Articles tagged as "Elimination of gender inequalities"

Research on intimate partner violence prevention - complex ethical issues

Ethical challenges of randomized violence intervention trials: examining the SHARE intervention in Rakai, Uganda.

Wagman JA, Paul A, Namatovu F, Ssekubugu R, Nalugoda F. Psychol Violence. 2016 Jul;6(3):442-451.

Objective: We identify complexities encountered, including unanticipated crossover between trial arms and inadequate 'standard of care' violence services, during a cluster randomized trial (CRT) of a community-level intimate partner violence (IPV) and HIV prevention intervention in Uganda.

Methods: Concepts in public health ethics - beneficence, social value of research, fairness, standard of care, and researcher responsibilities for post-trial benefits - are used to critically reflect on lessons learned and guide discussion on practical and ethical challenges of violence intervention CRTs.

Results: Existing ethical guidelines provide incomplete guidance for responding to unexpected crossover in CRTs providing IPV services. We struggled to balance duty of care with upholding trial integrity, and identifying and providing appropriate standard of care. While we ultimately offered short-term IPV services to controls, we faced additional challenges related to sustaining services beyond the 'short-term' and post-trial.

Conclusion: Studies evaluating community-level violence interventions, including those combined with HIV reduction strategies, are limited yet critical for developing evidence-based approaches for effectively preventing IPV. Although CRTs are a promising design, further guidance is needed to implement trials that avoid introducing tensions between validity of findings, researchers' responsibilities to protect participants, and equitable distribution of CRT benefits.

Abstract access

Editor’s notes: Data from 81 countries indicate that 30% of women aged 15 and above have experienced physical and/or sexual intimate partner violence in their lifetime. Settings with the highest intimate partner violence prevalence were found to be in sub-Saharan Africa, the region most affected by HIV.  Intimate partner violence is now widely accepted to be both a precursor to and sequelae of HIV infection. In response, a growing number of combination intimate partner violence and HIV prevention programmes have been implemented and systematically evaluated through randomised trials. The authors of this paper discuss some of the practical, ethical and safety challenges introduced by randomised trials on violence prevention, drawing on experience from a project in rural Uganda.

International guidelines have been established for the ethical conduct of biomedical research involving human subjects. The subject of violence against women and the method of randomised controlled trials are not easily resolved with these standard guidelines. In response, specialised recommendations for conducting safe and ethical population-based survey research on violence against women have been developed. These guidelines are an important development, but randomised trials to evaluate intimate partner violence prevention programmes face practical challenges in responding to common research ethics and safety considerations. These include: what to offer control communities in a trial investigating the optimal delivery approach for an activity likely to be effective in a setting with no standard of care. This needs to be done while maintaining the integrity of the study.

Drawing from their experience of the SHARE trial in the Rakai District in Uganda, the authors offer three reflections from lessons learned. (1) Ongoing need to formally update programmes that address multiple and overlapping vulnerabilities of individuals experiencing intimate partner violence and at risk of, or living with, HIV. (2) Cluster-randomised trials are a promising approach for programme evaluation but introduce numerous challenges with practical and ethical implications. (3) Given widespread underreporting of intimate partner violence, evaluation of violence programmes may have particularly high levels of unanticipated demand. The authors advocate for a framework of relevant considerations to be developed to guide researchers working on activities to reduce intimate partner violence. These guidelines should address potentially common challenges. They also encourage researchers to share field lessons arising from their studies in order to a) contribute to the development of this framework b) for revising and improving guidelines for the ethical conduct of intimate partner violence programmes in low resource settings.

Africa
Uganda
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High rates of intimate partner violence against women in Tanzania

Magnitude and factors associated with intimate partner violence in mainland Tanzania.

Kazaura MR, Ezekiel MJ, Chitama D. BMC Public Health. 2016 Jun 10;16(1):494. doi: 10.1186/s12889-016-3161-3.

Background: In Tanzania like in many sub-Saharan countries the data about Intimate Partner Violence (IPV) are scarce and diverse. This study aims to determine the magnitude of IPV and associated factors among ever partnered women in urban mainland Tanzania.

