Concurrent sexual partnerships and the HIV epidemics in Africa: evidence to move forward

Sexual Risk among Pregnant Women at Risk of HIV Infection in Cape Town, South Africa: What Does Alcohol Have to Do with It?

This study examines baseline associations between alcohol use and HIV sexual risk among a cohort of HIV-uninfected pregnant women (n = 1201) residing in a high HIV burdened community in Cape Town, South Africa. Alcohol use was measured using a modified version of the Alcohol Use Disorder Identification Test (AUDIT). HIV sexual risk was measured through a composite variable of four risk factors: diagnosis with a STI, self-report of > 1 recent sex partners, partner HIV serostatus (unknown or HIV+) and condomless sex at last sex. Any past year alcohol use prior to pregnancy was reported by half of participants (50%); 6.0% reported alcohol use during pregnancy. Alcohol use prior to pregnancy was associated with increased odds of being at high risk of HIV (aOR = 1.33, 95% CI 1.05-1.68, for 2 risks and aOR = 1.47, 95% CI 0.95-2.27 for 3 risks). In addition to reducing alcohol use, several other strategies to address HIV sexual risk were identified. Evidence-based interventions to address alcohol use and other HIV sexual risk behaviors during pregnancy in South Africa are desperately needed. Qualitative work exploring individual and community level drivers of alcohol use among pregnant and breastfeeding women in this setting could support development of a culturally tailored intervention to address these issues in this population.

Sexual vulnerability of migrant women in the multicultural context of French Guiana: A societal issue

Background

French Guiana is a multicultural French territory in Amazonia with an old migration history and a high prevalence of HIV infection. The objective of this study was to evaluate situations of sexual vulnerability and their associated factors among migrant women in French Guiana.

Methods

A cross-sectional epidemiological study was carried out in 2021 in the French Red Cross Prevention and Health Centers of the two main cities of French Guiana (Cayenne and Saint Laurent du Maroni). Analysis was performed with multivariate stepwise logistic regression using Stata 15.0 software.

Findings

A total of 382 migrant women were included, with a median age of 31 years, mainly born in Haiti (80%), Suriname (9%), or Dominican Republic (6%), undocumented (71%), and with financial difficulties (77%). Among the 20% having casual partners, 57% reported unprotected sexual intercourse, more often the Haitian and Surinamese women. A history of rape was reported by 20% of women, most often in the country of origin (71%). Lifetime rape was associated with being threatened [aOR = 3.69 (1.96-6.96)] or being physically abused [aOR = 12.95 (6.51-25.75)] in the multivariate analysis. Among the women surveyed, 30% reported having ever exchanged sex for money, food, or shelter in their lifetime. Transactional sex is more common among Dominican women [aOR = 5.59 (1.84-16.95)] and women living in French Guiana for more than 2 years [aOR = 2.32 (1.38-3.92)]. Transactional sex is also associated with alcohol misuse [aOR = 2.57 (1.46-4.53)], history of threats [aOR = 2.03 (1.14-3.63)], history of rape [aOR = 1.92 (1.03-3.60)], and depressive disorders [aOR = 2.08 (1.21-3.60)].

Interpretation

Migrant women in French Guiana are in a situation of sexual vulnerability. An intervention focused on sexual education and the promotion of prevention tools among Haitian women is advisable. Better prevention and support for transactional sex are needed to prevent violence and its mental health and alcohol misuse consequences for all women, especially Dominican women.

From a drought to HIV: An analysis of the effect of droughts on transactional sex and sexually transmitted infections in Malawi

Each year there are over 300 natural disasters globally with millions of victims that cost economic losses near USD$100 billion. In the context of climate change, an emerging literature linking extreme weather events to HIV infections suggests that efforts to control the HIV epidemic could be under threat. We used Demographic and Health Survey (DHS) data collected during the 2015-2016 harsh drought that affected several areas of Malawi to provide new evidence on the effect of an unanticipated economic shock on sexual behaviours of young women and men. We find that amongst women employed in agriculture, a six-months drought doubles their likelihood of engaging in transactional sex compared to women who were not affected by the drought and increases their likelihood of having a sexually transmitted infections (STI) by 48% in the past twelve months. Amongst men employed outside of agriculture, drought increases by 50% the likelihood of having a relationship with a woman engaged in transactional sex. These results suggest that women in agriculture experiencing economic shocks as a result of drought use transactional sex with unaffected men, i.e. men employed outside agriculture, as a coping mechanism, exposing themselves to the risk of contracting HIV. The effect was especially observed among non-educated women. A single drought in the last five years increases HIV prevalence in Malawi by around 15% amongst men and women. Overall, the results confirm that weather shocks are important drivers of risky sexual behaviours of young women relying on agriculture in Africa. Further research is needed to investigate the most adequate formal shock-coping strategies to be implemented in order to limit the negative consequences of natural disasters on HIV acquisition and transmission.

High HIV incidence among young women in South Africa: Data from a large prospective study

Introduction

South Africa has the highest national burden of HIV globally. Understanding drivers of HIV acquisition in recently completed, prospective studies in which HIV was an endpoint may help inform the strategy and investments in national HIV prevention efforts and guide the design of future HIV prevention trials. We assessed HIV incidence and correlates of incidence among women enrolled in ECHO (Evidence for Contraceptive Options and HIV Outcomes), a large, open-label randomized clinical trial that compared three highly effective. reversible methods of contraception and rates of HIV acquisition.

Methods

During December 2015 to October 2018, ECHO followed sexually active, HIV-seronegative women, aged 16–35 years, seeking contraceptive services and willing to be randomized to one of three contraceptive methods (intramuscular depot medroxyprogesterone acetate, copper intrauterine device, or levonorgestrel implant) for 12–18 months at nine sites in South Africa. HIV incidence based on prospectively observed HIV seroconversion events. Cox proportional hazards regression models were used to define baseline cofactors related to incident HIV infection.

Results

5768 women were enrolled and contributed 7647 woman-years of follow-up. The median age was 23 years and 62.5% were ≤24 years. A total of 345 incident HIV infections occurred, an incidence of 4.51 per 100 woman-years (95%CI 4.05–5.01). Incidence was >3 per 100 woman-years at all sites. Age ≤24 years, baseline infection with sexually transmitted infections, BMI≤30, and having new or multiple partners in the three months prior to enrollment were associated with incident HIV.

Conclusions

HIV incidence was high among South African women seeking contraceptive services. Integration of diagnostic management of sexually transmitted infections alongside delivery of HIV prevention options in health facilities providing contraception services are needed to mitigate ongoing risks of HIV acquisition for this vulnerable population.

Clinical trial registration

ClinicalTrials.gov, number NCT02550067 was the main Clinical Trial from which this secondary, non-randomized / observational analysis was derived with data limited to just South African sites.

Making sense of fidelity: young Africans' cross-national and longitudinal representations of fidelity and infidelity in their HIV-related creative narratives, 1997-2014

Mutual fidelity and partner reduction have been identified as key behavioural strategies to prevent HIV transmission in sub-Saharan Africa, particularly following recognition of the role that multiple concurrent sexual partnerships play in driving generalised HIV epidemics. We analysed social representations of fidelity and infidelity in a sample of 1,343 narratives about HIV written by young Africans between 1997 and 2014. The narratives were written at four different time points (1997, 2005, 2008, 2014) by authors aged 10-24 in urban and rural areas of Senegal, Burkina Faso, South-east Nigeria, Kenya and Eswatini. We combined three analytical approaches: descriptive statistics of quantifiable characteristics of the narratives, thematic data analysis and a narrative-based approach. In the sample, fidelity is often promoted as the ideal by narrators, peers and romantic partners, in line with broader discourses around HIV prevention, romantic relationships, familial obligations, and religious and moral imperatives. However, mutual fidelity is rarely modelled in the narratives and representations of combining methods to prevent HIV from entering relationships via infidelity are uncommon. Representations of fidelity reflect loss-framed fear arousal techniques that perpetuate HIV-related stigma. Narrative-based approaches that facilitate skills-building, critical reflection and address stigma can better address fidelity and partner reduction.

Concurrency measures in the era of temporal network epidemiology: a review

Diseases spread over temporal networks of interaction events between individuals. Structures of these temporal networks hold the keys to understanding epidemic propagation. One early concept of the literature to aid in discussing these structures is concurrency-quantifying individuals' tendency to form time-overlapping 'partnerships'. Although conflicting evaluations and an overabundance of operational definitions have marred the history of concurrency, it remains important, especially in the area of sexually transmitted infections. Today, much of theoretical epidemiology uses more direct models of contact patterns, and there is an emerging body of literature trying to connect methods to the concurrency literature. In this review, we will cover the development of the concept of concurrency and these new approaches.

