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Leddy AM, Zakaras JM, Shieh J, Conroy AA, Ofotokun I, Tien PC, Weiser SD. Intersections of food insecurity, violence, poor mental health and substance use among US women living with and at risk for HIV: Evidence of a syndemic in need of attention. PLoS One 2021; 16:e0252338. [PMID: 34038490 PMCID: PMC8153505 DOI: 10.1371/journal.pone.0252338] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 05/12/2021] [Indexed: 11/18/2022] Open
Abstract
Background Food insecurity and intimate partner violence (IPV) are associated with suboptimal HIV prevention and treatment outcomes, yet limited research has explored how food insecurity and IPV intersect to influence HIV-related behaviors. To fill this gap, we conducted a qualitative study with women living with or at risk for HIV in the United States. Methods We conducted 24 in-depth interviews with women enrolled in the San Francisco and Atlanta sites of the Women’s Interagency HIV study (WIHS). Participants were purposively sampled so half were living with HIV and all reported food insecurity and IPV in the past year. Semi-structured interviews explored experiences with food insecurity and IPV, how these experiences might be related and influence HIV risk and treatment behaviors. Analysis was guided by an inductive-deductive approach. Results A predominant theme centered on how food insecurity and IPV co-occur with poor mental health and substance use to influence HIV-related behaviors. Women described how intersecting experiences of food insecurity and IPV negatively affected their mental health, with many indicating using substances to “feel no pain”. Substance use, in turn, was described to perpetuate food insecurity, IPV, and poor mental health in a vicious cycle, ultimately facilitating HIV risk behaviors and preventing HIV treatment adherence. Conclusions Food insecurity, IPV, poor mental health and substance use intersect and negatively influence HIV prevention and treatment behaviors. Findings offer preliminary evidence of a syndemic that goes beyond the more widely studied “SAVA” (substance use, AIDS, and violence) syndemic, drawing attention to additional constructs of mental health and food insecurity. Quantitative research must further characterize the extent and size of this syndemic. Policies that address the social and structural drivers of this syndemic, including multi-level and trauma-informed approaches, should be implemented and evaluated to assess their impact on this syndemic and its negative health effects.
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Affiliation(s)
- Anna M Leddy
- Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, United States of America
| | - Jennifer M Zakaras
- Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, United States of America
| | - Jacqueline Shieh
- Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, United States of America
| | - Amy A Conroy
- Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, United States of America
| | - Ighovwerha Ofotokun
- School of Medicine, Emory University and Grady Healthcare System, Atlanta, GA, United States of America
| | - Phyllis C Tien
- Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, United States of America.,Department of Veteran Affairs Medical Center, San Francisco, CA, United States of America
| | - Sheri D Weiser
- Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, United States of America
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Social and Structural Barriers to Primary Care Access Among Women Living With HIV in Metro Vancouver, Canada: A Longitudinal Cohort Study. J Assoc Nurses AIDS Care 2021; 32:548-560. [PMID: 33989244 DOI: 10.1097/jnc.0000000000000234] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
ABSTRACT This study examines correlates of being unable to access primary care in the past 6 months among cisgender (cis) and trans women living with HIV (WLWH). Data were drawn from a longitudinal community-based cohort study of WLWH (ages 14+) in Metro Vancouver, Canada (2014-2017). Of 291 participants contributing 914 observations, 15.5% reported being unable to access primary care at baseline. In multivariable analysis, increased odds of being unable to access primary care was associated with (a) having im/migrated to Canada, and, in the past 6 months, (b) identifying as gender minority, (c) experiencing physical or sexual violence, (d) having suicidal ideation or attempts. Decreased odds were associated with recently accessing HIV-specific resources. Our findings suggest that primary health care for WLWH should address high levels of violence and mental health conditions as well as barriers to services for gender minority and im/migrant WLWH.
