.17, 10.37), repeat clients (AOR = 4.29; 95% CI = 2.24, 8.20), and regular partners (AOR = 2.80; 95% CI = 1.43, 5.45) than FSWs with low CM exposure. They were also less likely to be infected with gonorrhea or chlamydia (AOR = 0.53; 95% CI = 0.31, 0.87). Pathway analyses suggested CM acted above and beyond peer education; reduction in gonorrhea or chlamydia was attributable to CM.

Conclusions: CM is a central part of HIV prevention programming among FSWs, empowering them to better negotiate condom use and access services, as well as address other concerns in their lives.

Abstract access 

Editor’s notes: Community mobilization is a group empowerment strategy that focuses on the structural drivers of HIV transmission. Starting in 2003, the Karnataka Health Promotion Trust in India collaborated with female sex workers to recruit peer educators. This led to the creation of drop-in centres, distribution of presumptive treatment of gonorrhoea and chlamydia infection, and ultimately the formation of locally-sustained collectives and community-based organisations. In 2011, half of female sex workers in Karnataka were members of one of these groups. Members of these groups were more likely to have used condoms with their sex partners and were less likely to contract either gonorrhoea or chlamydia. The findings suggest that community mobilization may work because it is strongly associated with both collective (power with) and individual (power to) empowerment of sex workers. This is one of the first studies of community engagement to include biological outcomes for HIV and sexually transmitted infection, rather than self-reported measures of behaviour that may be susceptible to bias. The results suggest that such community empowerment approaches may form an integral part of HIV prevention programming in sex worker communities. 

Asia
India
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Does land ownership by women reduce HIV risk?

Women's land ownership and risk of HIV infection in Kenya

Muchomba FM, Wang JS, Agosta LM. Soc Sci Med. 2014 Aug;114:97-102. doi: 10.1016/j.socscimed.2014.05.055. Epub 2014 Jun 2.

Theory predicts that land ownership empowers women to avoid HIV acquisition by reducing their reliance on risky survival sex and enhancing their ability to negotiate safer sex. However, this prediction has not been tested empirically. Using a sample of 5 511 women working in the agricultural sector from the 1998, 2003 and 2008-09 Kenya Demographic and Health Surveys, we examined the relationship between women's land ownership and participation in transactional sex, multiple sexual partnerships and unprotected sex, and HIV infection status. We controlled for demographic characteristics and household wealth, using negative binomial and logistic regression models. Women's land ownership was associated with fewer sexual partners in the past year (incidence rate ratio, 0.98; 95% confidence interval [CI], 0.95-1.00) and lower likelihood of engaging in transactional sex (odds ratio [OR], 0.67; 95% CI: 0.46-0.99), indicators of reduced survival sex, but was not associated with unprotected sex with casual partners (OR, 0.64; 95% CI, 0.35-1.18) or with unprotected sex with any partner among women with high self-perceived HIV risk (OR, 1.02; 95% CI, 0.57-1.84), indicating no difference in safer sex negotiation. Land ownership was also associated with reduced HIV infection among women most likely to engage in survival sex, i.e., women not under the household headship of a husband (OR, 0.40; 95% CI, 0.18-0.89), but not among women living in husband-headed households, for whom increased negotiation for safer sex would be more relevant (OR, 1.74; 95% CI, 0.92-3.29). These findings suggest that reinforcing women's land rights may reduce reliance on survival sex and serve as a viable structural approach to HIV prevention, particularly for women not in a husband's household, including unmarried women and female household heads.