Assessment of an HIV-prevention intervention for couples in peri-urban Uganda: pervasive challenges to relationship quality also challenge intervention effectiveness

Reducing multiple and concurrent partnerships has been identified as a priority in generalised HIV epidemics, yet developing successful interventions to bring about such behaviour change has proven challenging. We offered a three-session intervention aimed to improve couple relationship quality and address HIV risk factors, particularly concurrent sexual partnerships (CSP), in a peri-urban community of Kampala, Uganda. Before launching the intervention, a different group of community members participated in eight single-gender focus group discussions (FGDs) which explored issues of couple relationship quality and satisfaction. Findings from the FGDs guided the intervention. All 162 couples invited to the intervention completed a survey pre- and post-intervention. In FGDs, women and men discussed challenges faced in their relationships, including pervasive dissatisfaction, financial constraints, deception and lack of trust, poor communication, lack of sexual satisfaction, and concurrent sexual partnerships. A difference-in-difference analysis showed no measurable impact of the intervention on relationship quality or sexual risk behaviours over a six-month follow-up among 183 individuals who participated in the intervention, although many stated in response to open-ended questions that they had experienced positive relationship changes. Qualitative findings suggest high demand for couple-focused interventions but also reveal many individual-, couple-, community- and structural-level factors which contribute to women and men seeking concurrent sexual partnerships. More intensive interventions may be needed to overcome these barriers to behaviour change and reduce HIV risk. These findings also raise questions about how to interpret divergent qualitative and quantitative data, a topic which has received little attention in the literature.

Determinants of intergenerational sexual relationships and HIV risk among South African women outpatients in Gauteng

Age-discrepant sexual relationships may place women at risk for HIV infection in South Africa. Results are based on medical records and case-control interview data of 889 sexually experienced women outpatients aged 15-29 in a Gauteng township. Women with partners at least ten years older (intergenerational) show an elevated chance of having an early sexual debut, concurrent and transactional partners, and intimate partner violence. Hardship during childhood including parental loss, food insecurity and abuse are related to age asymmetric relationships. HIV is two times more likely (aOR=1.96) with an intergenerational partner. Transactional sex increases the odds of HIV independently (aOR=1.76) as does intimate partner violence (aOR=1.6). To the extent that transactional and intergenerational sex overlap the chance of contracting HIV increases more than two-fold (uOR=4.57). Girls (15-19) with intergenerational partners face the highest chance of HIV (uOR=8.55) compared to other age groups. They are also five times more likely than controls to have lived with a cross-age partner. Our findings indicate there are multiple pathways emanating from childhood leading to women's choice of intergenerational partners, and the link to HIV is strongest among the youngest women.

Seroprevalence and Determinants of Human Immunodeficiency Virus Infection Among Women of Reproductive Age in Mozambique: A Multilevel Analysis

Background

Human immunodeficiency virus (HIV) has continued to be one of the foremost public health problems globally. Even as more people living with the disease can now have access to antiretroviral therapy (ART), there are still some regions in the world with high transmission rates. The objective of this study was to examine the prevalence and individual-, household- and community-level factors associated with HIV infection among women of reproductive age in Mozambique.

Methods

We used nationally representative cross-sectional data from the 2015 Survey of Indicators on Immunization, Malaria and HIV or Acquired Immunodeficiency Syndrome (AIDS) in Mozambique. A sample of 4726 women of reproductive age was included in this study. Prevalence was measured in percentage and the factors for HIV infection were examined using a multivariable multilevel logistic regression model. The level of significance was set at P < 0.05.

Results

The seroprevalence of HIV among women in Mozambique was 10.3% (95% CI 9.2%, 11.6%). Furthermore, women who had two, three and four or more total lifetime number of sex partners were 2.73, 5.61 and 3.95 times as likely to have HIV infection when compared with women with only one lifetime sex partners, respectively. In addition, women of Islam religion had 60% reduction in HIV infection when compared with Christian women (adjusted odds ratio, AOR = 0.40; 95% CI 0.16, 0.99). The individual-level model (model B) had the best model fitness with the lowest Akaike information criterion (AIC) = 500.87 and Bayesian information criterion (BIC) = 648.88. The variations in the odds of HIV infection across communities (σ² = 9.61 × 10^–8; SE = 0.55) and households (σ² = 1.02 × 10^–4; SE = 1.02) were estimated. Results from the median odds ratio (MOR = 1.00) did not show any evidence of community and household contextual factors shaping HIV infection. MOR equal to unity (1) indicated that there were no community or household variances given the ICC of 0.0%. At both community and household levels, the explained variances were each 100%. This implied total variances in HIV infection has been explained by the individual-level factors.

Conclusion

In this study, we found that having multiple total lifetime number of sexual partners and religion were predisposing factors for HIV infection at individual woman level. Female headship and wealth quintiles were associated with HIV infection at household level. Community illiteracy, intimate partner violence, poverty and geographical region were associated with HIV infection at community level. Therefore, multifaceted health intervention by stakeholders in the healthcare system will be useful in addressing the multilevel predisposing factors of HIV infection among Mozambican women.

Multilayered Stigma and Vulnerabilities for HIV Infection and Transmission: A Qualitative Study on Male Sex Workers in Zimbabwe

Male sex workers are marginalized in most societies due to intersectional stigma between prostitution and homosexuality. In Zimbabwe, a proliferation of male sex workers in major cities such as Harare and Bulawayo has been reported. However, there is a shortage of studies that explore their lives. The current qualitative study aims to describe the practices of sex work, life contexts, and HIV risks and vulnerabilities based on in-depth interviews among 15 male sex workers in Bulawayo. Our studies suggest that the stigma against male sex workers comes from diverse sectors including culture (“homosexuality is un-African, introduced by the Whites”), religion (“same sex is a sin before the God”), law and police (“homosexuality is illegal in Zimbabwe. Engaging in it can send one to prison”), media (“the media is hostile to sex workers particularly men as we are regarded as abnormal and unclean”), and their family (“should they get to know about it, they will disown me”). In this context, male sex workers were excluded from national HIV prevention and treatment programs. They had limited knowledge and many misconceptions about HIV. The stigma and discrimination from health-care providers also discouraged them from health seeking or HIV testing. The non-disclosure to female partners of convenience and sexual relations further increased their vulnerabilities to HIV infection and transmission. Current efforts to address the HIV epidemic should pay attention to male sex workers and tackle the intersecting stigma issues. male sex workers need support and tailored HIV prevention and treatment services to improve their HIV prevention practices, health, and well-being.

'PrEP should be for men only': Young heterosexual men's views on PrEP in rural South Africa

BACKGROUND

Gaps persist in HIV testing, treatment, and prevention services for men, leading to higher attributable mortality compared to women. We sought to characterise HIV prevention knowledge, risk behaviours, and interest in pre-exposure prophylaxis (PrEP) among young men in rural South Africa.

METHODS

We conducted interviews with HIV-negative heterosexual men which were thematically analysed to identify key themes.

RESULTS

Among 31 participants, median age was 26 (IQR23-31), 77% were unemployed, 52% reported previous STI, 84% reported casual sexual partners. Men acknowledged inconsistent condom use with multiple partners, reporting high-risk sexual behaviour despite recognised risk. Mistrust between partners was common. Respondents reported willingness to take PrEP to protect themselves and their partner, though anticipated stigma and structural barriers. Men worried that if their female partner had PrEP, she would become sexually active with others.

CONCLUSIONS

In rural South Africa, young heterosexual men acknowledged high HIV-risk behaviour, expressed concern about acquiring HIV, and recognised the value of PrEP. Men were often not supportive of their female partners taking PrEP. Implementing HIV prevention services needs to incorporate young men's perspectives and may require gender-specific interventions, including addressing stigma, differentiated service delivery models such as community-based services or adapting facility services to target men.

Factors associated with HIV in younger and older adult men in South Africa: findings from a cross-sectional survey

OBJECTIVE

This study investigated the behavioural, psychosocial and biological factors associated with HIV in a younger group of men (15 to 24 years) compared with an older group of men (25 to 35 years).

DESIGN

A household-based, cross-sectional study was conducted.

SETTING

Men were randomly selected using a two-stage random sampling method in KwaZulu-Natal, South Africa, between June 2014 and June 2015.

PARTICIPANTS

Overall, we interviewed 1472 younger men and 1138 older men. Only participants who could speak English or Zulu, were able to provide informed consent and who were expected to be living in the study area for the next 12 months were enrolled into the study.

PRIMARY AND SECONDARY OUTCOMES

HIV status was the primary outcome for the study. Men's HIV status was derived from blood samples collected in the study which were tested for HIV antibodies.

RESULTS

HIV prevalence was higher among older men (35.4%, 95% CI: 31.7 to 39.1) than younger men (7.6%, 95% CI: 6.2 to 9.4, p<0.01). Older men, who completed secondary school had a lower likelihood of being HIV positive (adjusted OR (AOR): 0.41, 95% CI: 0.27 to 0.63, p<0.001) and those with greater food insecurity had a higher likelihood of being HIV positive (AOR: 1.57, 95% CI: 1.05 to 2.34, p=0.04). Younger men with a higher number of lifetime sexual partners had a higher likelihood of being HIV positive (AOR: 1.04, 95% CI: 0.99 to 1.09, p=0.09).

CONCLUSION

Given that the HIV prevalence is higher in the older men, community based interventions need to target older men for medical circumcision and support HIV positive men to improve their material conditions early. For younger men intervening to reduce HIV risk behaviours at a young age before these behaviours become entrenched should be central to HIV prevention programmes.

Alcohol use and sexual risk behaviors in the Armed Forces of the Democratic Republic of the Congo

Background

Alcohol misuse is an important contributor to sexual acquisition and transmission of HIV in military communities. This cross-sectional study quantified the prevalence of probable problematic alcohol use among male service members in the Armed Forces of the Democratic Republic of the Congo (FARDC), identified associated factors, and investigated associations of alcohol misuse with risky sexual behaviors.