Methods: Data for this report were extracted from a big quasi-experimental survey that was used to evaluate MAP (MAP - Men as Partners) project. Data were collected using standard questions as those in big surveys like Demographic and Health Surveys. Data analyses involved descriptive statistics to characterize IPV. Associations between IPV and selected variables were based on Chi-square test and we used binary logistic regression to assess factors associated with women's perpetration to physical IPV and Odds Ratio (OR) as outcome measures with their 95 % confidence intervals (CI).

Results: The lifetime exposure to IPV was 65 % among ever-married or ever-partnered women with 34, 18 and 21 % reporting current emotional, physical and sexual violence respectively. Seven percent of women reported having ever physically abused partners. The prevalence of women perpetration to physical IPV was above 10 % regardless to their exposure to emotional, physical or sexual IPV.

Conclusions: IPV towards women in this study was high. Although rates are low, there is some evidence to suggest that women may also perpetrate IPV against their partners. Based on hypothesis of IPV and HIV co-existence, there should be strategies to address the problem of IPV especially among women.

Abstract  Full-text [free] access 

Editor’s notes: This paper adds to the growing evidence of the extent of intimate partner violence in the United Republic of Tanzania perpetrated towards women and some evidence of intimate partner violence against men. The authors conducted a cross-sectional study to evaluate the CHAMPION (Channeling Men’s Positive Involvement in a National HIV/AIDS Response) study in one district in six regions in Tanzania (Dar es Salaam, Kagera, Mbeya, Mwanza, Tabora and Ruvuma).

The authors did not find any association between the prevalence of intimate partner violence and demographic characteristics. This was unlike other studies, which found an association between intimate partner violence and age, education and marital status. This may have been due to limitations in the design of the study, but may also suggest that intimate partner violence is widespread across age and education. The paper strengthens calls for more programmes to address intimate partner violence.

Gender
Africa
United Republic of Tanzania
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Preventing risky sexual behaviour and intimate partner violence in adolescents

Effects of PREPARE, a multi-component, school-based HIV and intimate partner violence (IPV) prevention programme on adolescent sexual risk behaviour and IPV: cluster randomised controlled trial.

Mathews C, Eggers SM, Townsend L, Aaro LE, de Vries PJ, Mason-Jones AJ, De Koker P, McClinton Appollis T, Mtshizana Y, Koech J, Wubs A, De Vries H. AIDS Behav. 2016 May 3. [Epub ahead of print]

Young South Africans, especially women, are at high risk of HIV. We evaluated the effects of PREPARE, a multi-component, school-based HIV prevention intervention to delay sexual debut, increase condom use and decrease intimate partner violence (IPV) among young adolescents. We conducted a cluster RCT among Grade eights in 42 high schools. The intervention comprised education sessions, a school health service and a school sexual violence prevention programme. Participants completed questionnaires at baseline, 6 and 12 months. Regression was undertaken to provide ORs or coefficients adjusted for clustering. Of 6244 sampled adolescents, 55.3 % participated. At 12 months there were no differences between intervention and control arms in sexual risk behaviours. Participants in the intervention arm were less likely to report IPV victimisation (35.1 vs. 40.9 %; OR 0.77, 95 % CI 0.61-0.99; t(40) = 2.14) suggesting the intervention shaped intimate partnerships into safer ones, potentially lowering the risk for HIV.

Abstract access

Editor’s notes: Worldwide, HIV is one of the leading causes of death among adolescents. A key objective of the Global Strategy for Women’s, Children’s and Adolescents’ Health, launched in 2015, is to end the HIV epidemic by 2030. In South Africa, the prevalence and incidence of HIV remains high among young South Africans, especially among women. Early sexual debut and condomless sex are risk factors for HIV and other sexually transmitted infections. Another important risk factor in South Africa is the high level of intimate partner violence, which can also increase the risk of HIV infection among women. This cluster randomised trial sought to address these risk factors among young adolescents (average age 13 years) in public high schools in the Western Cape. The education component of the programme comprised 21 sessions delivered weekly immediately after school. One explanation for the lack of an effect on sexual behaviour was sub-optimal exposure to the activity as a result of poor attendance at sessions. Overall, the mean attendance was 8.02 sessions with higher attendance among girls than among boys. Even so, self-reported intimate partner violence – a factor that predisposes HIV infection – was reduced. The investigators suggest that this may be because attendance was higher at earlier sessions, which addressed gender issues, so more participants received exposure to content associated with intimate partner violence than sexual behaviour.