Abstract access 

Editor’s notes: A range of social and economic factors influence the degree to which individuals and communities are vulnerable to HIV infection. In some settings, a lack of land ownership has been shown to increase women’s risk of partner violence. This paper assessed whether women who own land have lower HIV risk. For single women or women in female-headed households, land ownership was associated with a reduced risk of HIV infection. Interestingly, lower HIV risk didn’t appear to be associated with an increased ability to negotiate safer sex practices, but rather arise from women's reduced economic reliance on high-risk sexual partnerships. The findings also suggest that women's own access to land had a greater influence on their HIV risk than household-level wealth, suggesting that household level wealth is not the same as wealth owned by women. Although the analysis is of cross-sectional data, and so causality cannot be established, the findings suggest that increasing women’s ownership of land may provide a structural mechanism to reduce women’s HIV vulnerability. This contributes to the increasing body of evidence that points to the potentially important role that economic empowerment programmes may play in helping to reduce women’s vulnerability to HIV.

Africa
Kenya
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Intimate partner violence common among microbicide trial participants

Hidden harms: women's narratives of intimate partner violence in a microbicide trial, South Africa.

Stadler J, Delany-Moretlwe S, Palanee T, Rees H. Soc Sci Med. 2014 Jun;110:49-55. doi: 10.1016/j.socscimed.2014.03.021. Epub 2014 Mar 22.

In a context of high rates of intimate partner violence (IPV), trials of female-controlled technologies for HIV prevention such as microbicides may increase the possibility of social harms. Seeking to explore the relationship between IPV and microbicide use further, this paper documents women’s narratives of participating in the Microbicide Development Program (MDP) trial in Johannesburg, South Africa, and experiences of partner violence and conflict. A social science sub-study, nested within the trial, was conducted between September 2005 and August 2009, and 401 serial in-depth-interviews were undertaken with 150 women. Using coded interview transcripts, we describe the distribution of IPV and the possible association thereof with microbicide gel use and trial participation. More than a third of these 150 women reported IPV, of which half the cases were related to involvement in the trial. In their narratives, those women reporting IPV cast their partners as authoritarian, controlling and suspicious and reported verbal abuse, abandonment, and in some cases, beatings. Shared experiences of everyday violence shaped women’s feelings of unease about revealing their participation in the trial to intimate partners and attempted concealment further contributed to strains and conflict within relationships. Our findings point to the role of social scientific enquiry in identifying the less obvious, hidden negative impacts of participation in a clinical trial therefore exposing limitations in the biomedical construction of ‘social harms’, as well as the implications thereof for potential future use outside the clinical trial setting.

Abstract access 

Editor’s notes: Violence within intimate partnerships is common globally. Longitudinal research from South Africa and Uganda has shown that women in violent relationships are at increased risk of acquiring HIV infection. This study presents qualitative data, collected as part of a nested study of 150 women in Orange Farm, South Africa who participated in the Microbicide Development Programme (MDP) trial. Although experiences of violence were not framed as a social harm in the trial, or actively explored in the research, violence did emerge as an important issue. More than a third of respondents were living with men who were physically or psychologically violent and/or controlling. The violent events resulting from trial participation were primarily psychological, along with some incidents of physical violence.

Women described using a range of strategies to try to minimise the risk of violence that could result from being part of the trial. Some women were very adept at negotiating gel use with a controlling, violent or potentially violent partner.  The pervasiveness of violence and its links with HIV vulnerability illustrates the challenges of reducing women's risk of HIV acquisition. The findings suggests that female initiated technologies, such as microbicides, are urgently needed, but that broader programmes, to address violence within relationships, will also be important. The findings also raise issues of how to conceptualise and respond to such forms of social harms within clinical trials. The findings suggest that trialists need to be better equipped to deal with IPV, for example by providing counselling and social and legal referral, as well as possibly supporting the sharing of successful strategies between women. It also highlights the potential synergies that could be obtained by more effectively bringing together biomedical developments, such as microbicides, along with broader development initiatives, that seek to prevent violence within relationships. 

Africa
South Africa
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Valuing respect – ‘real men’ in urban South Africa

'Men value their dignity': securing respect and identity construction in urban informal settlements in South Africa.

