Articles tagged as "Eliminate gender inequalities"

Do progestin-only injectable contraceptives increase HIV risk? Evidence is still inconclusive.

Use of hormonal contraceptives and HIV acquisition in women: a systematic review of the epidemiological evidence.

Polis CB, Curtis KM. Lancet Infect Dis. 2013 Sep;13(9):797-808. doi: 10.1016/S1473-3099(13)70155-5. Epub 2013 Jul 19.

Whether or not the use of hormonal contraception affects risk of HIV acquisition is an important question for public health. We did a systematic review, searching PubMed and Embase, aiming to explore the possibility of an association between various forms of hormonal contraception and risk of HIV acquisition. We identified 20 relevant prospective studies, eight of which met our minimum quality criteria. Of these eight, all reported findings for progestin-only injectables, and seven also reported findings for oral contraceptive pills. Most of the studies that assessed the use of oral contraceptive pills showed no significant association with HIV acquisition. None of the three studies that assessed the use of injectable norethisterone enanthate showed a significant association with HIV acquisition. Studies that assessed the use of depot-medroxyprogesterone acetate (DMPA) or non-specified injectable contraceptives had heterogeneous methods and mixed results, with some investigators noting a 1·5-2·2 times increased risk of HIV acquisition, and others reporting no association. Thus, some, but not all, observational data raise concern about a potential association between use of DMPA and risk of HIV acquisition. More definitive evidence for the existence and size of any potential effect could inform appropriate counselling and policy responses in countries with varied profiles of HIV risk, maternal mortality, and access to contraceptive services.

Abstract access 

Editor’s notes: There has been increasing focus on the question of whether women using progesterone-only injectable contraceptives may be at increased risk of HIV acquisition. This systematic review illustrates the difficulty in drawing conclusions from a relatively small number of observational studies. The data show little evidence of an association between the use of oral contraceptives and HIV acquisition, but the data on injectable contraceptives are inconclusive. Relatively few studies met the minimum quality criteria (n=8). These studies are difficult to interpret due to methodological issues such as residual confounding by differing patterns of condom use or other sexual behaviours, and long inter-survey intervals which reduces accuracy of measuring time-dependent variables (both exposures and the outcome). The message to women therefore remains the same as the current WHO recommendations – the current data are not sufficiently conclusive to change policy, but women who use progestin-only injectables should be strongly advised to always use condoms and other HIV preventive measures to prevent HIV.

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Disproportionately high HIV risk and gender disparity in prevalence among urban poor in Sub-Saharan Africa

The disproportionate high risk of HIV infection among the urban poor in sub-Saharan Africa.

Magadi MA. AIDS Behav. 2013 Jun;17(5):1645-54. doi: 10.1007/s10461-012-0217-y.

The link between HIV infection and poverty in sub-Saharan Africa (SSA) is rather complex and findings from previous studies remain inconsistent. While some argue that poverty increases vulnerability, existing empirical evidence largely support the view that wealthier men and women have higher prevalence of HIV. In this paper, we examine the association between HIV infection and urban poverty in SSA, paying particular attention to differences in risk factors of HIV infection between the urban poor and non-poor. The study is based on secondary analysis of data from the Demographic and Health Surveys from 20 countries in SSA, conducted during 2003-2008. We apply multilevel logistic regression models, allowing the urban poverty risk factor to vary across countries to establish the extent to which the observed patterns are generalizable across countries in the SSA region. The results reveal that the urban poor in SSA have significantly higher odds of HIV infection than urban non-poor counterparts, despite poverty being associated with a significantly lower risk among rural residents. Furthermore, the gender disparity in HIV infection (i.e. the disproportionate higher risk among women) is amplified among the urban poor. The paper confirms that the public health consequence of urban poverty that has been well documented in previous studies with respect to maternal and child health outcomes does apply to the risk of HIV infection. The positive association between household wealth and HIV prevalence observed in previous studies largely reflects the situation in the rural areas where the majority of the SSA populations reside.