Achieving high, sustained attendance rates at after-school programmes is challenging and as the investigators note, perhaps the most efficient way to ensure that adolescents receive adequate exposure to HIV risk reduction programmes is to embed them in the school curriculum. However, programmes also need to address other structural, social and environmental factors affecting HIV infection.

Africa
South Africa
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Intimate partner violence is a challenge to PrEP adherence

Intimate partner violence and adherence to HIV pre-exposure prophylaxis (PrEP) in African women in HIV serodiscordant relationships: a prospective cohort study.

Roberts ST, Haberer J, Celum C, Mugo N, Ware NC, Cohen CR, Tappero JW, Kiarie J, Ronald A, Mujugira A, Tumwesigye E, Were E, Irungu E, Baeten JM. J Acquir Immune Defic Syndr. 2016 May 26. [Epub ahead of print]

Background: Intimate partner violence (IPV) is associated with higher HIV incidence, reduced condom use, and poor adherence to antiretroviral therapy and other medications. IPV may also affect adherence to pre-exposure prophylaxis (PrEP).

Methods: We analyzed data from 1785 HIV-uninfected women enrolled in a clinical trial of PrEP among African HIV-serodiscordant couples. Experience of verbal, physical, or economic IPV was assessed at monthly visits by face-to-face interviews. Low PrEP adherence was defined as clinic-based pill count coverage <80% or plasma tenofovir levels <40 ng/mL. The association between IPV and low adherence was analyzed using generalized estimating equations, adjusting for potential confounders. In-depth interview transcripts were examined to explain how IPV could impact adherence.

Results: 16% of women reported IPV during a median of 34.8 months of follow-up (IQR 27.0 - 35.0). Overall, 7% of visits had pill count coverage <80% and 32% had plasma tenofovir <40 ng/mL. Women reporting IPV in the past 3 months had increased risk of low adherence by pill count (adjusted RR 1.49, 95% CI 1.17-1.89) and by plasma tenofovir (adjusted RR 1.51, 95% CI 1.06-2.15). Verbal, economic, and physical IPV were all associated with low adherence. However, the impact of IPV diminished and was not statistically significant 3 months after the reported exposure. In qualitative interviews, women identified several ways in which IPV affected adherence, including stress and forgetting, leaving home without pills, and partners throwing pills away.

Conclusion: Women who reported recent IPV in the Partners PrEP Study were at increased risk of low PrEP adherence. Strategies to mitigate PrEP non-adherence in the context of IPV should be evaluated.

Abstract access

Editor’s notes: The high rates of HIV infection in women underscore persistent gender inequalities, in particular that of violence against women. Intimate partner violence (IPV) puts women at increased risk of HIV infection. Further, among women living with HIV, IPV has also been associated with lower rates of treatment uptake and adherence to antiretroviral therapy (ART). The interaction between IPV and HIV is complex, and includes biological, socio-economic and cultural mechanisms. This is the first study to examine the association between IPV and adherence to HIV pre-exposure prophylaxis (PrEP).  Women who had experienced IPV in the past three months were 50% more likely than women who had never experienced IPV to have poor adherence, as measured by both pills counts and drug levels in the blood.  Recent IPV was also associated with an increase in the risk of HIV infection.  Women in the study were in stable, serodiscordant relationships, had enrolled in the study together with their partners, and were using PrEP with their partner’s consent. The proportion of women reporting IPV during the study was much lower than national estimates in the region.  These findings are thus of concern for PrEP demonstration projects focusing on key populations at high risk of HIV, who may experience higher rates of IPV and be less likely to have partner support. 

PrEP is a key element of combination HIV prevention strategies in high-risk populations, but requires high adherence in order to be effective. Programmes focusing on promoting PrEP adherence in women who have experienced violence are urgently needed.  More broadly, HIV prevention programmes should be expanded to integrate IPV prevention as an important component to reducing women’s risk of HIV.

Africa
Kenya, Uganda
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Intimate partner violence among female sex workers living with HIV must be addressed to improve their wellbeing and reduce onward transmission of HIV

A prospective cohort study of intimate partner violence and unprotected sex in HIV-positive female sex workers in Mombasa, Kenya.