Methods

Participants included 2549 active duty male soldiers ≥ 18 years old. Data were collected via computer-assisted personal-interview from October 2013–April 2014. The Alcohol Use Disorders Identification Test (AUDIT) was used to identify probable problematic alcohol use (AUDIT score ≥ 8) compared to no/low-risk alcohol use (AUDIT score ≤ 7). Bivariate logistic regressions were used to identify factors associated with probable problematic alcohol use. Several multivariable logistic regressions (adjusted for age, marital status, education level) were used to examine associations of probable problematic alcohol use with risky sexual behaviors. Tests were two sided; statistical significance was defined as p < 0.05.

Results

Fifteen percent of men screened positive for probable problematic alcohol use. The odds of probable problematic alcohol use were elevated among men who were single and living with a partner (OR = 1.66; 95% CI = 1.24–2.21), ranked as a non-commissioned officer [NCO] (OR = 1.40; 95% CI = 1.10–1.77), and in the 30–39 and 40–49 age groups (OR 30–39 age group = 2.17; 95% CI = 1.56–3.02; OR 40–49 age group = 1.79; 95% CI = 1.26–2.55). Probable problematic alcohol use was associated with increased odds of having sex with a sex worker (SW), having multiple sexual partners, and participating in transactional sex (aOR sex with a SW = 2.36; 95% CI = 1.78–3.13; aOR multiple sexual partners = 2.08; 95% CI = 1.66–2.60; aOR transactional sex = 1.99; 95% CI = 1.59–2.50).

Conclusions

Results emphasize the need to address alcohol use in the FARDC and integrate alcohol abuse education into HIV prevention programs among male service members. Alcohol abuse prevention efforts should target men who are 30–49 years of age, unmarried, and ranked as a NCO. Messages and interventions to reduce alcohol misuse in relation to risky sexual behaviors are needed.

Partner faithfulness and sexual reproductive health practices in Botswana: does perception of partner infidelity influence sexual risk behaviours of people aged 10-34 years?

The main aim of this study was to test whether perception of partner infidelity prompts people to adopt behaviour that is meant to compensate for the increased risk of infection posed by their partner's infidelity; or whether it prompts people to engage in behaviour that magnifies the risk associated with partner infidelity. Data used were derived from the fourth and latest Botswana AIDS Impact Survey (BAIS IV) conducted in 2013. The sample consisted of 6985 people aged 10-34 years. Logistic regression analysis was used to identify factors associated with perception of partner infidelity and sexual risk behaviours. Perception of partner infidelity with the current and most recent partner was 39.6% while perception of partner infidelity with other previous sexual partners was 79.9%. The main socio-demographic factors associated with perception of partner infidelity were being a man, being single and having secondary education, while sexual risk behaviours associated with perception of partner infidelity were having multiple sexual partners and being involved in multiple concurrent sexual partnerships. These relationships were statistically significant at the 5% level. Botswana's HIV prevention strategies should seek to improve partner communication within relationships in order to enhance people's confidence and skills so as to minimize perceptions of infidelity.

Constructions of sexuality and HIV risk among young people in Venda, South Africa: implications for HIV prevention

The study explored constructions of sexuality among young people of Venda in Limpopo, South Africa, and cultural practices that can be used to develop context-specific HIV prevention programmes. HIV prevention can be promoted by including some cultural practices in prevention programmes and changing some aspects of culture that may contribute negatively to health. Six focus group discussions were held with school-going young people (Grades 10 to 12) in urban and rural areas to explore their constructions of sexuality and HIV risk. Four focus group discussions were held with community leaders in the same areas to explore their constructions of young people's sexuality and cultural practices relevant to HIV prevention. Through discourse analysis, the following dominant discourses that influence young people's sexual risk behaviour were identified: rite of passage, the male sexual drive discourse (sex is natural and unavoidable); discourse of hegemonic masculinity (sex to prove masculinity); sex as a commodity; non-adherence to cultural practices; and HIV is normalised (AIDS is like flu). Some alternative constructions and shifts in gender norms were noticed, especially among female participants. The constructions of young people were not culture-specific but similar to those identified in other South African cultures. Community leaders identified a few cultural practices that could be considered in HIV prevention, for example, reinstating the rite of passage to provide age-appropriate sex and HIV education (behavioural intervention), and promoting traditional male circumcision (biological intervention). Cultural practices that contribute negatively to health should be challenged such as current constructions of gender roles (masculinity and femininity) and the practice that parents do not talk to young people about sex (both structural interventions).

Alcohol use and its association with sexual risk behaviors in the Armed Forces of the Republic of the Congo

Background

Previous research has shown alcohol misuse amplifies the risk of acquiring sexually transmitted infections [STIs], including HIV, by increasing high risk sexual behaviors. Military populations are particularly vulnerable to both alcohol misuse and STIs due to the unique conditions of military service. This study estimated the prevalence of probable hazardous and harmful alcohol use and examined associations with transactional sex, sex with a sex worker, and multiple sexual partners among military personnel in the Armed Forces of the Republic of the Congo (FAC).

Methods

A secondary analysis of data collected from a 2014 seroprevalence and behavioral epidemiology risk survey was performed. Participants included 703 active duty male service members 18 years of age or older who reported ever having sex. Patterns of harmful and hazardous drinking were measured with the Alcohol Use Disorders Identification Test (AUDIT). Participants with an AUDIT score ≥ 8 (indicative of probable hazardous and harmful alcohol use, and possible alcohol dependence) were compared to those with an AUDIT score ≤ 7.

Results

A total of 15.8% received a score of 8 or higher on the AUDIT. These participants were more likely to be lower educated and of lower military rank. In separate multivariable models, an AUDIT score ≥ 8 was significantly associated with higher odds of sex with a commercial sex worker and having multiple sexual partners.

Conclusions

Study results emphasize the need to address patterns of harmful and hazardous alcohol use in the FAC and integrate alcohol misuse education into the HIV prevention program. The development of military-specific interventions to reduce alcohol-related risky sexual behaviors are also needed. Lastly, implementing policies such as restricting alcohol availability and sales on military bases, and adding warning labels to advertisements and containers may provide a more comprehensive response to reduce problematic alcohol use.

HIV voluntary counselling and testing and behaviour changes among youths in Nigeria

Voluntary counselling and testing (VCT) for HIV has been promoted as a strategy to prevent HIV pandemics by changing sexual behaviour. Despite the provision of VCT in countries with generalized or high-burden epidemics, including Nigeria, the extent of its influence on behavioural change remains a conjecture. The main objective of this study was to examine the influence of HIV VCT on sexual behaviour changes among youths in Nigeria. The study utilized 2013 Nigeria Demographic and Health Survey (NDHS) data. Data were analysed from a nationally representative sample drawn from 8046 females and 6031 males aged 15-24 giving a total sample of 14,077 never-married youths. Descriptive and analytical analyses were carried out, including multivariate logistic regression. The study found a low uptake of HIV VCT and regional variation in behavioural changes between female and male youths. Voluntary HIV counselling and testing was found to be a protective factor for condom use at last sex for female youths, but significantly reduced the likelihood of primary sexual abstinence for both females and males, as well as having a single sexual partner for female youths. After controlling HIV VCT with other variables, certain socioeconomic factors were found to be significantly associated with behavioural changes. Thus, the attitudes of most Nigerian youths towards voluntary HIV counselling and testing needs to be improved through socioeconomic factors for healthy sexual activity. To achieve this, government and non-governmental organizations, as well as religious leaders and policymakers, should engage in appropriate and long-term activities directed at the sexual health needs of never-married youths, through voluntary HIV counselling and testing, to encourage them to change their sexual behaviour.

'You just have to grin and bear' - emotional suppression among women in polygyny in Cameroon

Polygyny is a matrimonial union in which a single man is simultaneously married to multiple wives. On a daily basis, women in polygynous unions suffer from financial, emotional and physical burdens. This study explores women's perceptions of this matrimonial regime and the factors influencing their sexual health decision-making in Cameroon. Drawing on interviews with twenty-three women aged 23 to 80 years living in polygynous unions, we explore women's daily life and perceptions on polygyny. Using content analysis, meaning units relating to respondents' experiences and perceptions were identified and condensed into codes and categories that were later grouped into themes. Five themes emerged - refusal and tolerance; heavy workload and responsibility; lack of power in sexual health decision-making; discrimination and unequal treatment of spouses; and emotional suppression. Women reported emotional suppression, limited rights, discrimination and poor living conditions as being the most significant problems that they encountered. Addressing the discrimination faced by women in polygynous unions will entail adopting and implementing laws to protect women's rights and promote their empowerment.

Relationship power and HIV sero-status: an analysis of their relationship among low-income urban Zimbabwean postpartum women

Background

HIV disproportionately infects women in many regions. Zimbabwe is one of the countries, most heavily affected. Unequal gender power relations between men and women can increase women’s vulnerability to HIV. The aim of this paper was to determine the relationship between gender power and HIV sero-status among postpartum women in Zimbabwe.

Methodology

A cross-sectional survey was conducted among 2042 women aged 15–49 years, attending postnatal-care at six public primary health care clinics in low-income urban communities of Harare in 2011. Women were asked about relationship power factors using an interviewer-administered questionnaire. The questionnaire included adapted WHO multi-country study items, which measure partner violence perpetrated against women. HIV status data were based on rapid HIV diagnostic tests done during earlier antenatal visits. The analysis was restricted to women with known HIV test results (n = 1951). Multivariable logistic regression analyses were performed to assess the predictors of HIV and relationship power factors.

