"This is the medicine:" A Kenyan community responds to a sexual concurrency reduction intervention

Decade of research into the acceptability of interventions aimed at improving adolescent and youth health and social outcomes in Africa: a systematic review and evidence map

OBJECTIVE

Interventions aimed at improving adolescent health and social outcomes are more likely to be successful if the young people they target find them acceptable. However, no standard definitions or indicators exist to assess acceptability. Acceptability research with adolescents in low-and-middle-income countries (LMICs) is still limited and no known reviews systhesise the evidence from Africa. This paper maps and qualitatively synthesises the scope, characteristics and findings of these studies, including definitions of acceptability, methods used, the type and objectives of interventions assessed, and overall findings on adolescent acceptability.

DESIGN

We conducted a systematic review of peer-reviewed studies assessing intervention acceptability with young adults (aged 10-24) in Africa, published between January 2010 and June 2020.

DATA SOURCES

Web of Science, Medline, PsycINFO, SociIndex, CINAHL, Africa-wide, Academic Search Complete and PubMed were searched through July 2020.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Papers were selected based on the following inclusion criteria: if they (1) reported primary research assessing acceptability (based on the authors' definition of the study or findings) of one or more intervention(s) with adolescents and young adults 10-24; (2) assessed acceptability of intervention(s) aimed at positively influencing one or more development outcome(s), as defined by sustainable development goal (SDG) indicators; (3) reported on research conducted in Africa; (4) were in the English Language; (5) were peer-reviewed and and (6) were published between 1 January 2010 and 30 June 2020.

DATA EXTRACTION AND SYNTHESIS

Abstracts were reviewed independently by the two first authors to determine relevance. Full text of potentially eligible studies were retrieved and independently examined by the same two authors; areas of disagreement or lack of clarity were resolved through discussion by the two authors and-where necessary-the assessment of a third author.

RESULTS

55 studies were considered eligible for inclusion in the review. Most studies were conducted in Southern Africa, of which 32 jointly in South Africa and Uganda. The majority of interventions assessed for acceptability could be classified as HIV or HPV vaccine interventions (10), E-health (10), HIV testing interventions (8), support group interventions (7) and contraceptive interventions (6). The objectives of most interventions were linked to SDG3, specifically to HIV and sexual and reproductive health. Acceptability was overall high among these published studies. 22 studies provided reasons for acceptability or lack thereof, some specific to particular types of interventions and others common across intervention types.

CONCLUSIONS

Our review exposes considerable scope for future acceptability research and review work. This should include extending acceptability research beyond the health (and particularly HIV) sector and to regions in Africa where this type of research is still scarce; including adolescents earlier, and potentially throughout the intervention process; further conceptualising the construct of acceptability among adolescents and beyond; and examining the relationship between acceptability and uptake.

It's the network, stupid: a population's sexual network connectivity determines its STI prevalence

There is little consensus as to why sexually transmitted infections (STIs), including HIV and bacterial vaginosis (BV) are more prevalent in some populations than others. Using a broad definition of sexual network connectivity that includes both structural and conductivity-related factors, we argue that the available evidence suggests that high prevalence of traditional STIs, HIV and BV can be parsimoniously explained by these populations having more connected sexual networks. Positive feedback, whereby BV and various STIs enhance the spread of other STIs, then further accentuates the spread of BV, HIV and other STIs. We review evidence that support this hypothesis and end by suggesting study designs that could further evaluate the hypothesis, as well as implications of this hypothesis for the prevention and management of STIs.

It's the network, stupid: a population's sexual network connectivity determines its STI prevalence

There is little consensus as to why sexually transmitted infections (STIs), including HIV and bacterial vaginosis (BV) are more prevalent in some populations than others. Using a broad definition of sexual network connectivity that includes both structural and conductivity-related factors, we argue that the available evidence suggests that high prevalence of traditional STIs, HIV and BV can be parsimoniously explained by these populations having more connected sexual networks. Positive feedback, whereby BV and various STIs enhance the spread of other STIs, then further accentuates the spread of BV, HIV and other STIs. We review evidence that support this hypothesis and end by suggesting study designs that could further evaluate the hypothesis, as well as implications of this hypothesis for the prevention and management of STIs.

Could differences in implicit attitudes to sexual concurrency play a role in generalized HIV epidemics?