Abstract   Full-text [free] access 

Editor’s notes: Evidence on the association between socio-economic position and HIV incidence in sub-Saharan Africa (SSA) has been mixed and appears to be changing over time. Although wealth was previously a predictor of HIV infection, it has recently been suggested that poverty is increasingly driving new infections in mature epidemics, especially in rural areas, where the majority of the population in SSA resides. With high rates of urbanisation both in SSA and globally (according to UNAIDS 2 of every 3 people living with HIV will be living in urban areas by 2030), this article provides important disaggregated evidence of the higher risk of HIV infection among the urban poor as well, and particularly among poor urban women. Even after controlling for sexual behaviour, the results suggest that other structural factors that characterise the environment, in which the urban poor live, such as unemployment, discrimination and violence, may be playing a key role. Interestingly, higher educational attainment was found to be associated with higher HIV risk among the urban poor, while it appeared to be protective among the better-off urban population. This may be pointing towards the ‘inverse equity hypothesis’, discussed in another paper this month (Hargreaves et al.), whereby groups with higher socio-economic position (wealth and/or education) are expected to benefit first from HIV/health interventions, thereby initially widening the gap in health outcomes until the poor catch up. 

Africa
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Intimate partner violence associated with poor ART adherence, disease progression and hospitalization

The clinical implications of high rates of intimate partner violence against HIV-positive women.

Siemieniuk RA, Krentz HB, Miller P, Woodman K, Ko K, Gill MJ. J Acquir Immune Defic Syndr. 2013 May 24. [Epub ahead of print]

Introduction: Intimate partner violence (IPV) is associated with increased risk of HIV infection among women; however whether IPV affects outcomes after HIV infection is uncertain. We assess the impact of IPV on HIV-positive women.

Methods: All HIV-positive women who received outpatient HIV care in southern Alberta between March 2009 and January 2012 were screened for IPV. The associations with IPV of socio-demographic factors, health related quality of life, clinical status, and hospitalizations were obtained from a regional database and evaluated with multivariable regression analysis.

Results: Of 339 women screened, 137 (40.4%) reported experiencing IPV. Those disclosing IPV had higher rates of smoking [adjusted prevalence ratio (APR)=5.07; 95% confidence interval = 2.72-9.43; illicit drug use (APR=7.58, 2.45-23.26);a history of incarceration (APR=4.84, 1.85-12.68); depression (APR=2.50, 1.15-5.46); and anxiety disorders (APR=5.75, 2.10-15.63).Health related quality of life was diminished with IPV (APR=2.94, 1.40-6.16) for poor/fair vs. very good/excellent. IPV-exposed women were hospitalized 256 times /1000 patient-years compared to 166/1000 patient-years among IPV-unexposed (P<0.001). The relative risk was increased for HIV-unrelated hospitalizations (1.42, 1.16-1.73) and for HIV-related hospitalizations after outpatient HIV care was initiated (2.19, 1.01-4.85). Modifiable contributors to the poor outcomes included decreased use of antiretroviral therapy (APR=0.55, 0.34-0.91) and additional interruptions in care longer than one year (APR=1.90, 1.07-3.39).

Conclusions: IPV is associated with deleterious HIV-related and HIV-unrelated health outcomes, of which suboptimal engagement in care is a contributor. To improve outcomes, practitioners should aim to increase engagement in care of these women in particular.

Abstract access 

Editor’s notes: This is one of several papers published this month, looking at the issue of violence by an intimate partner (intimate partner violence) and HIV. Previous epidemiological research featured in HIV This Month has provided evidence that exposures to violence put women at increased HIV risk in Uganda. Importantly, this study looks at whether HIV positive women who have experienced violence have poorer clinical outcomes. The findings show the broad range of health issues that HIV positive IPV exposed women face – including depression and anxiety disorders. The analysis also shows that women who had been exposed to IPV had decreased and interrupted use of antiretroviral therapy, and increased hospitalization (both HIV unrelated and HIV related).  These findings are not unique to women in Canada. One of the other papers published this month was among HIV positive women in an inner-city London clinic, and also found high levels of violence, including during pregnancy (Dhairyawan et al., 2013). Another was among gay and bisexual men in Canada which also found high levels of violence and an association with a history of childhood abuse and with poor clinical outcomes. In combination, the findings point to the urgent need to ensure that HIV clinical services are better equipped to address their client’s exposures to intimate partner violence, both as an end in itself, as well as to help improve their HIV treatment prognosis.

