Factors associated with forced sex among women accessing health services in rural Haiti: implications for the prevention of HIV infection and other sexually transmitted diseases

The Distribution and Consequences of Sexual Misconduct Perpetrated by Peacekeepers in Haiti: An Exploratory Cross-Sectional Analysis

During the United Nations Stabilization Mission in Haiti (MINUSTAH), reports of sexual abuse and exploitation and children fathered by peacekeepers were brought forward to the UN. In 2017, a cross-sectional mixed-methods survey was administered by Haitian research assistants using SenseMaker® (Cognitive Edge, Singapore), a rapid data collection tool that allows participants to share a narrative on a topic of interest. In total, 2541 self-interpreted narratives in relation to the experiences of Haitian women and girls vis-à-vis peacekeepers were collected from a convenience sample of Haitian males and females across Haiti. This exploratory secondary data analysis analyzes whether narratives about sexual misconduct perpetrated by MINUSTAH peacekeepers were associated with rural, semi-urban, or urban locations and investigates the relationship between sharing narratives about sexual misconduct and the desire to engage with the UN/MINUSTAH. After adjustment, narratives addressing sexual misconduct were more likely to be shared in rural locations, compared to urban locations (RRrural: 1.19; 95% CI: 1.03, 1.38). Personal experiences of sexual misconduct were more likely (RRsex: 4.52; 95% CI: 3.34, 6.12) to be associated with rejection of the UN/MINUSTAH, compared to personal narratives of positive/neutral experiences. This research is an empirical steppingstone to understanding the distribution and consequences of peacekeeper-perpetrated sexual abuse and exploitation in Haiti.

Hurricane impact associated with transactional sex and moderated, but not mediated, by economic factors in Okay, Haiti

Natural disasters, such as hurricanes, often negatively affect the economic wellbeing of affected individuals. Under such conditions, women may engage in transactional sexual behaviors in order to compensate for lost income and provide for their households. In this study, we evaluated the relationship between hurricane impact and transactional sex and if this relationship was moderated, or mediated, through economic factors. Between December 2017 and February 2018, approximately one year after the area was hit by a category 4 hurricane (Hurricane Matthew), we interviewed a random sample of female microfinance members (n = 304) in Okay, Haiti. We estimated the association between hurricane impact and transactional sex using log-binomial regression. Next, we tested for economic moderation of this relationship by incorporating interaction terms between hurricane impact and food insecurity, poverty, and loss of income generating materials in three separate log-binomial models. Finally, we assessed possible mediation of this relationship by loss of income generating resources and a latent variable, economic stress, using a structural equation model. We found participants who had experienced hurricane impact were 58% more likely to have engaged in transactional sex [prevalence ratio (95% confidence interval): 1.58 (1.19-2.09)]. This relationship was significant and strongly positive among women who were food insecure and had high poverty but not so among women who were food secure and had low poverty, respectively. The final structural equation model (with fit: χ2 = 19.700, degrees of freedom = 15; CFI = 0.958; TLI = 0.941; RMSEA = 0.040) revealed that the relationship was not mediated through economic factors. However, the association between hurricane impact and transactional sex remained significant while controlling for these economic factors. Notably, the findings that the relationship between hurricane impact and transactional sex was moderated, but not mediated, by economic factors implies populations at-risk of experiencing natural disasters should be preemptively targeted with economic interventions to build capacity and resilience before such a disaster hits.

Transactional Sex and HIV Risk among Adolescent School Girls in Ethiopia: Mixed Method Study

Background

Young people in Sub-Saharan Africa are affected by HIV pandemic to a greater extent than elsewhere. Transactional sex among adolescent school girls with older men commonly called "sugar daddies" is one of the major factors fueling the spread of the infection due to the extended sexual network. Thus, this study aimed to assess the magnitude and factors associated with transactional sex among adolescent girls and "sugar daddies" in relation to HIV/AIDS.

Methods

Mixed method cross-sectional study was done among 620 female students in Hawassa town, South Ethiopia, from September 2010 to May 2011. A structured questionnaire and in-depth interview check list were used to collect the quantitative and qualitative data, respectively. Survey participants were selected randomly from five preparatory schools whereas ten in-depth interview participants were recruited by a snowball sampling technique from the same schools. Data were entered using Epi-Info and analyzed by SPSS. A descriptive statistics followed by multivariable logistic regression analyses were conducted to identify factors associated with transactional sex with "sugar daddy". Both crude and adjusted odds ratios with 95% confidence interval were reported. We used OpenCode software for coding and categorizing the in-depth interviews and quotes that represent the informants opinion were used to support the quantitative findings.