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Stockman JK, Anderson KM, Tsuyuki K, Horvath KJ. LinkPositively: A Trauma-Informed Peer Navigation and Social Networking WebApp to Improve HIV Care among Black Women Affected by Interpersonal Violence. J Health Care Poor Underserved 2021; 32:166-188. [PMID: 34934301 PMCID: PMC8687146 DOI: 10.1353/hpu.2021.0056] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
In the U.S., Black women living with HIV/AIDS (WLHA) are affected disproportionately by interpersonal violence, which often co-occurs with adverse mental health and/or substance use, and exacerbates existing poor HIV care outcomes. Peer navigation has been successful in improving HIV care; however, HIV clinics often lack resources for sustainability and may not account for socio-structural barriers unique to Black WLHA. To address this gap, we developed LinkPositively, a culturally-tailored, trauma-informed WebApp for Black WLHA affected by interpersonal violence to improve HIV care outcomes. Using focus group data from nine Black WLHA and peer navigators, we developed LinkPositively. Core components include: virtual peer navigation to facilitate skill-building to cope with barriers and navigate care; social networking platform for peer support; educational and self-care tips; GPS-enabled resource locator for HIV care and support service agencies; and medication self-monitoring/reminder system. If efficacious, LinkPositively will shift the HIV prevention and care paradigm for Black WLHA.
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Affiliation(s)
- Jamila K Stockman
- is an Associate Professor at the University of California, San Diego in the School of Medicine, Department of Medicine, Division of Infectious Diseases and Global Public Health and Director of the Disparities Core of the UC San Diego Center for AIDS Research. is a Clinical Research Coordinator at the University of California, San Diego in the School of Medicine, Department of Medicine, Division of Infectious Diseases and Global Public Health and a PhD Student at Emory University, Rollins School of Public Health in the Department of Behavioral, Social, and Health Education Sciences. is an Assistant Professor at the University of California, San Diego in the School of Medicine, Department of Medicine, Division of Infectious Diseases and Global Public Health. is an Associate Professor at San Diego State University in the Department of Psychology
| | - Katherine M Anderson
- is an Associate Professor at the University of California, San Diego in the School of Medicine, Department of Medicine, Division of Infectious Diseases and Global Public Health and Director of the Disparities Core of the UC San Diego Center for AIDS Research. is a Clinical Research Coordinator at the University of California, San Diego in the School of Medicine, Department of Medicine, Division of Infectious Diseases and Global Public Health and a PhD Student at Emory University, Rollins School of Public Health in the Department of Behavioral, Social, and Health Education Sciences. is an Assistant Professor at the University of California, San Diego in the School of Medicine, Department of Medicine, Division of Infectious Diseases and Global Public Health. is an Associate Professor at San Diego State University in the Department of Psychology
| | - Kiyomi Tsuyuki
- is an Associate Professor at the University of California, San Diego in the School of Medicine, Department of Medicine, Division of Infectious Diseases and Global Public Health and Director of the Disparities Core of the UC San Diego Center for AIDS Research. is a Clinical Research Coordinator at the University of California, San Diego in the School of Medicine, Department of Medicine, Division of Infectious Diseases and Global Public Health and a PhD Student at Emory University, Rollins School of Public Health in the Department of Behavioral, Social, and Health Education Sciences. is an Assistant Professor at the University of California, San Diego in the School of Medicine, Department of Medicine, Division of Infectious Diseases and Global Public Health. is an Associate Professor at San Diego State University in the Department of Psychology
| | - Keith J Horvath
- is an Associate Professor at the University of California, San Diego in the School of Medicine, Department of Medicine, Division of Infectious Diseases and Global Public Health and Director of the Disparities Core of the UC San Diego Center for AIDS Research. is a Clinical Research Coordinator at the University of California, San Diego in the School of Medicine, Department of Medicine, Division of Infectious Diseases and Global Public Health and a PhD Student at Emory University, Rollins School of Public Health in the Department of Behavioral, Social, and Health Education Sciences. is an Assistant Professor at the University of California, San Diego in the School of Medicine, Department of Medicine, Division of Infectious Diseases and Global Public Health. is an Associate Professor at San Diego State University in the Department of Psychology
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Hartmann M, Otticha S, Agot K, Minnis AM, Montgomery ET, Roberts ST. Tu'Washindi na PrEP: Working With Young Women and Service Providers to Design an Intervention for PrEP Uptake and Adherence in the Context of Gender-Based Violence. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2021; 33:103-119. [PMID: 33821679 PMCID: PMC8384060 DOI: 10.1521/aeap.2021.33.2.103] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
HIV pre-exposure prophylaxis (PrEP) reduces HIV acquisition among adolescent girls and young women (AGYW). Existing evidence suggests that uptake and adherence are low among AGYW and that relationship factors such as gender-based violence (GBV) are important barriers. Through a community-based participatory research (CBPR) process, a youth advisory board (YAB), service providers (SP), and a study team developed the Tu'Washindi na PrEP intervention to support AGYW PrEP use in the context of GBV. The YAB also guided the formative research and interpretation of results. The authors pretested the intervention with SP, AGYW and their partners, and community change agents, and then developed guides for AGYW support clubs, community-based male sensitization sessions, and couples-based events that included formulation of story lines for dramatized PrEP negotiation and information dissemination skills. Stakeholder engagement led to an intervention responsive to AGYW's needs for PrEP support in the context of their relationships, which was evaluated through a 6-month pilot community randomized controlled trial.