Gibbs A, Sikweyiya Y, Jewkes R. Glob Health Action. 2014 Apr 8;7:23676. doi: 10.3402/gha.v7.23676. eCollection 2014.

Background: Urban informal settlements remain sites of high HIV incidence and prevalence, as well as violence. Increasing attention is paid on how configurations of young men's masculinities shape these practices through exploring how men build respect and identity. In this paper, we explore how young Black South Africans in two urban informal settlements construct respect and a masculine identity.

Methods: Data are drawn from three focus groups and 19 in-depth interviews.

Results: We suggest that while young men aspire to a 'traditional' masculinity, prioritising economic power and control over the household, we suggest that a youth masculinity emerges which, in lieu of alternative ways to display power, prioritises violence and control over men's sexual partners, men seeking multiple sexual partners and men's violence to other men. This functions as a way of demonstrating masculinity and their position within a public gender order.

Discussion: We suggest there are three implications of the findings for working with men on violence and HIV-risk reduction. First, there exist a number of contradictions in men's discourses about masculinity that may provide spaces and opportunities for change. Second, it is important to work on multiple issues at once given the way violence, alcohol use, and sexual risk are interlinked in youth masculinity. Finally, engaging with men's exclusion from the capitalist system may provide an important way to reduce violence.

 Abstract  Full-text [free] access 

Editor’s notes: This paper illustrates the impact of unemployment and deprivation on young men in South Africa.  The authors show how the structural factors of economic, political and social exclusion shape the experience of young men in urban KwaZulu Natal.  Young men use their power over women, and violence with other men, to prove they are ‘real men’.  Meanwhile, they aspire to be respected as successful partners and fathers. Many young men aspired to be in loving, long-term relationships. These findings show the complexity of the construction of masculinity.  While there are structural factors that shape violent behaviour these findings suggest that there may be opportunities to support more gender equitable masculinities. 

Africa
South Africa
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Physical as well as sexual partner violence is associated with increased HIV risk

Intimate partner violence and HIV infection among women: a systematic review and meta-analysis

Li Y, Marshall CM, Rees HC, Nunez A, Ezeanolue EE, Ehiri JE. 4 J Int AIDS Soc. 2014 Feb 13;17:18845. doi: 10.7448/IAS.17.1.18845. eCollection 2014.

Introduction: To assess evidence of an association between intimate partner violence (IPV) and HIV infection among women.

Methods: Medline/PubMed, Embase, Web of Science, EBSCO, Ovid, Cochrane HIV/AIDS Group's Specialized Register and Cochrane Central Register of Controlled Trials were searched up to 20 May 2013 to identify studies that examined the association between IPV and HIV infection in women. We included studies on women aged ≥15 years, in any form of sexually intimate relationship with a male partner.

Results: Twenty-eight studies [(19 cross-sectional, 5 cohorts and 4 case-control studies) involving 331 468 individuals in 16 countries - the US (eight studies), South Africa (four studies), East Africa (10 studies), India (three studies), Brazil (one study) and multiple low-income countries (two studies)] were included. Results were pooled using RevMan 5.0. To moderate effect estimates, we analyzed all data using the random effects model, irrespective of heterogeneity level. Pooled results of cohort studies indicated that physical IPV [pooled RR (95% CI): 1.22 (1.01, 1.46)] and any type of IPV [pooled RR (95% CI): 1.28 (1.00, 1.64)] were significantly associated with HIV infection among women. Results of cross-sectional studies demonstrated significant associations of physical IPV with HIV infection among women [pooled OR (95% CI): 1.44 (1.10, 1.87)]. Similarly, results of cross-sectional studies indicated that combination of physical and sexual IPV [pooled OR (95% CI): 2.00 (1.24, 3.22) and any type of IPV [pooled OR (95% CI): 1.41 (1.16, 1.73)] were significantly associated with HIV infection among women.

