HIV risk environment for Ghanaian women: challenges to prevention

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.

A multiplicative effect of Education and Wealth associated with HIV-related knowledge and attitudes among Ghanaian women

BACKGROUND

Knowledge and attitudes regarding HIV play a crucial role in prevention and control efforts. Understanding the factors influencing HIV-related knowledge and attitudes is essential for formulating effective interventions and policies. This study aims to investigate the possibility of an interaction between education and wealth in influencing HIV-related knowledge and attitudes among women in Ghana.

METHODS

Cross-sectional data from the Ghana Multiple Indicator Cluster Survey (MICS), a nationally representative sample, were analyzed. Statistical summaries were computed using place of residence, marital status, education level, wealth index quintile, use of insurance, functional difficulties, and exposure to modern media. Furthermore, a three-model Logistic regression analysis was conducted; Model 1 with main effects only, Model 2 with the interaction between education and wealth, and Model 3 with additional covariates. To account for the complexity of the survey data, the svyset command was executed in STATA.

RESULTS

Although most interaction terms between wealth index quintiles and education levels did not show statistical significance, a few exceptions were observed. Notably, women with primary education in the second, middle, and fourth wealth quintiles, along with those with secondary education in the second wealth quintile, exhibited a negative significant association with HIV-related attitude level. However, no significant associations were found between other factors, including age, place of residence, marital status, and health insurance, and HIV-related attitude. The study also found significant associations between socioeconomic variables and HIV-related knowledge. There was a significant positive association between higher levels of education and HIV-related knowledge level. Women in wealthier quintiles had a significant positive association with HIV-related knowledge level. Factors such as place of residence and media exposure, including radio and television were also observed to be associated with HIV-related knowledge level.

CONCLUSIONS

This study highlights the importance of socioeconomic status and media exposure in shaping HIV-related knowledge and attitudes among women in Ghana. Policy interventions should focus on reducing socioeconomic disparities, ensuring equitable access to education and healthcare services, and utilizing media platforms for effective HIV information dissemination.

Male and Female Conceptualizations of Sexual Harassment in Tanzania: The Role of Consent, Male Power, and Social Norms

Sexual harassment is pervasive worldwide, yet there is a lack of clarity on its conceptualization in many settings, especially in low-income countries. Context-specific conceptualization of sexual harassment is vital to develop effective measurement tools, estimate its magnitude, and the design of interventions to address it. We explored how different population groups in Mwanza, Tanzania, understood, conceptualized, and experienced sexual harassment. This study employed a qualitative research design involving 74 in-depth interviews and 13 focus group discussions with participants from educational, workplace, and public settings in Mwanza, Tanzania. Participants were adolescent girls and boys, adult women and men. We explored individual-level perceptions and experiences of sexual harassment, and community norms and expectations around sexual harassment. We analyzed the data using a thematic approach. Participants' perceptions of sexual harassment emphasized the critical role of consent, the expression of male power, and social norms with regard to sexual harassment. Sexual harassment was understood to be a result of men being in positions of power and in charge of material resources, school grades, or employment opportunities. These in turn enabled them to take advantage of girls and women. Social norms around male and female interactions, courtship and seduction, expressions of sexual interest were crucial in delineating what was and what was not considered sexual harassment. Sexual harassment is a fluid concept, and its definition is highly dependent on contextual factors. Consent underpins the conceptualization of sexual harassment and is a fundamental feature in the definition and measurement of sexual harassment in Tanzania. Consent is largely determined by sexual norms around male and female interactions and gendered power. There is a need for consensus in schools, workplaces, and communities about what constitutes sexual harassment in order to measure and address it appropriately.

Premarital Counseling Practices among Christian and Muslim Lay Counselors in Ghana

We examined premarital counseling services offered by Christian and Muslim lay counselors in Ghana. Participants including clergy, Islamic clerics, and laity practicing in four urban centers were interviewed. Thematic analysis showed that common issues covered include medical screening, beliefs and values, expectations, partner knowledge, roles and duties, sex, parenthood, financial management, communication, and conflicts. The findings offer important insight into religious premarital counseling in Ghana and contribute to the global literature on premarital counseling.

A Mixed Methods Analysis of the Venue-Related Social and Structural Context of Drug Use During Sex Among Male Clients of Female Sex Workers in Tijuana, Mexico

Drug use during sex increases risks for HIV acquisition. Male clients of female sex workers (FSW) represent both a key population at risk for HIV as well as a transmission bridge population. In Tijuana, Mexico, drug use is prevalent and there is a need to understand male clients' drug use during sex with FSW. Characteristics of sex work venues may confer higher risks for drug use, risky sex, and HIV/STI. It is essential to understand the venue-related social and structural factors associated with drug use during sex in order to inform HIV prevention interventions with male clients in this region. We used a Mixed-Methods Sequential Explanatory Design to conduct an enriched examination of drug use during sex among male clients of FSW in Tijuana. Findings from logistic regression analysis showed that drug use during sex was significantly correlated with police harassment (AOR = 4.06, p < .001) and methamphetamine use (AOR = 33.77, p < .001). In-depth interview data provided rich meaning behind and context around the quantitative associations. Social and structural interventions to reduce police harassment, methamphetamine use, and promote condom availability are needed to reduce risks for HIV among male clients of FSW in Tijuana.

Kinship and Intimate Partner Violence Against Married Women in Ghana: A Qualitative Exploration

In African societies, kinship ties determine how women are socialized, their access to power and wealth, as well as custody of children, often considered important factors in married women's experience of intimate partner violence (IPV). Yet studies that examine how kinship norms influence IPV are scant. Using in-depth interviews collected from women identifying with both matrilineal and patrilineal descent systems, we explored differences in Ghanaian women's experiences of IPV in both kin groups. Results show that while IPV occurs across matrilineal and patrilineal societies, all women in patrilineal societies narrated continuous pattern of emotional, physical, and sexual assault, and their retaliation to any type of violence almost always culminated in more experience of violent attacks and abandonment. In matrilineal societies, however, more than half of the women recounted frequent experiences of emotional violence, and physical violence occurred as isolated events resulting from common couple disagreements. Sexual violence against matrilineal women occurred as consented but unwanted sexual acts, but patrilineal women narrated experiencing violent emotional and physical attack with aggressive unconsented sexual intercourse. Contextualizing these findings within existing literature on IPV against women suggests that policies aimed at addressing widespread IPV in Ghanaian communities should appreciate the dynamics of kinship norms.

