Articles tagged as "Elimination of gender inequalities"

How to enhance adolescents’ autonomy and self-esteem. Cash and schooling help

Editor’s notes: Recent randomized trials of interventions including cash transfers to adolescent girls to encourage school attendance in South Africa have failed to show an effect on the incidence of HIV or pregnancy and had mixed effects on the incidence of HSV2.  However, these large trials both found that school attendance was rather high in the study populations possibly limiting the opportunities for making an impact on HIV.  McPhail et al. now report an interesting study that explores what the young women chose to spend their cash on; who controlled the cash and whether there were adverse consequences of giving cash to dependents rather than to the household or its head.  This is important because some studies elsewhere have suggested that such payments might upset the family dynamic and introduce tensions.  In this relatively poor South African setting (which is still considerably less poor than many other communities in neighbouring countries), the authors found minimal harms and many benefits.  Women used the money to express their autonomy and to build their status among their peers and community.  Money was not wasted on drugs and alcohol that might increase risks of HIV, although it was also not spent on condoms or family planning services (which are anyway provided to some extent at no cost in this community).  Although the HPTN 068 randomised trial in which the study was embedded did not show any impact on the primary and secondary biological endpoints (incidence of HIV, HSV2 and pregnancy), the benefits described in terms of adolescent development are important in their own right.  Cash transfers for people near the poverty line and keeping girls in school probably have many complex and important benefits beyond HIV prevention.

Improving school attendance and integrating reproductive health or HIV prevention into the curriculum feels as though it should be an essential part of HIV programming.  Yet, several large well-designed studies have failed to demonstrate significant effects on HIV incidence, pregnancy or other biological markers.  Hallfors et al. have examined one such negative trial in more detail.  They show that in the trial in Kenya where orphaned children were supported with uniforms, school fees and regular nurse visits, it appeared that the intervention did lead to a higher attendance at school.  However, this did not translate into differences in the biological markers chosen for the endpoints of the trial. The authors comment that “the association between school support and HIV/HSV-2 prevention appears to be weak or under-specified”.  However, as with the cash transfers, the benefits may be much broader than changes in the biological endpoints specified.  Furthermore, it is plausible that a stronger educational input may eventually translate into HIV-relevant outcomes beyond the timeframe of the study.  Trials in these areas are hard to design.  We do need to build a stronger case for the real impact on HIV of different aspects of schooling both in terms of quantity and of quality.  But that should not detract from the obvious benefits of investing in better education for all. 


Cash transfers for HIV prevention: what do young women spend it on? Mixed methods findings from HPTN 068.

MacPhail C, Khoza N, Selin A, Julien A, Twine R, Wagner RG, Goméz-Olivé X, Kahn K, Wang J, Pettifor A. BMC Public Health. 2017 Jul 11;18(1):10. doi: 10.1186/s12889-017-4513-3.

Background: Social grants have been found to have an impact on health and wellbeing in multiple settings. Who receives the grant, however, has been the subject of discussion with regards to how the money is spent and who benefits from the grant.

Methods: Using survey data from 1214 young women who were in the intervention arm and completed at least one annual visit in the HPTN 068 trial, and qualitative interview data from a subset of 38 participants, we examined spending of a cash transfer provided to young women conditioned on school attendance.

Results: We found that spending was largely determined and controlled by young women themselves and that the cash transfer was predominately spent on toiletries, clothing and school supplies. In interview data, young women discussed the significant role of cash transfers for adolescent identity, specifically with regard to independence from family and status within the peer network. There were almost no negative consequences from receiving the cash transfer.

Conclusions: We established that providing adolescents access to cash was not reported to be associated with social harms or negative consequences. Rather, spending of the cash facilitated appropriate adolescent developmental behaviours. The findings are encouraging at a time in which there is global interest in addressing the structural drivers of HIV risk, such as poverty, for young women.

Abstract  Full-text [free] access 


Process evaluation of a clinical trial to test school support as HIV prevention among orphaned adolescents in western Kenya.