Wilson KS, Deya R, Yuhas K, Simoni J, Vander Stoep A, Shafi J, Jaoko W, Hughes JP, Richardson BA, McClelland RS. AIDS Behav. 2016 Apr 19. [Epub ahead of print]

We conducted a prospective cohort study to test the hypothesis that intimate partner violence (IPV) is associated with unprotected sex in HIV-positive female sex workers in Mombasa, Kenya. Women completed monthly visits and quarterly examinations. Any IPV in the past year was defined as ≥1 act of physical, sexual, or emotional violence by the current or most recent emotional partner ('index partner'). Unprotected sex with any partner was measured by self-report and prostate specific antigen (PSA) test. Recent IPV was associated with significantly higher risk of unprotected sex (adjusted relative risk [aRR] 1.91, 95 % CI 1.32, 2.78, p = 0.001) and PSA (aRR 1.54, 95 % CI 1.17, 2.04, p = 0.002) after adjusting for age, alcohol use, and sexual violence by someone besides the index partner. Addressing IPV in comprehensive HIV programs for HIV-positive women in this key population is important to improve wellbeing and reduce risk of sexual transmission of HIV.

Abstract access  

Editor’s notes: Intimate partner violence (IPV) is the most common form of gender-based violence globally. A recent systematic review reported high prevalence of IPV in sub-Saharan Africa, ranging from 30% to 66% among ever partnered women. Negative outcomes associated with IPV include increased risk of HIV infection and there are multiple pathways through which IPV may increase the risk of HIV infection in women. These include reduced sexual relationship power and ability to negotiate condom, and more risky sexual behaviour. Furthermore, IPV may be a marker of relationships with men who have a history of violent behaviour and may be at increased risk of HIV themselves. Women living with HIV are also at increased risk of IPV, which in turn can increase the risk of condomless sex and onward transmission of HIV.

Female sex workers are a key population disproportionately affected by violence, substance abuse and HIV. This longitudinal study of female sex workers in Kenya found a significant association between IPV and condomless sex. It highlights the value of using both self-reported behavioural and biological markers of sexual behaviour to gain a more complete understanding of the relationship between IPV and risky sexual behaviour. Comprehensive HIV programmes must address IPV to improve both the health and well-being of women living with HIV and to reduce sexual transmission of HIV. 

Africa
Kenya
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Addressing property rights may impact on women’s experiences of violence

Perceived impact of a land and property rights program on violence against women in rural Kenya: a qualitative investigation.  

Hilliard S, Bukusi E, Grabe S, Lu T, Hatcher AM, Kwena Z, Mwaura-Muiru E, Dworkin SL. Violence Against Women. 2016 Mar 6. pii: 1077801216632613. [Epub ahead of print] 

The current study focuses on a community-led land and property rights program in two rural provinces in western Kenya. The program was designed to respond to women's property rights violations to reduce violence against women and HIV risks at the community level. Through in-depth interviews with 30 women, we examine the perceived impact that this community-level property rights program had on violence against women at the individual and community level. We also examine perceptions as to how reductions in violence were achieved. Finally, we consider how our findings may aid researchers in the design of structural violence-prevention strategies. 

Abstract access  

Editor’s notes: This paper reports on women’s experiences of violence following reporting of disinheritance to a community–led property rights violations programme in Kenya. The research was set in two rural districts in Kenya, where HIV prevalence is high (23.8-33%) and property rights violations are common. Interviews were conducted with women who participated in GROOTS-Kenya’s Community Land and Property Watch Dog Model (CWDG). This model is comprised of volunteer women and men. These people monitor women’s disinheritance locally and mediate land disputes. They also refer unresolved cases to formal adjudication mechanisms and raise awareness about women’s rights.  

The researchers found that for nearly all of the women, violence ceased immediately on reporting cases of violent disinheritance to the CWDG. The presence of the CWDG led to a broader reduction in sexual and domestic violence against women at the community level. The women explained that this was for four reasons: (a) improved individual- and community-level knowledge about women’s rights/improved knowledge about violence against women, (b) the existence of a community-based mechanism for reporting cases of violence, (c) the responsiveness of the CWDG to cases of violence, and (d) fears that perpetrators had about the legal consequences of perpetrating violence. This research contributes to a growing body of evidence that addressing structural factors such as economic empowerment is important. However, there is a need to strengthen this approach through providing women with property rights.  Property rights may empower women more than other economic empowerment approaches such as micro-finance.  