Fertility regulation as identity maintenance: Understanding the social aspects of birth control

We take a dialogical approach to exploring fertility regulation practices and show how they can maintain or express social identity. We identify three themes in educated Ghanaian women's accounts of how they navigate conflicting social demands on their identity when trying to regulate fertility: secrecy and silence - hiding contraception use and avoiding talking about it; tolerating uncertainty - such as using unreliable but more socially acceptable contraception; and wanting to be fertile and protecting menses. Family planning programmes that fail to tackle such social-psychological obstacles to regulating fertility will risk reproducing social spaces where women struggle to claim their reproductive rights.

Considerations for purposeful HIV status disclosure among women living with HIV in Ghana

Although disclosure of positive HIV status has recognized benefits, enacted and perceived stigma is a continuing problem in Ghana, especially affecting women living with HIV (WLHIV). This qualitative study investigates how WLHIV make these decisions. We interviewed 40 WLHIV, analysing their transcripts using thematic content analysis. Four themes emerged from the data: selectivity in disclosure; disclosure for education, prevention and to provide support; concern for the potential confident, and safety in secrets. Women's awareness of and concerns about HIV-related stigma led them to seriously weigh the costs and benefits of disclosure decisions. Overall, our participants disclosed only when they believed that disclosure would benefit them or the confidant. They did not condone open disclosure, and preferred non-disclosure to minimize harm to themselves and loved ones. Though disclosure occurred for HIV education and prevention purposes, personal safety was the priority. We recommend revision of current post-HIV testing and pre-treatment counselling procedures to incorporate WLHIVs' judgements about disclosure and discussion of the perceived benefits of disclosure. Disclosure is an intricate process that involves support seeking and educating others while averting harm. Continued research of the factors related to disclosure is important to enhance understanding of the disclosure process.

Gender Equity and HIV/AIDS Prevention: Comparing Gender Differences in Sexual Practice and Beliefs among Zimbabwe University Students

We assess gender differences in HIV prevention knowledge, attitudes and practices with a focus on cultural, sociological, and economic variables. A randomized cross-sectional study was used in order to achieve high participation and broad comparative assessment. An eight-page questionnaire was administered to 933 randomly selected students at the University of Zimbabwe. Survey items addressed sexual decision-making, condom use, limiting sexual partners, cultural power dynamics and access to HIV testing. We found marked gender differences with men reporting beliefs of entitlement to dominate women, an assumed leadership in decision-making concerning condom use and an attitude that when a woman says “no” to sex, really, “it depends.” Women acknowledged gender-based cultural attitudes but are much more likely to support women's rights to sexual expression. A multi-faceted approach to gender equity training is needed to challenge men and women to change attitudes and increase social awareness that respects cultural traditions while still inspiring both men and women to champion justice and equality between genders.

Nursing Care of AIDS Patients in Uganda

This article reports the findings from a participatory action research study concerning the experience of Ugandan nurses caring for individuals with HIV illness. Six key informants from government and non-governmental organizations were interviewed using a semistructured format. Six nurses from a large national referral hospital in Kampala, Uganda, participated in 10 focus group meetings during a period of 11 months. In-depth interviews, focus groups, and photovoice were used to collect the data. Findings indicate that nurses faced many challenges in their daily care, including poverty, insufficient resources, fear of contagion, and lack of ongoing education. Nurses experienced moral distress due to the many challenges they faced during the care of their patients. Moral distress may lead nurses to quit their jobs, which would exacerbate the acute shortage of nurses in Uganda. This study provides important knowledge for guiding clinical practice and nursing education in resource-constrained countries like Uganda.

Exploring the linkage between exposure to mass media and HIV testing among married women and men in Ghana

Although HIV testing is critical to the treatment and prevention of HIV/AIDS, utilization rate of HIV testing services among married women and men remains low in Ghana. Mass media, as a tool to increase overall HIV testing turnouts, has been considered one of the important strategies in promoting and enhancing behavioural changes related to HIV/AIDS prevention. Using the 2014 Ghana Demographic and Health Survey, the current study examines the relationship between levels of exposure to print media, radio, and television and the uptake of HIV testing among married women and men in Ghana. Results show that HIV testing is more prevalent among married women than their male counterparts. We also find that higher levels of exposure to radio is associated with HIV testing among women, while higher levels of exposure to print media and television are associated with HIV testing among men. Implications of these findings are discussed for Ghana's HIV/AIDS strategic framework, which aims to expanding efforts at dealing with the HIV/AIDS epidemic. Specifically, it is important for health educators and programme planners to deliver HIV-related messages through television, radio, and print media to increase the uptake of HIV testing particularly among married women and men in Ghana.

A short history of HIV prevention programs for female sex workers in Ghana: lessons learned over 3 decades

BACKGROUND

Female sex workers (FSWs) in Ghana have a 10-fold greater risk for acquiring HIV than the general adult population, and they contribute a substantial proportion of the new HIV infections in the country. Although researchers have conducted behavioral and biological surveys, there has been no review of the contextual, programmatic, and epidemiological changes over time.

METHODS

The authors conducted a historical review of HIV prevention programs in Ghana. We reviewed the use of different interventions for HIV prevention among FSWs and data from program monitoring and Integrated Biological and Behavioral Surveillance Surveys. In particular, we looked at changes in service access and coverage, the use of HIV testing and counseling services, and the changing prevalence of HIV and other sexually transmitted infections.

RESULTS

HIV prevention interventions among FSWs increased greatly between 1987 and 2013. Only 72 FSWs were reached in a pilot program in 1987, whereas 40,508 FSWs were reached during a national program in 2013. Annual condom sales and the proportion of FSWs who used HIV testing and counseling services increased significantly, whereas the prevalence of gonorrhea and chlamydia decreased. The representation of FSWs in national HIV strategic plans and guidelines also improved.

