Pathways from Resilient Coping to Safer Sex Communication Among African, Caribbean, and Black Women in Toronto, Canada: Results from a Cross-sectional Survey

A syndemic of inequitable gender norms and intersecting stigmas on condom self-efficacy and practices among displaced youth living in urban slums in Uganda: a community-based cross-sectional study

BACKGROUND

Adverse socio-cultural factors compromise the implementation of HIV prevention strategies among displaced youth. While condoms are an affordable and effective HIV prevention strategy for youth, stigma and inequitable gender norms may constrain condom self-efficacy (i.e., knowledge, intentions, and relationship dynamics that facilitate condom negotiation) and use. Further, knowledge of contextually appropriate HIV prevention approaches are constrained by limited understanding of the socio-cultural conditions that affect condom self-efficacy and use among displaced youth. Guided by syndemics theory, we examine independent and joint effects of adverse socio-cultural factors associated with condom self-efficacy and use among displaced youth living in urban slums in Kampala, Uganda.

METHODS

We conducted a community-based cross-sectional survey of displaced youth aged 16-24 years living in five slums in Kampala. We used multivariable logistic regression and multivariate linear regression to assess independent and two-way interactions among adverse socio-cultural factors (adolescent sexual and reproductive health-related stigma [A-SRH stigma], perceived HIV-related stigma, and beliefs in harmful inequitable gender norms) on condom self-efficacy and recent consistent condom use. We calculated the prevalence and co-occurrence of adverse socio-cultural factors; conducted regression analyses to create unique profiles of adverse socio-cultural factors; and then assessed joint effects of adverse socio-cultural factors on condom self-efficacy and practices.

RESULTS

Among participants (mean age: 19.59 years; SD: 2.59; women: n = 333, men: n = 112), 62.5% were sexually active. Of these, only 53.3% reported recent consistent condom use. Overall, 42.73% of participants reported two co-occurring adverse socio-cultural factors, and 16.63% reported three co-occurring exposures. We found a joint effect of beliefs in harmful inequitable gender norms with high A-SRH stigma (β = - 0.20; p < 0.05) and high A-SRH stigma with high perceived HIV stigma (β = - 0.31; p < 0.001) on reduced condom self-efficacy. We found a multiplicative interaction between high A-SRH stigma with high perceived HIV stigma (aOR = 0.52; 95% CI 0.28, 0.96) on recent consistent condom use. Additionally, we found that condom self-efficacy (aOR = 1.01; 95% CI 1.05, 1.16) and safer sexual communication (aOR = 2.12; 95% CI 1.54, 2.91) acted as protective factors on inconsistent condom use.

CONCLUSIONS

Displaced youth living in urban slums exhibited low consistent condom use. Intersecting stigmas were associated with lower condom self-efficacy-a protective factor linked with increased consistent condom use. Findings highlight the importance of gender transformative and intersectional stigma reduction approaches to increase sexual agency and safer sex practices among Kampala's slum-dwelling displaced youth.

Exploring uptake of HIV/STI knowledge and safer sex-efficacy in an arts-based sexual health workshop among Northern and Indigenous adolescents in the Northwest Territories, Canada

ABSTRACTLimited research has evaluated sexual health promotion projects with adolescents living in Arctic regions. The study objective was to examine changes in STI knowledge and safer sex efficacy among youth in the Northwest Territories (NWT), Canada who participated in arts-based sexual health workshops. We used a pre/post-test design with a convenience sample of students aged 13-18 years recruited from 17 NWT communities. We conducted summary statistics and comparisons between pre and post-test scores using paired t-tests. Among participants (n = 610), we found statistically significant increases in STI knowledge overall (mean difference = 3.9; p < 0.001) and across gender and age stratifications. There were statistically significant increases in safer sex efficacy overall (mean difference = 0.9, p < 0.001), across genders, and among participants: aged <15 years, in rural communities, reporting food insecurity, reporting dating violence, and Indigenous youth. No statistically significant differences in safer sex efficacy were observed among participants who were aged ≥15, sexually active, reporting consistent condom use, and using drugs/alcohol. Findings signal the promise of youth-targeted, arts-based sexual health workshops for improving STI knowledge and safer sex efficacy among adolescents in the NWT. Further research can explore how safer sex efficacy may be shaped by age, substance use, and sexual experience to inform tailored interventions.