Africa
Kenya
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The power of love

Power and the association with relationship quality in South African couples: Implications for HIV/AIDS interventions.

Conroy AA, McGrath N, van Rooyen H, Hosegood V, Johnson MO, Fritz K, Marr A, Ngubane T, Darbes LA. Soc Sci Med. 2016 Jan 28;153:1-11. doi: 10.1016/j.socscimed.2016.01.035. [Epub ahead of print]

Introduction: Power imbalances within sexual relationships have significant implications for HIV prevention in sub-Saharan Africa. Little is known about how power influences the quality of a relationship, which could be an important pathway leading to healthy behavior around HIV/AIDS.

Methods: This paper uses data from 448 heterosexual couples (896 individuals) in rural KwaZulu-Natal, South Africa who completed baseline surveys from 2012 to 2014 as part of a couples-based HIV intervention trial. Using an actor-partner interdependence perspective, we assessed: (1) how both partners' perceptions of power influences their own (i.e., actor effect) and their partner's reports of relationship quality (i.e., partner effect); and (2) whether these associations differed by gender. We examined three constructs related to power (female power, male equitable gender norms, and shared power) and four domains of relationship quality (intimacy, trust, mutually constructive communication, and conflict).

Results: For actor effects, shared power was strongly and consistently associated with higher relationship quality across all four domains. The effect of shared power on trust, mutually constructive communication, and conflict were stronger for men than women. The findings for female power and male equitable gender norms were more mixed. Female power was positively associated with women's reports of trust and mutually constructive communication, but negatively associated with intimacy. Male equitable gender norms were positively associated with men's reports of mutually constructive communication. For partner effects, male equitable gender norms were positively associated with women's reports of intimacy and negatively associated with women's reports of conflict.

Conclusions: Research and health interventions aiming to improving HIV-related behaviors should consider sources of shared power within couples and potential leverage points for empowerment at the couple level. Efforts solely focused on empowering women should also take the dyadic environment and men's perspectives into account to ensure positive relationship outcomes.

 Abstract  Full-text [free] access 

Editor’s notes: This paper reports findings of a study conducted in rural KwaZulu-Natal province in South Africa. KwaZulu-Natal has the highest adult HIV prevalence in South Africa of 17%. The study draws on data from 448 couples (896 individuals) that completed a 2012 baseline study of “Uthando Lwethu” – a randomised controlled trial of a couples-based programme to improve relationship dynamics and uptake of couples-based HIV testing and counselling. 

The findings highlight several implications for HIV programmes in sub-Saharan Africa.  They illustrate that gender transformative activities may have a positive effect on relationships, especially where they do not inadvertently conflict with relationship values such as intimacy. The findings also highlight the synergistic potential of gender-focused programmes and couple-based programmes focusing on HIV, to both improve relationships and reduce HIV-associated behavioural risk.  Further, the findings suggest the importance of the construct of shared gender power when considering the prioritisation of resources and efforts for couple-based programmes. This highlights the potential for developing new ways of conceptualising power with couples that go beyond dyadic constructs at the individual level.

Gender
Africa
South Africa
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Gender inequity expressed as infidelity and jealousy by Nicaraguan men

Gender-specific jealousy and infidelity norms as sources of sexual health risk and violence among young coupled Nicaraguans.

Boyce S, Zeledon P, Tellez E, Barrington C. Am J Public Health. 2016 Feb 18:e1-e8. [Epub ahead of print]

Gender inequity negatively affects health in Central America. In 2011, we conducted 60 semistructured interviews and 12 photovoice focus groups with young coupled men and women in Leon, Nicaragua, to explore the ways in which social norms around marriage and gender affect sexual health and gender-based violence. Participants' depictions of their experiences revealed gendered norms around infidelity that provided a narrative to justify male expressions of jealousy, which included limiting partner autonomy, sexual coercion, and physical violence against women, and resulted in increased women's risk of sexually transmitted infections, including HIV. By understanding and taking account of these different narratives and normalized beliefs in developing health- and gender-based violence interventions, such programs might be more effective in promoting gender-equitable attitudes and behaviors among young men and women in Nicaragua.