Hallfors DD, Cho H, Hartman S, Mbai I, Ouma CA, Halpern CT. Prev Sci. 2017 Jul 21. doi: 10.1007/s11121-017-0827-8. [Epub ahead of print]

Orphaned adolescents are a large and vulnerable population in sub-Saharan Africa, at higher risk for HIV than non-orphans. Yet prevention of new infection is critical for adolescents since they are less likely than adults to enter and remain in treatment and are the only age group with rising AIDS death rates. We report process evaluation for a randomized controlled trial (RCT) testing support to stay in school (tuition, uniform, nurse visits) as an HIV prevention strategy for orphaned Kenyan adolescentsThe RCT found no intervention effect on HIV/HSV-2 biomarker outcomes. With process evaluation, we examined the extent to which intervention elements were implemented as intended among the intervention group (N = 412) over the 3-year study period (2012-2014), the implementation effects on school enrollment (0-9 terms), and whether more time in school impacted HIV/HSV-2. All analyses examined differences as a whole, and by gender. Findings indicate that school fees and uniforms were fully implemented in 94 and 96% of cases, respectively. On average, participants received 79% of the required nurse visits. Although better implementation of nurse visits predicted more terms in school, a number of terms did not predict the likelihood of HIV/HSV-2 infection. Attending boarding school also increased number of school terms, but reduced the odds of infection for boys only. Four previous RCTs have been conducted in sub-Saharan Africa, and only one found limited evidence of school impact on adolescent HIV/HSV-2 infection. Our findings add further indication that the association between school support and HIV/HSV-2 prevention appears to be weak or under-specified.

Abstract access 

Kenya, South Africa
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How did SASA! reduce violence against women?

Exploring couples' processes of change in the context of SASA!, a violence against women and HIV prevention intervention in Uganda.

Starmann E, Collumbien M, Kyegombe N, Devries K, Michau L, Musuya T, Watts C, Heise L. Prev Sci. 2017 Feb; 18(2): 233–244. doi:  10.1007/s11121-016-0716-6. Epub 2016 Sep 29. 

There is now a growing body of research indicating that prevention interventions can reduce intimate partner violence (IPV); much less is known, however, about how couples exposed to these interventions experience the change process, particularly in low-income countries. Understanding the dynamic process that brings about the cessation of IPV is essential for understanding how interventions work (or don't) to reduce IPV. This study aimed to provide a better understanding of how couples' involvement with SASA!-a violence against women and HIV-related community mobilisation intervention developed by Raising Voices in Uganda-influenced processes of change in relationships. Qualitative data were collected from each partner in separate in-depth interviews following the intervention. Dyadic analysis was conducted using framework analysis methods. Study findings suggest that engagement with SASA! contributed to varied experiences and degrees of change at the individual and relationship levels. Reflection around healthy relationships and communication skills learned through SASA! activities or community activists led to more positive interaction among many couples, which reduced conflict and IPV. This nurtured a growing trust and respect between many partners, facilitating change in longstanding conflicts and generating greater intimacy and love as well as increased partnership among couples to manage economic challenges. This study draws attention to the value of researching and working with both women, men and couples to prevent IPV and suggests IPV prevention interventions may benefit from the inclusion of relationship skills building and support within the context of community mobilisation interventions.

Abstract  Full-text [free] access 

Editor’s notes: Evidence from sub-Saharan Africa suggests community mobilization approaches work at many different levels to prevent intimate partner violence. However it is unclear how they work. This study interviewed ten couples (men and women interviewed separately) who participated in the SASA! activities and reported reductions in intimate partner violence over time. Findings suggest that engagement with SASA! by one or both members of the couple resulted in a range of change processes at the individual and relational levels. The biggest changes were seen in couples with severe intimate partner violence and in couples where one or both partners experienced high-intensity exposure to SASA! Changes were not usually universal or rapid but often uneven and slow. Overall, greater awareness of healthy relationship values and increased relational resources – communication and self-regulation skills – led to improved relationships.

Of interest to people involved in programmes on intimate partner violence, is that focusing on promoting positive relationship values and dynamics - such as love, respect and trust are effective.  Indeed, they were far more effective, than focusing on gender roles such as sharing of household tasks – which created conflict. The findings suggest intimate partner violence programmes should consider mixed-sex approaches that work with both men and women. These programmes should include promoting love and intimacy as a mechanism to achieve more balanced power in relationships and reduce violence. 