CONCLUSIONS

Ghana offers an important historical example of an evolving HIV prevention program that-despite periods of inactivity-grew in breadth and coverage over time. The prevention of HIV infections among sex workers has gained momentum in recent years through the efforts of the national government and its partners-a trend that is critically important to Ghana's future.

HIV/AIDS fatalism, beliefs and prevention indicators in Gabon:comparisons between Gabonese and Malians

HIV/AIDS fatalism may impact on individuals' health-seeking behaviour and HIV-prevention efforts. This descriptive study measured levels of HIV/AIDS fatalism and documented HIV/AIDS beliefs and practices among a sample of Gabonese and Malians living in Gabon, West Africa. The Powe Fatalism Inventory-HIV/AIDS version was used to measure levels of fatalism, while a short-answer survey was used to document personal beliefs and behaviours related to HIV and AIDS among 160 people in Gabon. The mean score of HIV/AIDS fatalism for the total sample was 6.8 on a 15-point scale. Malians had a more fatalistic outlook than Gabonese (mean scores 9.4 versus 5.3), Muslims were more fatalistic than persons of other religions (mean scores 9.2 versus 5.3), while healthcare providers were less fatalistic than non-providers (mean scores 3.8 versus 7.4). People that did not believe that HIV/AIDS is a punishment from God had a lower mean score of fatalism than those who did. Most of the sample believed that AIDS is a real disease, and most did not think that only immoral people discuss HIV and AIDS. The HIV-prevention indicators that related to lower scores of fatalism included knowing HIV-positive people, having had more years of formal education, a willingness to disclose one's HIV status (if known), and experience of HIV/AIDS education. Respondents who had tested for HIV were no less fatalistic than those who had never tested. The findings provide data from a part of the world where HIV/AIDS beliefs have rarely been documented. The results indicate a need for additional studies on correlations between HIV/ AIDS fatalism, HIV-prevention behaviours, and religious belief systems.

Marriage, widowhood, divorce and HIV risks among women in sub-Saharan Africa

OBJECTIVE

Studies on associations between marriage and HIV infection among women in sub-Saharan Africa are generally inconclusive. Not enough is known about HIV risks among divorced and widowed women. This study examined the relationship between marital status and HIV infection among women in seven sub-Saharan African countries.

METHODS

Retrospective data from the Demographic and Health Surveys were combined with HIV biomarker data from the AIDS Indicator Survey (AIS) for analysis. Random-effects complementary log-log models were applied to examine the relationship between marital status and HIV risks controlling for theoretically relevant covariates.

FINDINGS

Compared to never-married women, widowed women were significantly more likely to be HIV positive. Similarly, married women were more likely to be infected with HIV, compared to never-married women in Lesotho and Zimbabwe. In Tanzania and Zimbabwe, divorced women had higher risks of HIV infection, compared to never-married women.

CONCLUSION

Findings suggest that specific HIV programs be directed at vulnerable women, in particular those widowed. Similar programs are needed for both poorer and wealthier women.

Maternal Mortality and Female Literacy Rates in Developing Countries during 1970–2000: A Latent Growth Curve Analysis

Background. The gross longitudinal relationship between female literacy and maternal mortality ratios has not been adequately investigated even though the knowledge of the relationship is crucial for designing maternal mortality reduction programs through female literacy campaigns and improvements. The objective of the study was to examine the dynamic relationship between female literacy and mortality ratios. A longitudinal study design spanning three decades, 1970–2000, was used. Country level data on 143 nations belonging to six geographical regions for the duration 1970–2000 were secured from websites hosted by global agencies such as World Bank and the United Nations were utilized. Maternal mortality ratios (1970–2000) ranged from 147 to 271 across the six regions. The longitudinal relationship between female literacy rates and maternal mortality ratios was examined using a latent growth curve approach. The study found that rates of change in female literacy and maternal mortality ratios are negatively related. Steady rates of increase in female literacy were associated with declining maternal mortality ratios as well. We find that female literacy programs are of immense value in reducing maternal mortality ratios given their ability to yield sustained reductions in mortality levels in developing countries.

Stigma in AIDS nursing care in sub-saharan Africa and the Caribbean

Some nurses who provide AIDS care, in addition to experiencing stigma themselves, also exhibit negative attitudes and perpetrate stigma and discrimination toward persons living with HIV (PLWHAs). We used a participatory research approach to explore the nature, context, and influence of stigma on the nursing care provided to PLWHAs in four low- and middle-income countries: Jamaica, Kenya, South Africa, and Uganda. Eighty-four registered nurses, enrolled nurses, and midwives participated in interviews and 79 participated in 11 focus groups. Nurses were very aware of the stigma and discrimination that AIDS evoked, and made adjustments to their care to decrease the manifestation of AIDS stigma. Despite the assurance that PLWHAs were treated equally, and that universal precautions were used consistently, we found that in reality, nurses sometimes made decisions about nursing care that were based on the appearance of the patient or knowledge of his or her status.

Risk Factors for Physical Domestic Violence in a High-Prevalence HIV Setting: Findings from Project Accept Baseline Data (HPTN-043)

Zimbabwe faces an acute generalized HIV/AIDS epidemic combined with rapidly deteriorating economic and political conditions, under which levels of domestic violence are on the rise. We aimed to determine possible demographic and behavioral factors associated with physical domestic violence in a rural setting in order to better inform both national and local domestic violence and HIV prevention policies. Using the Project Accept baseline data set, we selected demographic, socio-economic, and behavioral variables that might be associated with physical domestic violence based on a review of the literature. Univariate and multivariate analyses were carried out, and odds ratios (OR) were computed using logistic regression. Women reporting physical domestic violence were significantly more likely to report (i) a history of childhood domestic violence (OR=2.96, P<0.001), (ii) two or more lifetime partners (OR=1.94, P<0.001), (iii) some form of sexual abuse as a child (OR=1.82, not significant), and (iv) low or medium socio-economic status as measured by type of homestead (OR=1.4, P=0.04) than women who reported no experience of physical domestic violence. Married women were less likely to experience physical domestic violence than unmarried women (OR=0.65, P=0.011). Women at greatest risk of domestic violence include those with a personal history of violence or sexual abuse, multiple lifetime partners, and low or medium socio-economic status. Risk assessments and joint interventions for both domestic violence reduction and HIV prevention should target these population groups, which are effective both on the public health and global heath diplomacy levels.