Results

HIV prevalence was 15.3% (n = 299/1951). Three quarters of the women (76.9%, n = 1438/1871) reported some level of relationship control in their current/most recent intimate relationship. HIV positive women reported higher levels of control by the male partner in their intimate relationships. In adjusted models, the study found a significant association between relationship-control by the male partner and women’s HIV status (AOR 1.11, 95% CI 1.01–1.22), and the decision-making dimensions of relationship power. Although there were indications of high male partner control in participants’ intimate relationships, some women still had agency, as they were able to make independent decisions to fall pregnant. These women were less likely to be HIV positive (AOR 0.54, 95% CI 0.29–1.00). Having a partner who ever refused use of a family planning method was associated with increased odds of having a positive HIV status among the postpartum women (AOR 1.88, 95% CI 1.20–2.90).

Conclusion

Unequal gender power relations continue to be a risk factor for heterosexual transmission of HIV. This suggests that prevention efforts have not successfully resulted in gender equality. HIV prevention interventions should address gender power dynamics to help curb the disproportionate HIV burden among women.

Cognitive and behavioural determinants of multiple sexual partnerships and condom use in South Africa: Results of a national survey

Background

Human immunodeficiency virus (HIV) risky behaviours including multiple sexual partnership (MSP) and non-condom use (nCU) are known to be drivers of the spread of HIV; cognitive factors including perceived susceptibility of HIV, self-efficacy and attitudes play a significant role in influencing risky sexual behaviours.

Objectives

We sought to investigate personal beliefs, perceptions, thoughts and actions that are associated with MSP and nCU in South Africa.

Methods

We analysed nationally representative data from the 2012 National HIV Communication Survey (NCS) that included about 10 000 participants aged 16–55 years. Five constructs were created to measure psychosocial and cognitive determinants. Cronbach’s alpha coefficient for internal consistency reliability was calculated. Multivariable logistic regression was used to determine factors associated with MSP and nCU.

Results

Of the 6061 sexually active respondents, 13% (95% CI: 11.47–13.12) reported MSP and 52.7% (n = 3158 of 6039) (95% CI: 51.0–53.55) nCU at last sex. Factors associated with MSP included perceived benefits, adjusted odds ratio (aOR) = 2.16 (95% CI: 1.80–2.58), perceived susceptibility to HIV, aOR = 2.22 (95% CI: 1.83–2.69) and engaging in intergenerational sex, aOR = 2.14 (95% CI: 1.78–2.56). Predictors of nCU were perceived benefits, aOR = 1.25 (95% CI: 1.09–1.43); perceived susceptibility to HIV, aOR = 1.6 (95% CI: 1.39–1.83); and personal beliefs, aOR = 1.35 (95% CI: 1.13–1.62).

Conclusion

Cognitive and behavioural factors were found to be predictors of risky sexual behaviours for HIV. This highlights the importance of considering personal perception and reasoning when attempting to understand and influence an individual’s sexual behaviour. This could be done through enhancing awareness of HIV risk in the general population and by influencing cognitive behaviour change through community mobilisation, advocacy and creating activities to improve self-esteem.

Effects of Migration on Risky Sexual Behavior and HIV Acquisition in South Africa: A Systematic Review and Meta-analysis, 2000-2017

While human mobility has been implicated in fueling the HIV epidemic in South Africa, the link between migration and HIV has not been systematically reviewed and quantified. We conducted a systematic review of the role of migration in HIV risk acquisition and sexual behaviour based on 29 studies published between 2000 and 2017. Furthermore, we performed a meta-analysis of the association between migration and HIV risk acquisition in four of the studies that used HIV incidence as an outcome measure. The systematic review results show that HIV acquisition and risky sexual behavior were more prevalent among both male and female migrants compared to their non-migrant counterparts. The meta-analysis results demonstrate that migration was significantly associated with increased HIV acquisition risk (aOR = 1.69, 95% CI 1.33-2.14; I² = 35.0%). There is an urgent need for effective combination HIV prevention strategies (comprising biomedical, behavioral and structural interventions) that target migrant populations.

Consistent condom use among highly effective contraceptive users in an HIV-endemic area in rural Kenya

Background

Women of reproductive age are at the highest risk of both HIV infection and unintended pregnancy in sub-Saharan Africa. Highly effective contraceptives (HECs) such as hormonal injectable and implants are widely used in this region. HECs are effective for preventing pregnancies. However, unlike condoms, HECs offer no protection against HIV. Dual-method use, or the use of condoms with HECs, is an ideal option to reduce HIV risk but is infrequently practiced. Rather, women tend not to use condoms when they use HECs and increase their HIV risk from their sexual partners. However, it remains unknown whether HIV status affects such tendency. Given the increasing popularity of HECs in sub-Saharan Africa, this study examined the association between the use of HECs and condom use among HIV-positive and negative women.

Methods

A cross-sectional study was conducted among 833 sexually active women aged 18–49 years, recruited from six clinics in Siaya county, Kenya. From March to May 2017, female research assistants interviewed the women using a structured questionnaire. Multiple logistic regression analysis was conducted to examine the association between HEC use and consistent condom use in the past 90 days, adjusting for potential confounders. It was also examined with regular partners (husbands or live-in partners) and non-regular partners, separately. In addition, a sub-sample analysis of HIV-negative or unknown women was conducted.

Results

In total, 735 women were available for the analysis. Among the women, 231 (31.4%) were HIV-positive. HIV-positive women were more likely to use HECs than HIV-negative or status unknown women (70.1% vs. 61.7%, p = 0.027). HEC use was significantly associated with decreased condom use with a regular partner (adjusted odds ratio (AOR) = 0.25; 95% CI 0.15–0.43, p<0.001) and a non-regular partner (AOR = 0.25; 95% CI 0.11–0.58, p = 0.001). However, compared with HIV-negative or status unknown women, HIV-positive women were more likely to use HECs and condoms consistently with a regular partner (AOR = 6.54, 95% CI 2.15–20.00, p = 0.001). Other factors significantly associated with consistent condom use included partner’s positive attitude toward contraception, partner’s HIV-positive status, high HIV risk perception, and desire for children in the future.

Conclusion

Dual-method use was limited among HIV-negative women and women who had HIV-negative partners due to inconsistent condom use. The use of HECs was significantly associated with decreased condom use, regardless of partner type and their HIV status. Due to this inverse association, HIV-negative women may increase their HIV risk from their sexual partners. Therefore, interventions should be strengthened to reduce their dual risks of HIV infection and unintended pregnancy by promoting dual-method use. Family planning services should strengthen counseling on the possible risk of HIV infection from their sexual partners and target not only women but also their partners, who may play a key role in condom use.

Sexual Behavior With Noncommercial Partners: A Concurrent Partnership Study Among Middle-Aged Female Sex Workers in China

Female sex workers (FSWs) often engage in concurrent partnerships, meaning they have multiple sexual relationships at the same time. The objective of this study was to investigate sexual concurrency and its associations with condom use and syphilitic infections among FSWs over age 35. Respondent-driven sampling was used to recruit 1,245 FSWs in Nanning, Hefei, and Qingdao, China. FSWs were asked to report whether they had concurrent partners in the past six months. Concurrency was defined as engagement in sex with commercial clients and (1) husbands and boyfriends (n = 167); (2) husbands only (n = 301); or (3) boyfriends only (n = 469). FSWs with only commercial clients were used as the comparison group (n = 308). Across all groups, the percentage of FSWs with prevalent and active syphilis ranged from 19.6% to 25.6% and 9.1% to 11.5%, respectively. Condom use was low with noncommercial sexual partners and was more likely to be used when FSWs' boyfriends had other partners. Three components of the theory of planned behavior were significantly associated with consistent condom use. Concurrent relationships may lead to increased transmission of syphilis at the workplace and family levels. Effective interventions should target concurrency with both commercial and noncommercial partners.

Concurrence and selection of sexual partners as predictors of condom use among Mexican indigenous migrant workers

OBJECTIVE

To identify if the selection of mixed sexual partners and the existence of concurrent partners are predictors of condom use in indigenous migrant agricultural workers from Colima, Mexico.

METHODS

Analytical cross-sectional study using an egocentric sexual network approach. Community interviewers applied a structured questionnaire to 192 indigenous migrant workers in a sugarcane agro-industrial context. Data were analyzed with binary logistic regression; odds ratios (OR) and 95% confidence intervals (CI 95%) were estimated.

RESULTS

In the logistic regression model, adjusted odds (OR; 95% CI) of steady condom use were lower within partnerships of the same indigenous ethnicity compared to other partnerships (0.30; 0.17-0.53), partnerships that were concurrent to other partnerships (0.27; 0.15-0.50), and partnerships that used illegal drugs during sex to other partnerships (0.23; 0.11-0.49). Those variables were actually associated with increased risk of unprotected sex (occasionally or never using condoms), and therefore exposures were unprotected.

CONCLUSION

Sexual partners of the same ethnicity, concurrent partnerships and partnerships that use illegal drugs favor the low frequency of constant condom use and, in turn, the vulnerability to STIs and HIV transmission in indigenous migrant agricultural workers.