Results

A substantial number of female students, 71(11.5%), reported to have had transactional sex with older men. Most of the respondents who dated "sugar daddies" (93%) had multiple sexual partners concurrently and sequentially, and among them, only 22.7% had consistent condom use. Girls who were in older age group [OR (CI) 6.87 (3.48-13.58)], who had lost both parents [OR (CI) 2.99 (1.14-7.84)], had perceived less economic status [OR: 25.41; 95% CI: 7.80-82.76] and engaged in substance abuse [OR (CO) 5.8 (2.1-15.77)] had higher odds of practicing transactional sex with "sugar daddies". In-depth interviewed participants also revealed that they were involved in transactional sex for monetary while having concurrent and subsequent sexual network with their schoolmates and other young partners.

Conclusion

Transactional sex among female students was high, and the sexual network they had with the young men put young people in the network at risk of HIV and other sexually transmitted infections. Therefore, HIV prevention programs shall focus on transactional sex among adolescent school girls to halt transmission of HIV among the generation.

'Life under the tent is not safe, especially for young women': understanding intersectional violence among internally displaced youth in Leogane, Haiti

BACKGROUND

Haiti's 2010 earthquake devastated social, health, and economic infrastructure and left 2 million persons homeless. Over 6 years later 61,000 people remain displaced, most lacking protection, services, and durable solutions. Structural contexts elevate risks of gender-based violence (GBV) targeting internally displaced (ID) girls and women.

OBJECTIVE

We used an intersectionality framework to explore lived experiences and understanding of violence among ID young men and women in Leogane, Haiti.

METHODS

We conducted six focus groups, three with ID young women (n = 30) and three with ID young men (n = 30) aged 18-24 years, and 11 in-depth individual interviews with frontline workers in Leogane. Focus groups and interviews were conducted in Kreyol, transcribed verbatim, translated into English, and analyzed using narrative thematic techniques.

RESULTS

Findings revealed violence experienced by ID youth was (re)produced at the intersection of gender, poverty, displacement, and age. Multi-level forms of violence included structural (e.g. poverty), community (e.g. gender norms, and interpersonal (e.g. family expectations) dimensions. Coping strategies spanned intrapersonal (hope), community (social support), and structural (employment/education) dimensions.

CONCLUSIONS

Interventions to reduce violence should be tailored to address the social inequities that emerge at the intersection of youth, poverty, displacement, and hegemonic gender norms.

“This Method, I Think, Can Shed New Light”

Improving the reproductive health of immigrant populations requires understanding the specific context of risk and need. As part of a field trial of the FemCap™, a woman-initiated cervical barrier contraceptive, we conducted postintervention focus group discussions (FGDs) with 20 women (five FGDs) of Haitian background, the majority of whom were born in Haiti and spoke Haitian Créole at home, at a community health center in south Florida. Participants discussed the role of religion and inequitable gender norms in Haitian traditions about family planning decisions and provided important insights into the gender-power nuances of their partnership dynamics vis à vis the use of female barrier methods. Encouraged by more equitable gender norms in the United States, participants were eager to serve as health education agents, with strong altruistic sentiments toward other Haitian girls and women who they felt could be encouraged to negotiate for greater reproductive decision-making power.

HIV and alcohol knowledge, self-perceived risk for HIV, and risky sexual behavior among young HIV-negative men identified as harmful or hazardous drinkers in Katutura, Namibia

Background

Namibia’s HIV prevalence is 13.3 %. Alcohol is associated with sexual risk-taking, leading to increased HIV risk. Baseline sexual behaviors, HIV and alcohol knowledge, and self-perceived HIV risk were examined among men reporting high-risk drinking in Katutura, Namibia.

Methods

HIV negative men, ≥ 18 years, were screened for harmful or hazardous levels of drinking and >1 recent sex partner prior to randomization into control or intervention arm. SAS 9.3 and R 3.01 were used for descriptive baseline cohort analyses.

Results

A total of 501 participants who met criteria were included in analysis (mean Alcohol Use Disorders Identification Test [AUDIT] =12.4). HIV and alcohol knowledge were high with the majority (>85 and 89.8–98 %, respectively) of respondents correctly answering assessment questions. Despite high knowledge levels, 66.7 % of men felt they were at some or high risk of HIV acquisition. Among those respondents, 56.5 % stated often wanting to have sex after drinking and 40.3 % stated sex was better when drunk. Among respondents with non-steady partners [n = 188], 44.1 % of last sexual encounters occurred while the participant was drunk and condoms were not used 32.5 % of those times. Among persons who were not drunk condoms were not used 13.3 % of those times.

Conclusions

Sex with casual partners was high. Inconsistent condom use and alcohol use before sex were frequently reported. Increased emphasis on alcohol risk-reduction strategies, including drinking due to peer pressure and unsafe sexual behaviors, is needed.