HIV/AIDS knowledge and uptake of HIV counselling and testing among undergraduate private university students in Accra, Ghana

Background

HIV Counselling and Testing (VCT) and knowledge about HIV are some key strategies in the prevention and control of HIV/AIDS in Ghana. However, HIV knowledge and utilization of VCT services among university students is low. The main objective was to determine the level of HIV/AIDS knowledge and to explore factors associated with the use HIV counselling and testing among private university students in Accra, Ghana.

Materials and methods

A cross-sectional study was conducted using structured questionnaires among 324 conveniently selected students enrolled at a privately owned tertiary institution in Accra, Ghana.

Results

The respondents consisted of 56.2% males and 43.8% females aged 17 – 37 years. The mean HIV/AIDS knowledge score of was 7.70. There was a significant difference in knowledge of HIV/AIDS by gender where female students had more knowledge about HIV/AIDS than males [t (322) = 2.40, p = 0.017]. The ANOVA results showed that there was a significant difference in HIV/AIDS knowledge according to the age groups [F (3, 321) = 6.26, p = 0. 0001] and marital status [F (3, 321) = 4.86, p = 0. 008] of the sample. Over half of the participants had not tested for HIV, although over 95% of them knew where to access counseling and testing services. The study also revealed a significant association between demographic variables, testing for HIV and intention to test in the future. Participants who were never married (single), aged 17 – 20 years and had knowledge of two routes of HIV transmission were more likely to have taken an HIV test. Males were more likely to take an HIV test in the future than females. Majority of the students receive HIV/AIDS information from both print and electronic media, but few of them received such information from parents.

Conclusion

The students HIV knowledge was very good, yet HIV testing were low. Health education and HIV intervention programmes must not only provide accurate information, but must be made to help to equip private university students, especially females to test for HIV consistently.

Consuming sex: the association between modern goods, lifestyles and sexual behaviour among youth in Madagascar

Background

Ethnographic evidence suggests that transactional sex is sometimes motivated by youth’s interest in the consumption of modern goods as much as it is in basic survival. There are very few quantitative studies that examine the association between young people’s interests in the consumption of modern goods and their sexual behaviour. We examined this association in two regions and four residence zones of Madagascar: urban, peri-urban and rural Antananarivo, and urban Antsiranana. We expected risky sexual behaviour would be associated with interests in consuming modern goods or lifestyles; urban residence; and socio-cultural characteristics.

Methods

We administered a population-based survey to 2, 255 youth ages 15–24 in all four residence zones. Focus group discussions guided the survey instrument which assessed socio-demographic and economic characteristics, consumption of modern goods, preferred activities and sexual behaviour. Our outcomes measures included: multiple sexual partners in the last year (for men and women); and ever practicing transactional sex (for women).

Results

Overall, 7.3% of women and 30.7% of men reported having had multiple partners in the last year; and 5.9% of women reported ever practicing transactional sex. Bivariate results suggested that for both men and women having multiple partners was associated with perceptions concerning the importance of fashion and a series of activities associated with modern lifestyles. A subset of lifestyle characteristics remained significant in multivariate models. For transactional sex bivariate results suggested perceptions around fashion, nightclub attendance, and getting to know a foreigner were key determinants; and all remained significant in multivariate analysis. We found peri-urban residence more associated with transactional sex than urban residence; and ethnic origin was the strongest predictor of both outcomes for women.

Conclusions

While we found indication of an association between sexual behaviour and interest in modern goods, or modern lifestyles, such processes did not single-handedly explain risky sexual behaviour among youth; these behaviours were also shaped by culture and conditions of economic uncertainty. These determinants must all be accounted for when developing interventions to reduce risky transactional sex and vulnerability to HIV.

Negotiating safer sex among married women in Ghana

Recent evidence across sub-Saharan Africa shows married women face heightened risks of contracting HIV compared to the never-married. Vulnerability of married women to HIV infection is linked to a number of factors including their inability to negotiate safer sex, inter alia, asking their husbands to use condoms or refusing sexual intercourse even in high risk situations. This study examined what influences married women's ability to say they can ask their sexual partners to use condoms or refuse sexual intercourse. Demographic and Health Survey data from 2,950 married women were analyzed using complementary log-log models. Married women in Ghana were more likely to say they can ask their husbands to use condoms when they know condoms can protect against HIV transmission and had been tested for their HIV serostatus. Also, women who know sexual abstinence can protect against HIV transmission were more likely to say they can refuse sex. Wealthier and highly educated women were more likely to say they can refuse to have sex with their husbands or ask them to use condoms, compared to poorer and less educated women. It is recommended that policy makers promote specific knowledge related to HIV prevention (condom use, HIV testing), while improving the social and economic circumstances of married women in Ghana.

Can women 'refuse' condoms? Dilemmas of condom negotiation among men living with HIV in South Africa

This paper describes challenges that men living with HIV experience in negotiating condom use with sexual partners. After testing HIV-positive, the men in this study attended support groups of people living with HIV. Here they were taught to behave 'responsibly' by adopting safer sex measures. However, some men faced strong resistance from women concerning condom use, particularly from women with whom they had been sexually involved prior to testing HIV-positive. This paper explores the reasoning behind the rejection of condoms by women, focusing specifically on the nature of relationships, disclosure of HIV status and gender power dynamics. Analysis of the findings, which are taken from an ethnographic study conducted over 14 months, indicates that efforts to initiate condom use allowed women to challenge men's authority in sexual affairs and assert their own (limited) agency - albeit by demanding unprotected sex. However, women's rejection of condoms occurred in a knowledge vacuum about their own HIV risk because male partners had failed to disclose their HIV status prior to initiating condoms. Interventions need to encourage men to disclose their HIV status before they initiate condom use with their sexual partners. Furthermore men need to encourage their partners to be open about their sexual needs.