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Female sex workers in Cote d’Ivoire experience high levels of physical and sexual violence alongside intimidation from the police

Physical and sexual violence affecting female sex workers in Abidjan, Cote d'Ivoire: Prevalence, and the relationship between violence, the work environment, HIV and access to health services.

Lyons C, Ketende S, Drame F, Grosso A, Diouf D, Ba I, Shannon K, Ezouatchi R, Bamba A, Kouame A, Baral S. J Acquir Immune Defic Syndr. 2017 Feb 6. doi: 10.1097/QAI.0000000000001310. [Epub ahead of print]

Background: Violence is a human rights violation, and an important measure in understanding HIV among female sex workers (FSW). However, limited data exist regarding correlates of violence among FSW in Cote d'Ivoire. Characterizing prevalence and determinants of violence and the relationship with structural risks for HIV can inform development and implementation of comprehensive HIV prevention and treatment programs.

Methods: FSW > 18 years were recruited through respondent driven sampling (RDS) in Abidjan, Cote d'Ivoire. In total, 466 participants completed a socio-behavioral questionnaire and HIV testing. Prevalence estimates of violence were calculated using crude and RDS adjusted estimates. Relationships between structural risk factors and violence were analyzed using chi squared tests, and multivariable logistic regression.

Results: RDS Police refusal of protection was associated with physical (adjusted Odds Ratio [aOR]:2.6; 95%CI: 1.7,4.4) and sexual violence (aOR: 3.0; 95%CI: 1.9,4.8). Blackmail was associated with physical (aOR: 2.5; 95%CI: 1.5,4.2) and sexual violence (aOR: 2.4; 95%CI: 1.5,4.0). Physical violence was associated with fear (aOR: 2.2; 95%CI: 1.3,3.1) and avoidance of seeking health services (aOR:1.7; 95%CI:1.1-2.6).

Conclusions: Violence is prevalent among FSW in Abidjan and associated with features of the work environment. These relationships highlight layers of rights violations affecting FSW, underscoring the need for structural interventions and policy reforms to improve work environments; and to address police harassment, stigma, and rights violations to reduce violence and improve access to HIV interventions.

Abstract access  

Editor’s notes: The authors report the findings of a study with female sex workers in Cote d’Ivoire.  They explored prevalence and determinants of violence and the relationship with structural risks for HIV. Of the women interviewed, 60% had experienced physical violence and, for these women, 85% had experienced physical violence in the last 12 months. Of these women around 70% reported violence after starting sex work. Almost half of the women surveyed had experienced sexual violence. The main perpetrators were clients. There were associations between being HIV positive and physical violence. Around 11% of the women were HIV positive but a quarter feared seeking health services due to their engagement in sex work.

A quarter of the women reported that police had refused them protection. Around a third had been intimidated or harassed by the police, and there were associations between experiences of physical or sexual violence and arrest, blackmail or condom refusal. The authors conclude that these findings illustrate an urgent need for improving the work environments for female sex workers in Cote d’Ivoire.  There is also a need to address police harassment and violence. The authors argue for the need for policy reforms to address legal barriers focussing on sex work.

Côte d'Ivoire
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Violence and sex work in Uganda

Policing the epidemic: high burden of workplace violence among female sex workers in conflict-affected northern Uganda.

Muldoon KA, Akello M, Muzaaya G, Simo A, Shoveller J, Shannon K. Glob Public Health. 2017 Jan;12(1):84-97. Epub 2015 Oct 27.

Sex workers in sub-Saharan Africa experience a high burden of HIV with a paucity of data on violence and links to HIV risk among sex workers, and even less within conflict-affected environments. Data are from a cross-sectional survey of female sex workers in Gulu, northern Uganda (n = 400). Logistic regression was used to determine the specific association between policing and recent physical/sexual violence from clients. A total of 196 (49.0%) sex workers experienced physical/sexual violence by a client. From those who experienced client violence the most common forms included physical assault (58.7%), rape (38.3%), and gang rape (15.8%) Police harassment was very common, a total of 149 (37.3%) reported rushing negotiations with clients because of police presence, a practice that was significantly associated with increased odds of client violence (adjusted odds ratio: 1.61, 95% confidence intervals: 1.03-2.52). Inconsistent condom use with clients, servicing clients in a bar, and working for a manager/pimp were also independently associated with recent client violence. Structural and community-led responses, including decriminalisation, and engagement with police and policy stakeholders, remain critical to addressing violence, both a human rights and public health imperative.