Intimate partner violence and symptoms of sexually transmitted infections: are the women from low socio-economic strata in Bangladesh at increased risk

BACKGROUND

There is little research on whether women who are either poor or illiterate and have experienced intimate partner violence (IPV) have a unique risk of sexually transmitted infections (STIs). Most such research concerns families displaced by wars and conflicts.

PURPOSE

Therefore, we aimed to further this important area of inquiry by (1) addressing whether an association exists between experiences of physical and/or sexual IPV within the past year and symptoms of STI and (2) exploring the relationship between low socio-economic status and IPV and the relative roles they play as obstacles to reducing women's risk of STI in a nationally representative sample of Bangladesh.

METHOD

This paper used data from the 2007 Bangladesh Demographic Health Survey. The analyses were based on the responses of 4,195 currently married women. Exposure was determined from women's experiences of physical and sexual IPV within the past year. Genital sores and genital discharge were used as proxy outcome variables of the symptoms of STI. Descriptive statistics and multivariate logistic regression analysis were used in the study.

RESULTS

Experience of any physical and/or sexual IPV were associated with genital sores (adjusted odds ratio [AOR] = 1.79; 95 % confidence interval [CI], 1.28-2.51) and genital discharge (AOR 1.90, 95 % CI 1.42-2.53). Severity of physical IPV appeared to have more profound consequences on the outcome measured. Findings also demonstrated that for the risk of STI, women at the nexus of poverty or illiteracy and IPV were not more uniquely disadvantaged.

CONCLUSIONS

The results suggest that for the risk of STI, the negative effect of having experienced IPV extends across all socio-economic backgrounds and is not limited to women at either at the nexus of poverty or illiteracy and IPV. Findings underscore the calls for protecting women from all forms of physical and sexual violence from their husbands as a part of interventions to reduce the risk of STI.

"I am proud of myself, just the way I am" (Mwen fyé de tét mwen, jan mwen ye ya): a qualitative study among young Haitian women seeking care for sexually transmitted infections (STIs) in Haiti

Haitian women are twice as likely as men to have HIV/AIDs. Factors underlying the feminization of HIV are complex. Self-esteem is an important correlate of sexual behavior. However, its meaning and impact on health behaviors may be influenced by cultural factors. This qualitative study took place in Haiti 4 months after the 2010 earthquake and examines the meaning of self-esteem among young Haitian women seeking treatment for a recurrent sexually transmitted infection (STI). The meaning of self-esteem was derived from a sense of gratitude and was rooted in their ability to provide for family. This may have led to behaviors such as not using condoms or having sex with partners in concurrent relationships. This article highlights the resilience and resourcefulness of Haitian women, provides insight into how women with apparent positive self-images were led to make choices that placed them at high risk for contracting HIV, and concludes with recommendations for future interventions.

HIV, poverty and women

This review examines the interactions of financial status and HIV and its implications for women. MEDLINE and Google scholar were searched using the keywords 'women', 'poverty' and 'HIV' in any field of the article. The search was limited to articles published in English over the last 10 years. The first section of the article tries to establish whether poverty or wealth is a risk factor for HIV. There is credible evidence for both arguments. While wealth shows an increased risk for both sexes, poverty places women at a special disadvantage. The second section explains how the financial status interacts with other 'non biological' factors to put women at increased risk. While discrimination based on these factors disadvantage women, there are some paradoxical observations that do not fit with the traditional line of explanation (e.g. paradoxical impact of wealth and education on HIV). The final section assesses the impact of HIV in driving poverty and the role of women in interventional programmes. The specific impact of poverty on females in families living with HIV is less explored. Though microfinance initiatives to empower women are a good idea in theory, the actual outcome of such a programme is less convincing.

Sexual violence towards married women in Bangladesh

This article explored the magnitude and nature of within marriage sexual violence against women and factors associated with physically forced sex by husbands in urban and rural Bangladesh using population-based survey data from 2001 (n = 2,702). Results showed high prevalence of lifetime sexual violence: 37 % in urban and 50 % in rural areas. An overwhelming majority of the women reported being sexually abused by husbands more than once. Logistic regression analyses revealed that six out of ten independent variables included in the models were significant. The factors positively associated with physically forced sex by husbands during the last 12 months were: history of physical abuse of husband's mother by his father; level of controlling behavior by husband; and forced or coerced first sex. Women's age (20-24 compared to 15-19) and dowry demand at marriage increased the likelihood of this violence in the rural area. Urban women in the second and third income quartiles were more likely to be exposed to this violence compared to women in the first quartile. Results highlight the need for prevention programs targeting men, which would help at the same time to break the cycle of intergenerational exposure and thereby transmission of violence. Notions of gender equality; women's sexual rights; and women's right to consent and choice need to be widely promoted particularly among men.