Conclusions: Available evidence suggests a moderate statistically significant association between IPV and HIV infection among women. To further elucidate the strength of the association between IPV and HIV infection among women, there is a need for high-quality follow-up studies conducted in different geographical regions of the world, and among individuals of diverse racial/cultural backgrounds and varying levels of HIV risks.

Abstract Full-text [free] access

Editor’s notes: Globally, an estimated 30% of partnered women will experience physical and/or sexual violence. As well as being a violation of human rights, there is growing evidence about the different ways in which violence and the fear of violence may limit women’s ability to prevent themselves from acquiring infection, or access services. This paper presents a systematic review and meta-analysis of current evidence on whether exposures to violence by an intimate partner increase women’s HIV risk. Commonly, debates on this issue focus on forced sex. The findings suggest that the issue is more complex – with exposures to physical violence also being associated with increased HIV risk. Exposures to both physical and sexual violence by partners, which is an indicator of more severe partner violence, found stronger effect estimates. The pathways underlying the documented associations may be multiple: as well as forced sex, women may have difficulties negotiating condom use or accessing services. Other studies have suggested that there may also be other characteristics of the relationship.  These are that men who are violent are also more likely to have other risk behaviours such as problematic alcohol use or multiple sexual partners. These result in them being more likely to be HIV positive than non-violent men. The findings suggest that violence prevention activities may reduce HIV risk. They also highlight the need to ensure that HIV services are sensitive to, and able to support, women who have experienced or fear violence.

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HIV positive women transitioning from jail experience greater comorbidity and worse HIV treatment outcomes than men

Gender disparities in HIV treatment outcomes following release from jail: results from a multicenter study.

Meyer JP, Zelenev A, Wickersham JA, Williams CT, Teixeira PA, Altice FL. Am J Public Health 2014 Mar;104(3):434-41. doi: 10.2105/AJPH.2013.301553. Epub 2014 Jan 16.

Objectives: We assessed gender differences in longitudinal HIV treatment outcomes among HIV-infected jail detainees transitioning to the community.

Methods. Data were from the largest multisite prospective cohort study of HIV-infected released jail detainees (n = 1 270) the Enhancing Linkages to HIV Primary Care and Services in Jail Setting Initiative, January 2008 and March 2011, which had 10 sites in 9 states. We assessed baseline and 6-month HIV treatment outcomes, stratifying by gender.

Results: Of 867 evaluable participants, 277 (31.9%) were women. Compared with men, women were more likely to be younger, non-Hispanic White, married, homeless, and depressed, but were similar in recent alcohol and heroin use. By 6 months postrelease, women were significantly less likely than men to experience optimal HIV treatment outcomes, including (1) retention in care (50% vs 63%), (2) antiretroviral therapy prescription (39% vs 58%) or optimal antiretroviral therapy adherence (28% vs 44%), and (3) viral suppression (18% vs 30%). In multiple logistic regression models, women were half as likely as men to achieve viral suppression.

Conclusions: HIV-infected women transitioning from jail experience greater comorbidity and worse HIV treatment outcomes than men. Future interventions that transition people from jail to community-based HIV clinical care should be gender-specific.

Abstract  Full-text [free] access

Editor’s notes: In the United States of America, the HIV epidemic is highly concentrated among populations who interact with the criminal justice system. Similarly, attrition from HIV care is markedly higher among people living with HIV who interact with the criminal justice system. This attrition is for complex reasons, with this population being disproportionately comprised of those with socio-economic instability, psychiatric disorders, and substance use disorders. This study assessed whether there are gender differences in the longitudinal HIV treatment outcomes among HIV-positive jail detainees transitioning to the community. The study found that among 867 people living with HIV released from jail, women were less likely than men to engage in every point along an HIV treatment cascade. It was also found that women were half as likely as men to achieve viral load suppression (VLS) at six months, even after controlling for substance use, psychiatric disorders, and utilization of linkage support services. The findings are in contrast to evidence from community settings, where if anything, women tend to fare better than men in engagement along the HIV treatment cascade. The authors highlight the need for a more gender sensitive service provision that recognizes the increased prevalence of comorbid conditions, including depression, substance use, housing instability and homelessness among women.

