Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Female sex workers are a population who are at heightened risk of HIV infection secondary to biological, behavioural, and structural risk factors. However, three decades into the HIV pandemic, understanding of the burden of HIV among these women remains limited. We aimed to assess the burden of HIV in this population compared with that of other women of reproductive age.

METHODS

We searched PubMed, Embase, Global Health, SCOPUS, PsycINFO, Sociological Abstracts, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Web of Science, and POPLine for studies of female sex workers in low-income and middle-income countries published between Jan 1, 2007, and June 25, 2011. Studies of any design that measured the prevalence or incidence of HIV among female sex workers, even if sex workers were not the main focus of the study, were included. Meta-analyses were done with the Mantel-Haenszel method with a random-effects model characterising an odds ratio for the prevalence of HIV among female sex workers compared with that for all women of reproductive age.

FINDINGS

Of 434 selected articles and surveillance reports, 102 were included in the analyses, representing 99,878 female sex workers in 50 countries. The overall HIV prevalence was 11·8% (95% CI 11·6-12·0) with a pooled odds ratio for HIV infection of 13·5 (95% CI 10·0-18·1) with wide intraregional ranges in the pooled HIV prevalence and odds ratios for HIV infection. In 26 countries with medium and high background HIV prevalence, 30·7% (95% CI 30·2-31·3; 8627 of 28,075) of sex workers were HIV-positive and the odds ratio for infection was 11·6 (95% CI 9·1-14·8).

INTERPRETATION

Although data characterising HIV risk among female sex workers is scarce, the burden of disease is disproportionately high. These data suggest an urgent need to scale up access to quality HIV prevention programmes. Considerations of the legal and policy environments in which sex workers operate and actions to address the important role of stigma, discrimination, and violence targeting female sex workers is needed.

FUNDING

The World Bank, UN Population Fund.

Multi-person sex among a sample of adolescent female urban health clinic patients

Adolescent sexual activity involving three or more people is an emerging public health concern. The goal of this exploratory, cross-sectional study was to describe the prevalence, correlates, and context of multiple-person sex among a sample of adolescent females seeking health care from an urban clinic. Because sex involving multiple people may either be consensual (i.e., "three-ways" or "group sex") or forced (i.e., "gang rape"), we use the term "multi-person sex" (MPS) to encompass these experiences. Subjects were 328 females, ages 14-20 years old, who utilized a Boston-area community- or school-based health clinic between April and December of 2006, and completed an anonymous survey using computer-assisted self-interview software. Overall, 7.3% reported ever having had a MPS experience. Of these, 52% reported ever being pressured to engage in MPS and 43% reported ever being threatened or forced. Condom nonuse by at least one male participant in the most recent MPS was reported by 45%. Controlling for potential demographic confounders, MPS was associated with cigarette smoking (adjusted prevalence ratio [APR], 3.83; 95% confidence interval [CI], 1.56-9.44), sexual initiation prior to age 15 (APR, 2.50; 95% CI, 1.04-5.98), ever being diagnosed with an STI (APR, 2.55; 95% CI, 1.08-6.03), dating violence victimization (APR, 4.43; 95% CI, 1.68-11.69), childhood sexual abuse victimization (APR, 4.30; 95% CI, 1.83-10.07) and past-month pornography exposure (APR, 4.79; 95% CI, 1.91-11.98). Additional study of the perpetration and prevention of adolescent MPS is urgently needed.

Injection drug use, sexual risk, violence and STI/HIV among Moscow female sex workers

BACKGROUND/OBJECTIVES

The HIV prevalence in Eastern Europe and Central Asia continues to increase. While injection drug use (IDU) is leading factor, heterosexual transmission is on the rise. Little is known about female sex workers (FSWs) in the region despite the central role of commercial sex in heterosexual sexually transmitted infection (STI)/HIV transmission globally. The authors evaluated the prevalence of STI/HIV among Moscow-based FSWs and potential risk factors including IDU, sexual risks and violence victimisation.

METHODS

Moscow-based FSWs (n=147) completed a clinic-based survey and STI/HIV testing over an 8-month period in 2005.

RESULTS

HIV prevalence was 4.8%, and 31.3% were infected with at least one STI including HIV. Sexual behaviours significantly associated with STI/HIV included anal sex (adjusted odds ratio (AOR) 3.48), high client volume (three or more clients daily, AOR 2.71), recent subbotnik (sex demanded by police; AOR 2.50) and regularly being presented with more clients than initially agreed to (AOR 2.45). Past year experiences of physical violence from clients and threats of violence from pimps were associated with STI/HIV (AOR 3.14 and AOR 3.65, respectively). IDU was not significantly associated with STI/HIV. Anal sex and high client volume partially mediated the associations of abuse with STI/HIV.

CONCLUSIONS

Findings illustrate substantial potential for heterosexual STI/HIV transmission in a setting better known for IDU-related risk. Many of the STI/HIV risks observed are not modifiable by FSWs alone. STI/HIV prevention efforts for this vulnerable population will benefit from reducing coercion and abuse perpetrated by pimps and clients.

Sex trafficking and initiation-related violence, alcohol use, and HIV risk among HIV-infected female sex workers in Mumbai, India

Female sex workers (FSWs) are the group at greatest risk for human immunodeficiency virus (HIV) infection in India. Women and girls trafficked (ie, forced or coerced) into sex work are thought to be at even greater risk because of high exposure to violence and unprotected sex, particularly during the early months of sex work, that is, at initiation. Surveys were completed with HIV-infected FSWs (n = 211) recruited from an HIV-related service organization in Mumbai, India. Approximately 2 in 5 participants (41.7%) reported being forced or coerced into sex work. During the first month in sex work, such FSWs had higher odds of sexual violence (adjusted odds ratio [AOR], 3.1; 95% confidence interval [CI], 1.6-6.1), ≥ 7 clients per day (AOR, 3.3; 1.8-6.1), no use of condoms (AOR, 3.8, 2.1-7.1), and frequent alcohol use (AOR, 1.9; 1.0-3.4) than HIV-infected FSWs not entering involuntarily. Those trafficked into sex work were also at higher odds for alcohol use at first sex work episode (AOR, 2.2; 95% CI, 1.2-4.0). These results suggest that having been trafficked into sex work is prevalent among this population and that such FSWs may face high levels of sexual violence, alcohol use, and exposure to HIV infection in the first month of sex work. Findings call into question harm reduction approaches to HIV prevention that rely primarily on FSW autonomy.

Abuse from in-laws during pregnancy and post-partum: qualitative and quantitative findings from low-income mothers of infants in Mumbai, India

To examine experiences of perinatal (in pregnancy or post-partum) abuse from in-laws and to assess associations between such experiences and perinatal intimate partner violence (IPV) from husbands, as reported by Indian women residing in low-income communities in Mumbai. The present study includes both qualitative and quantitative research conducted across two phases of study. The qualitative phase involved face-to-face, semi-structured in-depth interviews (n = 32) with women seeking health care for their infants (6 months or younger) and self-reporting emotional or physical abuse from their husband. The quantitative arm involved survey data collection (n = 1,038) from mothers seeking immunization for their infants 6 months or younger at three large Urban Health Centers in Mumbai. Results of the qualitative study documented the occurrence of both non-physical and physical abuse from in-laws during pregnancy and post-partum. Non-physical forms of abuse included forced heavy domestic labor, food denial and efforts toward prevention of medical care acquisition. Quantitative results demonstrated that 26.3% of the sample reported perinatal abuse (non-physical and physical) from in-laws and that women experiencing perinatal sexual or physical IPV from husbands were significantly more likely to report perinatal abuse from in-laws (AOR = 5.33, 95% CI = 3.93-7.23). Perinatal abuse from in-laws is not uncommon among women in India and may be compromising maternal and child health in this context; such abuse is also linked to perinatal violence from husbands. Programs and interventions that screen and address IPV in pregnant and post-partum populations in India should be developed to include consideration of in-laws.