Domestic violence in India: insights from the 2005-2006 national family health survey

This article assesses the prevalence and risk factors of domestic violence in India. The study uses the 2005-2006 India National Family Health Survey-III (NFHS-III) and focuses on the 69,484 ever-married women ages 15 to 49 from all regions, who were administered the domestic violence module. The results show that 31% of respondents experienced physical violence in the past 12 months before the survey; the corresponding figure for sexual violence was 8.3%. The multivariate logistic regression results show key determinants of physical and sexual violence. Some of the most salient findings are that urban residence, household wealth, affiliation with Christian religious denominations, wife's age at marriage and education are associated with lower risk of physical and sexual violence. In contrast, being employed and being the wife of a man who drank alcohol increased the odds of experiencing both physical and sexual violence. Moreover, respondents who believed that wife-beating was justified under certain circumstances were more likely to experience domestic violence. These results and significant regional differences observed in this study suggest that gender role conditioning and cultural norms both contribute to domestic violence. Interventions, therefore, need to go beyond the institutional and legal levels to include cultural capital, which addresses partner and relationship issues.

Unmet health needs identified by Haitian women as priorities for attention: a qualitative study

This 2009 qualitative study investigated Haitian women's most pressing health needs, barriers to meeting those needs and proposed solutions, and how they thought the community and outside organizations should be involved in addressing their needs. The impetus for the study was to get community input into the development of a Family Health Centre in Leogane, Haiti. Individual interviews and focus group discussions were conducted with 52 adult women in six communities surrounding Leogane. The most pressing health needs named by the women were accessible, available and affordable health care, potable water, enough food to eat, improved economy, employment, sanitation and education, including health education. Institutional corruption, lack of infrastructure and social organization, the cost of health care, distance from services and lack of transport as barriers to care were also important themes. The involvement of foreign organizations and local community groups, including grassroots women's groups who would work in the best interests of other women, were identified as the most effective solutions. Organizations seeking to improve women's health care in Haiti should develop services and interventions that prioritize community partnership and leadership, foster partnerships with government, and focus on public health needs.

Behavioral change communications on malaria prevention in Ghana

The purpose of this study is to assess the various communications strategies designed to promote insecticide-treated nets (ITN) use among pregnant women and children. This study is an exploratory study into the communications activities by institutions involved in malaria prevention in Ghana. In-depth interviews were conducted and the data were analyzed. We found that most of the interventions are aimed at encouraging the target markets to acquire ITNs, although most messages on malaria prevention are not integrated. Several challenges were noted, including financial constraints, lack of human resources, cultural barriers, negative publicity, and negative perceptions on malaria.

Environmental Change, Risky Sexual Behavior, and the HIV/AIDS Pandemic: Linkages Through Livelihoods in Rural Haiti

Local natural resources are central to rural livelihoods across much of the developing world. Such "natural capital" represents one of several types of assets available to households as they craft livelihood strategies. In order to explore the potential for environmental scarcity and change to contribute to perpetuation of the HIV/AIDS pandemic, we examine the association between declining natural capital and engaging in risky sexual behaviors, as potentially another livelihood strategy. Such association has been demonstrated in Kenya and Tanzania, through the fish-for-sex trade. To explore the possibility of this connection within rural Haitian livelihoods we use Demographic and Health Survey data, with a focus on rural women, combined with vegetation measures generated from satellite imagery. We find that lack of condom use in recent sexual encounters is associated with local environmental scarcity - controlling for respondent age, education, religion and knowledge of AIDS preventive measures. The results suggest that explicit consideration of the environmental dimensions of HIV/AIDS may be of relevance in scholarship examining factors shaping the pandemic.

The role of a microfinance program on HIV risk behavior among Haitian women

Microfinance loans targeted at vulnerable female populations have the potential to foster female economic independence, possibly leading to the negotiation of safer sexual practices and reduced HIV risk. This study assessed the relationship between experience with microfinance loans and HIV risk behavior among 192 female clients of the Haitian microfinance organization Fonkoze. Clients with longer microfinance experience were generally found to have lower indicators of HIV risk behavior and higher indicators of relationship power compared to those with shorter experience. In particular, those with longer memberships were 72% less likely to report partner infidelity, were 3.95 times more likely to use condoms with an unfaithful partner, and had higher average general power index scores compared to those with shorter experience. This study provides evidence that long-term exposure to microfinance is associated with reduced HIV risk behavior in Haitian women and that this reduction may be partly regulated by influencing relationship power. These results suggest the need to further explore the use of microfinance as a tool to prevent the spread of HIV.