Northern America
United States of America
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Intervention efforts needed to improve mental health status of young female sex workers in China

Age group differences in HIV risk and mental health problems among female sex workers in Southwest China.

Su S, Li X, Zhang L, Lin D, Zhang C, Zhou Y. AIDS Care 2014 Jan 13. [Epub ahead of print]

HIV risk and mental health problems are prevalent among female sex workers (FSWs) in China. The purpose of this research was to study age group differences in HIV risk and mental health problems in this population. In the current study, we divided a sample of 1 022 FSWs into three age groups (≤ 20 years, 21-34 years, and ≥ 35 years). Results showed that among the three groups (1) older FSWs (≥ 35 years) were likely to be socioeconomically disadvantaged (e.g., rural residency, little education, employment in low-paying venues, and low monthly income); (2) older FSWs reported the highest rates of inconsistent, ineffective condom use, and sexually transmitted diseases history; (3) younger FSWs (≤ 20 years) reported the highest level of depression, suicidal thoughts and suicide attempts, regular-partner violence, and substance use; (4) all health-related risks except casual-partner violence were more prevalent among older and younger FSWs than among FSWs aged 21-34 years; and (5) age had a significant effect on all health indicators except suicide attempts after controlling for several key demographic factors. These findings indicate the need for intervention efforts to address varying needs among FSWs in different age groups. Specific interventional efforts are needed to reduce older FSWs' exposure to HIV risk; meanwhile, more attention should be given to improve FSWs' mental health status, especially among younger FSWs.

Abstract access 

Editor’s notes: Previous research has shown that there are significant HIV risks persisting in the female sex worker (FSW) populations in China, including very low condom use, low HIV testing rates, and high rates of sexually transmitted infections. As with sex work populations in other parts of the world, research has also revealed high rates of substance use, depression, and violence among FSWs. In this study, conducted in two cities in south-western China, the research aimed to examine more closely the relationship between age, HIV risk, and mental health issues. The findings in this study reveal the older women (>35 years) tended towards more risky behaviour while the younger women (<20 years) expressed more issues around mental health. On first sight, this seems to contradict previous research; however, logically it makes sense that these two groups would tend towards more risky behaviour in order to gain and retain clients. The study has several implications for HIV and mental health interventions among FSWs in China. These include the need to provide knowledge, skills and counselling to improve coping strategies among FSWs, as well as extending health service coverage to women in sex work. 

Asia
China
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Intimate partner violence as a barrier to condom and diaphragm use in southern Africa

Intimate partner violence and condom and diaphragm non-adherence among women in an HIV prevention trial in southern Africa.

Kacanek D, Bostrom A, Montgomery ET, Ramjee G, de Bruyn G, Blanchard K, Rock A, Mtetwa S, van der Straten A; MIRA Team. J Acquir Immune Defic Syndr. 2013 Dec 1;64(4):400-8. doi: 10.1097/QAI.0b013e3182a6b0be.

Background: We longitudinally examined the effect of intimate partner violence (IPV) on condom and diaphragm non-adherence among women in the Methods for Improving Reproductive Health in Africa study, a phase III HIV prevention trial in southern Africa.

Methods: Recent IPV (fear of violence, emotional abuse, physical violence, or forced sex, in past 3 months), condom nonadherence, and diaphragm nonadherence were assessed at baseline, 12 month, and exit visits (up to 24 months). The association between IPV and (1) condom nonadherence or (2) diaphragm nonadherence across visits was modeled using Generalized Estimating Equations adjusting for potential confounders.