Northern America
Canada
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Exposure to intimate partner violence associated with an increased risk of new HIV infection in Uganda

Intimate partner violence is associated with incident HIV infection in women in Uganda

Kouyoumdjian, Fiona G.; Calzavara, Liviana M.; Bondy, Susan J.; O’Campo, Patricia; Serwadda, David; Nalugoda, Fred; Kagaayi, Joseph; Kigozi, Godfrey; Wawer, Maria; Gray, Ron. AIDS: 15 May 2013 - Volume 27 - Issue 8 - p 1331–1338 doi: 10.1097/QAD.0b013e32835fd851

Objectives: To quantify the association between intimate partner violence (IPV) and incident HIV infection in women in the Rakai Community Cohort Study between 2000 and 2009.

Design and methods: Data were from the Rakai Community Cohort Study annual surveys between 2000 and 2009. Longitudinal data analysis was used to estimate the adjusted incidence rate ratio (IRR) of incident HIV associated with IPV in sexually active women aged 15 - 49 years, using a multivariable Poisson regression model with random effects. The population attributable fraction was calculated. Putative mediators were assessed using Baron and Kenny’s criteria and the Sobel-Goodman test.

Results: Women who had ever experienced IPV had an adjusted IRR of incident HIV infection of 1.55 (95% CI 1.25 - 1.94, P = 0.000), compared with women who had never experienced IPV. Risk of HIV infection tended to be greater for longer duration of IPV exposure and for women exposed to more severe and more frequent IPV. The adjusted population attributable fraction of incident HIV attributable to IPV was 22.2% (95% CI 12.5 - 30.4). There was no evidence that either condom use or number of sex partners in the past year mediated the relationship between IPV and HIV.

Conclusion: IPV is associated with incident HIV infection in a population-based cohort in Uganda, although the adjusted population attributable fraction is modest. The prevention of IPV should be a public health priority, and could contribute to HIV

Abstract access

Editor’s notes: There has been a longstanding recognition that as well as enduring a fundamental abuse in its own right, women in violent relationships may be at increased risk of acquiring HIV, and may experience violence as a result of their infection. However, epidemiological evidence on the relationship between exposures to violence and HIV has been mixed. Analyses of cross-sectional data having mixed findings, but previous longitudinal research in South Africa has shown a clear association between exposures to violence and new HIV infection. Using data from Rakai, Uganda, this paper is an important addition to the evidence base, providing longitudinal evidence that the association between partner violence and risk of HIV acquisition holds in this East African setting. Importantly, the association was greater for severe forms of violence compared with minor forms of violence, as well as for more frequent exposures to violence. As in other studies, no evidence was found that this increase in risk was due to differences in condom use or the number of partners that women have. Although not explored in this paper, other authors have suggested that the association between intimate partner violence exposure and new HIV infection is due to a clustering of risk behaviours among men that result in violent men being more likely to be HIV positive than non-violent men, which in turn would increase their partner’s HIV risk.  

Africa
Uganda
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High incidence of HIV among young women in Uganda

Behavioral, Biological, and Demographic Risk and Protective Factors for New HIV Infections among Youth, Rakai, Uganda.

Santelli JS, Edelstein ZR, Mathur S, Wei Y, Zhang W, Orr MG, Higgins JA, Nalugoda F, Gray RH, Wawer MJ, Serwadda DM. J Acquir Immune Defic Syndr. 2013 Mar 26. [Epub ahead of print]

Prevalence of HIV infection is considerable among youth, although data on risk factors for new (incident) infections is limited. We examined incidence of HIV infection and risk and protective factors among youth in rural Uganda, including the role of gender and social transitions. Participants were sexually experienced youth (15-24 years-old) enrolled in the Rakai Community Cohort Study, 1999-2008 (n=6722). Poisson regression with robust standard errors was used to estimate incident rate ratios (IRR) and 95% confidence intervals (CI) of incident HIV infection. HIV incidence was greater among young women than young men (13.3 vs. 8.1 per 1000 person-years, respectively); this gender disparity was greater among teens (14.6 vs. 3.6). Beyond behavioral (multiple partners and concurrency) and biological factors (sexually transmitted infection (STI) symptoms), social transitions such as marriage and staying in school influenced HIV risk. In multivariate analyses among women, HIV incidence was associated with living in a trading village (adjusted IRR (aIRR)=1.46; CI=1.02-2.08), being a student (aIRR=0.23, CI=0.07-0.74), current marriage (aIRR=0.54, CI=0.37-0.80), having multiple partners, and STI symptoms. Among men, new infections were associated with former marriage (aIRR=4.91, CI 2.18-11.04), genital ulceration (aIRR=3.45; CI=1.91-6.23) and alcohol use (aIRR=2.06, CI=1.14-3.74). During the third decade of the HIV epidemic in Uganda, HIV incidence remains considerable among youth, with young women particularly at risk. The risk for new infections was strongly shaped by social transitions such as leaving school, entrance into marriage, and marital dissolution; the impact of marriage was different for young men than women.