Economic risk factors for HIV infection among women in rural Haiti: implications for HIV prevention policies and programs in resource-poor settings

AIMS

The goals of this study were to (1) estimate the prevalence of HIV infection among women accessing services at a women's health center in rural Haiti and (2) to identify economic risk factors for HIV infection in this population.

METHODS

Women who accessed healthcare services at this center between June 1999 and December 2002 were recruited to participate. The analysis was based on data from a case-control study of sexually transmitted diseases (STDs) in rural Haiti. HIV prevalence in the study population was 4%.

RESULTS

In multivariate analyses, partner occupation was associated with HIV infection in women, with mechanic (OR 9.0, 95% CI 1.8-45) and market vendor (OR 4.2, 95% CI 1.6-11) reflecting the strongest partner occupational risk factors. Partner's occupation as a farmer reduced the risk of infection in women by 60% (95% CI 0.14-1.1). Factors indicating low socioeconomic status (SES), such as food insecurity (OR 2.0, 95% CI 0.75-5.6) and using charcoal for cooking (OR 1.7, 95% CI 0.72-3.8) suggested an association with HIV infection.

CONCLUSIONS

Given pervasive gender inequality in Haiti, women's economic security often relies on their partners' income earning activities. Our findings show that although factors reflecting poverty are associated with HIV-positive status, stronger associations are observed for women whose partners indicated a more secure occupation (e.g., mechanic or market vendor). Policies and programs that expand access to education and economic opportunities for women and girls may have long-term implications for HIV prevention in Haiti and other resource-poor settings.

Causal links between binge drinking patterns, unsafe sex and HIV in South Africa: its time to intervene

South Africa has a massive burden of HIV and alcohol disease, and these pandemics are inextricably linked. Much evidence indicates that alcohol independently influences decisions around sex, and undermines skills for condom negotiation and correct use. Thus, not surprisingly, people with problem drinking in Africa have twofold higher risk for HIV than non-drinkers. Also, sexual violence incidents often coincide with heavy alcohol use, both among perpetrators and victims. Reducing alcohol harms necessitates both population- and individual-level interventions, especially raised taxation, regulation of alcohol advertising and provision of Brief Interventions. Alcohol counselling interventions must include discussion of linkages between alcohol and sex, and consequences thereof. Within positive-prevention services, alcohol reduction interventions could diminish HIV transmission. A trial is needed to definitively demonstrate that reduced drinking lowers HIV incidence. However, given available evidence, implementation of effective interventions could alleviate much alcohol-attributable disease, including unsafe sex, sexual violence, unintended pregnancy and, likely, HIV transmission.

Risk factors for HIV infection among Haitian adolescents and young adults seeking counseling and testing in Port-au-Prince

OBJECTIVES

Many Haitian adolescents and youth are highly vulnerable to HIV infection. It was important to define the risk factors of the young people who are already seeking care.

METHODS

Among 3391 sexually active 13- to 25-year-olds in our Voluntary Counseling and Testing (VCT) Center in Port-au-Prince from October 2005 to September 2006, we assessed associations between demographic and behavioral factors and HIV status using multivariable logistic regression analyses.

RESULTS

We diagnosed HIV infection in 6.3% of 2533 females and 5.5% of 858 males. Age-specific prevalence was 3.4% for 13- to 15-year-olds, 4.7% for 16-19, and 6.8% for 20-25 (P = 0.02). Poor education, not residing with parents, currently or formerly married, having a child, and being self-referred or referred by others VCT services were significant predictors of HIV in females. HIV infection was associated with considering oneself at higher risk, although most youth did not recognize this risk. HIV in females was also associated with suspected/confirmed sexually transmitted infection, especially genital ulcers (ORadj = 2.28, 95% confidence interval: 1.26 to 4.13), years of sexual activity (Ptrend = 0.07), and suspicion that partners had other partners or an sexually transmitted infection. Among males, HIV was associated with drug use (though uncommon) and sexual debut with a casual/unknown person (ORadj = 3.18, 95% confidence interval: 1.58 to 6.42). HIV-infected young people were more likely to be rapid plasma reagin positive and less likely to use condoms.

CONCLUSION

Young Haitians are a key target for HIV prevention and care and avail themselves readily of youth-focused VCT services.