Food insecurity and sexual risk in an HIV endemic community in Uganda

Food insecurity has been linked to high-risk sexual behavior in sub-Saharan Africa, but there are limited data on these links among people living with HIV/AIDS, and on the mechanisms for how food insecurity predisposes individuals to risky sexual practices. We undertook a series of in-depth open-ended interviews with 41 individuals living with HIV/AIDS to understand the impact of food insecurity on sexual-risk behaviors. Participants were recruited from the Immune Suppression Clinic at the Mbarara University of Science and Technology in Mbarara, Uganda. Interviews were recorded, transcribed verbatim, translated, and coded following the strategy of grounded theory. Four major themes emerged from the interview data: the relationship between food insecurity and transactional sex for women; the impact of a husband’s death from HIV on worsening food insecurity among women and children; the impact of food insecurity on control over condom use, and the relationship between food insecurity and staying in violent/abusive relationships. Food insecurity led to increased sexual vulnerability among women. Women were often compelled to engage in transactional sex or remain in violent or abusive relationships due to their reliance on men in their communities to provide food for themselves and their children. There is an urgent need to prioritize food security programs for women living with HIV/AIDS and address broader gender-based inequities that are propelling women to engage in risky sexual behaviors based on hunger. Such interventions will play an important role in improving the health and well-being of people living with HIV/AIDS, and preventing HIV transmission.

More than just talk: the framing of transactional sex and its implications for vulnerability to HIV in Lesotho, Madagascar and South Africa

BACKGROUND

'Transactional sex' was regarded by the mid-1990s as an important determinant of HIV transmission, particularly in sub-Saharan Africa. Little attention has been paid to what the terms used to denote transactional sex suggest about how it is understood. This study provides a nuanced set of descriptions of the meaning of transactional sex in three settings. Furthermore, we discuss how discourses around transactional sex suggest linkages to processes of globalization and hold implications for vulnerability to HIV.

METHODS

The analysis in this article is based on three case studies conducted as part of a multi-country research project that investigated linkages between economic globalization and HIV. In this analysis, we contextualize and contrast the 'talk' about transactional sex through the following research methods in three study sites: descriptions revealed through semi-structured interviews with garment workers in Lesotho; focus groups with young women and men in Antananarivo, Madagascar; and focus groups and in-depth interviews with young women and men in Mbekweni, South Africa.

RESULTS

Participants' talk about transactional sex reveals two themes: (1) 'The politics of differentiation' reflects how participants used language to demarcate identities, and distance themselves from contextually-based marginalized identities; and (2) 'Gender, agency and power' describes how participants frame gendered-power within the context of transactional sex practices, and reflects on the limitations to women's power as sexual agents in these exchanges. Talk about transactional sex in our study settings supports the assertion that emerging transactional sexual practices are linked with processes of globalization tied to consumerism.

CONCLUSIONS

By focusing on 'talk' about transactional sex, we locate definitions of transactional sex, and how terms used to describe transactional sex are morally framed for people within their local context. We take advantage of an opportunity to comparatively explore such talk across three different study sites, and contribute to a better understanding of both emerging sexual practices and their implications for HIV vulnerability. Our work underlines that transactional sex needs to be reflected as it is perceived: something very different from, but of at least equal concern to, formal sex work in the efforts to curb HIV transmission.

Factors influencing condom use among women in Ghana: an HIV/AIDS perspective

Although in Ghana information on HIV infection and prevention, both in terms of quality and quantity, has increased considerably within the past few years, available literature indicates that behaviour change is yet to correspond with the amount of information and education provided. The objective of this study is to examine factors that influence condom use among women in Ghana in the context of HIV/AIDS prevalence. Data for this study are from the 2003 Ghana Demographic and Health Surveys (GDHS) and the study population (N=5 691) was analysed using logistic regression with the Health Belief Model (HBM) as an explanatory tool. The outcome variable for this study is condom use during last sexual intercourse. The HBM identifies perception of HIV/AIDS risks, awareness of its seriousness, knowledge about prevention, and confidence in condom use as predictors of safe sexual activity. Results show that the proportion of women reporting use of condoms remains tremendously low, in both the rural and urban areas. In the urban areas, only 15% of women reported having sex with condom during their last intercourse, whereas in the rural areas the proportion is even lower (10%). However, multivariate analyses based on the HBM components show that speaking with a partner about how to avoid AIDS (Odds Ratio = 1.63) and perceived benefits of using condoms (Odds Ratio = 1.54) are notable factors that predict condom use. Overall, the study points out that with the exception of perceived severity, the HBM can be applied to understand condom use among the study population. It will be important to emphasise all components of the HBM and empower women with condom negotiation skills.

Internal migration to Nairobi's slums: linking migrant streams to sexual risk behavior

Despite what is currently the most rapid urbanization on the globe, an alarming growth of impoverished urban slum settlements in Africa, and the highest rates of HIV in the world - with greater prevalence in urban than rural areas - insufficient attention has been paid to the relationship between urban poverty and risky sexual behavior. Although emerging research has focused on how slum residence is linked to risky behavior, there is a paucity of work on how migration to slums is related to risky sex. Using a sample of sexually active women from the 2000 Nairobi Cross-Sectional Slum Survey (NCSS), this paper demonstrates that the relationship between slum residence and risky behavior is a multifaceted one. Beyond the effect of current residence in slums migratory factors, specifically previous place of residence and length of time since arrival, prove to be significant cofactors, with the effect of the former conditioned by the latter. Perhaps more importantly, where migrants moved from appears to influence risky behavior in a non-uniform manner.