Results: Of 4 505 participants, 55% reported recent IPV during their trial participation. Women reported fearing violence (41%), emotional abuse (38%), being physically assaulted (16%), and forced sex (15%) by their regular male partner. IPV was associated with condom nonadherence in both study arms [adjusted odds ratio (AOR): 1.41, 95% confidence interval (CI): 1.24 to 1.61 (control arm) and AOR: 1.47, 95% CI: 1.28 to 1.69, (intervention arm)] and with diaphragm nonadherence (AOR 1.24, 95% CI: 1.06 to 1.45) adjusting for age, study sites, number of sex partners, and knowledge of male partner infidelity. Modeling effects of each form of IPV separately on nonadherence outcomes yielded similar results.

Conclusions: Prevalence of recent IPV was high and associated with condom and diaphragm nonadherence during the trial. Counseling in prevention trials should proactively address IPV, for its own sake, and in product and risk-reduction counselling. Strategies to encourage men's positive involvement in product use and prevent IPV perpetration should be considered.

Abstract access 

Editor’s notes: There is growing recognition that gender inequality and violence are important structural drivers of HIV vulnerability among women. This is one of a small number of longitudinal studies exploring this relationship, with the findings complementing other longitudinal evidence from South Africa and Uganda. Evidence shows that exposures to intimate partner violence are associated with incident HIV infection. The study utilized a relatively short recall period of the past three months. Despite this, it illustrates high levels of partner violence that participants experienced, and its significant association with inconsistent condom and diaphragm use. Interestingly, these associations did not appear to differ substantially by the form of partner violence experienced. This suggests that it is not only physical or sexual violence that is important. The authors stress the need to proactively integrate counselling on intimate partner violence into prevention trials. More broadly, the findings suggest that additional programme components may be needed, to enable women in violent relationships to benefit from HIV prevention technologies.

Africa
South Africa, Zimbabwe
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Low income consistently associated with virologic failure among women using HAART in the US - other predictors differ by race/ethnicity

Understanding the Disparity: Predictors of Virologic Failure in Women Using Highly Active Antiretroviral Therapy Vary by Race and/or Ethnicity.  

McFall AM, Dowdy DW, Zelaya CE, Murphy K, Wilson TE, Young MA, Gandhi M, Cohen MH, Golub ET, Althoff KN. J Acquir Immune Defic Syndr. 2013 Nov 1;64(3):289-98. doi: 10.1097/QAI.0b013e3182a095e9.

Background: Stark racial/ethnic disparities in health outcomes exist among those living with HIV in the United States. One of 3 primary goals of the National HIV/AIDS Strategy is to reduce HIV-related disparities and health inequities.

Methods: Using data from HIV-infected women participating in the Women's Interagency HIV Study from April 2006 to March 2011, we measured virologic failure (HIV RNA >200 copies/mL) after suppression (HIV RNA < 80 copies/mL) on highly active antiretroviral therapy. We identified predictors of virologic failure using discrete time survival analysis and calculated racial/ethnic-specific population-attributable fractions (PAFs).

Results: Of 887 eligible women, 408 (46%) experienced virologic failure during the study period. Hispanic and white women had significantly lower hazards of virologic failure than African American women [Hispanic hazard ratio, (HR) = 0.8, 95% confidence interval: (0.6 to 0.9); white HR = 0.7 (0.5 to 0.9)]. The PAF of virologic failure associated with low income was higher in Hispanic [adjusted hazard ratios (aHR) = 2.2 (0.7 to 6.5), PAF = 49%] and African American women [aHR = 1.8 (1.1 to 3.2), PAF = 38%] than among white women [aHR = 1.4 (0.6 to 3.4), PAF = 16%]. Lack of health insurance compared with public health insurance was associated with virologic failure only among Hispanic [aHR = 2.0 (0.9 to 4.6), PAF = 22%] and white women [aHR = 1.9 (0.7 to 5.1), PAF = 13%]. By contrast, depressive symptoms were associated with virologic failure only among African-American women [aHR = 1.6 (1.2 to 2.2), PAF = 17%].