Enhancing global control of alcohol to reduce unsafe sex and HIV in sub-Saharan Africa

Sub-Saharan Africa carries a massive dual burden of HIV and alcohol disease, and these pandemics are inextricably linked. Physiological and behavioural research indicates that alcohol independently affects decision-making concerning sex, and skills for negotiating condoms and their correct use. More than 20 studies in Africa have reported higher occurrence of HIV among people with problem drinking; a finding strongly consistent across studies and similar among women and men. Conflation of HIV and alcohol disease in these setting is not surprising given patterns of heavy-episodic drinking and that drinking contexts are often coterminous with opportunities for sexual encounters. HIV and alcohol also share common ground with sexual violence. Both perpetrators and victims of sexual violence have a high likelihood of having drunk alcohol prior to the incident, as with most forms of violence and injury in sub-Saharan Africa. Reducing alcohol harms necessitates multi-level interventions and should be considered a key component of structural interventions to alleviate the burden of HIV and sexual violence. Brief interventions for people with problem drinking (an important component of primary health care), must incorporate specific discussion of links between alcohol and unsafe sex, and consequences thereof. Interventions to reduce alcohol harm among HIV-infected persons are also an important element in positive-prevention initiatives. Most importantly, implementation of known effective interventions could alleviate a large portion of the alcohol-attributable burden of disease, including its effects on unsafe sex, unintended pregnancy and HIV transmission.

Domestic violence and forced sex among the urban poor in South India: implications for HIV prevention

This article examined the prevalence of physical and sexual violence among 1,974 married women from 40 low-income communities in Chennai, India. The authors found a 99% and 75% lifetime prevalence of physical abuse and forced sex, respectively, whereas 65% of women experienced more than five episodes of physical abuse in the 3 months preceding the survey. Factors associated with violence after multivariate adjustment included elementary/middle school education and variables suggesting economic insecurity. These domestic violence rates exceed those in prior Indian reports, suggesting women in slums may be at increased risk for HIV and other sexually transmitted infections.

Age differences at sexual debut and subsequent reproductive health: Is there a link?

BACKGROUND

Experiences at sexual debut may be linked to reproductive health later in life. Additionally, young women with older sexual partners may be at greater risk for HIV and sexually transmitted infections. This study examines sexual debut with an older partner and subsequent reproductive health outcomes among 599 sexually experienced women aged 15-24 who utilized voluntary counseling and testing or reproductive health services in Port-au-Prince, Haiti.

METHODS

Logistic regression models, controlling for socioeconomic and demographic factors, examined whether age differences at first sex were significantly associated with STI diagnosis in the previous 12 months and family planning method use at last intercourse.

RESULTS

Sixty-five percent of women reported sexual initiation with a partner younger or less than 5 years older, 28% with a partner 5 to 10 years older, and 7% with a partner 10 or more years older. There was a trend towards decreased likelihood of recent use of family planning methods in women who had first sexual intercourse with a partner 5 to 9 years older compared to women with partners who were younger or less than 5 years older. Age differences were not linked to recent STI diagnosis.

CONCLUSION

Programs focusing on delaying sexual debut should consider age and gender-based power differentials between younger women and older men. Future research should examine whether wide age differences at sexual debut are predictive of continued involvement in cross-generational relationships and risky sexual behaviors and explore the mechanisms by which cross-generational first sex and subsequent reproductive health may be connected.

Intimate partner and nonpartner violence against pregnant women in rural Haiti

OBJECTIVE

To examine the association between violence experienced by pregnant Haitian women in the previous 6 months and pregnancy-related symptom distress.

METHODS

A total of 200 women seeking prenatal care at community health dispensaries in the Artibonite Valley were interviewed.

RESULTS

Over 4 in 10 women (44.0%) reported that they had experienced violence in the 6 months prior to interview; 77.8% of these women reported that the violence was perpetrated by an intimate partner. Those who experienced intimate partner violence reported significantly greater pregnancy-related symptom distress (beta=0.23, P=0.001). No significant differences between violence perpetrated by family members or others and reporting of symptoms were observed (beta=0.06, P=0.38).

CONCLUSION

The findings indicate the need to integrate violence screening, resources, and primary prevention into prenatal care in rural Haiti.

Vulnerability, gender and "proxy negativity": women in relationships with HIV-positive men in Australia

In contemporary international HIV discourse, women are positioned as especially vulnerable to HIV. This vulnerability is ascribed to gender inequality and its many structural, social and sexual manifestations. It is an important discourse in that it foregrounds how the realities of women worldwide constrain their ability to control their lives and bodies and, consequently, their ability to protect themselves against HIV infection. At the same time, its analysis rarely exceeds a generalised description of gender and power and, as such, fails to usefully engage with the specificity of serodiscordant gender relationships. Drawing on qualitative interviews with HIV-negative women and their HIV-positive male partners, who participated in a larger study on HIV and heterosexuality in Australia, we argue that without a considered analysis of the gendered interplay of differing HIV statuses, the vulnerability discourse remains limited in its capacity to capture the diverse, complex ways in which these HIV-negative women negotiate HIV in their sexual lives, how they are positioned in their relationships, and how vulnerability can figure in less obvious ways. We discuss how gendered meanings invested in the women's HIV-negative status constituted a powerful conduit to heteronormality for their male partners. The mixing of serostatuses made it possible for the men to assume a kind of proxy negativity, a desired state of redeemed masculinity. We explore two ways in which this proxy negativity operated among the couples and shaped their sexual practices. As a result, this paper makes an important contribution by showing how vulnerability to HIV infection can hinge on the different ways serodiscordant couples manage gendered meanings around serostatus emotionally and sexually.

