Property rights violations as a structural driver of women's HIV risks: a qualitative study in Nyanza and Western Provinces, Kenya

Expanding the food environment framework to include family dynamics: A systematic synthesis of qualitative evidence using HIV as a case study

Food environment changes in low- and middle-income countries are increasing diet-related noncommunicable diseases (NCDs). This paper synthesizes the qualitative evidence about how family dynamics shape food choices within the context of HIV (Prospero: CRD42021226283). Guided by structuration theory and food environment framework, we used best-fit framework analysis to develop the Family Dynamics Food Environment Framework (FDF) comprising three interacting dimensions (resources, characteristics, and action orientation). Findings show how the three food environment domains (personal, family, external) interact to affect food choices within families affected by HIV. Given the growing prevalence of noncommunicable and chronic diseases, the FDF can be applied beyond the context of HIV to guide effective and optimal nutritional policies for the whole family.

Ensuring access to justice: the need for community paralegals to end AIDS by 2030

INTRODUCTION

The HIV response has long recognized that certain "key populations" such as individuals in detention, adolescent girls and young women, sex workers, people who use drugs, LGBTQ individuals, migrants and others face higher barriers to access to, uptake of, and retention in HIV prevention and treatment services. One approach to addressing these barriers is the training of community paralegals to advocate for the rights of individuals and to address discrimination in health settings.

DISCUSSION

Community paralegal programmes have been able to successfully address rights violations that impact access to health services and underlying determinants of health across a range of countries and populations, focusing upon issues such as discrimination and the denial of health services; unlawful detention of outreach workers, sex workers, persons who use drugs and men who have sex with men; and harmful traditional practices and gender-based violence. In addition to resolving specific cases, evaluations of paralegal programmes have found that these programmes increased legal literacy among key populations at risk of HIV and increased understanding of human rights among healthcare providers, resulting in improved access to HIV services. Some evaluations have noted challenges related to the sustainability of paralegal programmes similar to those raised with community health worker programmes more broadly.

CONCLUSIONS

To achieve global HIV goals, funding for legal literacy and paralegal programmes should be increased and interventions should be rigorously evaluated. Efforts should target discrimination in access to HIV prevention and treatment and criminalization of key populations, two key barriers to ensuring access to HIV prevention and treatment services.

The Impact of Land Tenure Security on a Livelihood Intervention for People Living with HIV in Western Kenya

Few studies have explored land access, a structural driver of health, and women's participation in livelihood interventions to improve food security and HIV outcomes. This qualitative study, embedded within Shamba Maisha (NCT02815579)-a randomized controlled trial (RCT) examining the impact of a multisectoral intervention among farmers living with HIV in western Kenya-sought to explore the influence of perceived access to and control of land on agricultural productivity, investments, and benefits. Thirty in-depth interviews (IDIs) were conducted with purposively sampled men and women, 3 to 6 months after receiving intervention inputs; data were deductively and inductively coded and analyzed. Farming practices and participation in Shamba Maisha were dependent on land tenure and participants' perceived strength of claim over their land, with participants who perceived themselves to be land insecure less likely to make long-term agricultural investments. Land tenure was influenced by a number of factors and posed unique challenges for women which negatively impacted uptake and success in the intervention. Data underscore the importance of secure land tenure for the success of similar interventions, especially for women; future interventions should integrate land security programming for improved outcomes for all.

Contextual drivers of HIV risk among young African women

INTRODUCTION

Significant progress has been made in the African HIV pandemic; however, the pace of incidence decline has slowed or stalled in many East and Southern African countries, especially among young women. This stall is worrying because many countries have burgeoning youth populations. There is an important window of opportunity to halt the epidemic as well as the potential for millions more infections if primary prevention efforts are not strengthened.

DISCUSSION

Many hyper-endemic settings have been exposed to numerous interventions; however, HIV incidence among young women has remained high. In this paper, we characterize the intervention context and examine how it can be strategically utilized to maximize HIV prevention interventions among young women. We begin by examining how contextual dynamics drive HIV risk. We illustrate how epidemiological contexts, gendered normative and economic contexts, and environmental contexts work synergistically to make young women especially vulnerable to HIV infection. We then examine how these contexts can undermine HIV prevention interventions. Finally, we discuss the importance of fully mapping out the intervention context to enhance the effectiveness of HIV prevention interventions.