Intimate partner violence and partner notification of sexually transmitted infections among adolescent and young adult family planning clinic patients

Patient-initiated partner notification of sexually transmitted infection (STI), i.e. patients informing their sexual partners of a diagnosis, is a cornerstone of STI prevention. Growing evidence suggests that women exposed to intimate partner violence (IPV) may fear such notification, or face negative consequences in response to STI disclosure. The current study assessed associations of IPV with fear of partner notification, and experiences of partner notification, among adolescent and young adult female family planning clinic patients. Women aged 16-29 years attending five family planning clinics in Northern California, USA (n = 1282) participated in a cross-sectional survey. A history of physical or sexual IPV was associated with fear of partner notification. Moreover, participants exposed to IPV were more likely to have partners say that it was not from them or otherwise accuse them of cheating in response to partner notification. Such partners were less likely to seek indicated STI treatment or testing. Current findings suggest that partner notification for STI may be compromised by IPV. Clinical practices and policies to support effective partner notification should include IPV assessment, and provide mechanisms to address related fears concerning partner notification.

School bullying perpetration and other childhood risk factors as predictors of adult intimate partner violence perpetration

OBJECTIVE

To assess the relationship between bullying peers as a child and adult intimate partner violence perpetration in a clinic-based sample of adult men. School bullying perpetration and intimate partner violence perpetration are both thought to stem from desire for power and control over others.

DESIGN

A cross-sectional survey was conducted between January 2005 and December 2006.

SETTING

Three urban community health centers in Boston, Massachusetts.

PARTICIPANTS

Men aged 18 to 35 years (n = 1491) seeking services at participating community health centers.

MAIN EXPOSURE

School bullying perpetration.

OUTCOME MEASURE

Past-year physical or sexual violence perpetration against a female partner (intimate-partner violence [IPV]).

RESULTS

Two-fifths of men reported perpetrating school bullying as a child (n = 610; 40.9%). Men who rarely bullied in school were 1.53 times more likely to perpetrate past-year IPV than men who did not bully (95% confidence interval [CI], 1.02-2.29); this risk was elevated to 3.82 times more likely to perpetrate any past-year IPV for those men who bullied peers frequently (95% CI, 2.55-5.73).

CONCLUSIONS

The present study indicates that bullying peers in school as a child, especially frequent bullying perpetration, is associated with increased risk for men's perpetration of IPV as an adult. The effect remains strong after controlling for common prior risk factors for both bullying and IPV perpetration. Future research is needed to discern the mechanisms and underlying root causes of abusive behavior, such as power and control, as a means to prevent violence perpetration across settings and life stages.

Coercive forms of sexual risk and associated violence perpetrated by male partners of female adolescents

CONTEXT

Partner violence is associated with STDs among female adolescents, but the mechanisms underlying this association remain unclear. Sexually coercive and deceptive behaviors of male partners that increase female STD risk may be factors in this relationship.

METHODS

A sample of 356 females aged 14-20 who attended adolescent health clinics in Greater Boston between April and December 2006 were assessed for physical and sexual violence perpetrated by male partners and for exposure to sexual risk factors. Adjusted logistic regression models were used to examine the associations between intimate partner violence and standard sexual risk behaviors (e.g., multiple partnerships) and coercive or deceptive sexual risk factors (e.g., coerced condom nonuse).

RESULTS

More than two-fifths of the sample had experienced intimate partner violence. In adjusted analyses, adolescents reporting intimate partner violence were more likely than others to report standard sexual risk behaviors--multiple partners, anal sex and unprotected anal sex (odds ratios, 1.7-2.2). They also were more likely to report coercive or deceptive sexual risk factors--partner sexual infidelity, fear of requesting condom use, negative consequences of condom request, and coerced condom nonuse (2.9-5.3).

CONCLUSION

The high prevalence of intimate partner violence against young women attending adolescent clinics strongly indicates the need to target this population for abuse-related interventions. This need is underlined by the observed association between partner violence and sexual risk involving coercion or deception by male partners. Clinic-based STD and pregnancy prevention efforts should include assessment of sexual risk factors that are beyond the control of young women, particularly for those experiencing abuse.

Gender-based disparities in infant and child mortality based on maternal exposure to spousal violence: the heavy burden borne by Indian girls

OBJECTIVES

To examine associations between intimate partner violence (IPV) against Indian women and risk of death among their infants and children, as well as related gender-based disparities.

DESIGN

Analyses of nationally representative data to estimate adjusted hazard ratios (aHRs) and attributable risks for infant and child mortality based on child gender and on IPV against mothers.

SETTING

India.

PARTICIPANTS

Women aged 15 to 49 years (n = 59,467) across all 29 Indian states participating in the Indian National Family Health Survey 3 provided information about 158,439 births and about infant and child mortality occurring during the 20 years before the survey.

MAIN OUTCOME MEASURES

Maternal IPV and infant and child (<5 years) mortality among boy vs girl children.

RESULTS

Infant mortality was greater among infants whose mothers experienced IPV (79.2 of 1000 births) vs those whose mothers did not experience IPV (59.1 of 1000 births) (aHR, 1.09; 95% confidence interval [CI], 1.03-1.15); this effect was significant only for girls (1.15; 1.07-1.24; for boys, 1.04; 0.97-1.11). Child mortality was also greater among children whose mothers experienced IPV (103.6 of 1000 births) vs those whose mothers did not experience IPV (74.8 per 1000 births) (aHR, 1.10; 95% CI, 1.05-1.15); again, this effect was significant only for girls (1.14; 1.07-1.21; for boys, 1.05; 0.99-1.12). An estimated 58,021 infant girl deaths and 89,264 girl child deaths were related to spousal violence against wives annually, or approximately 1.2 million female infant deaths and 1.8 million girl deaths in India between December 1985 and August 2005.

CONCLUSION

Intimate partner violence against women should be considered an urgent priority within programs and policies aimed at maximizing survival of children in India, particularly those attempting to increase the survival of girls 5 years and younger.

Male perpetration of intimate partner violence and involvement in abortions and abortion-related conflict

Men aged 18 to 35 years (n = 1318) completed assessments of perpetration of intimate partner violence (IPV), abortion involvement, and conflict regarding decisions to seek abortion. IPV was associated with greater involvement by men in pregnancies ending in abortion and greater conflict regarding decisions to seek abortion. IPV should be considered within family planning and abortion services; policies requiring women to notify or obtain consent of partners before seeking an abortion should be reconsidered; they may facilitate endangerment and coercion regarding such decisions.

Sex trafficking, sexual risk, sexually transmitted infection and reproductive health among female sex workers in Thailand

BACKGROUND

The trafficking of women and girls for sexual exploitation is an internationally recognised form of gender-based violence, and is thought to confer unique sexual and reproductive health vulnerabilities. To date, little research has compared sexual risk or health outcomes among female sex workers (FSWs) on the basis of experiences of sex trafficking.

AIM

To compare experiences of sexual risk and sexual and reproductive health outcomes among FSWs on the basis of experiences of trafficking as an entry mechanism to sex work.

METHODS

Data from a national sample of FSWs in Thailand (n=815) was used to assess (a) the prevalence of sex trafficking as an entry mechanism into sex work and (b) associations of sex trafficking with sexual risk and health outcomes.