Abstract access

Editor’s notes: Almost 40% of new HIV infections occur in people aged 15-24 years, and there is an urgent need to continue to focus on understanding the epidemiology of HIV infection in this age group, and strategies to prevent new infections.  There are few large, population-based longitudinal studies of HIV incidence in youth.  The study found, as expected, that HIV incidence was higher in young women than in young men, especially among the youngest age group studied (15-19 year olds), in whom incidence was over 4 times greater in young women than in young men. In addition to sexual behavioural factors and STI symptoms, alcohol use was associated with an increased risk of HIV infection, especially in men. This underlines the importance of interventions to address young women’s high HIV vulnerability and the potential value of alcohol-use interventions among young men.  

Africa
Uganda
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HIV infection increases mortality among HIV-positive pregnant women

The contribution of HIV to pregnancy-related mortality: a systematic review and meta-analysis.

Calvert C, Ronsmans PC. AIDS. 2013 Feb 25. [Epub ahead of print]

Whilst much is known about the contribution of HIV to adult mortality, remarkably little is known about the mortality attributable to HIV during pregnancy. In this paper the proportion of pregnancy-related deaths attributable to HIV based on empirical data was estimated from a systematic review of the strength of association between HIV and pregnancy-related mortality. Studies comparing mortality during pregnancy and the postpartum in HIV-infected and uninfected women were included. Summary estimates of the relative and attributable risks for the association between HIV and pregnancy-related mortality were calculated through meta-analyses. Varying estimates of HIV prevalence were used to predict the impact of the HIV epidemic on pregnancy-related mortality at the population level. 23 studies were included (17 from sub-Saharan Africa). Meta-analysis of the risk ratios (RR) indicated that HIV-infected women had eight times the risk of a pregnancy-related death compared with HIV-uninfected women (pooled RR: 7.74, 95% CI 5.37-11.16). The excess mortality attributable to HIV among HIV-infected pregnant and postpartum women was 994 per 100,000 pregnant women. We predict that 12% of all deaths during pregnancy and up to one year postpartum are attributable to HIV/AIDS in regions with a prevalence of HIV among pregnant women of 2%. This figure rises to 50% in regions with a prevalence of 15%.  The substantial excess of pregnancy-related mortality associated with HIV highlights the importance of integrating HIV and reproductive health services in areas of high HIV prevalence and pregnancy-related mortality.

Abstract access 

Editor’s notes: Millennium Development Goals include commitments to reduce maternal mortality. While HIV is a leading cause of death among women of reproductive age in sub-Saharan Africa, the contribution of HIV infection to overall maternal mortality is Africa has been less described. This analysis of this study indicates that a significant proportion of maternal deaths is due to HIV. While the contribution of HIV to maternal mortality is high in relatively low prevalence settings, it is remarkably and tragically high in high prevalence countries such as is seen in southern Africa: with an estimated 50% of maternal deaths due to HIV infection when prevalence is 15%. This modeling highlights the ongoing essential need to prevent new HIV infections if the MDGs will be met.

Epidemiology, Gender
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Supporting transgender people to reduce HIV risk

Gender Abuse, Depressive Symptoms, and HIV and Other Sexually Transmitted Infections among Male-to-Female Transgender Persons: A Three-Year Prospective Study.

Nuttbrock L, Bockting W, Rosenblum A, Hwahng S, Mason M, Macri M, Becker J Am J Public Health. 2013 Feb;103(2):300-7. doi: 10.2105/AJPH.2011.300568. Epub 2012 Jun 14.