Feeling Under Pressure: Perspectives of the Meaning of Love and Sexual Relationships Amongst Young Men in KwaZulu-Natal Province, South Africa

This study aimed to explore perspectives on the meaning of love and sexual relations amongst young men in KwaZulu-Natal province of South Africa. Gaining insights into these perspectives will help to understand the sexual behaviors of these young men better and to eventually develop more effective HIV prevention interventions. Focus group discussions were conducted in two study areas using a predetermined semistructured discussion guide. The findings indicate that the phenomenon of romantic relationship try-outs together with the idea of "feeling under pressure" to propose love to more than one woman seem to be accepted practices that often lead to multiple concurrent sexual partners and therefore potentially risky sexual behaviors. The fear of impregnating a woman is seen to be of a more significant concern than acquiring a sexually transmitted infection due to the stigma and embarrassment associated with pregnancy outside marriage. Given these findings, it is recommended that future studies investigate perspectives on sexuality and reproductive health in male populations in great detail prior to the development of behavioral change interventions because failure to do so may hamper well-intended but poorly targeted health interventions.

Sexual Networks of Racially Diverse Young MSM Differ in Racial Homophily But Not Concurrency

BACKGROUND

Substantial racial disparities exist in HIV infection among young men who have sex with men (YMSM). However, evidence suggests black YMSM do not engage in greater levels of risk behavior. Sexual networks may help explain this paradox. This study used egocentric exponential random graph models to examine variation in concurrency (ie, 2 or more simultaneous partners) and homophily (ie, same race/ethnicity partners) across race/ethnicity groups in a diverse sample of YMSM.

METHODS

Data for this study come from a longitudinal cohort study of YMSM. Participants (n = 1012) provided data regarding their sexual contacts during the 6 months before their first study visit. A series of egocentric exponential random graph models examined how providing separate estimates for homophily and concurrency parameters across race/ethnicity improved the fit of these models. Networks were simulated using these parameters to examine how local network characteristics impact risk at the whole network level.

RESULTS

Results indicated that homophily, but not concurrency, varied across race/ethnicity. Black participants witnessed significantly higher race/ethnicity homophily compared with white and Latino peers. Extrapolating from these models, black individuals were more likely to be in a connected component with an HIV-positive individual and closer to HIV-positive individuals. However, white individuals were more likely to be in large connected components.

CONCLUSIONS

These findings suggest that high racial homophily combined with existing disparities in HIV help perpetuate the spread of HIV among black YMSM. Nonetheless, additional work is required to understand these disparities given that homophily alone cannot sustain them indefinitely.

Factors associated with concurrent sexual partnerships among men who have sex with men in Yangon, Myanmar

Men who have sex with men (MSM) are considered to be one of the groups most at risk of contracting HIV. However, to date, information regarding MSM's sexual behaviors and the risk factors for their concurrent sexual partnerships (CSP) have not been known in Myanmar. This study aimed to identify factors associated with CSP among MSM.A cross-sectional study was conducted from September to October 2011 in Yangon, Myanmar. In total, 353 males who had self-reported sex with men were recruited using respondent-driven sampling method. Descriptive statistics and multivariate logistic regression analysis were performed. In total, 61.0% of the MSM reported having CSP. MSM who practiced sex trading in the past six months (adjusted odds ratio8.32; 95% confidence interval [CI]: 2.30-30.10), MSM who had diagnosed with STIs/HIV (AOR 6.71; 95% CI: 4.78-9.28), and MSM who engaged in unprotected insertive anal sex (AOR 1.27; 95% CI: 1.02-1.45) were more likely to have CSP. In contrast, MSM who used condoms consistently during the past six months (AOR = 0.27; 95% CI: 0.08-0.94), MSM who had a regular job (AOR = 0.21; 95% CI: 0.06-0.74), and MSM who initiated sexual activities later in their lives (AOR = 0.08; 95% CI: 0.03-0.25) were less likely to have CSP. Concurrent sexual partnerships are common among MSM in Myanmar. Findings suggest that interventions should focus on MSM who diagnosed with STIs/HIV, do not have regular jobs, and initiated their sexual activities at an early age.

Who are the male sexual partners of adolescent girls and young women? Comparative analysis of population data in three settings prior to DREAMS roll-out

BACKGROUND

The DREAMS (Determined Resilient Empowered AIDS-free, Mentored and Safe) Partnership aims to reduce HIV incidence among adolescent girls and young women (AGYW,15-24y) with a core package of evidence-based interventions. Some interventions, including voluntary HIV counselling and testing and circumcision, will be targeted at the male sexual partners of AGYW. A priority of DREAMS is to characterise the male partners for effective targeting.

METHODS

Using population-based data (2010-2015) in three DREAMS impact evaluation settings in Kenya and South Africa, we describe the demographic characteristics and sexual behaviour of male partners reported by AGYW, and the characteristics of males who report sexual activity with AGYW.

RESULTS

In all settings, over 90% of recent male partners reported by AGYW were aged <35 years. Median ages of spousal and non-spousal partners were 29 and 23 years respectively in uMkhanyakude (rural South Africa) and 21 and 20 years respectively in Nairobi (urban Kenya). Most males reporting an AGYW partner had never been married (89%) and many were in school (39%). Most male partners reported only 1 AGYW partner in the past year; in Gem (rural Kenya) and Nairobi 25%-29% reported 2+(AGYW or older female) partners. Concurrent partners were reported by 16% of male partners in Gem and 3-4% in uMkhanyakude. Two thirds of male partners in Gem reported testing for HIV in the past 6 months and under half in uMkhanyakude reported testing for HIV in the past year. Almost all (96%) partners in Nairobi were circumcised, compared to 45% in Gem and 43% in uMkhanyakude.

CONCLUSIONS

With almost all AGYW's sexual partners aged 15-34 years, this is an appropriate target group for DREAMS interventions. Encouraging young men to reduce their number of partners and concurrency, and uptake prevention and treatment services such as HIV testing, circumcision and ART is crucial in the effort to reduce HIV among both AGYW and young men.

HIV Epidemiology in Uganda: survey based on age, gender, number of sexual partners and frequency of testing

Background

Human Immunodeficiency Virus (HIV) is a major cause of morbidity and mortality in the world. When compared to the developed countries where HIV prevalence is on the decline, sub-Saharan Africa has experienced either a rise or stagnation in rates.

Objectives

The aim of this study was to test and educate the community in the villages of Masajja and Kibiri of Wakiso district in Uganda for HIV and safe sex practices.

Methods

A sociodemographic survey was also performed to obtain data for gender, age, number of sexual partners during the previous year, frequency of testing and if ever tested positive for other sexually transmitted diseases (STDs).

Results

While 7 of the tested individuals were positive for HIV, 77 reported that they had once tested positive for other STDs. Of the 7 HIV positive individuals, 4 were females and 3 males. Over half of the tested individuals reported only one sexual partner in past 12 months and more than a quarter were sexually active with more than one partner. Majority of our population also reported getting HIV tested every 6 months or less.

Conclusion

Robust implementation of methods such as education and frequent testing can lower Uganda's prevalence of HIV even further.

Alcohol and Cannabis Use and Sexual Risk Behaviors in the Malawi Defence Force

Substance abuse is a public health priority in the context of the HIV epidemic, especially in military communities. This cross-sectional study quantified alcohol and cannabis use in the Malawi Defence Force and investigated its associations with condom use, transactional sex, multiple sexual partners, and sexual violence. Participants were 944 male and female service members ≥ 18 years old. Data were collected in 2013 using a computer-assisted self-interview. Twenty-four percent of men and women screened positive for hazardous and harmful drinking [Alcohol Use Disorders Identification Test (AUDIT) score ≥ 8]. About 6% reported using cannabis in the past year and 10% reported using cannabis prior to 1 year ago. Multivariable models found elevated adjusted odds of transactional sex and multiple sexual partners for men with an AUDIT score ≥ 8, and men who reported ever using cannabis. The adjusted odds of experiencing sexual violence were also elevated for men who reported ever using cannabis. These findings add to the growing concern that substance use may perpetuate the HIV epidemic in Sub-Saharan Africa by increasing risky sexual behaviors. A comprehensive military HIV prevention response should include substance use education and appropriate care and treatment for individuals screening positive for hazardous and harmful drinking.

Covariates of high-risk sexual behaviour of men aged 50 years and above in sub-Saharan Africa

Since the advent of HIV/AIDS, sexuality studies in sub-Saharan Africa (SSA) have focused mainly on the sexual behaviour of the younger generation (15-49 years) and little has been done to understand the sexual behaviour of those a 50 years and above. The objective of this study is therefore to examine the covariates of high-risk sexual behaviour among men aged 50 years plus within the SSA region. Data from Demographic and Health Surveys of 10 SSA countries were pooled together and a sample of 5394 men aged 50 years plus who have ever had sex was analysed. Findings show that in SSA, a large proportion of men aged 50 years plus (74%) were sexually active and a substantial proportion of these men engaged in unsafe sexual behaviours, such as having multiple sexual partners and unprotected sex. The multivariate logistic regression analysis showed that involvement with multiple sexual partners was significantly associated with older age, urban residence, religion, having primary or secondary education, and ever taken an HIV test. Condom use at last sex was significantly associated with age at first sex, multiple sexual partners, level of education and ever been tested for HIV. These results suggest that HIV prevention and intervention programmes should also target older men as they are also sexually active and at risk of being infected because of unsafe sexual practices.