RESULTS

Approximately 10% of FSWs met criteria for trafficking as an entry mechanism to sex work. Compared with their non-trafficked counterparts, sex-trafficked FSWs were more likely to have experienced sexual violence at initiation to sex work (adjusted risk ratio (ARR) 2.29, 95% CI 1.11 to 4.72), recent workplace violence or mistreatment (ARR 1.38, 95% CI 1.13 to 1.67), recent condom failure (ARR 1.80, 95% CI 1.15 to 2.80), condom non-use (ARR 3.35, 95% CI 1.49 to 7.52) and abortion (ARR 2.83, 95% CI 1.48 to 5.39).

DISCUSSION

Both the prevalence of sex trafficking as an entry mechanism to sex work and the threats to sexual and reproductive health observed on the basis of trafficking status show the need for comprehensive efforts to identify and support this vulnerable population. Moreover, existing STI/HIV-prevention programming may be stymied by the limited condom-use capacity and high levels of violence observed among those trafficked into sex work.

Intimate partner violence perpetration, immigration status, and disparities in a community health center-based sample of men

OBJECTIVE

We examined disparities in male perpetration of intimate partner violence (IPV) based on immigration status.

METHODS

From 2005 to 2006, 1,668 men aged 18-35 who were recruited from community health centers anonymously completed an automated, computer-assisted self-interview. Men self-reported their immigrant status (e.g., native-born, <6 years in the U.S. [recent immigrants], or > or = 6 years in the U.S. [non-recent immigrants]) and IPV perpetration. We calculated differences in IPV perpetration based on immigrant status. Among immigrant men, we further examined differences in IPV perpetration based on English-speaking ability.

RESULTS

Recent immigrants were less likely to report IPV perpetration than native-born men in the overall sample (adjusted odds ratio [AOR] = 0.60, 95% confidence interval [CI] 0.36, 1.00). However, we observed no differences in IPV perpetration between non-recent immigrants and native-born men (AOR=0.88, 95% CI 0.63, 1.23). Among immigrant men, those who were non-recent immigrants and reported limited English-speaking ability were at the highest risk for IPV perpetration, compared with recent immigrants with high English-speaking ability (AOR=7.48, 95% CI 1.92, 29.08).

CONCLUSIONS

Although immigrant men were at a lower risk as a group for IPV perpetration as compared with non-immigrants, this lower likelihood of IPV perpetration was only evident among recent immigrants. Among immigrant men, those who arrived in the U.S. more than six years ago and reported speaking English relatively poorly appeared to be at greatest risk for using violence against partners. Future research should examine the effects of fear of legal sanctions, discrimination, and changes in gender roles to clarify the present findings.

Violence victimisation, sexual risk and sexually transmitted infection symptoms among female sex workers in Thailand

BACKGROUND/OBJECTIVES

Commercial sex work is a primary context for heterosexual HIV/AIDS transmission. Violence victimisation is considered to compromise women's ability to protect against HIV and other sexually transmitted infections (STI); little research has investigated violence as it relates to sexual risk and STI among female sex workers (FSW). This study sought to compare sexual risk and STI symptoms among FSW based on recent violence exposure.

METHODS

Data from 815 FSW in Thailand were used to assess the prevalence of physical or sexual violence within the context of sex work, and associations of victimisation with sexual risk and STI symptoms.

RESULTS

Approximately one in seven FSW (14.6%) had experienced violence in the week before the survey. Compared with their unexposed counterparts, FSW exposed to violence demonstrated a greater risk of condom failure (19.6% vs 12.3%, ARR 1.92, 95% CI 1.24 to 2.95) and client condom refusal (85.7% vs 69.0%, ARR 1.24, 95% CI 1.14 to 1.35). In analyses adjusted for sexual risk, violence related to STI symptoms collectively (ARR 1.11, 95% CI 1.02 to 1.21) and genital lesions as an individual STI symptom (ARR 1.78, 95% CI 1.20 to 2.66).

CONCLUSION

Physical and sexual violence against FSW in Thailand appears to be common, with women experiencing such violence demonstrating diminished capacity for STI/HIV harm reduction and greater prevalence of STI symptoms. Efforts to reduce violence towards this vulnerable population must be prioritised, as a means of protecting the health and wellbeing of FSW, and as a key component of STI/HIV prevention and control.

Pregnancy coercion, intimate partner violence and unintended pregnancy

BACKGROUND

Reproductive control including pregnancy coercion (coercion by male partners to become pregnant) and birth control sabotage (partner interference with contraception) may be associated with partner violence and risk for unintended pregnancy among young adult females utilizing family planning clinic services.

STUDY DESIGN

A cross-sectional survey was administered to females ages 16-29 years seeking care in five family planning clinics in Northern California (N=1278).

RESULTS

Fifty-three percent of respondents reported physical or sexual partner violence, 19% reported experiencing pregnancy coercion and 15% reported birth control sabotage. One third of respondents reporting partner violence (35%) also reported reproductive control. Both pregnancy coercion and birth control sabotage were associated with unintended pregnancy (AOR 1.83, 95% CI 1.36-2.46, and AOR 1.58, 95% CI 1.14-2.20, respectively). In analyses stratified by partner violence exposure, associations of reproductive control with unintended pregnancy persisted only among women with a history of partner violence.

CONCLUSIONS

Pregnancy coercion and birth control sabotage are common among young women utilizing family planning clinics, and in the context of partner violence, are associated with increased risk for unintended pregnancy.

The effect of maternal child marriage on morbidity and mortality of children under 5 in India: cross sectional study of a nationally representative sample

OBJECTIVE

To assess associations between maternal child marriage (marriage before age 18) and morbidity and mortality of infants and children under 5 in India. Design Cross-sectional analyses of nationally representative household sample. Generalised estimating equation models constructed to assess associations. Adjusted models included maternal and child demographics and maternal body mass index as covariates. Setting India. Population Women aged 15-49 years (n=124 385); data collected in 2005-6 through National Family Health Survey-3. Data about child morbidity and mortality reported by participants. Analyses restricted to births in past five years reported by ever married women aged 15-24 years (n=19 302 births to 13 396 mothers).

MAIN OUTCOME MEASURES

In under 5s: mortality related infectious diseases in the past two weeks (acute respiratory infection, diarrhoea); malnutrition (stunting, wasting, underweight); infant (age <1 year) and child (1-5 years) mortality; low birth weight (<2500 kg). Results The majority of births (73%; 13 042/19 302) were to mothers married as minors. Although bivariate analyses showed significant associations between maternal child marriage and infant and child diarrhoea, malnutrition (stunted, wasted, underweight), low birth weight, and mortality, only stunting (adjusted odds ratio 1.22, 95% CI 1.12 to 1.33) and underweight (1.24, 1.14 to 1.36) remained significant in adjusted analyses. We noted no effect of maternal child marriage on health of boys versus girls. Conclusions The risk of malnutrition is higher in young children born to mothers married as minors than in those born to women married at a majority age. Further research should examine how early marriage affects food distribution and access for children in India.

Maternal experiences of intimate partner violence and child morbidity in Bangladesh: evidence from a national Bangladeshi sample

OBJECTIVE

To provide an estimate of the risk of recent acute respiratory tract infection (ARI) and diarrhea among children 5 years and younger based on recent violence against their mothers.

DESIGN

The 2004 Bangladesh Demographic Health Survey, conducted from January 1 to May 31, 2004.

SETTING

Selected urban and rural areas of Bangladesh.

PARTICIPANTS

A total of 1592 women currently married, with at least 1 child 5 years of age or younger, each living with her husband and child(ren). Main Exposure Intimate partner violence (IPV) against women. Outcomes Measures The prevalence of past-year IPV was calculated. The risk of ARI and diarrhea within the past 2 weeks among young children was determined based on maternal experiences of IPV within the past year via analyses adjusted for demographics and environmental risks.