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Affiliation(s)
- Miriam Hartmann
- Women's Global Health Imperative, RTI International, Berkeley, California
| | | | - Kawango Agot
- Impact Research Development Organization, Kisumu, Kenya
| | - Alexandra M Minnis
- Women's Global Health Imperative, RTI International, Berkeley, California
| | | | - Sarah T Roberts
- Women's Global Health Imperative, RTI International, Berkeley, California
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Hatcher AM, Weiser SD, Cohen CR, Hagey J, Weke E, Burger R, Wekesa P, Sheira L, Frongillo EA, Bukusi EA. Food Insecurity and Intimate Partner Violence Among HIV-Positive Individuals in Rural Kenya. Am J Prev Med 2021; 60:563-568. [PMID: 33012622 PMCID: PMC7987870 DOI: 10.1016/j.amepre.2020.06.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/22/2020] [Accepted: 06/24/2020] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Intimate partner violence and food insecurity are both structural drivers of HIV acquisition, care, and treatment, but little is known about how the 2 conditions intersect in the lives of those already living with HIV. METHODS This study examined cross-sectional baseline data (collected in January 2016-December 2017) from an ongoing trial in southwestern Kenya. Trained interviewers asked enrolled participants living with HIV aged 18-60 years about household food insecurity (using the Household Food Insecurity Access Scale), intimate partner violence (using an adapted WHO multicountry study instrument), and sociodemographics. Negative binomial regression was used to examine the association between food insecurity and partner violence victimization (among women) or perpetration (among men). Secondary data were analyzed in August 2019-March 2020. RESULTS Of 720 participants, more than half of women reported experiencing intimate partner violence (57.6%) and most men reported perpetrating it (58.4%). Participants reporting any partner violence had higher Household Food Insecurity Access Scale scores (21.8) compared with those reporting no violence (21.3, p=0.02). Each categorical change in food insecurity (mild, moderate, severe) was associated with a 41% increased risk of an additional partner violence episode. In models controlling for relationship status, wealth, season of interview (lean versus not lean), and baseline physical health, each 1-point increase in food insecurity was associated with a 6% higher risk of violence victimization among women and 4% greater risk of men perpetrating partner violence. CONCLUSIONS This study highlights the interconnected nature of intimate partner violence and food insecurity among women and men living with HIV. This relationship suggests that enhancing food security may be a useful intervention strategy to prevent intimate partner violence and improve HIV-related health outcomes.