Relational concurrency, stages of infection, and the evolution of HIV set point viral load

HIV viral load (VL) predicts both transmission potential and rate of disease progression. For reasons that are still not fully understood, the set point viral load (SPVL) established after acute infection varies across individuals and populations. Previous studies have suggested that population mean SPVL (MSPVL) has evolved near an optimum that reflects a trade-off between transmissibility and host survival. Sexual network structures affect rates of potential exposure during different within-host phases of infection marked by different transmission probabilities, and thus affect the number and timing of transmission events. These structures include relational concurrency, which has been argued to explain key differences in HIV burden across populations. We hypothesize that concurrency will alter the fitness landscape for SPVL in ways that differ from other network features whose impacts accrue at other times during infection. To quantitatively test this hypothesis, we developed a dynamic, stochastic, data-driven network model of HIV transmission, and evolution to assess the impact of key sexual network phenomena on MSPVL evolution. Experiments were repeated in sensitivity runs that made different assumptions about transmissibility during acute infection, SPVL heritability, and the functional form of the relationship between VL and transmissibility. For our main transmission model, scenarios yielded MSPVLs ranging from 4.4 to 4.75 log10 copies/ml, covering much of the observed empirical range. MSPVL evolved to be higher in populations with high concurrency and shorter relational durations, with values varying over a clinically significant range. In linear regression analyses on these and other predictors, main effects were significant (P < 0.05), as were interaction terms, indicating that effects are interdependent. We also noted a strong correlation between two key emergent properties measured at the end of the simulations-MSPVL and HIV prevalence-most clearly for phenomena that affect transmission networks early in infection. Controlling for prevalence, high concurrency yielded higher MSPVL than other network phenomena. Interestingly, we observed lower prevalence in runs in which SPVL heritability was zero, indicating the potential for viral evolution to exacerbate disease burden over time. Future efforts to understand empirical variation in MSPVL should consider local HIV burden and basic sexual behavioral and network structure.

Bisexual and Bidirectional: Assessing the Potential for HIV Bridging in Mozambique

African men who have sex with men (MSM) frequently, and often concurrently, have female partners, raising concerns about HIV sexual bridging. We explored potential HIV transmission in Mozambique from and to female partners of MSM focusing on preferred anal sex role and circumcision status. Data collected in a respondent-driven sampling study of MSM in 2011 in Maputo and Beira. Men who had oral or anal sex with other men 12 months prior completed a questionnaire and consented for HIV testing. Statistical analysis explored demographic/risk characteristics and associations among circumcision status, anal sex with men, sexual positions during anal sex with men and vaginal or anal sex with women. We identified 326 MSM in Maputo and 237 in Beira with both male and female partners 3 months before the study. Of these, 20.8% in Maputo and 36.0% in Beira had any receptive anal sex with men 12 months prior, including 895 unprotected sexual acts with males in Maputo and 692 in Beira. Uncircumcised and exclusively insertive males, 27.7% of the sample in Maputo and 33.6% in Beira, had the most unprotected sex with females: 1159 total acts in Maputo and 600 in Beira. Sexual bridging between MSM and women likely varies geographically and is probably bi-directional, occurring within a generalized epidemic where HIV prevalence is higher among reproductive-age women than MSM. Prevention strategies emphasizing correct and consistent condom use for all partners and circumcision for bisexual men should be considered.

Greater wealth inequality, less polygyny: rethinking the polygyny threshold model

Monogamy appears to have become the predominant human mating system with the emergence of highly unequal agricultural populations that replaced relatively egalitarian horticultural populations, challenging the conventional idea-based on the polygyny threshold model-that polygyny should be positively associated with wealth inequality. To address this polygyny paradox, we generalize the standard polygyny threshold model to a mutual mate choice model predicting the fraction of women married polygynously. We then demonstrate two conditions that are jointly sufficient to make monogamy the predominant marriage form, even in highly unequal societies. We assess if these conditions are satisfied using individual-level data from 29 human populations. Our analysis shows that with the shift to stratified agricultural economies: (i) the population frequency of relatively poor individuals increased, increasing wealth inequality, but decreasing the frequency of individuals with sufficient wealth to secure polygynous marriage, and (ii) diminishing marginal fitness returns to additional wives prevent extremely wealthy men from obtaining as many wives as their relative wealth would otherwise predict. These conditions jointly lead to a high population-level frequency of monogamy.

Exploring HIV risks, testing and prevention among sub-Saharan African community members in Australia

Background

Significant health disparities persist regarding new and late Human Immunodeficiency Virus (HIV) diagnoses among sub-Saharan African (SSA) communities in Australia. Personal/cultural beliefs and practices influence HIV (risk, prevention, testing) within Australia and during visits to home countries.

Method

A community forum was conducted involving 23 male and female adult African community workers, members and leaders, and health workers; facilitated by cultural workers and an experienced clinician/researcher. The forum comprised small/large group discussions regarding HIV risk/prevention (responses transcribed verbatim; utilising thematic analysis).

Results

Stigma, denial, social norms, tradition and culture permeated perceptions/beliefs regarding HIV testing, prevention and transmission among African Australians, particularly regarding return travel to home countries.

Conclusions

International travel as a risk factor for HIV acquisition requires further examination, as does the role of the doctor in HIV testing and Pre-exposure Prophylaxis (PrEP). Further assessment of PrEP as an appropriate/feasible intervention is needed, with careful attention regarding negative community perceptions and potential impacts.

Implicit attitudes to sexual partner concurrency vary by sexual orientation but not by gender-A cross sectional study of Belgian students

High rates of sexual partner concurrency have been shown to facilitate the spread of various sexually transmitted infections. Assessments of explicit attitudes to concurrency have however found little difference between populations. Implicit attitudes to concurrency may vary between populations and play a role in generating differences in the prevalence of concurrency. We developed a concurrency implicit associations test (C-IAT) to assess if implicit attitudes towards concurrency may vary between individuals and populations and what the correlates of these variations are. A sample of 869 Belgian students (mean age 23, SD 5.1) completed an online version of the C-IAT together with a questionnaire concerning sexual behavior and explicit attitudes to concurrency. The study participants C-IATs demonstrated a strong preference for monogamy (-0.78, SD = 0.41). 93.2% of participants had a pro-monogamy C-IAT. There was no difference in this implicit preference for monogamy between heterosexual men and women. Men who have sex with men and women who have sex with women were more likely to exhibit implicit but not explicit preferences for concurrency compared to heterosexual men and women. Correlates of the C-IAT varied between men and women.

Mobility and increased risk of HIV acquisition in South Africa: a mixed-method systematic review protocol

BACKGROUND

In South Africa (home of the largest HIV epidemic globally), there are high levels of mobility. While studies produced in the recent past provide useful perspectives to the mobility-HIV risk linkage, systematic analyses are needed for in-depth understanding of the complex dynamics between mobility and HIV risk. We plan to undertake an evidence-based review of existing literature connecting mobility and increased risky sexual behavior as well as risk of HIV acquisition in South Africa.

METHODS/DESIGN

We will conduct a mixed-method systematic review of peer-reviewed studies published between 2000 and 2015. In particular, we will search for relevant South African studies from the following databases: MEDLINE, EMBASE, Web of Science, and J-STOR databases. Studies explicitly examining HIV and labor migration will be eligible for inclusion, while non-empirical work and other studies on key vulnerable populations such as commercial sex workers (CSW) and men who have sex with men (MSM) will be excluded.

DISCUSSION

The proposed mixed-method systematic review will employ a three-phase sequential approach [i.e., (i) identifying relevant studies through data extraction (validated by use of Distiller-SR data management software), (ii) qualitative synthesis, and (iii) quantitative synthesis including meta-analysis data]. Recurrent ideas and conclusions from syntheses will be compiled into key themes and further processed into categories and sub-themes constituting the primary and secondary outcomes of this study. Synthesis of main findings from different studies examining the subject issue here may uncover important research gaps in this literature, laying a strong foundation for research and development of sustainable localized migrant-specific HIV prevention strategies in South Africa.

SYSTEMATIC REVIEW REGISTRATION

Our protocol was registered with PROSPERO under registration number: CRD 42017055580. ( https://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42017055580 ).

Perceptions of why Malawians engage in concurrent sexual partnerships among a select population of radio listeners: findings from an exploratory study

Concurrent sexual partnerships have been identified as a potential driver in the HIV epidemic in Southern Africa. This study utilised an innovative approach to explore perceptions of why Malawians may engage in these relationships, and their suggestions for reducing the practice among a select population of radio listeners. Using radio listener feedback in the form of text messages, we analysed approximately 1 000 text messages sent by individuals who listened to a reality radio programme that included real stories, told by Malawians, on topics related to HIV/AIDS. Listeners suggested that lack of satisfaction with one's partner was the overarching reason why individuals had concurrent sexual partnerships. Within the context of lack of satisfaction, listeners cited alcohol use, poor communication and gendered norms as factors related to satisfaction. Listeners suggested that couple communication could increase satisfaction, which, in turn, could reduce concurrent sexual partnerships. Prevention efforts should consider how to utilise couple communication to improve satisfaction as an approach to reduce HIV risk in Southern Africa.

Modelling the human immunodeficiency virus (HIV) epidemic: A review of the substance and role of models in South Africa

We review key mathematical models of the South African human immunodeficiency virus (HIV) epidemic from the early 1990s onwards. In our descriptions, we sometimes differentiate between the concepts of a model world and its mathematical or computational implementation. The model world is the conceptual realm in which we explicitly declare the rules – usually some simplification of ‘real world’ processes as we understand them. Computing details of informative scenarios in these model worlds is a task requiring specialist knowledge, but all other aspects of the modelling process, from describing the model world to identifying the scenarios and interpreting model outputs, should be understandable to anyone with an interest in the epidemic.