RESULTS

More than 2 of 5 married Bangladeshi mothers (42.4%) with children aged 5 years and younger experienced IPV from their husbands in the past year. Mothers who experienced IPV were more likely to report recent ARI (adjusted odds ratio, 1.37; 95% confidence interval, 1.03-1.83) and diarrhea (adjusted odds ratio, 1.65; 95% confidence interval, 1.15-2.38) among their young children compared with those who did not experience IPV.

CONCLUSIONS

Large numbers of married Bangladeshi women with young children experience IPV. Associations of maternal experiences of IPV with 2 leading causes of childhood mortality strongly suggest that such abuse threatens not only the health of women but also that of their children. Prevention of IPV perpetration by men may be critical to the improvement of maternal and child health.

The prevalence of violence and relation to depression and illicit drug use among incarcerated women in Recife, Brazil

PURPOSE

To assess the prevalence and different types of violence experienced by women prisoners in Brazil and the effects of violence on women's depression and illicit drug use.

METHODS

Participants (N=377) were incarcerated women from a state prison in a northeastern city of Brazil. Multivariate logistic regression models (adjusted for age, education, partner status, prison history, drug related offense, and sentencing status) were used to assess associations between each type of violence (physical abuse, sexual abuse, and life threats) and each outcome variable: recent depression and illicit drug use.

RESULTS

The majority of participants (87%) reported experiencing some type of violence in their lifetime, including physical violence (83%), sexual victimization (36%), and threats on their life (29%.) Sexual violence was significantly related to both recent depression (Odds Ratio (OR)=2.8; 95% Confidence Interval (CI)=1.4-5.3) and recent substance use (OR=2.7; 95% CI=1.6-4.4) in adjusted models. Experiences of life threats were also significantly associated with illicit drug use (OR=2.2; 95% CI: 1.3-3.7), as was physical violence (OR=2.4; 95% CI: 1.2-4.9); however, neither of these latter two violence variables were significantly associated with depression.

CONCLUSION

Reports of lifetime violence victimization among this incarcerated sample of women were extremely prevalent and relevant to women's depression and illicit drug use. Prison efforts to address women's depression and illicit drug use may be most effective by incorporating aspects related to women's history of victimization, especially given the high rates of violence experienced by women in this sample.

Intimate partner violence functions as both a risk marker and risk factor for women's HIV infection: findings from Indian husband-wife dyads

CONTEXT AND OBJECTIVE

Female victims of intimate partner violence (IPV) consistently demonstrate elevated sexually transmitted infection/HIV prevalence. IPV is thought to function indirectly as a marker of abusive men's elevated sexually transmitted infection/HIV infection and/or directly via facilitating transmission to wives. The present examination utilizes a nationally representative sample of married Indian couples to test these mechanisms and determine whether (1) abusive husbands demonstrate higher HIV infection prevalence compared with nonabusive husbands and (2) the risk of wives' HIV infection based on husbands' HIV infection varies as a function of their exposure to IPV.

DESIGN, SETTING, AND PARTICIPANTS

The Indian National Family Health Survey-3 was conducted across all Indian states in 2005-2006. Analyses were limited to 20,425 husband-wife dyads, which provided both IPV data and HIV test results.

ANALYSES

Logistic regression models estimated the odds ratios and 95% confidence intervals (CIs) to evaluate the following associations: (1) husbands' HIV acquisition outside the marital relationship based on their perpetration of IPV and (2) wives' HIV infection based on husbands' HIV infection, as a function of their IPV exposure.

RESULTS

One third (37.4%) of wives experienced IPV; 0.4% of husbands and 0.2% of wives were HIV infected. Compared with nonabusive husbands, abusive husbands demonstrated increased odds of HIV acquisition outside the marital relationship in adjusted models (adjusted odds ratio [AOR] = 1.91; 95% CI 1.11 to 3.27). Husbands' HIV infection was associated with increased HIV risk among wives; this risk was elevated 7-fold in abusive relationships in adjusted models (AOR = 7.22; 95% CI 1.05 to 49.88).

CONCLUSIONS

Findings provide the first empirical evidence that abused wives face increased HIV risk based both on the greater likelihood of HIV infection among abusive husbands and elevated HIV transmission within abusive relationships. Thus, IPV seems to function both as a risk marker and as a risk factor for HIV among women, indicating the need for interwoven efforts to prevent both men's sexual risk and IPV perpetration.

HIV vulnerabilities of sex-trafficked Indian women and girls

OBJECTIVE

To qualitatively explore potential mechanisms that may confer heightened risk for HIV infection among survivors of sex trafficking in India.

METHODS

Case narratives of 61 repatriated women and girls who reported being trafficked into sex work and were receiving services at an NGO in Mysore, India, were reviewed. Narratives were analyzed to examine potential sources of HIV risk related to sex trafficking.

RESULTS

Participants were aged 14-30 years. Among the 48 women and girls tested for HIV, 45.8% were HIV positive. Narratives described very low levels of autonomy, with control exacted by brothel managers and traffickers. Lack of control appeared to heighten trafficked women and girls' vulnerability to HIV infection in the following ways: use of violent rape as a means of coercing initiation into sex work, inability to refuse sex, inability to use condoms or negotiate use, substance use as a coping strategy, and inadequate access to health care.

CONCLUSION

Sex trafficked women and girls lack autonomy and are rendered vulnerable to HIV infection through several means. Development of HIV prevention strategies specifically designed to deal with lack of autonomy and reach sex-trafficked women and girls is imperative.

Intimate partner violence perpetration, standard and gendered STI/HIV risk behaviour, and STI/HIV diagnosis among a clinic-based sample of men

Background:

The estimated one in three women worldwide victimised by intimate partner violence (IPV) consistently demonstrate elevated STI/HIV prevalence, with their abusive male partners’ risky sexual behaviours and subsequent infection increasingly implicated. To date, little empirical data exist to characterise the nature of men’s sexual risk as it relates to both their violence perpetration, and STI/HIV infection.

Methods:

Data from a cross-sectional survey of men ages 18–35 recruited from three community-based health clinics in an urban metropolitan area of the northeastern US (n = 1585) were analysed to estimate the prevalence of IPV perpetration and associations of such violent behaviour with both standard (eg, anal sex, injection drug use) and gendered (eg, coercive condom practices, sexual infidelity, transactional sex with a female partner) forms of sexual-risk behaviour, and self-reported STI/HIV diagnosis.

Results:

Approximately one-third of participants (32.7%) reported perpetrating physical or sexual violence against a female intimate partner in their lifetime; one in eight (12.4%) participants self-reported a history of STI/HIV diagnosis. Men’s IPV perpetration was associated with both standard and gendered STI/HIV risk behaviours, and to STI/HIV diagnosis (OR 4.85, 95% CI 3.54 to 6.66). The association of men’s IPV perpetration with STI/HIV diagnosis was partially attenuated (adjusted odds ratio (AOR) 2.55, 95% CI 1.77 to 3.67) in the multivariate model, and a subset of gendered sexual-risk behaviours were found to be independently associated with STI/HIV diagnosis—for example, coercive condom practices (AOR 1.67, 95% CI 1.04 to 2.69), sexual infidelity (AOR 2.46, 95% CI 1.65 to 3.68), and transactional sex with a female partner (AOR 2.03, 95% CI 1.36 to 3.04).

