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Johnson-Peretz J, Onyango A, Gutin SA, Balzer L, Akatukwasa C, Owino L, Arunga TMO, Atwine F, Petersen M, Kamya M, Ayieko J, Ruel T, Havlir D, Camlin CS. Clinical Implications of HIV Treatment and Prevention for Polygamous Families in Kenya and Uganda: "My Co-Wife Is the One Who Used to Encourage Me". J Int Assoc Provid AIDS Care 2024; 23:23259582241255171. [PMID: 38751360 PMCID: PMC11100383 DOI: 10.1177/23259582241255171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 03/27/2024] [Accepted: 04/23/2024] [Indexed: 05/19/2024] Open
Abstract
Polygamy is the practice of marriage to multiple partners. Approximately 6-11% of households in Uganda and 4-11% of households in Kenya are polygamous. The complex families produced by polygamous marriage customs give rise to additional considerations for healthcare providers and public health messaging around HIV care. Using 27 in-depth, semi-structured qualitative interviews with participants in two studies in rural Kenya and Uganda, we analysed challenges and opportunities that polygamous families presented in the diagnosis, treatment and prevention of HIV, and provider roles in improving HIV outcomes in these families. Overall, prevention methods seemed more justifiable to families where co-wives live far apart than when all members live in the same household. In treatment, diagnosis of one member did not always lead to disclosure to other members, creating an adverse home environment; but sometimes diagnosis of one wife led not only to diagnosis of the other, but also to greater household support.
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Affiliation(s)
- Jason Johnson-Peretz
- University of California, San Francisco (UCSF), Obstetrics, Gynecology & Reproductive Sciences, San Francisco, CA, USA
| | | | - Sarah A. Gutin
- University of California, San Francisco (UCSF), Community Health Systems, UCSF School of Nursing, San Francisco, CA, USA
| | - Laura Balzer
- University of California, Biostatistics, Epidemiology, and Computational Precision Health, Berkeley, CA, USA
| | | | | | | | - Fred Atwine
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Maya Petersen
- University of California, Biostatistics, Epidemiology, and Computational Precision Health, Berkeley, CA, USA
| | - Moses Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - James Ayieko
- Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Ted Ruel
- University of California, San Francisco (UCSF), HIV Adolescent and Young Adult Studies, Pediatrics, San Francisco, CA, USA
| | - Diane Havlir
- University of California, Biostatistics, Epidemiology, and Computational Precision Health, Berkeley, CA, USA
| | - Carol S. Camlin
- University of California, San Francisco (UCSF), Obstetrics, Gynecology & Reproductive Sciences, San Francisco, CA, USA
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Abstract
We examined the association of women empowerment and HIV testing in Nepalese women. Data from the 2012 Nepal Demographic and Health Survey provided a sample of 6,579 females ages 15-49 years. Women empowerment subcategories included participation in decision making, attitudes about safer sex negotiation, and sexual autonomy. Only 454 participants (6.9%) had been tested for HIV. Of note, 41.3% had high participation in decision making, 84.5% showed positive attitudes about safer sex negotiation, and 71.8% scored high in sexual autonomy. After adjusting potential confounders, the odds of being tested were higher for women with positive attitudes about safer sex negotiation (adjusted odds ratio = 1.444, 95% confidence interval: 1.006-2.072, p = .046) and high sexual autonomy (adjusted odds ratio = 3.138, 95% confidence interval: 1.375-7.164, p = .007). Age, education, and wealth were independent factors determining the women's HIV testing approach. Our study can be a guide for interventions and policies to empower women and encourage HIV testing in Nepal.