Background: Sexual partner concurrency has been implicated in the genesis of generalized HIV epidemic in South Africa. Most South Africans, however, disapprove of concurrency in surveys. These surveys test individuals' explicit attitudes which are susceptible to a number of important biases such as the social desirability bias. Assessment of implicit cognitions have been found to be better predictors of behaviour in socially sensitive domains. We hypothesized that South Africans may have implicit attitudes more tolerant of concurrency than lower concurrency prevalence populations. Methods: To test this hypothesis, we developed a concurrency-implicit association test (C-IAT) and compared the C-IATs of samples of South African and Belgian university students. Results: We found a large and statistically significant difference in the C-IAT between the South Africans (D600-score = -0.009, indicating absence of preference for concurrency or monogamy) and Belgians (D600-score = 0.783, indicating a strong preference for monogamy; t-test = 13.3; P < 0.0001). The effect size measure, Cohen's d, was found to be 0.88, which is considered a large effect size in this field. Conclusions: Our results are compatible with the thesis that differences in implicit attitudes to concurrency play a role in the genesis of generalised HIV epidemics.

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.

HIV prevalence by ethnic group covaries with prevalence of herpes simplex virus-2 and high-risk sex in Uganda: An ecological study

Background

HIV prevalence varies from 1.7% to 14.8% between ethnic groups in Uganda. Understanding the factors responsible for this heterogeneity in HIV spread may guide prevention efforts.

Methods

We evaluated the relationship between HIV prevalence by ethnic group and a range of risk factors as well as the prevalence of herpes simplex virus-2 (HSV-2), syphilis and symptomatic STIs in the 2004/2005 Uganda HIV/AIDS Sero-Behavioural Survey—a two stage, nationally representative, population based survey of 15–59-year-olds. Spearman’s correlation was used to assess the relationship between HIV prevalence and each variable.

Results

There was a positive association between HIV prevalence and HSV-2, symptomatic STIs and high-risk sex (sex with a non-cohabiting, non-marital partner) for women. Non-significant positive associations were present between HIV and high-risk sex for men and lifetime number of partners for men and women.

Conclusion

Variation in sexual behavior may contribute to the variations in HIV, HSV-2 and other STI prevalence by ethnic group in Uganda. Further work is necessary to delineate which combinations of risk factors determine differential STI spread in Uganda.

Incident Trichomonas vaginalis Is Associated With Partnership Concurrency: A Longitudinal Cohort Study

BACKGROUND

Sexual partner concurrency (PC) has been shown to be a risk factor for a number of sexually transmitted infections but it is unknown if it is a risk factor for Trichomonas vaginalis (TV).

OBJECTIVE

We assess if there is an association between PC and incident TV infection.

STUDY DESIGN

We used mixed effects logistic regression to assess the association between PC and incident TV in the Longitudinal Study of Vaginal Flora, a cohort study of 3620 women followed quarterly for 5 visits.

RESULTS

Trichomonas vaginalis was more common in those reporting definite/possible/unknown PC (15.6%/15.0%/18.3%) than those reporting no PC (5.2%; P < 0.001 for all 3 comparisons). After controlling for a range of confounders, incident TV remained associated with reporting that one's partner definitely (adjusted odds ratio, 5.4; 95% confidence interval, 3.7-8.0) and possibly (adjusted odds ratio, 3.4; 95% confidence interval, 2.2-5.1) engaged in PC in the preceding period.

CONCLUSIONS

Partner concurrency was associated with incident TV infection.

Significant rates of risky sexual behaviours among HIV-infected patients failing first-line ART: A sub-study of the Europe-Africa Research Network for the Evaluation of Second-line Therapy trial

There are limited data on the prevalence of risky sexual behaviours in individuals failing first-line antiretroviral therapy (ART) and changes in sexual behaviour after switch to second-line ART. We undertook a sexual behaviour sub-study of Ugandan adults enrolled in the Europe-Africa Research Network for the Evaluation of Second-line Therapy trial. A standardized questionnaire was used to collect sexual behaviour data and, in particular, risky sexual behaviours (defined as additional sexual partners to main sexual partner, inconsistent use of condoms, non-disclosure to sexual partners, and exchange of money for sex). Of the 79 participants enrolled in the sub-study, 62% were female, median age (IQR) was 37 (32-42) years, median CD4 cell count (IQR) was 79 (50-153) cells/µl, and median HIV viral load log was 4.9 copies/ml (IQR: 4.5-5.3) at enrolment. The majority were in long-term stable relationships; 69.6% had a main sexual partner and 87.3% of these had been sexually active in the preceding six months. At enrolment, around 20% reported other sexual partners, but this was higher among men than women (36% versus 6.7 %, p < 0.001). In 50% there was inconsistent condom use with their main sexual partner and a similar proportion with other sexual partners, both at baseline and follow-up. Forty-three per cent of participants had not disclosed their HIV status to their main sexual partner (73% with other sexual partners) at enrolment, which was similar in men and women. Overall, there was no significant change in these sexual behaviours over the 96 weeks following switch to second-line ART, but rate of non-disclosure of HIV status declined significantly (43.6% versus 19.6%, p <0.05). Among persons failing first-line ART, risky sexual behaviours were prevalent, which has implications for potential onward transmission of drug-resistant virus. There is need to intensify sexual risk reduction counselling and promotion of partner testing and disclosure, especially at diagnosis of treatment failure and following switch to second- or third-line ART.