Conclusions:

Men’s perpetration of physical and sexual violence against intimate partners is common among this population. Abusive men are at increased risk for STI/HIV, with gendered forms of sexual-risk behaviour partially responsible for this association. Thus, such men likely pose an elevated infection risk to their female partners. Findings indicate the need for interwoven sexual health promotion and violence prevention efforts targeted to men; critical to such efforts may be reduction in gendered sexual-risk behaviours and modification of norms of masculinity that likely promote both sexual risk and violence

E-mail Use Among a Sample of Intimate Partner Violence Shelter Residents

Although it is estimated that approximately 75% of U.S. adults have e-mail access, the proportion of battered women's shelter residents who use e-mail is currently unknown. Remaining in contact with residents following shelter stays is challenging. E-mail might hold promise for follow-up contact if a sufficient number of survivors use e-mail and safety concerns can be addressed. Among a convenience sample of residents of 11 Massachusetts shelters ( N = 57), the authors find that 47% had a current e-mail account. Among those with e-mail accounts, 89% used e-mail in locations other than their own homes; 81% reported that, to their knowledge, their e-mail accounts had never been accessed by unauthorized dating partners; and 88% reported that they thought it would be safe for the shelter to e-mail them following their departure. Additional research assessing the feasibility (i.e., safety, acceptability, and cost benefit) of remaining in contact with shelter residents via the Internet would be beneficial.

Premigration exposure to political violence and perpetration of intimate partner violence among immigrant men in Boston

OBJECTIVES

We examined associations between premigration political violence exposure and past-year intimate partner violence (IPV) perpetration among immigrant men attending community health centers in Boston.

METHODS

A convenience sample of immigrant men (N = 379; aged 18-35 years), largely from the Caribbean and Cape Verde, who attend community health centers, completed an anonymous, cross-sectional survey on risk and protective factors for male-perpetrated IPV and respondents' exposure to political violence.

RESULTS

One in 5 (20.1%) immigrant men reported that they were exposed to political violence before arrival in the United States. Men reporting political violence exposure were significantly more likely to report IPV perpetration than were men not reporting such exposure (adjusted odds ratio [AOR] = 2.84; 95% confidence interval [CI] = 1.41, 5.74). Significant associations with political violence exposure were observed for both physical (AOR = 2.69; 95% CI = 1.11, 6.54) and sexual (AOR = 2.37; 95% CI = 1.04, 5.44) IPV perpetration.

CONCLUSIONS

To our knowledge, our findings document for the first time the significant association between premigration political violence exposure and recent IPV perpetration among immigrant men. Additional work is needed to examine underlying mechanisms to inform culturally appropriate programs.

Intimate partner violence and HIV infection among married Indian women

CONTEXT

Despite reductions in prevalence of human immunodeficiency virus (HIV) infection among the general population of India, women account for a rising percentage of all HIV cases with husbands' risk behavior described as the major source of women's infection. Intimate partner violence (IPV) has been described as being associated with heterosexual transmission of HIV to women in India and elsewhere.

OBJECTIVE

To assess the relationship between experiencing IPV and the occurrence of HIV infection in a nationally representative sample of married Indian women tested for HIV.

DESIGN, SETTING, AND PARTICIPANTS

The Indian National Family Health Survey 3 was conducted across all Indian states in 2005 through 2006. The nationally representative sample included 124,385 married women; analyses conducted in 2007 and 2008 were limited to 28,139 married women who provided IPV data and HIV test results via systematic selection into respective subsamples.

MAIN OUTCOME MEASURES

Prevalence estimates of lifetime IPV and HIV infection were calculated and demographic differences assessed. Intimate partner violence was conceptualized as physical violence with or without sexual violence and then was further categorized as physical violence only vs physical and sexual violence. Regression models were used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for HIV infection among Indian women based on experiences of IPV after adjusting for demographics and women's HIV risk behaviors.

RESULTS

One-third of married Indian women (35.49%) reported experiencing physical IPV with or without sexual violence from their husbands; 7.68% reported both physical and sexual IPV, and 27.80% reported experiencing physical IPV in the absence of sexual violence. Approximately 1 in 450 women (0.22%) tested positive for HIV. In adjusted models, married Indian women experiencing both physical and sexual violence from husbands demonstrated elevated HIV infection prevalence vs those not experiencing IPV (0.73% vs 0.19%; adjusted OR, 3.92; 95% CI, 1.41-10.94; P = .01). Physical IPV alone was not associated with risk of HIV infection. Women's personal sexual risk behaviors were not associated with HIV infection.

CONCLUSIONS

Among married Indian women, physical violence combined with sexual violence from husbands was associated with an increased prevalence of HIV infection. Prevention of IPV may augment efforts to reduce the spread of HIV/AIDS.

Prevalence and patterns of sexual assault across the life span among incarcerated women

This study investigated the prevalence of and associations among sexual assault by life stage (childhood, adolescence, or adulthood) and perpetrator (family, stranger, friend, or partner) via a survey of a statewide sample of incarcerated women (N = 484). Participants were 18 to 56 years old, and the majority were White (56%). Results demonstrate higher rates of sexual assault in childhood (35%) and adulthood (22%) as compared with adolescence (14%). Logistic regression analyses revealed significant associations between childhood sexual assault by family and adulthood sexual assault by friend, stranger, and partner; adolescent sexual assault was not significantly associated with sexual assault in childhood or adulthood. These findings suggest that the lifetime sexual victimization pattern of incarcerated women differs from that seen in the general population.

Social and environmental contexts of adolescent and young adult male perpetrators of intimate partner violence: a qualitative study

The purpose of the current study was to examine qualitatively the life contexts of young males enrolled in programs addressing perpetration of intimate partner violence (IPV). Semistructured interviews were conducted with 19 males recruited from these programs. Interviews were coded to examine life contexts and analyzed using a content analysis approach. Five themes emerged across interviews: (a) disruptive home environment; (b) lack of positive male role models; (c) a peer context characterized by substance use, gang involvement, and behaviors supporting the sexual maltreatment of girls; (d) school circumstances characterized by a lack of academic support; and (e) community exposures to violence. These factors were often interrelated within the various contexts of participants. Further research is needed to provide insight into whether and how these issues may contribute to IPV perpetration. Efforts to support young males regarding a broad array of concerns should be included in programming to reduce IPV perpetration.

“Running a Train”

The authors used qualitative research methods to explore the context and sexual risk behavior associated with sexual intercourse involving multiple males and one female, commonly called “running a train.” Participants were 20 adolescent males aged 14 to 22 years who were either perpetrators of dating violence or perceived by teachers to be at risk for dating violence perpetration. Trains were reported to be spontaneous or planned events, to occur in a variety of settings, and to be recreational behavior for male peers. Alcohol and drug use were frequently reported to both precede and co-occur with trains. Respondents provided motivations for both condom use and nonuse during trains. While respondents did not regard trains as sexual assault, they described numerous tactics used to coerce females' participation. Further investigation of the prevalence, causes, and consequences of this phenomenon is urgently needed.

Male partner pregnancy-promoting behaviors and adolescent partner violence: findings from a qualitative study with adolescent females

OBJECTIVE

To examine the context of pregnancy and sexual health among adolescent females with a history of intimate partner violence (IPV). This paper reports on a subset of females who described abusive male partners' explicit pregnancy-promoting behaviors (ie, messages and behaviors that led females to believe their partner was actively trying to impregnate them).

METHODS

Semistructured interviews were conducted with 53 sexually active adolescent females, with known history of IPV, about violence, sexual experiences, and related behaviors. Interviews were analyzed using a content analysis approach; 14 interviews in which females reported that partners were actively trying to impregnate them were further analyzed for pregnancy and contraceptive use.

RESULTS

Participants (N = 53) were aged 15 to 20 years, with notable minority representation, 21% African American (n = 11) and 38% Latina (n = 20). Over half (n = 31, 58%) had experienced pregnancy. A key finding was that approximately one quarter of participants (26%, n = 14) reported that their abusive male partners were actively trying to get them pregnant. Females' stories revealed that abusive male partners desiring pregnancy manipulated condom use, sabotaged birth control use, and made explicit statements about wanting her to become pregnant.