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Persson A, Kelly-Hanku A, Mek A, Mitchell E, Nake Trumb R, Worth H, Bell S. Polygyny, Serodiscordance and HIV Prevention in Papua New Guinea: A Qualitative Exploration of Diverse Configurations. THE ASIA PACIFIC JOURNAL OF ANTHROPOLOGY 2020. [DOI: 10.1080/14442213.2020.1758202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Muldoon KA, King R, Zhang W, Birungi J, Nanfuka M, Tibengana S, Afolabi O, Moore DM. Sexual Health Consequences of Forced Sexual Debut Among Ugandan Women in HIV Serodiscordant Partnerships: Results From the HAARP Study. JOURNAL OF INTERPERSONAL VIOLENCE 2018; 33:1731-1747. [PMID: 29739290 DOI: 10.1177/0886260517752155] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Sexual coercion, especially forced sexual debut, is associated with lifelong adverse health consequences. This is compounded in regions, such as Uganda, where the dual impact of HIV and violence critically shapes women's sexual health risks. Among a sample of women in HIV serodiscordant relationships, we investigated the prevalence and consequences of forced sexual debut. Data for this analysis come from the Highly Active Antiretroviral Treatment as Prevention (HAARP) Study, a cohort of HIV serodiscordant couples in Jinja, Eastern Uganda, and investigates the role of forced sexual debut on two outcomes: age of sexual debut and having more than three lifetime sexual partners. Bivariate and multivariate linear regressions were used to model age at sexual debut using β and adjusted (A) β and 95% confidence intervals (CIs). Bivariate and multivariate logistic regressions were used to model having more than three lifetime sexual partners and used odds ratios (ORs) and adjusted OR (AOR) and 95% CI. A total of 574 women were included in this analysis, median age 35 years, and 241 (41.99%) were living with HIV. A quarter (24.21%) of women experienced forced sexual debut at the median age of 16 years. Forced sexual debut was significantly associated with earlier age of sexual debut (β = -1.17, 95% CI: [-1.64, -0.68]). Forced sexual debut was significantly associated with having more than three sexual partners (AOR: 1.99, 95% CI: [1.33, 2.99]), in addition to older age (AOR: 1.02, 95% CI: [1.01, 1.05]). Speaking Lusoga, the primary language in Jinja (the study site) was associated with lower odds of having more than three sexual partners (AOR: 0.63, 95% CI: [0.43, 0.92]). Forced sexual debut was a common experience significantly associated with younger age of sexual debut and higher number of lifetime sexual partners. Safe and consensual first sexual experiences for young women play an important role in reducing HIV risk and lay the foundation for healthy and safe sexual health.
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Affiliation(s)
- Katherine A Muldoon
- 1 Ottawa Hospital Research Institute, Ontario, Canada
- 2 University of Ottawa, Ontario, Canada
| | - Rachel King
- 3 University of California, San Francisco, USA
| | - Wendy Zhang
- 4 British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | | | | | | | - Omoboade Afolabi
- 4 British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - David M Moore
- 4 British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- 6 University of British Columbia, Vancouver, Canada
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Rudrum S, Oliffe JL, Benoit C. Discourses of masculinity, femininity and sexuality in Uganda's Stand Proud, Get Circumcised campaign. CULTURE, HEALTH & SEXUALITY 2017; 19:225-239. [PMID: 27684495 DOI: 10.1080/13691058.2016.1214748] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
This paper analyses discourses of masculinity, femininity and sexuality in Stand Proud, Get Circumcised, a public health campaign promoting circumcision as an HIV-prevention strategy in Uganda. The campaign includes posters highlighting the positive reactions of women to circumcised men, and is intended to support the national rollout of voluntary medical male circumcision. We offer a critical discourse analysis of representations of masculinity, femininity and sexuality in relation to HIV prevention. The campaign materials have a playful feel and, in contrast to ABC (Abstain, Be faithful, Use condoms) campaigns, acknowledge the potential for pre-marital and extra-marital sex. However, these posters exploit male anxieties about appearance and performance, drawing on hegemonic masculinity to promote circumcision as an idealised body aesthetic. Positioning women as the campaign's face reasserts a message that women are the custodians of family health and simultaneously perpetuates a norm of estrangement between men and their health. The wives' slogan, 'we have less chance of getting HIV', is misleading, because circumcision only directly prevents female-to-male HIV transmission. Reaffirming hegemonic notions of appearance- and performance-based heterosexual masculinity reproduces existing unsafe norms about masculinity, femininity and sexuality. In selling male circumcision, the posters fail to promote an overall HIV-prevention message.