The Association Between Men's Concern About Demonstrating Masculine Characteristics and Their Sexual Risk Behaviors: Findings from the Dominican Republic

Quantitative analyses exploring the relationship between masculinities and men's sexual risk behaviors have most commonly used one dimension of masculinities: men's gender ideology. Examining other dimensions may enhance our understanding of and ability to intervene upon this relationship. In this article, we examined the association between gender role conflict/stress (GRC/S)-men's concern about demonstrating masculine characteristics-and three different sexual risk behaviors (having two or more sex partners in the last 30 days; never/inconsistent condom use with non-steady partners; and drinking alcohol at last sex) among a sample of heterosexual men in the Dominican Republic who were participating in an HIV prevention intervention (n = 293). The GRC/S Scale we used was adapted for this specific cultural context and has 17 items (α = 0.75). We used logistic regression to assess the relationship between GRC/S and each sexual behavior, controlling for sociodemographic characteristics. In adjusted models, a higher GRC/S score was significantly associated with increased odds of having two or more sex partners in the past 30 days (AOR 1.33, 95 % CI 1.01-1.74), never/inconsistent condom use with non-steady partners (AOR 1.45, 95 % CI 1.04-2.01), and drinking alcohol at last sex (AOR 1.56, 95 % CI 1.13-2.17). These results highlight the importance of expanding beyond gender ideology to understanding the influence of GRC/S on men's sexual risk behaviors. Interventions should address men's concern about demonstrating masculine characteristics to reduce the social and internalized pressure men feel to engage in sexual risk behaviors.

Gender Differences in Sexual and Reproductive Health Protective and Risk Factors of Batswana Adolescents: Implications for Parent and Adolescent Interventions

Adolescents in sub-Saharan Africa and in Botswana in particular continue to bear the brunt of the HIV epidemic. This analysis assessed gender differences among theory-based sexual and reproductive health protective and risk factors in a cross-sectional sample of 228 Batswana adolescents. Incongruence between preferred and actual sources of sexual information and several important gender differences in parent-adolescent relationships, psychosocial influences, and adolescent sexual behaviors were identified. Parents were the fourth most common source of information about sex; yet, over three-quarters of adolescents preferred to have parents teach them about sex. Boys reported more positive relationships with their parents and girls reported more positive attitudes toward transactional sex. Both boys and girls reported similarly low levels of parental monitoring, parental communication, and parental responsiveness, all of which are important protective factors. These findings suggest interventions should address these gender differences and consider offering parallel interventions for adolescents and their parents in Botswana.

Reducing substance use and risky sexual behaviour among drug users in Durban, South Africa: Assessing the impact of community-level risk-reduction interventions

Alcohol and other drug (AOD) use is increasingly recognised as having a direct and indirect effect on the transmission of human immunodeficiency virus (HIV). However, there is evidence to suggest that drug- and sex-related HIV risk-reduction interventions targeted at drug users within drug treatment centres or via community outreach efforts can lead to positive health outcomes. This study aimed to test whether a community-level intervention aimed at AOD users has an impact on risky AOD use and sexual risk behaviour. In 2007, in collaboration with a local non-governmental organisation (NGO) in Durban, an initiative was begun to implement a number of harm reduction strategies for injection and non-injection drug users. The NGO recruited peer outreach workers who received intensive initial training, which was followed by six-monthly monitoring and evaluation of their performance. Participants had to be 16 years of age or older, and self-reported alcohol and/or drug users. Peer outreach workers completed a face-to-face baseline questionnaire with participants which recorded risk behaviours and a risk-reduction plan was developed with participants which consisted of reducing injection (if applicable) and non-injection drug use and sex-related risks. Other components of the intervention included distribution of condoms, risk-reduction counselling, expanded access to HIV Testing Services, HIV/sexually transmitted infection care and treatment, and referrals to substance abuse treatment and social services. At follow-up, the baseline questionnaire was completed again and participants were also asked the frequency of reducing identified risk behaviours. Baseline information was collected from 138 drug users recruited into the study through community-based outreach, and who were subsequently followed up between 2010 and 2012. No injection drug users were reached. The data presented here are for first contact (baseline) and the final follow-up contact with the participants. There were no decreases in drug use practices such as use of cannabis, heroin, cocaine and Ecstasy after the intervention with drug users; however, there was a significant reduction in alcohol use following the intervention. While there was a substantial increase in the proportion of participants using drugs daily as opposed to more often, the reduction in the frequency of drug use was not statistically significant. Following the intervention, drug users had significantly fewer sexual partners, but there were no significant differences following the intervention with regard to frequency of sex or use of condoms. Substance use in general and during sex was, however, decreased. While the findings were mixed, the study shows that it is possible to provide HIV risk-reduction services to a population of substance users who are less likely to receive services through community outreach, and provide risk-reduction information, condoms and condom demonstration and other services. More intensive interventions might be needed to have a substantial impact on substance use and substance use-related HIV risk behaviours.

Late stage presentation of HIV-positive patients to antiretroviral outpatient clinic in Zambia

Background

The World Health Organization (WHO) and the Zambian Ministry of Health set out new guidelines on combination antiretroviral therapy (cART) in 2013 expanding the eligibility criteria for patients with HIV.

Objectives

The primary objective were to determine when cART was initiated in HIV-positive outpatients according to clinical and immunological criteria, and to identify what proportion of patients who were eligible for cART according to 2013 WHO and 2013 Zambian cART guidelines were currently on cART.

Methodology

This was a clinical audit of HIV-positive outpatients attending the cART clinic at Ndola Central Hospital in Ndola, Zambia, with retrospective cross-sectional chart review and survey design. Data were collected from clinical records and interviews with patients.

Results

A total of 99% of patients eligible for cART according to 2013 guidelines were on treatment. Clinical staging of patients at initiated on cART (n = 206) was as follows: 28% clinical stage I, 21% clinical stage II, 36% clinical stage III and 15% clinical stage IV. The median CD4 count when patients were started on cART was 147 cells/mm³.

Conclusion

The results show that a majority of patients were initiated on cART late in their disease course according to immunological (CD4 < 200 cell/mm³) and clinical criteria (stage III or IV). However, the vast majority of patients eligible for cART were currently on treatment. The late initiation of cART appears to be a result of late diagnosis of HIV.

Saturation effects and the concurrency hypothesis: Insights from an analytic model

Sexual partnerships that overlap in time (concurrent relationships) may play a significant role in the HIV epidemic, but the precise effect is unclear. We derive edge-based compartmental models of disease spread in idealized dynamic populations with and without concurrency to allow for an investigation of its effects. Our models assume that partnerships change in time and individuals enter and leave the at-risk population. Infected individuals transmit at a constant per-partnership rate to their susceptible partners. In our idealized populations we find regions of parameter space where the existence of concurrent partnerships leads to substantially faster growth and higher equilibrium levels, but also regions in which the existence of concurrent partnerships has very little impact on the growth or the equilibrium. Additionally we find mixed regimes in which concurrency significantly increases the early growth, but has little effect on the ultimate equilibrium level. Guided by model predictions, we discuss general conditions under which concurrent relationships would be expected to have large or small effects in real-world settings. Our observation that the impact of concurrency saturates suggests that concurrency-reducing interventions may be most effective in populations with low to moderate concurrency.

Characteristics and Risk Behaviors of Men Who Have Sex With Men and Women Compared With Men Who Have Sex With Men-20 US Cities, 2011 and 2014

BACKGROUND

Men who have sex with men (MSM) are heterogeneous with respect to sexual behavior. We examined differences in sex behaviors between men who have sex with men and women (MSMW) and men who have sex with men only (MSMO).

METHODS

Data for this analysis were from MSM who participated in National HIV Behavioral Surveillance in 2011 and 2014. We used the combined years to evaluate demographic and behavioral differences between MSMW and MSMO. Using log-linked Poisson regression models, adjusted prevalence ratios (aPR) were calculated for behavioral outcomes.

RESULTS

Overall, 2042 (11.9%) participants were classified as MSMW. MSMW were less likely than MSMO to have condomless sex with male partners [aPR 0.77; 95% confidence interval (CI): 0.74 to 0.81] and to have been diagnosed with another sexually transmitted disease (aPR 0.83; 95% CI: 0.72 to 0.95). MSMW were more likely than MSMO to have given money or drugs for sex (aPR 2.85; 95% CI: 2.52 to 3.24) or received money or drugs for sex (aPR 2.64; 95% CI: 2.37 to 2.93) and to ever have injected drugs (aPR 2.05; 95% CI: 1.80 to 2.34). MSMW had more total sex partners (median 6, interquartile range: 4-11 vs. 3, 2-8), casual sex partners (5, 2-10 vs. 3, 1-7), and condomless sex partners (2, 1-4 vs. 1, 0-2) in the last 12 months (P < 0.01 for all comparisons).

CONCLUSIONS

MSMW have distinct sexual risk behaviors from MSMO and may contribute to HIV transmission among women. MSMW could benefit from tailored interventions to reduce HIV risk behaviors.

HIV Incidence and Predictors of HIV Acquisition From an Outside Partner in Serodiscordant Couples in Lusaka, Zambia

OBJECTIVE

Evaluate the incidence and predictors of HIV acquisition from outside partners in serodiscordant couples.