CONCLUSIONS

Pregnancy-promoting behaviors of male abusive partners may be one potential mechanism underlying associations between adolescent IPV and pregnancy. These findings suggest that exploring pregnancy intentions and behaviors of partners of sexually active adolescents may help to identify youth experiencing IPV. The frequency of birth control sabotage and explicit attempts to cause pregnancy in adolescent IPV needs to be examined at the population level.

Intimate partner violence and unwanted pregnancy, miscarriage, induced abortion, and stillbirth among a national sample of Bangladeshi women

OBJECTIVE

To estimate (1) lifetime prevalence of physical and sexual victimisation from husbands among a national sample of Bangladeshi women, (2) associations of unwanted pregnancy and experiences of husband violence, and (3) associations of miscarriage, induced abortion, and fetal death/stillbirth and such victimisation.

DESIGN

Cross-sectional, nationally representative study utilizing matched husband-wife data from the 2004 MEASURE Bangladesh Demographic Health Survey.

SETTING

Bangladesh.

POPULATION

Married Bangladeshi women ages 13-40 years old (n = 2677).

METHODS

Bivariate and multivariate logistic regression analysis.

MAIN OUTCOME MEASURES

Relations of intimate partner violence to unwanted pregnancy, miscarriage, induced abortion and stillbirth.

RESULTS

Three out of four (75.6%) Bangladeshi women experienced violence from husbands. Less educated, poorer, and Muslim women were at greatest risk. Women experiencing violence from husbands were more likely to report both unwanted pregnancy (ORs(adj) 1.46-1.54) and a pregnancy loss in the form of miscarriage, induced abortion, or stillbirth (ORs(adj) 1.43-1.69). Assessed individually, miscarriage was more likely among victimised women (OR(adj) 1.81). A nonsignificant trend was detected for increased risk of induced abortion (OR(adj) 1.64); stillbirth was unrelated to violence from husbands.

CONCLUSION

Intimate partner violence is extremely prevalent and relates to unwanted pregnancy and higher rates of pregnancy loss or termination, particularly miscarriages, among Bangladeshi women. Investigation of mechanisms responsible for these associations will be critical to developing interventions to improve maternal, fetal, and neonatal health. Such programmes may be vital to reducing the significant health and social costs associated with both husband violence and unwanted and adverse pregnancy outcomes.

Intimate partner violence and sexually transmitted disease symptoms in a national sample of married Bangladeshi women

OBJECTIVES

To assess associations of intimate partner violence (IPV) with women's sexually transmitted disease (STD) symptoms, and to clarify biological and behavioral mechanisms underpinning heightened STD rates among abused women.

METHODS

A cross-sectional investigation of married couples (n=2865) sampled via the Bangladesh Demographic Health Survey.

RESULTS

Over one third (38%) of married Bangladeshi women experienced physical or sexual IPV in the 12 months preceding the survey. Victimization was bivariately associated with vaginal irritation/discharge, pelvic pain during intercourse, genital sores/ulcers, and vaginal discharge with odor (OR 1.39-2.09). IPV demonstrated an independent effect on vaginal irritation with discharge (adjusted OR 1.34) and vaginal discharge with odor (adjusted OR 2.08) after accounting for STD exposure (i.e., husbands' recent STD).

CONCLUSIONS

IPV elevates married Bangladeshi women's STD symptoms beyond the risk represented by husbands' STD alone, suggesting that high rates of STD among abusive men and the context of violence itself both relate to abused women's STD risk.

Contexts of condom use and non-condom use among young adolescent male perpetrators of dating violence

The purpose of this study was to examine qualitatively the context of and reasons for condom use and non-use among adolescent male perpetrators of dating violence. Semi-structured anonymous interviews were conducted with 19 adolescent males recruited from intervention programs for adolescent perpetrators of dating violence. Interviews included questions about dating violence perpetration, sexual relationships and risk behaviors. Interviews were analyzed using a content analysis approach and coded to examine boys' condom use and non-use behaviors and contexts. Participants (n=19) were aged 17-21 years and were predominantly white (n=9; 47%) or black (n=4; 21%). Half (n=10; 53%) indicated four or more sex partners in the past three months; half (n=10; 53%) reported no or inconsistent condom use in the past three months. Qualitative findings from this study revealed condom use in high-risk casual sex encounters, including 'trains' (1-2 girls having sex with several boys sequentially). Non-use of condoms was more common in steady, often abusive, relationships, although boys reported sexual infidelity in these relationships. These results indicate that non-use of condoms is occurring among adolescent male perpetrators of dating violence, particularly in the context of their steady relationships and despite reports of very high risk sexual activity including sexual infidelity, involvement in 'trains' and multiple sex partners. Sexual health interventions integrated with dating violence and sexual assault prevention efforts and tailored to adolescents are needed.

HIV prevalence and predictors of infection in sex-trafficked Nepalese girls and women

CONTEXT

Sex trafficking of girls and women is widespread across South Asia and is recognized as both a violent gender-based crime and major human rights violation. Inadequate empirical data exist to characterize this phenomenon and its related health consequences, such as human immunodeficiency virus (HIV) infection.

OBJECTIVE

To determine the prevalence of HIV infection among repatriated sex-trafficked Nepalese girls and women and to identify trafficking-related predictors of such infection.

DESIGN

Medical and case records of 287 repatriated girls and women reporting being trafficked from Nepal for sexual exploitation and receiving rehabilitative services between January 1997 and December 2005 at a major nongovernmental organization were systematically reviewed in January 2006.

SETTING

Major Nepalese nongovernmental organization providing shelter and care to repatriated survivors of sex trafficking.

MAIN OUTCOME MEASURES

Prevalence of and risk for HIV based on demographic characteristics and on trafficking- and prostitution-related experiences.

RESULTS

Among 287 repatriated Nepalese sex-trafficked girls and women, 109 (38.0%) tested positive for HIV. Among those with complete documentation of trafficking experiences (n = 225), median age at time of trafficking was 17.0 years, with 33 (14.7%) trafficked prior to age 15 years. Compared with those trafficked at 18 years or older, girls trafficked prior to age 15 years were at increased risk for HIV (adjusted odds ratio [AOR], 3.70; 95% confidence interval [CI], 1.32-10.34), with 20 of 33 (60.6%) infected among this youngest age group. Additional factors associated with HIV positivity included being trafficked to Mumbai (AOR, 4.85; 95% CI, 2.16-10.89) and longer duration of forced prostitution (AOR, 1.02; 95% CI, 1.01-1.03; indicating increased risk per additional month of brothel servitude). In post hoc analyses, girls trafficked prior to age 15 years had increased odds of having been detained in multiple brothels (odds ratio [OR], 5.03; 95% CI, 1.96-12.93) and in brothels for a duration of 1 year or more (OR, 2.67; 95% CI, 1.12-6.33) vs those trafficked at 18 years or older.

CONCLUSIONS

In this study, repatriated Nepalese sex-trafficked girls and women were found to have a high prevalence of HIV infection, with increased risk among those trafficked prior to age 15 years. Present findings demonstrate the need for greater attention to reducing and intervening in sex trafficking in South Asia, particularly among the very young.

Migration, sexual exploitation, and women's health: a case report from a community health center

An estimated 50,000 women and children are annually trafficked into the United States, resulting in complex health and social consequences and significant risk for violence. This article presents a case of a trafficked woman identified in the U.S. health system and describes the vulnerabilities to forced prostitution as a result of trafficking and the challenges in providing an effective and comprehensive response to meet safety and health care needs. Health care providers are in a unique position to identify and support U.S. sex trafficking victims; thus, education and training for health care professionals on trafficking is needed.