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Affiliation(s)
- Abigail M Hatcher
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, California; Faculty of Health Science, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
| | - Sheri D Weiser
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Craig R Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, California
| | - Jill Hagey
- Department of Medicine, Duke University, Durham, North Carolina
| | - Elly Weke
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Rachel Burger
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, California
| | - Pauline Wekesa
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Lila Sheira
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Edward A Frongillo
- Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, South Carolina
| | - Elizabeth A Bukusi
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, California; Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya; Department of Global Health, University of Washington, Seattle, Washington; Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington
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Colombini M, Scorgie F, Stangl A, Harvey S, Ramskin L, Khoza N, Mashauri E, Baron D, Lees S, Kapiga S, Watts C, Delany-Moretlwe S. Exploring the feasibility and acceptability of integrating screening for gender-based violence into HIV counselling and testing for adolescent girls and young women in Tanzania and South Africa. BMC Public Health 2021; 21:433. [PMID: 33658000 PMCID: PMC7927237 DOI: 10.1186/s12889-021-10454-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 02/17/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Gender-based violence (GBV) undermines HIV prevention and treatment cascades, particularly among women who report partner violence. Screening for violence during HIV testing, and prior to offering pre-exposure prophylaxis (PrEP) to HIV uninfected women, provides an opportunity to identify those at heightened HIV risk and greater potential for non-adherence or early discontinuation of PrEP. The paper describes our experience with offering integrated GBV screening and referral as part of HIV counselling and testing. This component was implemented within EMPOWER, a demonstration project offering combination HIV prevention, including daily oral PrEP, to young women in South Africa and Tanzania. METHODS Between February 2017 and March 2018, a process evaluation was conducted to explore views, experiences and practices of stakeholders (study participants and study clinical staff) during implementation of the GBV screening component. This article assesses the feasibility and acceptability of the approach from multiple stakeholder perspectives, drawing on counselling session observations (n = 10), in-depth interviews with participants aged 16-24 (n = 39) and clinical staff (n = 13), and notes from debriefings with counsellors. Study process data were also collected (e.g. number of women screened and referred). Following a thematic inductive approach, qualitative data were analysed using qualitative software (NVivo 11). RESULTS Findings show that 31% of young women screened positive for GBV and only 10% requested referrals. Overall, study participants accessing PrEP were amenable to being asked about violence during HIV risk assessment, as this offered the opportunity to find emotional relief and seek help, although a few found this traumatic. In both sites, the sensitive and empathetic approach of the staff helped mitigate distress of GBV disclosure. In general, the delivery of GBV screening in HCT proved to be feasible, provided that the basic principles of confidentiality, staff empathy, and absence of judgment were observed. However, uptake of linkage to further care remained low in both sites. CONCLUSION Most stakeholders found GBV screening acceptable and feasible. Key principles that should be in place for young women to be asked safely about GBV during HIV counselling and testing included respect for confidentiality, a youth-friendly and non-judgmental environment, and a functioning referral network.
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Affiliation(s)
- Manuela Colombini
- grid.8991.90000 0004 0425 469XDepartment of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - Fiona Scorgie
- grid.11951.3d0000 0004 1937 1135Wits Reproductive Health Institute, Witwatersrand University, Johannesburg, South Africa
| | - Anne Stangl
- grid.419324.90000 0004 0508 0388International Center for Research on Women, Washington, DC USA
| | - Sheila Harvey
- grid.8991.90000 0004 0425 469XDepartment of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
- grid.452630.60000 0004 8021 6070Mwanza Intervention Trials Unit, Mwanza, Tanzania
| | - Lethabo Ramskin
- grid.11951.3d0000 0004 1937 1135Wits Reproductive Health Institute, Witwatersrand University, Johannesburg, South Africa
| | - Nomhle Khoza
- grid.11951.3d0000 0004 1937 1135Wits Reproductive Health Institute, Witwatersrand University, Johannesburg, South Africa
| | - Emma Mashauri
- grid.452630.60000 0004 8021 6070Mwanza Intervention Trials Unit, Mwanza, Tanzania
| | - Deborah Baron
- grid.11951.3d0000 0004 1937 1135Wits Reproductive Health Institute, Witwatersrand University, Johannesburg, South Africa
| | - Shelley Lees
- grid.8991.90000 0004 0425 469XDepartment of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - Saidi Kapiga
- grid.452630.60000 0004 8021 6070Mwanza Intervention Trials Unit, Mwanza, Tanzania
- grid.8991.90000 0004 0425 469XDepartment of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Charlotte Watts
- grid.8991.90000 0004 0425 469XDepartment of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - Sinead Delany-Moretlwe
- grid.11951.3d0000 0004 1937 1135Wits Reproductive Health Institute, Witwatersrand University, Johannesburg, South Africa
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Logie CH, Wang Y, Lalor P, Williams D, Levermore K. Pre and Post-exposure Prophylaxis Awareness and Acceptability Among Sex Workers in Jamaica: A Cross-Sectional Study. AIDS Behav 2021; 25:330-343. [PMID: 32666244 DOI: 10.1007/s10461-020-02972-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The HIV prevention cascade is understudied among sex workers in Jamaica, where sex work and same sex practices are criminalized. We implemented a cross-sectional survey with cisgender women, transgender women, and cisgender men sex workers in Jamaica. We conducted multivariable logistic regression analyses to identify factors associated with PrEP and PEP awareness and acceptability. Participants (n = 340) included cisgender men (n = 124), transgender women (n = 101), and cisgender women (n = 115). PEP awareness was low (33.2%), yet acceptability was high (70.8%). In multivariable analyses, recent sexual violence, recent client violence, and sex work social cohesion were associated with PEP awareness and acceptability. One-third (32.7%) reported PrEP awareness, with high acceptability (80.2%). Relationship status and recent physical violence were associated with PrEP awareness and acceptability. In multivariable analyses, gender identity was not associated with differences in PEP/PrEP awareness/acceptability. Findings highlight the need to increase PEP and PrEP awareness and access among sex workers in Jamaica.