Correlates of HIV testing among women in Ghana: some evidence from the Demographic and Health Surveys

Ghana's strategic framework for controlling HIV/AIDS endorses voluntary HIV testing as an important strategy toward risk reduction and HIV/AIDS prevention. Yet, like other sub-Saharan African countries, utilization of testing services in Ghana is very low. Using the 2003 Ghana Demographic and Health Surveys and applying both complementary and negative log-log models, this study investigates the correlates of HIV testing among women aged 15-49. Two major dependent variables are considered, "ever tested for AIDS" and "wanting to test for AIDS." Results show that majority of Ghanaian women have not tested for HIV but say they want to do so. Having tested for HIV is strongly related to respondents' knowledge about someone dead of AIDS and other socio-economic and demographic variables such as education, region of residence, rural-urban residence, religion, and marital status. Majority of Ghanaian women do not know where to get an HIV test, although knowing where to get a test was significantly related to wanting to get the test done. To increase voluntary testing for HIV among women in Ghana it is recommended that testing services be made more accessible and visible especially to those residing in rural areas who may be economically disadvantaged. Interventions, including routine checking of HIV serostatus among patients seeking healthcare in clinics and home/work-based testing programs, must be encouraged as ways of expanding access among women in Ghana.

Understanding Women's Risk for HIV Infection Using Social Dominance Theory and the Four Bases of Gendered Power

Theoretical models to date have fallen short of accounting for the alarming worldwide rates of HIV infection in women through heterosexual contact. In this article, social dominance theory and the four bases of gendered power—force, resource control, social obligations, and consensual ideologies—are used to organize and explain international research findings on women's risk of contracting HIV from male sexual partners. Research suggests that the four bases of gendered power contribute to women having less power than men in heterosexual relationships, resulting in challenges to preventing HIV transmission from male partners. Social dominance theory also recognizes the intersections among various group-based hierarchies, such as race and class, thereby helping explain why women of color and low-income women are disproportionately affected by HIV. The intergroup focus of social dominance theory points to gender inequality as increasing men's risk of HIV infection as well, and the construct of social dominance orientation helps to explain individual differences in HIV risk behavior. We discuss the ways the current theoretical framework can prove useful in helping to guide future research addressing the connections between power and HIV risk, including exploring mediators and links to other theoretical models. We also discuss the implications the framework has for intervention efforts aimed at reducing HIV rates worldwide, such as supporting efforts at increasing women's representation in hierarchy-enhancing positions, incorporating empowerment issues into current interventions, promoting use of female condoms, and targeting heterosexual men for interventions.

The Impact of Intervention on Sexual Practices of HIV Positive Individuals in Southeast Nigeria

Objective. To describe the impact of repeating behavioral educational intervention on sexual practices of HIV positive individuals. Method. A prospective cohort study of HIV positive individual was conducted in southeast Nigeria from June 2007 to May 2008. Information on sexual practices was collected at initial visit; education was given and its impact was evaluated afterwards. Results. Knowledge about risk of unprotected intercourse increased by 41%, condom use by 27% (P < .001) and consistent condom use by 55% (P < .001). The significant predictors of consistent condom use include male gender, multiple sexual partner, as well as good knowledge of HIV transmission, higher educational status and being married. Non use of condom at postintervention survey were characterized by female gender (n = 4), monogamous relationship (n = 10), little or no education (n = 10), and unmarried (n = 7) respondents. Conclusion. Repeated behavioral education intervention improves consistent condom use among HIV positive individuals and will help curb the spread of HIV/AIDS.

The impact of HIV education on the lives of Ugandan nurses and nurse-midwives

In this ethnography, I explored the impact of an HIV/AIDS education program on the lives of 24 Ugandan nurses and nurse-midwives. Nurses who previously had viewed themselves simply as providers of advice and sympathy now saw themselves as more holistic, collaborative caregivers. They voiced an increased awareness of their role as leaders and advocates in the community with respect to policy. The education program had positive and synergistic effects on the nurses' professional practice, communication and problem-solving skills, confidence, and engagement in political and social change activities.

Safe sex pioneers: class identity, peer education and emerging masculinities among youth in Mozambique

Studies on sexual behaviour within the area of HIV prevention in sub-Saharan Africa have largely focussed on unsafe sex and obstacles to condom use rather than examined factors potentially favouring safe sex. The present study examines how class, gender and peer education affects safe sex in male youth and identifies the reasons behind condom use by combining a questionnaire survey with ethnographic fieldwork. Findings from the field study among male secondary school youth in Maputo, Mozambique point to middle class youth from urban schools as more likely to use condoms than working class youth from suburban schools. Examining the meanings behind use or non-use of condoms the study identified narratives in middle class youth favouring safe sex in response to better social conditions, career opportunities and ‘modern’ masculinities, whereas working class youth explained non-use of condoms as due to lack of hope and job opportunities and by reference to fatalist ideas that life is out of their hands and that it’s better to ‘live in the moment’.

Safe sex pioneers: class identity, peer education and emerging masculinities among youth in Mozambique

Studies on sexual behaviour within the area of HIV prevention in sub-Saharan Africa have largely focussed on unsafe sex and obstacles to condom use rather than examined factors potentially favouring safe sex. The present study examines how class, gender and peer education affects safe sex in male youth and identifies the reasons behind condom use by combining a questionnaire survey with ethnographic fieldwork. Findings from the field study among male secondary school youth in Maputo, Mozambique point to middle class youth from urban schools as more likely to use condoms than working class youth from suburban schools. Examining the meanings behind use or non-use of condoms the study identified narratives in middle class youth favouring safe sex in response to better social conditions, career opportunities and ‘modern’ masculinities, whereas working class youth explained non-use of condoms as due to lack of hope and job opportunities and by reference to fatalist ideas that life is out of their hands and that it’s better to ‘live in the moment’.

HIV testing and care in Canadian Aboriginal youth: a community based mixed methods study

Background

HIV infection is a serious concern in the Canadian Aboriginal population, particularly among youth; however, there is limited attention to this issue in research literature. The purpose of this national study was to explore HIV testing and care decisions of Canadian Aboriginal youth.

Methods

A community-based mixed-method design incorporating the Aboriginal research principles of Ownership, Control, Access and Possession (OCAP) was used. Data were collected through surveys (n = 413) and qualitative interviews (n = 28). Eleven community-based organizations including urban Aboriginal AIDS service organizations and health and friendship centres in seven provinces and one territory assisted with the recruitment of youth (15 to 30 years).