Geographic mobility and potential bridging for sexually transmitted infections in Agbogbloshie, Ghana

Short-term mobility can significantly influence the spread of infectious disease. In order for mobile individuals to geographically spread sexually transmitted infections (STIs), individuals must engage in sexual acts with different partners in two places within a short time. In this study, we considered the potential of mobile individuals as bridge populations - individuals who link otherwise disconnected sexual networks and contributed to ongoing STI transmission. Using monthly retrospective panel data, we examined associations between short-term mobility and sexual partner concurrency in Agbogbloshie, Ghana. We also examined bridging by the location of sex acts and the location of sexual partners in concurrent triads, and whether mobile individuals from our sample were more likely to be members of geographic bridging triads. Although reported rates of sexual partnership concurrency were much higher for men compared to women, mobility was only associated with increased concurrency for women. Additionally, this association held for middle-distance mobility and short-duration trips for women. Taking into account the location of sex acts and the location of sexual partners, about 22% of men (21.7% and 22.4% for mobile and non-mobile men, respectively) and only 3% of women (1.4% and 3.3% for mobile and non-mobile women, respectively) were potential bridges for STIs over the last year. Our results highlight the gendered nature of mobility and sexual risk behavior, reflecting the normative social context that encourages women to conceal certain types of sexual behavior.

Gender inequality dynamics in the prevention of a heterosexual HIV epidemic in sub-Saharan Africa

This paper critiques the approach to the elimination of gender inequality as an HIV prevention strategy in the just ended era of the Millennium Development Goals, with the aim of contributing to the formulation of policy guidelines for sub-Saharan Africa in the Sustainable Development Goals. The aim is to underscore the mutual responsibility of women and men in achieving a sustainable HIV response and ending the epidemic. While taking into account the real vulnerability of women, prevention programmes can reflect gender dynamics more accurately so that attention is given to the role of both sexes in propagating - or stemming - a predominantly heterosexual HIV epidemic. More emphasis could be given to the harm caused to both men and women by certain norms related to masculinity and sexuality, and the subsequent need for combined efforts in reducing intimate partner violence and concurrency. The empowerment and engagement of both women and men as agents of change would need to be dealt with more creatively.

A population's higher-risk sexual behaviour is associated with its average sexual behaviour-An ecological analysis of subpopulations in Ethiopia, Kenya, South Africa, Uganda and the United States

BACKGROUND

Given the large variation in the prevalence of sexually transmitted infections between populations it is important to characterize how sexual vary between populations. In this paper we assess how the distribution of lifetime sexual partners varies between populations. We ask: do populations with higher mean lifetime sexual partners merely differ by virtue of the presence of a core-group with increased number of partners or do the population distributions move as more coherent wholes?

METHODS

We defined those in the top decile of lifetime sex partners in each country as constituting the higher-risk behaviour group (HRB). Spearman's correlation was used to evaluate the relationship between mean lifetime partners and prevalence of those in the HRB by ethnic group within Ethiopia, Kenya, South Africa, Uganda and the United States. In each case, data from nationally representative surveys were used. Two-sample Wilcoxon rank-sum were applied to test if there was a difference in the number of lifetime partners between the highest and lowest-risk subpopulations, separately for men and women. To account for autocorrelation, all analyses were conducted using means/medians excluding those in the HRB. A P-value of <0.05 was considered statistically significant.

RESULTS

In each country, a positive correlation existed between subpopulations' mean lifetime partners and the prevalence of the HRB. Spearman's correlation varied from 0.20 to 0.99 for men and 0.74 to 1.0 for women. This association was statistically significant in 6 out of 10 comparisons. There was a statistically significant difference in the number of lifetime partners between the highest and lowest-risk ethnic groups in all countries except South Africa, where the difference was only significant for women.

CONCLUSIONS

Our results suggest that sexual behaviours vary coherently between different populations. As such, sexually transmitted infection control efforts would benefit from including both targeted campaigns focusing on the HRB and population-strategies that seek to address factors responsible for high mean risk behaviour.

On the road again: concurrency and condom use among Uganda truck drivers

Long-distance truck drivers have been shown to be a critical population in the spread of HIV in Africa. In 2009, surveys with 385 Ugandan long-distance truck drivers measured concurrency point prevalence with two methods; it ranged from 37.4% (calendar-method) to 50.1% (direct question). The majority (84%) of relationships reported were long-term resulting in a long duration of overlap (average of 58 months) across concurrent partnerships. Only 7% of these men reported using any condoms with their spouses during the past month. Among all non-spousal relationships, duration of relationship was the factor most strongly associated with engaging in unprotected sex in the past month in a multivariable analyses controlling for partner and relationship characteristics. Innovative intervention programs for these men and their partners are needed that address the realities of truck drivers' lifestyles.