We examined gender abuse and depressive symptoms as risk factors for HIV and other sexually transmitted infections (HIV/STI) among male-to-female transgender persons (MTFs). We conducted a 3-year prospective study of factors associated with incident HIV, syphilis, hepatitis B, chlamydia, and gonorrhea among 230 MTFs from the New York Metropolitan Area. Statistical techniques included Cox proportional hazards analysis with time varying covariates. Among younger MTFs (aged 19-30 years), gender abuse predicted depressive symptoms (Center for Epidemiologic Studies Depression score ≥ 20), and gender abuse combined with depressive symptoms predicted both high-risk sexual behavior (unprotected receptive anal intercourse) and incident HIV/STI. These associations were independent of socioeconomic status, ethnicity, sexual orientation, hormone therapy, and sexual reassignment surgery. Gender abuse is a fundamental distal risk factor for HIV/STI among younger MTFs. Interventions for younger MTFs are needed to reduce the psychological impact of gender abuse and limit the effects of this abuse on high-risk sexual behavior. Age differences in the impact of gender abuse on HIV/STI suggest the efficacy of peer-based interventions in which older MTFs teach their younger counterparts how to cope with this abuse.

Abstract access 

Editor’s notes: Transgender persons often face significant discrimination and violence as part of their daily lives, and it is not surprising that depressive symptoms and sexual risk taking may be a consequence. It is important that policy makers, care providers, and others realize that violence, stigma, and self-stigma have serious mental health and overall health sequelae that violate human rights. This study has a quite large number of recruited participants (237 HIV-positive, and 354 HIV-negative) and is notable for its respective inclusion of transgender persons in the design of the study. Additionally the study is notable for documenting the beneficial coping skills of older transgender people and highlighting the value they may bring to improving coping skills and self-esteem in younger transgender people.

Northern America
United States of America
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Reproductive rights of women living with HIV

Community attitudes towards childbearing and abortion among HIV-positive women in Nigeria and Zambia.

Kavanaugh ML, Moore AM, Akinyemi O, Adewole I, Dzekedzeke K, Awolude O, Arulogun O. Cult Health Sex. 2013 Feb;15(2):160-74. doi: 10.1080/13691058.2012.745271. Epub 2012 Nov 23

Although stigma towards HIV-positive women for both continuing and terminating a pregnancy has been documented, to date few studies have examined relative stigma towards one outcome versus the other. This study seeks to describe community attitudes towards each of two possible elective outcomes of an HIV-positive woman's pregnancy - induced abortion or birth - to determine which garners more stigma and document characteristics of community members associated with stigmatising attitudes towards each outcome. Data come from community-based interviews with reproductive-aged men and women, 2401 in Zambia and 2452 in Nigeria. Bivariate and multivariate analyses revealed that respondents from both countries overwhelmingly favoured continued childbearing for HIV-positive pregnant women, but support for induced abortion was slightly higher in scenarios in which anti-retroviral therapy (ART) was unavailable. Zambian respondents held more stigmatising attitudes towards abortion for HIV-positive women than did Nigerian respondents. Women held more stigmatising attitudes towards abortion for HIV-positive women than men, particularly in Zambia. From a sexual and reproductive health and rights perspective, efforts to assist HIV-positive women in preventing unintended pregnancy and to support them in their pregnancy decisions when they do become pregnant should be encouraged in order to combat the social stigma documented in this paper.

Abstract access 

Editor’s notes: Women’s rights to make reproductive health choices extend fully to women living with HIV. The World Health Organization (WHO), the Joint United Nations Programme on HIV/AIDS (UNAIDS), and the Office of the High Commissioner on Human Rights (OHCHR) all affirm the reproductive rights of HIV-positive individuals to choose between continuing and terminating a pregnancy, calling for access to safe abortion services in countries where it is legal for individuals who choose the latter option. This study primarily focused on attitudes towards continued childbearing versus induced abortion in two relatively high prevalence countries, in particular in contexts where induced abortion is not generally viewed favorably. However it does reflect the continued interest overall in childbearing regardless of HIV status for many women. Interestingly, the findings also indicated greater favorability towards a continuation of pregnancy for women on ART – perhaps reflecting a growing understanding that effective PMTCT interventions significantly lower the risk of vertical HIV transmission.

Africa
Nigeria, Zambia
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Hormonal contraception and the risk for HIV acquisition

Hormonal contraception and HIV acquisition - What is the evidence? What are the policy and operational implications?