CONCLUSIONS

Understanding an intervention context, and how its features work together to amplify young women's risk in hyper-endemic settings can contribute to sustained momentum in reducing HIV incidence among young women and help to limit the reach of the HIV pandemic into new generations of Africans.

A review of transactional sex for natural resources: Under-researched, overstated, or unique to fishing economies?

Environmental change is projected to decrease the availability of key natural resources. Decreasing availability of resources that support food security and livelihoods for vulnerable populations is hypothesised to increase engagement in transactional sex. Therefore, we systematically examined the peer-reviewed literature to characterise what is known about transactional sex for natural resources, document the natural resources that are exchanged for sex, and identify qualitative trends. Of the 1063 articles, 33 were retained for full abstraction. A majority of articles were published after 2005 (93%) and focused on Africa (90%). Two-thirds of articles focused on sex-for-fish exchanges. Reports of transactional sex were also found for other resources, including agricultural land (12%) as well as food, water, and fuel in emergency contexts (12%). Migration and altered resource availability were described as underlying causes of transactional sex. Some studies described an increased risk of sexually transmitted infection, including HIV, as a health consequence of transactional sex. We offer three possible explanations for why the preponderance of previous studies have focused on sex-for-fish rather than other natural resources, and suggest directions for future research.

Examining Men's Perceptions of GBV Prevention Programming Content

As global efforts to engage men in preventing gender-based violence (GBV) continue to grow, understanding male participants' perceptions of prevention events is needed. Data from a global sample of 319 men who had attended GBV prevention events were used to (a) assess men's perceptions of what topics were covered, (b) determine whether profiles of these perceptions could be identified, and (c) describe the degree to which content prerception profiles are associated with levels of men's motivation and confidence related to antiviolence action. Latent class analysis identified four perception profiles of prevention topics. Implications for GBV prevention programming are discussed.

Provider Perspectives on Intimate Partner Violence in Bluefields, Nicaragua

BACKGROUND

Intimate partner violence represents a significant public health problem and a substantial human rights' issue for women and girls throughout the world. Design and Purpose: The purpose of this study was to answer these research questions: What are the current practices for addressing gender violence in the RACS? What do professionals consider to be the current strengths and gaps in policies related to gender violence in this region? By employing a qualitative descriptive approach (Sandelowski, 2000 ), researchers traveled from the US to Bluefields, Nicaragua, in 2012. The multidisciplinary team of two US nurses, a prosecutor, and a victim-witness advocate interviewed 18 key informants, police officers, advocates, and nurses, and observed court processes.

METHODS

Interviews were transcribed verbatim and analyzed in the language the interview was conducted in. Researchers coded data independently and identified emergent themes.

FINDINGS

Informants described the complexity of the nature and dynamics of gender violence, strongly informed by Nicaragua's fairly progressive laws. The participants described holistic, fully integrated services as the intended functioning of the system. These services were often thwarted by gaps-fragmentation and lack of resources-and were additionally hampered by substantial individual and structural economical obstacles.

A Qualitative Investigation of the Impact of a Livelihood Intervention on Gendered Power and Sexual Risk Behaviors Among HIV-Positive Adults in Rural Kenya

Despite the recognized links between food insecurity, poverty, and the risk of HIV/AIDS, few randomized trials have evaluated the impact of livelihood interventions on HIV risk behaviors. The current study draws upon data collected from a qualitative process evaluation that was embedded into a pilot randomized controlled trial that tested whether a multisectoral agricultural intervention (Shamba Maisha) affected the HIV-related health of HIV-positive adults in rural Kenya. In the current study, we drew upon longitudinal, in-depth interviews with 45 intervention participants and nine control participants (N = 54) in order to examine the impacts of the intervention on gendered power and sexual risk reduction among both women and men. Female and male participants in the intervention described positive changes in sexual practices and gendered power dynamics as a result of intervention participation. Changes included reduced sexual risk behaviors, improved gender-related power dynamics, and enhanced quality of intimate relationships. These findings illuminate how a multisectoral agricultural intervention may affect inequitable gender relations and secondary transmission risk. Further research is needed to explore how to best leverage agricultural interventions to address the important intersections between poverty and inequitable gender relations that shape HIV risks.