Results

Average age of survey participants was 21.5 years (median = 21.0 years) and qualitative interview participants was 24.4 years (median = 24.0). Fifty-one percent of the survey respondents (210 of 413 youth) and 25 of 28 interview participants had been tested for HIV. The most common reason to seek testing was having sex without a condom (43.6%) or pregnancy (35.4%) while common reasons for not testing were the perception of being low HIV risk (45.3%) or not having had sex with an infected person (34.5%). Among interviewees, a contributing reason for not testing was feeling invulnerable. Most surveyed youth tested in the community in which they lived (86.5%) and 34.1% visited a physician for the test. The majority of surveyed youth (60.0%) had tested once or twice in the previous 2 years, however, about one-quarter had tested more than twice. Among the 26 surveyed youth who reported that they were HIV-positive, 6 (23.1%) had AIDS at the time of diagnosis. Delays in care-seeking after diagnosis varied from a few months to seven years from time of test.

Conclusion

It is encouraging that many youth who had tested for HIV did so based on a realistic self-assessment of HIV risk behaviours; however, for others, a feeling of invulnerability was a barrier to testing. For those who tested positive, there was often a delay in accessing health services.

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.

Homelessness and mental health in Ghana: everyday experiences of Accra's migrant squatters

This article discusses everyday experiences of transient homelessness in Ghana's capital, Accra. Episodic interviews with individuals living in squatter settlements in the wealthy East Legon suburb explored: (1) roots of homelessness; (2) everyday experiences and coping strategies; (3) relationship between experiences and (mental) health; (4) needs and interventions. Three intersecting forms of insecurity framed participants' everyday experience: financial, legal and psychosocial. Physical and psychological stresses were common; physical illnesses rare. Coping strategies facilitated adaptation but not transformation of everyday circumstances. We explore possibilities for intervention and discuss relevance of this study to the health psychology and African literatures on homelessness.

Food insufficiency is associated with high-risk sexual behavior among women in Botswana and Swaziland

BACKGROUND

Both food insufficiency and HIV infection are major public health problems in sub-Saharan Africa, yet the impact of food insufficiency on HIV risk behavior has not been systematically investigated. We tested the hypothesis that food insufficiency is associated with HIV transmission behavior.

METHODS AND FINDINGS

We studied the association between food insufficiency (not having enough food to eat over the previous 12 months) and inconsistent condom use, sex exchange, and other measures of risky sex in a cross-sectional population-based study of 1,255 adults in Botswana and 796 adults in Swaziland using a stratified two-stage probability design. Associations were examined using multivariable logistic regression analyses, clustered by country and stratified by gender. Food insufficiency was reported by 32% of women and 22% of men over the previous 12 months. Among 1,050 women in both countries, after controlling for respondent characteristics including income and education, HIV knowledge, and alcohol use, food insufficiency was associated with inconsistent condom use with a nonprimary partner (adjusted odds ratio [AOR] 1.73, 95% confidence interval [CI] 1.27-2.36), sex exchange (AOR 1.84, 95% CI 1.74-1.93), intergenerational sexual relationships (AOR 1.46, 95% CI 1.03-2.08), and lack of control in sexual relationships (AOR 1.68, 95% CI 1.24-2.28). Associations between food insufficiency and risky sex were much attenuated among men.

CONCLUSIONS

Food insufficiency is an important risk factor for increased sexual risk-taking among women in Botswana and Swaziland. Targeted food assistance and income generation programs in conjunction with efforts to enhance women's legal and social rights may play an important role in decreasing HIV transmission risk for women.

Risk factors for domestic physical violence: national cross-sectional household surveys in eight southern African countries

Background

The baseline to assess impact of a mass education-entertainment programme offered an opportunity to identify risk factors for domestic physical violence.

Methods

In 2002, cross-sectional household surveys in a stratified urban/rural last-stage random sample of enumeration areas, based on latest national census in Botswana, Lesotho, Malawi, Mozambique, Namibia, Swaziland, Zambia and Zimbabwe. Working door to door, interviewers contacted all adults aged 16–60 years present on the day of the visit, without sub-sampling. 20,639 adults were interviewed. The questionnaire in 29 languages measured domestic physical violence by the question "In the last year, have you and your partner had violent arguments where your partner beat, kicked or slapped you?" There was no measure of severity or frequency of physical violence.

Results

14% of men (weighted based on 1,294/8,113) and 18% of women (weighted based on 2,032/11,063) reported being a victim of partner physical violence in the last year. There was no convincing association with age, income, education, household size and remunerated occupation. Having multiple partners was strongly associated with partner physical violence. Other associations included the income gap within households, negative attitudes about sexuality (for example, men have the right to sex with their girlfriends if they buy them gifts) and negative attitudes about sexual violence (for example, forcing your partner to have sex is not rape). Particularly among men, experience of partner physical violence was associated with potentially dangerous attitudes to HIV infection.

Conclusion

Having multiple partners was the most consistent risk factor for domestic physical violence across all countries. This could be relevant to domestic violence prevention strategies.

Globalization and social determinants of health: The role of the global marketplace (part 2 of 3)

Globalization is a key context for the study of social determinants of health (SDH): broadly stated, SDH are the conditions in which people live and work, and that affect their opportunities to lead healthy lives. In the first article in this three part series, we described the origins of the series in work conducted for the Globalization Knowledge Network of the World Health Organization's Commission on Social Determinants of Health and in the Commission's specific concern with health equity. We identified and defended a definition of globalization that gives primacy to the drivers and effects of transnational economic integration, and addressed a number of important conceptual and methodological issues in studying globalization's effects on SDH and their distribution, emphasizing the need for transdisciplinary approaches that reflect the complexity of the topic. In this second article, we identify and describe several, often interacting clusters of pathways leading from globalization to changes in SDH that are relevant to health equity. These involve: trade liberalization; the global reorganization of production and labour markets; debt crises and economic restructuring; financial liberalization; urban settings; influences that operate by way of the physical environment; and health systems changed by the global marketplace.