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Dziva Chikwari C, Bernays S, Dringus S, Simms V, Weiss HA, Sibanda E, Kranzer K, Ncube G, Chikodzore R, Webb K, Chirimambowa T, Sithole K, Ndondo N, Apollo T, Mutseta M, Ferrand RA. Addressing the challenges and relational aspects of index-linked HIV testing for children and adolescents: insights from the B-GAP study in Zimbabwe. Implement Sci Commun 2020; 1:99. [PMID: 33292817 PMCID: PMC7640428 DOI: 10.1186/s43058-020-00091-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 10/21/2020] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Index-linked HIV testing, targeted at sexual contacts or children of individuals with HIV, may improve yield and efficiency. The B-GAP study evaluated index-linked testing approaches in health facility and community-based settings. This paper reports on a qualitative study to understand factors that affect uptake of index-linked HIV testing for children and adolescents. METHODS We conducted four focus group discussions (FGDs) with caregivers who had their children tested through B-GAP and one FGD with providers who offered index-linked HIV testing to indexes. We aimed to understand enabling and inhibiting factors in the decision-making process. Translated and transcribed transcripts were read for familiarisation. Following initial coding, analytical memos were written to identify emerging key themes across the data. RESULTS Our findings showed there was inadequate emphasis on paediatric HIV in routine care which had a negative impact on subsequent uptake of testing for children. Once the decision to test had been made, access to facilities was sometimes challenging and alleviated by community-based testing. A key finding was that HIV testing is not a discrete event but a process that was influenced by relationships with other family members and children themselves. These relationships raised complex issues that could prevent or delay the testing process. CONCLUSION There is a need to improve messaging on the importance of HIV testing for children and adolescents and to provide support to caregivers and their families in order to improve testing uptake. Addressing access barriers through the provision of community-based testing and implementing a family-centred approach can optimise index-linked testing.
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Affiliation(s)
- Chido Dziva Chikwari
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK.
- Biomedical Research and Training Institute, 10 Seagrave Road, Avondale, Harare, Zimbabwe.
| | - Sarah Bernays
- Global Health Department, London School of Hygiene and Tropical Medicine, London, UK
- School of Public Health, University of Sydney, Sydney, Australia
| | - Stefanie Dringus
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Victoria Simms
- Biomedical Research and Training Institute, 10 Seagrave Road, Avondale, Harare, Zimbabwe
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Helen A Weiss
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Katharina Kranzer
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
- Biomedical Research and Training Institute, 10 Seagrave Road, Avondale, Harare, Zimbabwe
| | | | | | - Karen Webb
- Organization for Public Health Interventions and Development, Harare, Zimbabwe
| | | | - Kenny Sithole
- Biomedical Research and Training Institute, 10 Seagrave Road, Avondale, Harare, Zimbabwe
| | - Nonhlanhla Ndondo
- Biomedical Research and Training Institute, 10 Seagrave Road, Avondale, Harare, Zimbabwe
| | | | | | - Rashida A Ferrand
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
- Biomedical Research and Training Institute, 10 Seagrave Road, Avondale, Harare, Zimbabwe
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Gottert A, Pulerwitz J, Haberland N, Mathebula R, Rebombo D, Spielman K, West R, Julien A, Twine R, Peacock D, Kang Dufour MS, Gómez-Olivé FX, Pettifor A, Lippman SA, Kahn K. Gaining traction: Promising shifts in gender norms and intimate partner violence in the context of a community-based HIV prevention trial in South Africa. PLoS One 2020; 15:e0237084. [PMID: 32817692 PMCID: PMC7446856 DOI: 10.1371/journal.pone.0237084] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 07/20/2020] [Indexed: 02/06/2023] Open
Abstract