Successful Aging with Sickle Cell Disease: Using Qualitative Methods to Inform Theory

Little is known about the lives of adults with sickle cell disease (SCD). This article reports findings from a qualitative pilot study, which used life review as a method to explore influences on health outcomes among middle-aged and older adults with SCD, Six females with SCD, recruited from two urban sickle cell clinics in the U.S., engaged in semi-structured, in-depth life review interviews. MaxQDA2 software was used for qualitative data coding and analysis. Three major themes were identified: vulnerability factors, self-care management resources, and health outcomes. These themes are consistent with the Theory of Self-Care Management for Sickle Cell Disease. Identifying vulnerability factors, self-care management resources, and health outcomes in adults with SCD may aid in developing theory-based interventions to meet health care needs of younger individuals with SCD. The life review process is a useful means to gain insight into successful aging with SCD and other chronic illnesses.

Psychosocial impact of poverty on antiretroviral nonadherence among HIV-TB coinfected patients in Lima, Peru

OBJECTIVE

Tuberculosis and HIV coinfection poses unique clinical and psychosocial complexities that can impact nonadherence to highly active antiretroviral treatment (HAART).

METHODS

This was a prospective case series to identify risk factors for HAART nonadherence among 43 patients with HIV and tuberculosis (TB) in Lima, Peru. Nonadherence was defined by patient self-report.

RESULTS

The median initial CD4 and HIV viral load were 63 and 159,000, respectively. Patients had received a median of 6.1 months of ART. Univariable analysis found low social support, substance use, and depression to be associated with nonadherence. In multivariable analysis, low social support was associated with nonadherence.

CONCLUSIONS

In the authors' urban cohort of HIV-TB coinfected individuals in Lima, Peru, substance use, depression, and lack of social support were key barriers to adherence. These findings suggest that adherence interventions may be unsuccessful unless they target the underlying psychosocial challenges faced by patients living with TB and AIDS.

Sex, money, and premarital partnerships in southern Malawi

In this paper, I argue two main points. First, in premarital, sexual partnerships in rural Malawi, the purpose of money exchange extends beyond the alleviation of female partners' economic constraints, and, second, by clarifying this broader purpose, it becomes possible to recognize where women exert control over their own sexual selves. These findings come from field observations and a rich set of in-depth interviews (N=54), bolstered on occasion by survey data, conducted with young women and men, aged 15-24 years, in the Balaka district in the southern region of the country. This research demonstrates that, contrary to typical expectations, money and gift transfers in sexual partnerships are part and parcel of the courting practices of young Malawian women and men. Transfers are as much about the expression of love and commitment as they are about meeting the financial needs of women or the acquisition of sex for men. Using narrative information to shed light on the semiotics of the sex-money link, these findings from Malawi offer a new perspective that broadens usual interpretations of transactional sex, the understanding of which is critical in fighting AIDS.

Community health workers as a cornerstone for integrating HIV and primary healthcare

Haiti is the poorest and most heavily HIV-burdened country in the Western hemisphere, with even less health infrastructure than many countries of sub-Saharan Africa. Since the early 1980s the HIV epidemic has affected the poorest communities in Haiti, who lack access to even basic healthcare. Large-scale HIV treatment requires that basic healthcare services be built and scaled up simultaneously with HIV-prevention and -care programmes. Such improvement in access to general healthcare will require substantial investments in health infrastructure, service delivery and human development. This study describes the contribution of the non-governmental organization, Zanmi Lasante (ZL) to the HIV prevention and treatment scale-up and to the ongoing efforts to improve primary healthcare (PHC) services in the public health system in Haiti. The model depends on community health workers (CHWs) who supervise antiretroviral therapy (ART) and provide community outreach, including active case finding and outreach to marginalized populations. Zanmi Lasante has recruited, trained and financed a large cadre of CHWs to provide such linkages between communities and health centres in rural Haiti. The study analysed key components of their work--their self-perception, their role in enhancing community uptake of services and their role in targeting vulnerable groups. We found that most patients at risk were properly identified at a community level. The CHWs are facilitating the uptake of PHC services, including by the most vulnerable households. The general training of CHWs has created a positive self-definition in these cadres of their medical, patient support and health service roles; although with some variability across different groups. The results of this study will be used to emphasize, standardized and strengthen the biosocial training of CHWs.