Delvaux T, Buvé A. Eur J Contracept Reprod Health Care. 2013 Feb;18(1):15-26. doi: 10.3109/13625187.2012.744819

Family planning (FP) is essential in achieving the United Nations Millennium Development Goals. The authors review the evidence on HIV acquisition among women using hormonal contraception, and discuss the policy and operational implications. Longitudinal studies conducted in sub-Saharan Africa published between 2008 and 2012, as well as key policy documents related to contraception and HIV were reviewed. Findings on hormonal contraception and HIV acquisition conducted in sub- Saharan Africa are inconsistent. While in the large scale studies no statistically significant association between oral contraceptive use and HIV acquisition was found, results for injectables were mixed. Potential biases, such as those resulting from self-selection, related to the observational study design and main confounders such as condom use, sexual activity and contraceptive use are discussed in this article. It is currently not possible to conclude whether the use of hormonal contraceptives is associated with a greater risk of acquiring HIV, or not. The use of male or female condoms for dual protection should be promoted in FP programmes. While there is need for further research on a broader range of contraceptive methods and HIV transmission, studies documenting acceptability of currently less used/more recent contraceptive methods are also warranted.

Abstract access 

Editor’s notes: Barrier methods such as female and male condoms, when used consistently and correctly reduce risk of both pregnancy and HIV transmission. Recent studies have raised concern that hormonal methods utilized for contraception may biologically specifically increase the risk for HIV acquisition, beyond the clear loss of the barrier to HIV transmission. The methodological challenges to ensure that confounders are not present in these studies, described in the abstract, remain.  Dual protection (barrier plus hormonal contraception) are a challenge to implement, but their uptake should be promoted until more definitive results can be obtained.

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Comprehensive care and HIV prevention for survivors of sexual violence

Uptake to HIV Post-Exposure Prophylaxis in Haiti: Opportunities to Align Sexual Violence, HIV PEP and Mental Health.

Marc L, Honoré JG, Néjuste P, Setaruddin M, Lamothe NN, Thimothé G, Cornely JR. Am J Reprod Immunol. 2012 Dec 28. doi: 10.1111/aji.12053. [Epub ahead of print]

Sexual violence is a public health problem in Haiti, potentially augmenting HIV transmission. Reports from L'Hôpital de l'Université d'État d'Haiti (HUEH) suggest severe underutilization of antiretroviral post-exposure prophylaxis (ARV-PEP) among rape survivors. With a cross-sectional design using mixed methods, informational interviews were conducted with HUEH personnel to learn about post-rape service offerings. HUEH surveillance data were used to estimate the sexual assault reporting rate/100,000 and to examine the proportion of survivors receiving ARV-PEP within 72 hr, stratified by age (<18 years, ≥18 years). Informational interviews revealed that survivors were navigated through two hospital algorithms to receive post-rape care; however, <5% of victims sought mental health services. Surveillance data show that 2193 sexual assault survivors (adult and pediatric) reported a rape to HUEH personnel between 2004 through first quarter of 2010. Annual estimates suggest a twofold increase comparing cases in 2004 versus 2009. Between 2008 and 2009, uptake to ARV-PEP within 72 hr was lower for pediatric (38.4%; N = 131/341) compared with adult survivors (60.1%; N = 83/138) (χ(2)  = 18.8, P < 0.001). The prioritization of funding and comprehensive interventions that align sexual violence, HIV, and mental health is crucial to support the timely uptake to ARV-PEP.

Abstract access 

Editor’s notes: Survivors of sexual and gender based violence require biomedical interventions such as post-exposure prophylaxis of HIV (ARV-PEP) and other sexually transmitted infections. Sensitization and training of police and emergency room workers has increased the availability of ARV-PEP, though it is of concern that in a large urban hospital in Haiti PEP was not more widely utilized, and that the uptake was so low (38%) among children. Comprehensive services for survivors of sexual assault should include mental health services, both for immediate interventions as well as for long-term follow up. Hospital based surveys may be methodologically limited, but it is of concern that fewer than 5% of sexual assault survivors sought mental health services. The psychosocial service needs of such survivors should not be underestimated and planners need to take these needs seriously.

Latin America
Haiti
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