METHODS

Demographic, behavioral, and clinical exposures were measured quarterly in a cohort of serodiscordant cohabiting couples in Zambia from 1995 to 2012 (n = 3049). Genetic analysis classified incident infections as those acquired from the study partner (linked) or acquired from an outside partner (unlinked). Factors associated with time to unlinked HIV infection were evaluated using multivariable Cox proportional hazards regression stratified by sex.

RESULTS

There were 100 unlinked infections in couples followed for a median of 806 days. Forty-five infections occurred in women [1.85/100 couple-years; 95% confidence interval (CI): 1.35 to 2.47]. Risk of female unlinked infection (vs. nonseroconverting females) was associated with reporting being drunk weekly/daily vs. moderate/nondrinkers at baseline [adjusted hazard ratio (aHR) = 5.44; 95% CI: 1.03 to 28.73], genital ulcers (aHR = 6.09; 95% CI: 2.72 to 13.64), or genital inflammation (aHR = 11.92; 95% CI: 5.60 to 25.37) during follow-up adjusting for age, years cohabiting, income, contraceptive use, previous pregnancies, history of sexually transmitted infections, and condomless sex with study partner. Fifty-five infections occurred in men (1.82/100 couple-years; 95% CI: 1.37 to 2.37). Risk of male unlinked infection was associated with genital inflammation (aHR = 8.52; 95% CI: 3.82 to 19.03) or genital ulceration (aHR = 2.31; 95% CI: 2.05 to 8.89), reporting ≥1 outside sexual partner (aHR = 3.86; 95% CI: 0.98 to 15.17) during follow-up, and reporting being drunk weekly/daily vs. moderate/nondrinkers at baseline (aHR = 3.84; 95% CI: 1.28 to 11.55), controlling for age, income, circumcision status, and history of sexually transmitted infection.

CONCLUSIONS

Predictors of unlinked infection in serodiscordant relationships were alcohol use, genital inflammation, and ulceration. Causes of genital inflammation and ulceration should be screened for and treated in HIV-negative individuals. Counseling on risk of alcohol use and sex with outside partners should be discussed with couples where 1 or both are HIV-negative, including in counseling on use of pre-exposure prophylaxis to prevent HIV acquisition in the HIV-negative partner (when feasible and affordable).

Concurrency and other sexual partnership patterns reported in a survey of young people in rural Northern Tanzania

African adolescents and young adults remain at substantial risk of infection with HIV and other sexually transmitted infections (STIs), and AIDS is the leading cause of death among African adolescents (10–19 years). Sexual partnership patterns influence transmission risk of sexually transmitted infections. We describe patterns reported by youth (15-30y) in a community-based survey in Tanzania. Among participants reporting multiple partners, we investigated factors associated with reported concurrency. Female (N = 6513) and male (N = 7301) participants had median ages of 21 and 22 years, respectively. Most participants (92%) reported having previously been sexually active, of whom 15% of males and <1% of females reported ≥4 partners in the past year. The point prevalence of concurrency was 2.3% (95%CI 1.9–2.9) for females and 10.6% (95%CI 9.3–12.1) for males. High levels of multiple and concurrent partnerships were reported by those previously married. Females were more likely than males to report having spousal/regular partners and longer partnership lengths. Compared to males, the partnerships reported by females were less likely to be new partnerships, and more likely to be defined by the respondent as still ‘ongoing’. Females reporting younger sexual debut were more likely to report concurrent sexual partners. Far fewer young women reported multiple and concurrent partnerships, but we cannot definitively conclude that concurrency was uncommon for women, because stigma towards women’s multiple sexual partnerships might contribute to substantial under-reporting, as was found in extensive qualitative research in the study population. This study provides one of the most comprehensive quantitative descriptions of partnership patterns of young people in an African setting. Interventions addressing sexual risk among youth should involve male partners, empower women to protect themselves within different types of partnerships, and encourage a greater openness about young people’s sexual relationships.

Demographic and behavioural risk factors associated with Trichomonas vaginalis among South African HIV-positive men with genital ulcer disease: a cross-sectional study

OBJECTIVES

Demographic and risky sexual behaviours may increase the risk for Trichomonas vaginalis (TV) infection and, thus, enhance HIV transmission to uninfected partners. We assessed the demographic and behavioural risk factors associated with TV among South African HIV-positive men with genital ulcer disease.

METHODS

We conducted a cross-sectional study with data from a randomised controlled trial conducted by the Centers for Disease Control and Prevention and the London School of Hygiene and Tropical Medicine. The data were obtained from three primary healthcare clinics in South Africa. At baseline (n=387), participants reported on demographics, sexual behaviour, history of sexually transmitted infections and clinical ulcers. The outcome TV was measured using real-time multiplex PCR assays and a Rotor-gene 3000 platform from the first and past urine samples of all participants. Logistic regression model estimated ORs and 95% CIs adjusted for demographics, sexual risk behaviours and ulcer conditions.

RESULTS

An estimated 11.4% of TV was detected among the men. The odds of TV infection were significantly associated with high blister counts (OR 4.0, 95% CI 1.6 to 28, p=0.01), ulcer pain (OR 0.4, 95% CI 0.2 to 0.7, p=0.003), number of days with ulcers (OR 0.4, 95% CI 0.2 to 0.8, p=0.006), sought treatment before coming into clinics (OR 0.07, 95% CI 0.002 to 0.7, p=0.005) and being unqualified worker (OR 2.5, 95% CI 0.9 to 6.7 p=0.05). Multivariate analyses revealed that increased days with ulcers (OR 0.1, 95% CI 0.04 to 0.5, p=0.002) and ulcer pain intensity (OR 0.08, 95% CI 0.007 to 1.1, p=0.05) remained significantly associated with decreased odds of TV infection. Men from the Sotho ethnic group were eight times more likely to have TV infection (OR 8.6, 95% CI 1.3 to 55.7, p<0.02) than men from the other ethnic groups.

CONCLUSION

HIV-positive men with severe ulceration should be screened and treated for TV to minimise HIV transmission to uninfected partners.

Partnership duration, concurrency, and HIV in sub-Saharan Africa

A widely accepted explanation for the exceptionally high HIV prevalence in sub-Saharan Africa is the practice of long-term overlapping heterosexual partnering. This article shows that long-duration concurrent partnering can be protective against HIV transmission rather than promoting it. Monogamous partnering prevents sexual transmission to anyone outside the partnership and, in an initially concordant-seronegative partnership, prevents sexual acquisition of HIV by either partner. Those protections against transmission and acquisition last as long as the partnership persists without new outside partnerships. Correspondingly, these two protective effects characterise polygynous partnerships, whether or not the polygyny is formal or informal, until a partner initiates a new partnership. Stable and exclusive unions of any size protect against HIV transmission, and more durable unions provide a longer protective effect. Survey research provides little information on partnership duration in sub-Saharan Africa and sheds no light on the interaction of duration, concurrency, and HIV. This article shows how assumptions about partnership duration in individual-based sexual-network models affect the contours of simulated HIV epidemics. Longer mean partnership duration slows the pace at which simulated epidemics grow. With plausible assumptions about partnership duration and at levels of concurrency found in the region, simulated HIV epidemics grow slowly or not at all. Those results are consistent with the hypothesis that long-duration partnering is protective against HIV and inconsistent with the hypothesis that long-term concurrency drives the HIV epidemics in sub-Saharan Africa.

Risky Sex and HIV Acquisition Among HIV Serodiscordant Couples in Zambia, 2002-2012: What Does Alcohol Have To Do With It?

In this paper we evaluate the effects of heavy alcohol consumption on sexual behavior, HIV acquisition, and antiretroviral treatment (ART) initiation in a longitudinal open cohort of 1929 serodiscordant couples in Lusaka, Zambia from 2002 to 2012. We evaluated factors associated with baseline heavy alcohol consumption and its association with condomless sex with the study partner, sex outside of the partnership, and ART initiation using multivariable logistic regression. We estimated the effect of alcohol consumption on HIV acquisition using multivariable Cox models. Baseline factors significantly associated with women’s heavy drinking (drunk weekly or more in 12-months before enrollment) included woman’s older age (adjusted prevalence odds ratio [aPOR] = 1.04), partner heavy drinking (aPOR = 3.93), and being HIV-infected (aPOR = 2.03). Heavy drinking among men was associated with less age disparity with partner (aPOR per year disparity = 0.97) and partner heavy drinking (aPOR = 1.63). Men’s being drunk daily (aOR = 1.18), women’s being drunk less than monthly (aOR = 1.39) vs. never drunk and being in a male HIV-negative and female HIV-positive union (aOR = 1.45) were associated with condomless sex. Heavy alcohol use was associated with having 1 or more outside sex partners among men (aOR drunk daily = 1.91, drunk weekly = 1.32, drunk monthly = 2.03 vs. never), and women (aOR drunk monthly = 2.75 vs. never). Being drunk weekly or more increased men’s risk of HIV acquisition (adjusted hazard ratio [aHR] = 1.72). Men and women being drunk weekly or more was associated (p < 0.1) with women’s seroconversion (aHR = 1.42 and aHR = 3.71 respectively). HIV-positive women who were drunk monthly or more had lower odds of initiating ART (aOR = 0.83; 95% CI = 0.70–0.99) adjusting for age, months since baseline and previous pregnancies. Individuals in HIV-serodiscordant couples who reported heavy drinking had more outside sex partnerships and condomless sex with their study partner and were more likely to acquire HIV. HIV-positive women had lower odds of initiating ART if they were heavy drinkers.