Abstract access

Editor’s notes: This interesting paper explored persistent gender inequity in Nicaragua and its effects on sexual health and experiences of gender-based violence. The authors draw on an understanding that in Nicaragua gender inequity is expressed through local ideas of ‘machismo’, the masculine expectation of dominance over women. This is demonstrated through overemphasized heterosexuality, and aggression, and ‘marianismo’, the feminine expectation of submissiveness, dependence, and sexual naivety. The authors conducted two semi-structured in-depth interviews with 30 young coupled men (n = 15) and women (n = 15) and focus groups with a subsample of women (n= 6) and men (n= 5) who participated in interviews. They also asked these participants to take three photos about a discussion topic, which were discussed at a following session.

Their findings revealed two themes concerning fidelity and jealousy. Participants discussed the social acceptability of infidelity by men, and jealous behaviour by men. Women reported having little power to influence their husbands to remain faithful or to stop being jealous. The authors argue that infidelity and jealousy norms are expressions of gender inequity and impact on women’s risk of sexually transmitted infections, sexual coercion, and violence. These factors reflect constrained female sexuality and economic power. The authors conclude that while gender norms in Nicaragua are changing, progress toward gender equity is slow. Programmes to address gender inequity should frame this in terms of jealousy and infidelity, complemented with structural and systemic programmes to address gender-based social and economic inequities.

Gender
Latin America
Nicaragua
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Inequalities in decision-making and carrying the burden of taking PrEP in serodiscordant relationships

Gendered differences in the perceived risks and benefits of oral PrEP among HIV-serodiscordant couples in Kenya.

Carroll JJ, Ngure K, Heffron R, Curran K, Mugo NR, Baeten JM. AIDS Care. 2016 Jan 11:1-7. [Epub ahead of print]

Pre-exposure prophylaxis (PrEP) is effective for preventing HIV among HIV-serodiscordant heterosexual couples. Gender roles may influence perceived personal and social risks related to HIV-prevention behaviors and may affect use of PrEP. In this study, interviews and focus groups were conducted with 68 individuals from 34 mutually disclosed serodiscordant heterosexual partnerships in Thika, Kenya. Sociocultural factors that affect adherence to PrEP were explored using grounded analysis. Three factors were identified, which shape perceptions of PrEP: gendered power dynamics and control over decision-making in the household; conflicts between risk-reduction strategies and male sexual desire; culture-bound definitions of women's work. Adherence to PrEP in the Partners PrEP Study was high; however, participants articulated conflicting interests related to PrEP in connection with traditional gender roles. The successful delivery of PrEP will require understanding of key social factors, particularly related to gender and dyadic dynamics around HIV serostatus.

Abstract access 

Editor’s notes: If the use of pre-exposure prophylaxis (PrEP) and other biomedical approaches to HIV-prevention are to be rolled out effectively, it is vital to understand the barriers and facilitators for use. In this paper, the authors explore factors that shape perceived risks, benefits and barriers of using oral PrEP and other associated HIV-prevention strategies in Partners PrEP trial in Uganda. The authors identified three themes. Firstly ‘gendered power dynamics and control over decision-making in the household’ highlighted how men and women have different power in decision-making about PrEP use. The majority of women reported that the decision lay with their partner and men reported that they were solely responsible for their decision to use PrEP. However, women said they used subtler ways to exert their decision. Some men suggested that the use of PrEP should be a joint decision. The second theme, ‘conflicts between risk-reduction strategies and male sexual desire’ revealed that use of condoms for HIV prevention conflicted with men’s desire for pleasure, especially for seronegative men. For seropositive women concerns were voiced about men seeking sexual pleasure elsewhere. The third theme of culture-bound definitions of women’s work in the household highlighted how taking PrEP was seen to be ‘labour’ and a household task. HIV-seronegative men thus considered the management of clinic visits and drug regimens to be women’s responsibility and PrEP taking, as men’s burden. Thinking PrEP taking was a burden on men; HIV-seropositive women framed their responsibilities in terms of sacrifices that they made for their families. However, seropositive men did not refer to PrEP as a burden at all.

The authors conclude that while these reported gender differences between partners taking PrEP are stresses, given the high adherence to PrEP in the Partners PrEP trial they did not seem to be a deterrent. This study confirms evidence of gender inequalities in decision-making about the use HIV prevention technologies, including PrEP and condoms. Further, the authors provide new insights into the ‘labour’ discourse of taking medication and attending clinics and illustrate that this burden is seen as women’s work. 

Gender
Africa
Kenya
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