Exploring the Protective Value of Using Sexting for Condom Negotiation on Condom use Determinants and Practices Among Forcibly Displaced Adolescents in the Slums of Kampala, Uganda

Given the global growth of adolescent texting, we evaluate texting-based sexual communication as a potential site for interventions encouraging condom use cascades, particularly among displaced adolescents-a population with disproportionate levels of sexually transmitted infections, including HIV. With data from 242 forcibly displaced adolescents in the slums of Kampala, Uganda, we used path analysis to examine pathways from gender/dating relationship to condom determinant (knowledge of where to access condoms) and practices (access/use of condoms), through sexting-based condom negotiation, controlling for sexting practices. We found direct pathways from gender (boys vs. girls) and from dating relationship (dating vs. not) to condom determinant. Sexting-based condom negotiation partially mediated the pathway from gender/dating relationship to condom determinant, and fully mediated the pathways from gender/dating relationship to condom practices. Future digital sexual health interventions should consider the utility of texting-based applications in promoting knowledge and use of condoms among adolescents.

Stigma, Social Support, and Sexual Behavior Among Female Sex Workers at Risk for HIV in Malawi

Lack of social support and sex work stigma may hinder STI/HIV prevention for female sex workers (FSW). We explored the associations between sex work stigma and social support with sexual behaviors in Malawi. In 2017, 150 HIV-negative, venue-based FSW completed a behavioral survey containing sex work stigma items and social support. Linear binomial regression models were used to estimate prevalence differences of inconsistent condom use and substance use before sex by social support and stigma. A majority (93%) reported sex work-related internalized stigma. About 50% reported family or friend isolation. Social support was high (mean index: 86.53). Inconsistent condom use and substance use before sex had little to no association with stigma and social support. Malawian FSW largely internalize stigma and experience isolation from family and friends yet have high levels of social support. Large-scale evaluations should investigate the role of stigma and social support in STI/HIV prevention for FSW.

Sexually transmitted infection testing awareness, uptake and diagnosis among urban refugee and displaced youth living in informal settlements in Kampala, Uganda: a cross-sectional study

BACKGROUND

Sexually transmitted infection (STI) prevention needs among urban refugee and displaced youth are understudied. The study objective was to explore factors associated with the STI prevention cascade (STI services awareness, testing, diagnosis) among urban refugee and displaced youth in Kampala, Uganda.

METHODS

We implemented a cross-sectional survey with youth aged 16-24 years in informal settlements in Kampala. We conducted bivariate and multivariable logistic regression analyses to identify social ecological (intrapersonal, interpersonal, community) level factors associated with STI testing services awareness, lifetime STI testing, and lifetime STI diagnosis.

RESULTS

Participants (n=445; mean age 19.3, SD 2.6, years) included young women (n=333, 74.8%) and young men (n=112, 25.2%). Less than half (43.8%) were aware of community STI services. One-quarter (26.1%) reported lifetime STI testing. Of these, 39.5% reported a lifetime STI diagnosis. In multivariable analyses among young women, age, lifetime sex partners, and lower adolescent sexual and reproductive health (SRH)-related stigma were associated with STI services awareness; and age, lower adolescent SRH-related stigma, and food security were associated with STI testing. Among young men, time in Uganda and lower HIV-related stigma were associated with STI services awareness; and age, condom self-efficacy, and increased adolescent SRH-related stigma were associated with testing. Lifetime sex partners, lower condom self-efficacy, and lower adolescent SRH-related stigma were associated with lifetime STI diagnosis.

CONCLUSIONS

Social ecological factors including stigma (adolescent SRH-related, HIV-related) were associated with STI testing and diagnosis among young urban refugees. Gender, age and stigma-tailored strategies can advance the STI prevention cascade among urban young refugees.