Collaborative Interpersonal Psychotherapy for HIV-Positive Women in Kenya: A Case Study From the Mental Health, HIV and Domestic Violence (MIND) Study

We examine the efficacy of nonspecialists delivering interpersonal psychotherapy (IPT) to HIV-positive (HIV+) women. We describe a case in which local personnel without prior mental health training delivered IPT for the treatment of depression and posttraumatic stress disorder in an HIV+ woman who reported experiencing gender-based violence and was enrolled in HIV care at the Family AIDS, Care, Education and Services program in Kisumu, Kenya.

Perceived Impact of a Land and Property Rights Program on Violence Against Women in Rural Kenya: A Qualitative Investigation

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Attitudes Toward Restricting the Sexual and Reproductive Rights of Women Living With HIV Infection in Yemen

A considerable amount of research has demonstrated the pervasive and destructive power of discrimination against people living with HIV, which limits their full and equal participation in society. This study surveyed 613 young adults from Yemen about their attitudes toward the sexual and reproductive rights of women living with HIV (WLWH). Among survey respondents, 80% believed that WLWH should be sterilized and not allowed to get married. Furthermore, 62% thought that WLWH should be forced to have abortions if they became pregnant. Men were more likely than women to impose restrictions on the sexual and reproductive rights of WLWH. HIV stigma predicted respondent attitudes toward WLWH, but religiosity and knowledge about HIV did not. The results of the study have implications for developing programs to protect and promote the rights of WLWH in Yemen.

Gender-specific risk factors for virologic failure in KwaZulu-Natal: automobile ownership and financial insecurity

We sought to examine which socioeconomic indicators are risk factors for virologic failure among HIV-1 infected patients receiving antiretroviral therapy (ART) in KwaZulu-Natal, South Africa. A case-control study of virologic failure was conducted among patients recruited from the outpatient clinic at McCord Hospital in Durban, South Africa between October 1, 2010 and June 30, 2012. Cases were those failing first-line ART, defined as viral load >1,000 copies/mL. Univariate logistic regression was performed on sociodemographic data for the outcome of virologic failure. Variables found significant (p < 0.05) were used in multivariate models and all models were stratified by gender. Of 158 cases and 300 controls, 35 % were male and median age was 40 years. Gender stratification of models revealed automobile ownership was a risk factor among males, while variables of financial insecurity (unemployment, non-spouse family paying for care, staying with family) were risk factors for women. In this cohort, financial insecurity among women and automobile ownership among men were risk factors for virologic failure. Risk factor differences between genders demonstrate limitations of generalized risk factor analysis.

The effect of women's property rights on HIV: a search for quantitative evidence

In recent years, efforts to reduce HIV transmission have begun to incorporate a structural interventions approach, whereby the social, political, and economic environment in which people live is considered an important determinant of individual behaviors. This approach to HIV prevention is reflected in the growing number of programs designed to address insecure or nonexistent property rights for women living in developing countries. Qualitative and anecdotal evidence suggests that property ownership may allow women to mitigate social, economic, and biological effects of HIV for themselves and others through increased food security and income generation. Even so, the relationship between women's property and inheritance rights (WPIR) and HIV transmission behaviors is not well understood. We explored sources of data that could be used to establish quantitative links between WPIR and HIV. Our search for quantitative evidence included (1) a review of peer-reviewed and "gray" literature reporting on quantitative associations between WPIR and HIV, (2) identification and assessment of existing data-sets for their utility in exploring this relationship, and (3) interviews with organizations addressing women's property rights in Kenya and Uganda about the data they collect. We found no quantitative studies linking insecure WPIR to HIV transmission behaviors. Data-sets with relevant variables were scarce, and those with both WPIR and HIV variables could only provide superficial evidence of associations. Organizations addressing WPIR in Kenya and Uganda did not collect data that could shed light on the connection between WPIR and HIV, but the two had data and community networks that could provide a good foundation for a future study that would include the collection of additional information. Collaboration between groups addressing WPIR and HIV transmission could provide the quantitative evidence needed to determine whether and how a WPIR structural intervention could decrease HIV transmission.