Abstract access  

Editor’s notes: Sex workers are at increased risk of HIV and of violence from multiple perpetrators. There is a paucity of research examining violence among sex workers in conflict-affected areas. Sex work in Uganda is illegal. A police presence can reduce sex workers ability to screen for dangerous clients, negotiate sex acts, price and condom use. This study is from northern Uganda. The site, now at peace, has experienced 20 years of war. A quarter of sex workers are living with HIV. The paper examines the prevalence of client violence, police arrest and other factors, and how they interrelate.

Participants in the study were usually young (median age 21 years), poorly educated and had ≥1 child. One third had been abducted into the Lord’s Resistance Army and two thirds had lived in an Internal Displacement Camp. Some 49% had experienced recent physical or sexual violence from clients.  Eight percent had been gang raped in the past six months. Policing, inconsistent condom use, having sex in a bar and working for a manager or pimp were significantly associated with client violence. Sex workers in this survey face a high prevalence of violence and HIV. Decriminalisation of sex work is vital if sex workers are to access labour and human rights protection and to reduce the high prevalence of violence and HIV

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High prevalence of gender based violence among adolescent female sex workers - need to improve access to health services

Prevalence and correlates of sexual and gender-based violence against Chinese adolescent women who are involved in commercial sex: a cross-sectional study.

Zhang XD, Myers S, Yang HJ, Li Y, Li JH, Luo W, Luchters S. BMJ Open. 2016 Dec 19;6(12):e013409. doi: 10.1136/bmjopen-2016-013409.

Objectives: Despite the vast quantity of research among Chinese female sex workers (FSWs) to address concerns regarding HIV/sexually transmitted infection (STI) risk, there is a paucity of research on issues of sexual and gender-based violence (SGBV) and the missed opportunity for sexual and reproductive health (SRH) promotion among young FSWs. Our research aimed to assess the prevalence and correlates of SGBV among Chinese adolescent FSWs, and to explore SRH service utilisation.

Design and methods: A cross-sectional study using a one-stage cluster sampling method was employed. A semistructured questionnaire was administered by trained peer educators or health workers. Multivariable logistic regression was conducted to determine individual and structural correlates of SGBV.

Setting and participants: Between July and September 2012, 310 adolescent women aged 15-20 years, and who self-reported having received money or gifts in exchange for sex in the past 6 months were recruited and completed their interview in Kunming, Yunnan Province, China.

Results: Findings confirm the high prevalence of SGBV against adolescent FSWs in China, with 38% (118/310) of participants affected in the past year. Moreover, our study demonstrated the low uptake of public health services and high rates of prior unwanted pregnancy (52%; 61/118), abortion (53%; 63/118) and self-reported STI symptoms (84%; 99/118) in participants who were exposed to SGBV. Forced sexual debut was reported by nearly a quarter of FSWs (23%; 70/310) and was independently associated with having had a drug-using intimate partner and younger age (<17 years old) at first abortion. When controlling for potential confounders, having experienced SGBV was associated with frequent alcohol use, having self-reported symptoms of STI, having an intimate partner and having an intimate partner with illicit drug use.

Conclusions: This study calls for effective and integrated interventions addressing adolescent FSWs' vulnerability to SGBV and broader SRH consequences.

Abstract  Full-text [free] access 

Editor’s notes: The paper reports a study conducted to measure the prevalence and correlates of sexual and gender-based violence among Chinese adolescent female sex workers, given the paucity of data on this. A cross-sectional survey was conducted in the Yunnan Province, which has a relatively high HIV-1 prevalence. Around 300 women aged 15-19 years, who had received money or gifts in exchange for sex in the past six months were recruited for a survey.

The survey revealed that over half the female sex workers were married or cohabiting but lived predominantly with other sex workers or friends, or alone. The majority reported that they had been a sex worker for less than six months. Over the past year, 82% of the female sex workers had an intimate partner, and most of these relationships were for less than one year. Alcohol use was common, with 83% of the female sex workers reporting drinking alcohol at least twice a week. Inconsistent condom use in the past month was reported by 57% of the female sex workers.