Background HIV and violence prevention programs increasingly seek to transform gender norms among participants, yet how to do so at the community level, and subsequent pathways to behavior change, remain poorly understood. We assessed shifts in endorsement of equitable gender norms, and intimate partner violence (IPV), during the three-year community-based trial of Tsima, an HIV ‘treatment as prevention’ intervention in rural South Africa. Methods Cross-sectional household surveys were conducted with men and women ages 18–49 years, in 8 intervention and 7 control communities, at 2014-baseline (n = 1,149) and 2018-endline (n = 1,189). Endorsement of equitable gender norms was measured by the GEM Scale. Intent-to-treat analyses assessed intervention effects and change over time. Qualitative research with 59 community members and 38 staff examined the change process. Results Nearly two-thirds of men and half of women in intervention communities had heard of the intervention/seen the logo; half of these had attended a two-day workshop. Regression analyses showed a 15% improvement in GEM Scale score over time, irrespective of the intervention, among men (p<0.001) and women (p<0.001). Younger women (ages 18–29) had a decreased odds of reporting IPV in intervention vs. control communities (aOR 0.53; p<0.05). Qualitative data suggest that gender norms shifts may be linked to increased media access (via satellite TV/smartphones) and consequent exposure to serial dramas modeling equitable relationships and negatively portraying violence. Tsima’s couple communication/conflict resolution skills-building activities, eagerly received by intervention participants, appear to have further supported IPV reductions. Conclusions There was a population-level shift towards greater endorsement of equitable gender norms between 2014–2018, potentially linked with rapid escalation in media access. There was also an intervention effect on reported IPV among young women, likely owing to improved couple communication. Societal-level gender norm shifts may create enabling environments for interventions to find new traction for violence and HIV-related behavior change.
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Affiliation(s)
- Ann Gottert
- Population Council/Project SOAR, Washington, D.C., United States of America
- * E-mail:
| | - Julie Pulerwitz
- Population Council/Project SOAR, Washington, D.C., United States of America
| | - Nicole Haberland
- Population Council/Project SOAR, Washington, D.C., United States of America
| | | | - Dumisani Rebombo
- Sonke Gender Justice, Bushbuckridge Local Municipality, South Africa
- Independent Consultant, Johannesburg, South Africa
| | - Kathryn Spielman
- Population Council/Project SOAR, Washington, D.C., United States of America
| | - Rebecca West
- Division of Prevention Science, Department of Medicine, University of California San Francisco, San Francisco, CA, United States of America
| | - Aimée Julien
- Department of Epideiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Dean Peacock
- Sonke Gender Justice, Bushbuckridge Local Municipality, South Africa
- Promundo, Washington, D.C., United States of America
- University of Cape Town School of Public Health, Cape Town, South Africa
| | - Mi-Suk Kang Dufour
- Division of Prevention Science, Department of Medicine, University of California San Francisco, San Francisco, CA, United States of America
| | - F. Xavier Gómez-Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Audrey Pettifor
- Department of Epideiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sheri A. Lippman
- Division of Prevention Science, Department of Medicine, University of California San Francisco, San Francisco, CA, United States of America
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Haberland N, Ndwiga C, McCarthy K, Pulerwitz J, Kosgei R, Mak’anyengo M, Peltz A, Wong VJ, Kalibala S. Addressing Intimate Partner Violence and Power in Intimate Relationships in HIV Testing Services in Nairobi, Kenya. AIDS Behav 2020; 24:2409-2420. [PMID: 32026250 PMCID: PMC7395047 DOI: 10.1007/s10461-020-02801-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Intimate partner violence (IPV) undermines women’s uptake of HIV services and violates their human rights. In a two-arm randomized controlled trial we evaluated a short intervention that went a step beyond IPV screening to discuss violence and power with women receiving HIV testing services during antenatal care (ANC). The intervention included training and support for HIV counselors, a take-home card for clients, and an on-site IPV counselor. One third (35%) of women (N = 688) reported experiencing IPV in the past year; 6% were living with HIV. Among women experiencing IPV, program participants were more likely to disclose violence to their counselor than women receiving standard care (32% vs. 7%, p < 0.001). At second ANC visit, intervention group women were significantly more likely to report that talking with their counselor made a positive difference (aOR 2.9; 95% CI 1.8, 4.4; p < 0.001) and felt more confident in how they deserved to be treated (aOR 2.7; 95% CI 1.7, 4.4; p < 0.001). Exploratory analyses of intent to use ARVs to prevent mother-to-child transmission and actions to address violence were also encouraging.