Antiretroviral therapy in resource-poor settings. Decreasing barriers to access and promoting adherence

Since 2002, the HIV Equity Initiative of the nongovernmental organization Partners in Health has been expanded in conjunction with the Haitian MOH to cover 7 public clinics. More than 8000 HIV-positive persons, 2300 of whom are on antiretroviral therapy (ART) are now followed. This article describes the interventions to promote access to care and adherence to ART developed in reference to the specific context of poverty in rural Haiti. User fees for clinic attendance have been waived for all patients with HIV and tuberculosis and for women presenting for prenatal services. Additionally, HIV testing has been integrated into the provision of primary care services to increase HIV case finding among those presenting to clinic because of illness, rather than solely focusing on those who present for voluntary counseling and testing (VCT). Once a patient is diagnosed with HIV, medications and monitoring tests are provided free of charge and transportation costs for follow-up appointments are covered to defray patients' out-of-pocket expenses. Patients are given home-based adherence support from a network of health workers who provide psychosocial support and directly observed therapy. In addition, the neediest patients receive nutritional support. Following the description of the program is an approximation of the costs of these interventions and a discussion of their impact.

Health Seeking Behavior Among Pregnant Women in Rural Haiti

The purpose of this study was to further knowledge of health care seeking behavior among pregnant women in rural Haiti. Eighty-two pregnant women were interviewed to assess care seeking behaviors during pregnancy, satisfaction with services, reliance on social networks, and management of pregnancy-related illness. Twenty-five percent reported not seeking care in the formal health sector for a pregnancy-related illness; 32% delayed seeking care. Women relied primarily on their husbands and mothers for health care advice during pregnancy and times of illness, and coped with illness by lying down. Strategies for improving awareness and health care access are discussed.

The influence of power on HIV risk among pregnant women in rural Haiti

Given that condom use is not directly under a woman's control, the sexual division of power may play an important role in sexual behavior among pregnant women. We assessed the influence of factors related to the theory of gender and power (e.g., relationship power, abuse history, and sexual communication) on sexual behavior (e.g., two or more partners in the year prior to pregnancy, condom use, condom-use intentions, and STI diagnosis) among 196 pregnant women recruited from five community dispensaries in rural Haiti. Results showed that gender and power factors significantly related to sexual behavior. Gender and power factors were most significant for condom use and intention to use condoms, accounting for 18 and 25% of the variance above and beyond HIV knowledge and demographic covariates, respectively. These results suggest the need to create prevention interventions that restore power imbalances, provide support for women suffering abuse, and strengthen communication skills.

Power, control, and intimate partner sexual violence in Haiti

This study sought to determine how power and control in intimate relationships influenced women's exposure to sexual violence. Multilevel modeling was used to determine the risk of partner sexual violence in the past 12 months among 2240 women aged 15-49 years who were currently married or cohabiting. The data were drawn from the 2000 Haiti Demographic and Health Survey. Strong positive effects on intimate partner sexual violence were found for husband's jealousy and perpetration of controlling behavior and women's endorsement of traditional norms concerning a husband's rights to beat his wife. Female dominance in decision making about purchases for daily household needs was positively associated with intimate partner sexual violence but its effects were mediated by relationship quality. The effect of wife's education on intimate partner violence was nonlinear. The analysis also showed that high community female headship rates were independently associated with higher risks of partner sexual violence. The findings highlight the importance of adopting a multidimensional approach to the measurement of power in sexual relationships and the need for programs to work at multiple levels to address gender-based norms and the structural factors that put women at increased risk of sexual violence.

Reducing health disparities through culturally sensitive treatment for HIV+ adults in Haiti

There is a critical need to deliver empirically validated interventions to underserved populations. Haiti, the country most heavily affected by the AIDS epidemic in the Caribbean, accounts for approximately 50% of all cases in the region. Poverty, disparities in access to healthcare, and socio-political instability are among the reasons why the country has been ravaged by the disease. Ongoing projects in Haiti have shown that integrated prevention and care in resource poor settings are feasible and can be successful, as evidenced by a 50% drop in incidence among pregnant women since 1993. The AIDS prevention program has embarked on a comprehensive effort to culturally adapt a cognitive-behavioral stress management program for Haitian HIV+ individuals. The purpose of the program is to improve adherence to antiretroviral medication, reduce transmission to uninfected partners, and improve coping. This comprehensive approach is necessary to ensure the validity of the cross-cultural adaptation of this intervention.