Around a quarter of women’s first sexual experience was forced. Thirty-eight per cent of the female sex workers reported having experienced sexual and gender-based violence in the past year, with three quarters of women reporting the perpetrator as their intimate male partner and (62%) a male paying client. The female sex workers experiencing sexual and gender-based violence in the past year were more likely to be frequent drinkers or have a drug-using intimate partner. Women who experienced sexual and gender-based violence were more likely to report unwanted pregnancy, and less likely to use public health facilities or HIV testing services.

The authors suggest that their findings reveal a missed opportunity for the public health sector to address sexual and gender-based violence and associated sexual and reproductive health issues. However, they suggested there is a need to involve women-led community-based organisations to build relationships with female sex workers to enable them to utilise such services. There is also a need for further research on integrated programmes to prevent or reduce sexual and gender-based violence against adolescent female sex workers. 

Epidemiology, Gender
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Violence and HIV among poor urban women in the USA

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

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

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

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

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

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

Abstract access  

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

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

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

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

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

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

Abstract Full-text [free] access

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

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Preventing intimate partner violence for HIV positive women

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

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

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

Abstract access 

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

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

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

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

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Pregnancy and intimate partner violence among women living with HIV

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

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

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

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

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

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

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

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

Trial registration number: NCT01933477.

Abstract  Full-text [free] access 

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

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

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

South Africa
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Updated evidence that DMPA increases HIV risk among women

Update on hormonal contraceptive methods and risk of HIV acquisition in women: a systematic review of epidemiological evidence, 2016.

Polis CB, Curtis KM, Hannaford PC, Phillips SJ, Chipato T, Kiarie JN, Westreich DJ, Steyn PS. AIDS. 2016 Aug 5. [Epub ahead of print]

Objective and design: Some studies suggest that specific hormonal contraceptive (HC) methods (particularly depot medroxyprogesterone acetate [DMPA]) may increase women's HIV acquisition risk. We updated a systematic review to incorporate recent epidemiological data.

Methods: We searched for articles published between 1/15/2014-1/15/2016, and hand-searched reference lists. We identified longitudinal studies comparing users of a specific HC method against either (1) non-users of HC, or (2) users of another specific HC method. We added newly identified studies to those in the previous review, assessed study quality, created forest plots to display results, and conducted a meta-analysis for data on DMPA versus no HC.

Results: We identified ten new reports: five were considered "unlikely to inform the primary question". We focus on the other five reports, along with 9 from the previous review, considered "informative but with important limitations". The preponderance of data for oral contraceptive pills, injectable norethisterone enanthate (NET-EN), and levonorgestrel implants do not suggest an association with HIV acquisition, though data for implants are limited. The new, higher-quality studies on DMPA (or non-disaggregated injectables), which had mixed results in terms of statistical significance, had hazard ratios (HR) between 1.2 and 1.7, consistent with our meta-analytic estimate for all higher-quality studies of HR 1.4.

Conclusions: While confounding in these observational data cannot be excluded, new information increases concerns about DMPA and HIV acquisition risk in women. If the association is causal, the magnitude of effect is likely ≤HR 1.5. Data for other hormonal contraceptive methods, including NET-EN, are largely reassuring.

Abstract access

Editor’s notes: For several years there has been debate about whether the risk of HIV acquisition in women may be increased by the use of hormonal contraception. A systematic review published in 2014 included a meta-analysis of data from 22 studies, and this paper adds 10 new studies to the analysis. While these new papers carried some of the previous review’s limitations which cannot be ignored, the new data also lends further strength to the evidence and renewed analysis. The authors found some encouraging results which suggest that there is no significant increased risk of HIV with the use of oral contraceptives and the NET-EN injectable. However, this analysis does suggest that there is an increased risk of 1.4-1.5 of HIV with the use of DMPA. This is particularly concerning given the widespread use of this product throughout the world, and especially in areas where high rates of new HIV infections continue to persist, such as sub-Saharan Africa. Studies continue to explore this association of risk, and will hopefully produce evidence in the near future to definitively provide guidance as to how clinicians should direct the use of DMPA in women at risk of HIV. 

Africa, Northern America
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