Conclusions: In this population of treated HIV-infected women, virologic failure was common, and correlates of virologic failure varied by race/ethnicity. Strategies to reduce disparities in HIV treatment outcomes by race/ethnicity should address racial/ethnic-specific barriers including depression and low income to sustain virologic suppression.

Abstract access 

Editor’s notes: There has been a dramatic decrease in HIV/AIDS related mortality following the widespread introduction of HAART in the US. However, these improvements have been unequally distributed, with substantial variation by race/ethnicity. This study explored the levels and causes of virologic failure among 3 racial/ethnic groups of HIV positive women accessing treatment.  Virologic failure was common, with an annual failure rate of 23% - 27%. Low income was a large and consistent barrier to sustained virologic suppression across all groups, although there was a greater burden of poverty in Hispanic and African American women. Depressive symptoms were significantly associated with virologic failure only among African American women, whilst current smoking was significantly associated with an increased hazard of virologic failure among American women. The findings illustrate the challenges of sustaining virologic suppression, and the need for a greater understanding of the social, economic and cultural factors that may impact on consistent ART use.   

Northern America
United States of America
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Persistent gender inequities in ART uptake and retention in sub-Saharan Africa – strategies needed to better engage men.

Differences Between HIV-Infected Men and Women in Antiretroviral Therapy Outcomes - Six African Countries, 2004-2012.

Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep. 2013 Nov 29;62(47):946-52.

Evaluation of differences between human immunodeficiency virus (HIV)-infected men and women in antiretroviral therapy (ART) enrollment characteristics and outcomes might identify opportunities to improve ART program patient outcomes and prevention impact. During September 2008-February 2012, retrospective cohort studies to estimate attrition of enrollees (i.e. from death, stopping ART, or loss to follow-up) at 6-month intervals after ART initiation were completed among samples of adult men and women (defined as aged ≥15 years or aged ≥18 years) who initiated ART during 2004-2010 in six African countries: Côte d'Ivoire in western Africa; Swaziland, Mozambique, and Zambia in southern Africa; and Uganda and Tanzania in eastern Africa. Records for 13 175 ART enrollees were analyzed; sample sizes among the six countries ranged from 1 457 to 3 682. In each country, women comprised 61%-67% of ART enrollees. Median CD4 count range was 119-141 cells/µL for men and 137-161 cells/µL for women. Compared with women, a greater percentage of men initiated ART who had World Health Organization (WHO) HIV stage IV disease. In cohorts from western Africa and southern Africa, the risk for attrition was 15%-26% lower among women compared with men in multivariable analysis. However, in eastern Africa, differences between men and women in risk for attrition were not statistically significant. Research to identify country-specific causes for increased attrition and delayed initiation of care among men could identify strategies to improve ART program outcomes among men, which might contribute to prevention of new HIV infections in female partners.

Abstract   Full-text [free] access

Editor’s notes: Equitable access to treatment is a widely endorsed principle in all fields of medicine. This study on gender differences in the uptake and outcomes of antiretroviral therapy (ART) provides programme managers with the evidence to assess and possibly rectify any imbalance. The study is based on clinical cohort data from six geographically diverse African countries. The study found that (1) women account for the majority of patients on ART, (2) they are less likely to enrol with advanced HIV disease, and (3) they have lower attrition rates (mortality, loss to follow up, etc.), after adjusting for possible baseline predictors of survival such as the CD4 count. The first of the three findings may be related to higher eligibility rates in women, which is difficult to assess using clinical data alone. It may also be related to the evidence in favour of higher male attrition rates that was not as strong in the two East African sites. We also need to bear in mind that higher attrition may result from causes unrelated to HIV (see Sabin CA in this issue). Aside from these caveats, the results do indeed suggest that greater effort is necessary to engage men in HIV treatment and care programmes.  This will rectify the apparent imbalance in treatment uptake and outcomes, and it will also have implications for onward transmission to their (female) partners. 

Africa
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