Experiences of sex trafficking victims in Mumbai, India

OBJECTIVE

To explore mechanisms and contexts related to sex trafficking victimization among South Asian women and girls rescued from brothels in Mumbai, India.

METHODS

Records of residents at a major non-governmental organization providing rescue, shelter and care of minor girls and of women held against their will in brothels in Mumbai were systematically reviewed (n=160). Descriptive statistics were calculated, and demographic differences in trafficking mechanisms and pre-disposing contexts were explored.

RESULTS

The majority of victims (51.9%) were trafficked as minors and by individuals previously known to them (59.7%). Traffickers most commonly lured victims via promises of economic opportunity (55.0%) or kidnapped individuals via use of drugs or force (26.3%). Victims were most often trafficked from public settings (e.g., markets, train stations; 50.9%) and via public transportation (94.9%). Almost half (49.4%) reported some type of family disruption as directly leading to their being trafficked; violence involving husbands or other family members (38.0%) and marital separation or abandonment (32.9%) were the most common forms of disruption reported. Differences in experiences of trafficking were identified based on age, nationality, education, and marital status; no differences were found based on religion.

CONCLUSION

The interaction of poverty and gender-based mistreatment of women and girls in families heightens the risk of sex trafficking; further empirical research is needed on this critically understudied issue. Prevention efforts should work to improve economic opportunities and security for impoverished women and girls, educate communities regarding the tactics and identities of traffickers, as well as promote structural interventions to reduce trafficking.

Violence against wives, sexual risk and sexually transmitted infection among Bangladeshi men

OBJECTIVE

To assess the relationship between men's reported violence against wives and their sexual risk behaviours and sexual health.

DESIGN, SETTING AND PARTICIPANTS

Cross-sectional analyses of a survey of a nationally representative household-based sample of married men in Bangladesh (n = 3096).

MAIN OUTCOME MEASURE(S)

Physical and sexual violence against wives during the previous 12 months was assessed and examined for relations to men's extramarital sexual behaviours and sexually transmitted infection (STI) symptoms or diagnosis during this same period, as well as to men's disclosure of such infection to wives and condom use while infected.

RESULTS

More than 1 in 3 (36.84%) married Bangladeshi men reported physically and/or sexually abusing their wives in the past year. Men perpetrating such violence were more likely to report both premarital and extramarital sex partners (OR(adj)s 1.80-3.45; 95% CI 1.20 to 8.23); those reporting physical violence were more likely to report STI symptoms or diagnosis in the past year (OR(adj)s 1.68-2.52; 95% CI 1.24 to 3.73). Men perpetrating physical violence and contracting an STI were somewhat more likely to fail to disclose infection status to wives (OR(adj) 1.58; 95% CI 0.93 to 2.70) than infected men not reporting such abuse.

CONCLUSIONS

Violence against wives is common among Bangladeshi men. Men who perpetrate such abuse represent increased risk regarding their wives' sexual health because they are more likely to both participate in extramarital sexual behaviour and contract an STI compared with non-abusive husbands. Given the growing epidemic of HIV infection among monogamous South Asian women based on intercourse with infected non-monogamous husbands, research and intervention regarding men's violence in marriage and implications of such behaviour for women's sexual health should be prioritised.

Intimate partner violence around the time of pregnancy: association with breastfeeding behavior

OBJECTIVE

To assess associations of experiences of intimate partner violence (IPV) and breastfeeding behaviors among a large, population-based sample of U.S. women.

METHODS

Data were collected from women giving birth to live infants in 26 U.S. states and participating in the 2000-2003 Pregnancy Risk Assessment Monitoring System (PRAMS) (n = 118,579). Logistic regression analyses were conducted to assess the relations of experiences of IPV in the year prior to and during pregnancy to initiation and early cessation of breastfeeding.

RESULTS

Approximately 1 in 17 (5.8%) women delivering liveborn infants reported IPV either during or in the year prior to pregnancy. In crude logistic regression analyses, women who reported IPV in the year prior to pregnancy but not during pregnancy (OR 1.45, CI 1.26- 1.66), IPV during pregnancy but not in the year prior to pregnancy (OR 1.35, CI 1.11-1.64), and women reporting experiencing IPV across both periods (OR 1.52, CI 1.34-1.72) were significantly less likely to breastfeed the infants born subsequent to this pregnancy. Similarly, women reporting IPV around the time of pregnancy who initiated breastfeeding were more likely to cease breastfeeding by 4 weeks postpartum (ORs 1.41-1.71). In analyses adjusted for demographics and current smoking, however, experiences of IPV did not relate to women's risk for either outcome.

CONCLUSIONS

Although other factors beyond experiences of IPV may better predict a woman's decision or ability to breastfeed, abused women are overrepresented among mothers who do not or prematurely cease to breastfeed and should be identified and referred to appropriate services.

HIV prevalence and predictors among rescued sex-trafficked women and girls in Mumbai, India

OBJECTIVE

Despite the rapid spread of India's HIV epidemic through commercial sex and the large numbers of minor girls trafficked to India for sex work each year, little HIV research has been conducted among victims of sex trafficking. The present study examines the prevalence and predictors of HIV infection among sex-trafficked women and girls rescued from brothels in Mumbai, India.

DESIGN AND METHODS

Case records and HIV testing results of sex-trafficked women and girls (N = 175) were reviewed. HIV prevalence and HIV risk were assessed based on demographics and exposure to sex work.

RESULTS

Approximately one quarter (22.9%) of trafficked individuals tested positive for HIV. The mean age at trafficking was marginally younger for women and girls infected with HIV (15.9 years) as compared to those not infected (17.2 years; P = 0.06). Girls trafficked as minors reported longer periods of brothel confinement as compared to those trafficked at older ages (18.5 vs. 9.6 months; P = 0.007). Among Indian victims, those trafficked from the states of Karnataka or Maharashtra were more likely than those trafficked from West Bengal to be HIV-positive (odds ratio [OR] = 7.35, 95% confidence interval [CI]: 2.23 to 24.21). Longer duration in brothels was associated with greater likelihood of HIV infection; a 3% to 4% increased risk for HIV was observed for each additional month of brothel captivity.

CONCLUSIONS

Findings demonstrate the need for increased attention to HIV among young victims of sex trafficking in research and practice, and to the rescue of sex trafficking victims as a form of HIV prevention.

Immigration-Based Disparities in Adolescent Girls’ Vulnerability to Dating Violence

OBJECTIVES

Little data exists on dating violence among immigrant adolescents. The present study assessed disparities in experiences of physical and sexual dating violence based on immigrant status and language spoken at home among a large representative sample of adolescent girls.

METHODS

Data from the 1997-2003 Massachusetts Youth Risk Behavior Surveys (N = 7,970) were analyzed. Adjusted logistic regression analyses were conducted among the full sample and sexually active sub-sample. To further clarify immigration-based effects, separate analyses were conducted within age and racial/ethnic groups.

RESULTS

Being an immigrant was found to be protective against dating violence (OR 0.77, CI 0.60-0.98), but not among those reporting sexual intercourse. Stratified analyses revealed important differences in these effects based on age and race/ethnicity; only immigrant girls age 16 or older (OR 0.69, CI 0.48-0.99) and Hispanic immigrant girls (ORs 0.39-0.54) reported reduced risk for dating violence as compared to their non-immigrants peers. No differences in vulnerability to dating violence were detected based on immigrant status for Asian, Black, or White adolescents in stratified analyses.