Navigating HIV, pregnancy, and childbearing in South India: pragmatics and constraints in women's decision making

Based on ethnographic research conducted in 2004 and 2002-3, this article examines how poor women living with HIV in Tamilnadu, India navigate decisions about pregnancy and birth, and demonstrates that these decisions are influenced by a complex web of sociocultural factors. I argue that these decisions are informed by: 1) institutional interests of the state, NGOs, and international aid donors; 2). cultural constructions of gender and of the self; 3). Christian-based organizations; and 4). support group organizations, known as "networks" for people living with HIV/AIDS. Childbearing decisions emerged through a synthesis of coexisting structures and discourses which sometimes converged at the same conclusion despite differences in their underlying logics. I argue that the discourse of "positive living" fostered by the networks provided women with a framework for making reproductive decisions that was enabling. The article highlights how women pragmatically negotiated these various factors as they engaged in reproductive decision-making.

Sexual risk behavior among people living with HIV/AIDS in Togo

Since HIV in Africa is spread primarily through unprotected sex, safe sex practices such as condom use can reduce HIV spread significantly. Nevertheless, because sexual behavior involves complex dynamics, condom use is not an easy option for many people in Africa despite years of condom distribution intervention. In fact, the complex nature of sexuality complicates efforts to combat HIV spread and limits the effectiveness of many prevention efforts. This paper uses theoretical explanations--social representation theory, situated rationality theory, and social action theory--to examine the patterns of sexual risk behavior and the underlying reasons and rationalization among people living with HIV/AIDS in Lomé, Togo. Qualitative interviews were conducted with 151 people living with HIV/AIDS, recruited from 3 HIV/AIDS centers. The results of this in-depth study suggest that although people living with HIV/AIDS may be aware of the risk of infecting their sexual partners, they deliberately ignore the risk because other considerations, such as wanting a baby, take precedence. Consequently, condom access is inadequate to change risky sexual behavior that spreads HIV. It must be supplemented with adequate empowerment.

HIV/AIDS and the construction of Sub-Saharan Africa: Heuristic lessons from the social sciences for policy

There is no doubt that Sub-Saharan African countries face major problems due to the HIV/AIDS pandemic that has ravaged the region. Yet the Eurocentric construction of the region as the source of the virus not only creates negative stereotypes in social science disciplines like geography, but also glosses over the potential of social science disciplines to provide knowledge and influence policy about HIV/AIDS. This oppositional construction of the region has unfortunately contributed to a glossing over of many aspects of Sub-Saharan Africa's people, their environment, culture, history, politics, economics, gender relations, and the region's global status that would provide important input for policy aimed at curbing the devastating spread of HIV in the region. This paper argues that once we recognize that HIV is a global virus with trans-cultural implications, social science disciplines, such as geography, can reveal certain attributes about the region and its HIV/AIDS pandemic that can be used in policy formulation to combat the spread of the virus.

What’s Politics Got to Do with It? Health, the G8, and the Global Economy

This chapter examines the pledges made by developed countries, particularly the rich club of G8 nations, to make globalization work better for the world's poor. It shows that contrary to the ringing rhetoric, they find that levels of foreign aid remain pitifully inadequate.

HIV knowledge and sexual risk behaviors of street children in Takoradi, Ghana

A pilot survey was conducted among 100 street children aged 11-19 years and data collected regarding HIV knowledge, risk behaviors, home and sexual experiences, and factors that contributed to their relocation to the street environment. Data indicated that 80% of the street children had at least minimal knowledge of HIV and 54% perceived themselves to be at risk for contracting HIV. More than three-fourths of the females, and over half of the boys reported ever having sex. There were significant differences between males and females for sexual activity, physical and sexual abuse, and prostitution, as girls were more likely to be sexually active, physically abused, and involved in prostitution.

An examination of knowledge, attitudes and practices related to HIV/AIDS prevention in Zimbabwean university students: Comparing intervention program participants and non-participants

OBJECTIVES

This study represents a comprehensive assessment of differences between participants in an HIV/AIDS prevention program (SHAPE: Sustainability, Hope, Action, Prevention, Education) and non-participants in knowledge, attitudes and practices with a focus on cultural, sociological and economic variables.

METHODS

We developed an eight-page questionnaire that was administered to 933 randomly selected students at the University of Zimbabwe. Survey items addressed sexual decision-making, condom use, limiting sexual partners, cultural power dynamics and access to HIV testing.

RESULTS

Results show participants are statistically more likely to report being sexually abstinent, and understand the prevention benefits of condom use. SHAPE members had fewer sexual partners in the previous year than non-SHAPE members (1.4 vs. 2.2). SHAPE members were significantly more likely (67%) than non-SHAPE respondents (48%) to indicate that they knew their HIV sero-status and to state that they knew their status because they had been tested (85% vs. 71%).

DISCUSSION

Though we found differences between the groups suggesting that program participation increases awareness concerning gender equity, there continue to be many intractable cultural attitudes in this age group. Findings suggest that the attitudes and practices of young men and women are changing, but that progress in some areas does not assure progress in all areas.

Violence against substance-abusing South African sex workers: intersection with culture and HIV risk

The Republic of South Africa has become an epicentre of heterosexual HIV transmission among Black women, and the interface between violence against women, substance abuse, and HIV risk is becoming evident. This paper describes the characteristics of Black South African women who engage in sex work in Pretoria and examines their intersecting experiences of high-risk sexual behaviour, substance abuse, and victimization. Ninety-three women were recruited into the study. Field staff collected biological measures of drug use and administered a structured, self-report interview. Findings indicate that young South African women who engage in sex work and use drugs rely on this activity as their main source of income and are supporting other family members. The majority of sample women reported experiencing some victimization at the hand of men, either clients or boyfriends, with many reporting childhood abuse histories; young women also report great fear of future victimization. Findings also suggest that as a result of their decreased likelihood of using protection, women who reported any sexual or physical victimization are at increased risk for HIV and other STIs. Results support the critical need for targeted, comprehensive interventions that address substance abuse, sexual risk, and violence as interrelated phenomena.