"Once you join the streets you will have to do it": sexual practices of street children and youth in Uasin Gishu County, Kenya

BACKGROUND

Adolescents living in HIV endemic settings face unique sexual health risks, and in the context of abject poverty, orphanhood, social marginalization, and discrimination, adolescents may be particularly at-risk of horizontal HIV transmission. Street-connected children and youth are a particularly vulnerable and marginalized population and therefore may be a key population at-risk.

METHODS

We sought to describe the sexual behaviours of street-connected children and youth in order to comprehend their sexual practices and elucidate circumstances that put them at increased risk of contracting HIV utilizing qualitative methods from a sample of street-connected children and youth in Eldoret, Kenya. We recruited participants aged 11-24 years who had lived on the street for ≥ 3 months to participate in 25 in-depth interviews and 5 focus group discussions stratified by age and sex.

RESULTS

In total we interviewed 65 street-connected children and youth; 69 % were male with a median age of 18 years (IQR: 14-20.5 years). Participants identified both acceptable and unacceptable sexual acts that occur on the streets between males and females, between males, and between females. We grouped reasons for having sex into four categories based on common themes: pleasure, procreation, transactional, and forced. Transactional sex and multiple concurrent partnerships were frequently described by participants. Rape was endemic to street life for girls.

CONCLUSION

These findings have important policy and programming implications, specifically for the government of Kenya's adolescent reproductive health policy, and highlight the need to target out-of-school youth. There is an urgent need for social protection to reduce transactional sex and interventions addressing the epidemic of sexual and gender-based violence.

Youth Perspectives on Sexual Health Workshops: Informing Future Practice

Newcomer and street-involved youth provided their perspective on the design and content of a sexual education workshop. Following the workshop, focus group discussions were held with 80 youth from four youth-serving agencies. Youth expressed increased levels of confidence and empowerment, consistent with recent criticism that a focus on specific behaviors as intervention outcome measures may miss important psychosocial changes in participants. Some youth views on cultural adaptation of workshops were not consistent with current views expressed by some adult educators, highlighting the need to ensure a youth perspective is captured during intervention development. Finally, the dichotomous views that youth expressed regarding workshop activities emphasizes a research gap related to how best to adapt interventions to different cognitive capacities, literacy levels, and learning styles. Information of this kind is relevant in terms of knowledge translation from youth to program planners and educators.

Intimate partner violence and forced migration during pregnancy: Structural constraints to women's agency

Little is known about migration during pregnancy related to intimate partner violence (IPV). In this paper, we examine issues of agency in relation to pregnant women's migrations in a high HIV prevalence area of Kenya. We qualitatively explored forced migration among pregnant women, using data from in-depth interviews, focus groups and IPV screening forms. To quantitatively examine migration during pregnancy, we analysed data from a prospective study of 614 pregnant women. The qualitative data revealed that women had varied responses to violence in pregnancy, with some being able to leave the marital home voluntarily as a strategy to escape violence. Others were 'sent packing' from their marital homes when they dared to exercise autonomy, in some cases related to HIV status. Quantitative analyses revealed that pregnant women who migrated were more educated, less likely to be living with a partner and had fewer children than other women. Migration among pregnant women in Kenya illustrates the complexity of understanding women's agency in the context of IPV. The findings indicate that there is not a dichotomy between 'victim' and 'agent', but rather a complex dynamic between and within pregnant women, who may sequentially or simultaneously experience aspects of victimhood and/or agentic response.

Variations of Sexual Scripts Relating to Concurrency by Race, Class, and Gender in South Africa

It is unclear whether higher rates of sexual partner concurrency in Black South Africans are due to socioeconomic or cultural factors. We used a nationally representative sample of 9,728 individuals aged 16 to 55 from a study conducted in 2009 to examine how the norms pertaining to concurrency and the practice of concurrency vary by race, class, and gender. The percentage of men reporting point concurrency was 14%, 6.5%, and 2.5% in Blacks, coloreds, and Whites, respectively (p < 0.001). These percentages increased to 45.7%, 24.7%, and 11.7%, respectively, for those reporting lifetime concurrency (p < 0.001). In all the racial groups, men exhibited more favorable attitudes toward concurrency than women did. For a range of indicators, White men and women had less favorable attitudes toward concurrency than Black men and women. These differences remained after controlling for a range of confounding variables. In the adjusted logistic regression model, reported concurrency in men was associated with a younger age, Black race, being in the lowest income tertile, not being in a stable relationship, and expressing various positive attitudes toward concurrency.