CONCLUSIONS

The social context of immigration may offer protection regarding adolescent girls' vulnerability to dating violence, but effects are not uniform across age, sexual experience, or race and ethnicity. Additional research is needed to understand how immigration, social behavior, age, race and ethnicity may interact to produce disparities in vulnerability to gender-based violence.

Intimate partner violence victimization prior to and during pregnancy among women residing in 26 U.S. states: associations with maternal and neonatal health

OBJECTIVE

To conduct a population-based assessment of associations of intimate partner violence in the year prior to and during pregnancy with maternal and neonatal morbidity.

STUDY DESIGN

Data from women giving birth in 26 U.S. states and participating in the 2000 to 2003 Pregnancy Risk Assessment Monitoring System (n = 118,579) were analyzed.

RESULTS

Women reporting intimate partner violence in the year prior to pregnancy were at increased risk for high blood pressure or edema (adjusted odds ratio 1.37-1.40), vaginal bleeding (adjusted odds ratio 1.54-1.66), severe nausea, vomiting or dehydration (adjusted odds ratio 1.48-1.63), kidney infection or urinary tract infection (adjusted odds ratio 1.43-1.55), hospital visits related to such morbidity (adjusted odds ratio 1.45-1.48), and delivery preterm (adjusted odds ratio 1.37), of a low-birthweight infant (adjusted odds ratio 1.17), and an infant requiring intensive care unit care (adjusted odds ratio 1.31-1.33) compared with those not reporting intimate partner violence. Women reporting intimate partner violence during but not prior to pregnancy experienced higher rates of a subset of these concerns.

CONCLUSION

Women experiencing intimate partner violence both prior to and during pregnancy are at risk for multiple poor maternal and infant health outcomes, suggesting prenatal risks to children from mothers' abusive partners.

Masculine gender roles associated with increased sexual risk and intimate partner violence perpetration among young adult men

This study sought to assess the association between traditional masculine gender role ideologies and sexual risk and intimate partner violence (IPV) perpetration behaviors in young men's heterosexual relationships. Sexually active men age 18-35 years attending an urban community health center in Boston were invited to join a study on men's sexual risk; participants (N=307) completed a brief self-administered survey on sexual risk (unprotected sex, forced unprotected sex, multiple sex partners) and IPV perpetration (physical, sexual and injury from/need for medical services due to IPV) behaviors, as well as demographics. Current analyses included men reporting sex with a main female partner in the past 3 months (n=283). Logistic regression analyses adjusted for demographics were used to assess significant associations between male gender role ideologies and the sexual risk and IPV perpetration behaviors. Participants were predominantly Hispanic (74.9%) and Black (21.9%); 55.5% were not born in the continental U.S.; 65% had been in the relationship for more than 1 year. Men reporting more traditional ideologies were significantly more likely to report unprotected vaginal sex in the past 3 months (OR(adj) = 2.3, 95% CI = 1.2-4.6) and IPV perpetration in the past year (OR(adj) = 2.1, 95% CI = 1.2-3.6). Findings indicate that masculine gender role ideologies are linked with young men's unprotected vaginal sex and IPV perpetration in relationships, suggesting that such ideologies may be a useful point of sexual risk reduction and IPV prevention intervention with this population.

Social norms and beliefs regarding sexual risk and pregnancy involvement among adolescent males treated for dating violence perpetration

The present study explored perceived sexual norms and behaviors related to sexual risk and pregnancy involvement among adolescent males (ages 13 to 20) participating in programs for perpetrators of dating violence. The purpose of this study was to generate hypotheses regarding the contexts and mechanisms underlying the intersection of adolescent dating violence, sexual risk and pregnancy. Six focus groups were conducted (N = 34 participants). A number of major themes emerged: 1) male norm of multiple partnering, 2) perceived gain of male social status from claims of sexual activity, 3) perception that rape is uncommon combined with belief that girls claiming to be raped are liars, 4) perception that men rationalize rapes to avoid responsibility, 5) condom non-use in the context of rape and sex involving substance use, 6) beliefs that girls lie and manipulate boys in order to become pregnant and trap them into relationships, and 7) male avoidance of responsibility and negative responses to pregnancy. The combination of peer-supported norms of male multiple partnering and adversarial sexual beliefs appear to support increased male sexual risk, lack of accountability for sexual risk, and rationalization of rape and negative responses to pregnancy. Further research focused on the context of male sexual risk and abusive relationship behaviors is needed to inform intervention with young men to promote sexual health and prevent rape, dating violence, and adolescent pregnancy.

Asking about intimate partner violence: advice from female survivors to health care providers

Understanding the perspectives of women who have experienced IPV will allow us to identify specific techniques of addressing IPV that increase patient comfort and willingness to disclose and/or seek help. Our study objective was to identify what advice women who had experienced IPV would give health providers regarding how to ask about and discuss the issue of IPV. The women in our study advised that providers (1) give a reason for why they are asking about IPV to reduce women's suspicions and minimize stigma, (2) create an atmosphere of safety and support, (3) provide information, support and access to resources regardless of whether the woman discloses IPV. They emphasized that a provider's asking about IPV is an opportunity to raise patient awareness of IPV, communicate compassion and provide information and not merely a screening test to diagnose a pathologic condition.

Dating violence and sexually transmitted disease/HIV testing and diagnosis among adolescent females

OBJECTIVE

Previous studies demonstrate significant associations between dating-violence victimization and sexual risk behaviors among adolescent girls; however, a relationship between dating violence and actual sexually transmitted disease (STD)/HIV testing and diagnosis has yet to be investigated among a representative sample. The present study assesses associations between dating violence and STD/HIV testing and diagnosis among a representative sample of sexually active adolescent girls.

METHODS

Data from 9th- to 12th-grade female students completing the 1999 and 2001 Massachusetts Youth Risk Behavior Surveys and reporting having ever had sexual intercourse (N = 1641) were examined. Odds ratios for STD/HIV testing and diagnosis that were based on experiences of dating violence and adjusted for STD/HIV risk behaviors and demographics were calculated.

RESULTS

More than one third (38.8%) of adolescent girls tested for STD or HIV and more than half (51.6%) of girls diagnosed with STD/HIV reported experiencing dating violence. Compared with nonabused girls, girls who experienced both physical and sexual dating violence were 3.0 times more likely to have been tested for STD and HIV, and 2.6 times more likely to report an STD diagnosis.

CONCLUSIONS

After adjusting for STD/HIV risk behaviors, dating violence remains significantly associated with STD/HIV testing and diagnosis among sexually active adolescent girls.

Soft and hard contact lenses worn in combination

Each of 5 subjects with normal corneas was fitted with a Bausch & Lomb F3-series Soflens contact lens and with an experimental F3-series ultrathin Soflens. A best-fit PMMA lens was worn in combination with each of the soft lenses. In addition, a best-fit CAB lens and a tight PMMA lens were separately worn in combination with the ultrathin soft lens. Each of 3 subjects with keratoconus was fitted with an ultrathin soft lens combined with a PMMA lens. For the normal corneas, the combination that produced the least corneal edema after 5 hr was an ultrathin soft lens with either a PPM or CAB lens of best fit. Two of the 3 keratoconic subjects were able to wear their contact lens combination for the 5-hr test period; corneal swelling was 1.7% and 5.3% For all subjects, acuity with a combination co ntact lens system was better than with a soft or hard lens alone.

Rotation of spherical nonprism and prism-ballast hydrogel contact lenses on toric corneas

Six subjects were fitted binocularly with both nonprism and prism-ballast spherical HydrocurveTM contact lenses to evaluate lens rotation on toric corneas. The 1/2 delta and the 1 delta lenses rotated significantly less than the equivalent nonprism lenses. For 11 of 12 eyes, 1/2 delta was sufficient to stabilize the lens.