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Bowring AL, Ampt FH, Schwartz S, Stoové MA, Luchters S, Baral S, Hellard M. HIV pre-exposure prophylaxis for female sex workers: ensuring women's family planning needs are not left behind. J Int AIDS Soc 2020; 23:e25442. [PMID: 32064765 PMCID: PMC7025091 DOI: 10.1002/jia2.25442] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 11/28/2019] [Accepted: 12/05/2019] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Female sex workers (FSWs) experience overlapping burdens of HIV, sexually transmitted infections and unintended pregnancy. Pre-exposure prophylaxis (PrEP) is highly efficacious for HIV prevention. It represents a promising strategy to reduce HIV acquisition risks among FSWs specifically given complex social and structural factors that challenge consistent condom use. However, the potential impact on unintended pregnancy has garnered little attention. We discuss the potential concerns and opportunities for PrEP to positively or negatively impact the sexual and reproductive health and rights (SRHR) of FSWs. DISCUSSION FSWs have high unmet need for effective contraception and unintended pregnancy is common in low- and middle-income countries. Unintended pregnancy can have enduring health and social effects for FSWs, including consequences of unsafe abortion and financial impacts affecting subsequent risk-taking. It is possible that PrEP could negatively impact condom and other contraceptive use among FSWs due to condom substitution, normalization, external pressures or PrEP provision by single-focus services. There are limited empirical data available to assess the impact of PrEP on pregnancy rates in real-life settings. However, pregnancy rates are relatively high in PrEP trials and modelling suggests a potential two-fold increase in condomless sex among FSWs on PrEP, which, given low use of non-barrier contraceptive methods, would increase rates of unintended pregnancy. Opportunities for integrating family planning with PrEP and HIV services may circumvent these concerns and support improved SRHR. Synergies between PrEP and family planning could promote uptake and maintenance for both interventions. Integrating family planning into FSW-focused community-based HIV services is likely to be the most effective model for improving access to non-barrier contraception among FSWs. However, barriers to integration, such as provider skills and training and funding mechanisms, need to be addressed. CONCLUSIONS As PrEP is scaled up among FSWs, there is growing impetus to consider integrating family planning services with PrEP delivery in order to better meet the diverse SRHR needs of FSWs and to prevent unintended consequences. Programme monitoring combined with research can close data gaps and mobilize adequate resources to deliver comprehensive SRHR services respectful of all women's rights.
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Affiliation(s)
- Anna L Bowring
- Department of EpidemiologyJohns Hopkins School of Public HealthBaltimoreMDUSA
- Burnet InstituteMelbourneVictoriaAustralia
| | - Frances H Ampt
- Burnet InstituteMelbourneVictoriaAustralia
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Sheree Schwartz
- Department of EpidemiologyJohns Hopkins School of Public HealthBaltimoreMDUSA
| | - Mark A Stoové
- Burnet InstituteMelbourneVictoriaAustralia
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Stanley Luchters
- Burnet InstituteMelbourneVictoriaAustralia
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
- Department of Population HealthAga Khan UniversityNairobiKenya
- International Centre for Reproductive HealthDepartment of Public Health and Primary CareGhent UniversityGhentBelgium
| | - Stefan Baral
- Department of EpidemiologyJohns Hopkins School of Public HealthBaltimoreMDUSA
| | - Margaret Hellard
- Burnet InstituteMelbourneVictoriaAustralia
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
- Department of Infectious DiseasesThe Alfred HospitalMelbourneVictoriaAustralia
- Doherty Institute and Melbourne School of Population and Global HealthUniversity of MelbourneMelbourneVictoriaAustralia
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