Women’s Land Ownership and Relationship Power

Violence against women is a widespread societal problem substantiated and perpetuated through inequities that operate within numerous levels of the society. Challenging and ending gender-based violence therefore requires addressing social structures that perpetuate gendered hierarchies and maintain women’s susceptibility to experiencing violence worldwide. The present study examines novel approaches taken by women in two different countries in the Global South, one in Nicaragua and another in Tanzania, to examine macro-level processes involved in land ownership in regions where owning land is a marker of dominance. Using data from 492 women, results from structural equation models and qualitative thematic analyses demonstrate significant links among women’s ownership of land, relationship power, and receipt of physical and psychological violence in both the countries. Collectively, the findings suggest that when women own land, they gain power within their relationships and are less likely to experience violence. Implications for theoretical conceptualizations of eradicating violence against women and practical interventions are discussed.

PROVIDING WOMEN, KEPT MEN: Doing Masculinity in the wake of the African HIV/AIDS epidemic

This paper draws on ethnographic and interview based fieldwork to explore accounts of intimate relationships between widowed women and poor young men that emerged in the wake of economic crisis and a devastating HIV epidemic among the Luo ethnic group in Western Kenya. I show how the cooptation of widow inheritance practices in the wake of an overwhelming number of widows as well as economic crisis resulted in widows becoming providing women and poor young men becoming kept men. I illustrate how widows in this setting, by performing a set of practices central to what it meant to be a man in this society - pursuing and providing for their partners - were effectively doing masculinity. I will also show how young men, rather than being feminized by being kept, deployed other sets of practices to prove their masculinity and live in a manner congruent with cultural ideals. I argue that ultimately, women's practice of masculinity in large part seemed to serve patriarchal ends. It not only facilitated the fulfillment of patriarchal expectations of femininity - to being inherited - but also served, in the end, to provide a material base for young men's deployment of legitimizing and culturally valued sets of masculine practice.

What community-level strategies are needed to secure women's property rights in Western Kenya? Laying the groundwork for a future structural HIV prevention intervention

Despite the recognized need for structural-level HIV prevention interventions that focus on economic empowerment to reduce women's HIV risks, few science-based programs have focused on securing women's land ownership as a primary or secondary HIV risk reduction strategy. The current study focused on a community-led land and property rights model that was implemented in two rural areas of western Kenya where HIV prevalence was high (24-30%) and property rights violations were common. The program was designed to reduce women's HIV risk at the community level by protecting and enhancing women's access to and ownership of land. Through in-depth interviews with 50 program leaders and implementers of this program we sought to identify the strategies that were used to prevent, mediate, and resolve property rights violations. Results included four strategies: (1) rights-based education of both women and men individually and at the community level, (2) funeral committees that intervene to prevent property grabbing and disinheritance, (3) paralegal training of traditional leaders and community members and local adjudication of cases of property rights violations, and (4) referring property rights violations to the formal justice system when these are not resolved at the community level. Study participants underscored that local mediation of cases resulted in a higher success rate than women experienced in the formal court system, underscoring the importance of community-level solutions to property rights violations. The current study assists researchers in understanding the steps needed to prevent and resolve women's property rights violations so as to bolster the literature on potential structural HIV prevention interventions. Future research should rigorously test property rights programs as a structural HIV prevention intervention.

Preventing HIV infection in women

Although the number of new infections has declined recently, women still constitute almost half of the world's 34 million people with HIV infection, and HIV remains the leading cause of death among women of reproductive age. Prevention research has made considerable progress during the past few years in addressing the biological, behavioral, and social factors that influence women's vulnerability to HIV infection. Nevertheless, substantial work still must be performed to implement scientific advancements and to resolve many questions that remain. This article highlights some of the recent advances and persistent gaps in HIV prevention research for women and outlines key research and policy priorities.

Assessing barriers and facilitators of implementing an integrated HIV prevention and property rights program in Western Kenya

Despite the recognized need for structural HIV prevention interventions, few scientific programs have integrated women's property and inheritance rights with HIV prevention and treatment. The current study focused on a community-led land and property rights intervention that was implemented in two rural areas of Western Kenya with high HIV prevalence rates (24-30%). The program was designed to respond to women's property rights violations in order to reduce HIV risk at the local level. Through in-depth interviews with twenty program leaders, we identified several facilitators to program implementation, including the leadership of home-based HIV caregivers and involvement of traditional leaders in mediating property rights disputes. We also identified the voluntary basis of the intervention and its lack of integration with the formal justice system as implementation barriers. Our findings can guide future research and design of structural HIV prevention strategies that integrate women's economic empowerment through property and inheritance rights.