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Affiliation(s)
- Sarah Rudrum
- a Institute for Gender, Race, Sexuality and Social Justice , University of British Columbia , Vancouver , British Columbia , Canada
| | - John L Oliffe
- b School of Nursing , University of British Columbia , Vancouver , British Columbia , Canada
| | - Cecilia Benoit
- c Department of Sociology , University of Victoria , Victoria , British Columbia , Canada
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Muldoon KA, Kanters S, Birungi J, King RL, Nyonyintono M, Khanakwa S, Moore DM. 'He said, she said': assessing dyadic agreement of reported sexual behaviour and decision-making among an HIV sero-discordant couples cohort in Uganda. ACTA ACUST UNITED AC 2016; 43:142-146. [PMID: 27030697 DOI: 10.1136/jfprhc-2015-101323] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 02/26/2016] [Accepted: 02/26/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND The intimate nature of sexuality makes it challenging to accurately measure sexual behaviour. To assess response reliability, we examined agreement between couples in heterosexual HIV sero-discordant partnership on survey questions regarding condom use and sexual decision-making. METHODS Data for this analysis come from baseline data from a cohort study of HIV sero-discordant couples in Jinja, Uganda. We examined the degree of agreement between male and female partners on standard measures of sexual behaviour using the kappa (κ) statistic and 95% confidence intervals (95% CIs). RESULTS Among 409 couples, the median age for the male partner was 41 [interquartile range (IQR) 35-48] years and the female partner was 35 (IQR 30-40) years. Among 58.2% of the couples, the male was the HIV-positive partner. Questions with high or substantial couple agreement included condom use at last sex (κ=0.635, 95% CI 0.551-0.718) and frequency of condom use (κ=0.625, 95% CI 0.551-0.698). Questions with low or fair couple agreement included decision-making regarding condom use (κ=0.385, 95% CI 0.319-0.451), wanting more biological children (κ=0.375, 95% CI 0.301-0.449) and deciding when to have sex (κ=0.236, 95% CI 0.167-0.306). CONCLUSIONS Survey questions assessing condom use had the highest level of couple agreement and questions regarding sexual decision-making and fertility desire had low couple agreement. Questions with high agreement have increased reliability and reduced measurement bias; however, questions with low agreement between couples identify important areas for further investigation, particularly perceived relationship control and gender differences.
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Affiliation(s)
- Katherine A Muldoon
- Research Fellow, School of Population and Public Health, University of British Columbia, BC and BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Steve Kanters
- Statistician, School of Population and Public Health, University of British Columbia, BC and BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | | | - Rachel L King
- Senior Researcher, Global Health Sciences, University of California, San Francisco, CA USA.,Senior Researcher, Karolinska Institute, Stockholm, Sweden
| | | | - Sarah Khanakwa
- Centre Manager, The AIDS Support Organisation, Kampala, Uganda
| | - David M Moore
- Associate Professor, Department of Medicine, University of British Columbia, BC and BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
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King R, Min J, Birungi J, Nyonyintono M, Muldoon KA, Khanakwa S, Kaleebu P, Moore DM. Effect of Couples Counselling on Reported HIV Risk Behaviour among HIV Serodiscordant Couples by ART Use, HIV Status and Gender in Rural Uganda. PLoS One 2015; 10:e0136531. [PMID: 26384103 PMCID: PMC4575207 DOI: 10.1371/journal.pone.0136531] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 08/04/2015] [Indexed: 12/31/2022] Open
Abstract
Background We examined several measures of self-reported HIV risk behaviour in mutually disclosed sero-discordant couples over time to see if a couples counselling intervention was associated with changes in these behaviors. Methods We analysed data from a prospective cohort study of HIV sero-discordant couples in Jinja, Uganda collected between June 2009 and December 2011. Participants received couples counselling, at 3-monthly intervals. We examined trends in reported condom-use, number of concurrent sexual partners, knowledge of HIV serostatus of concurrent partners and condom use of concurrent partners using Generalized Estimating Equation models, comparing responses at study enrollment with responses at six, 12 18 and 24 months of follow-up. Results A total of 586 couples were enrolled and the female member was HIV positive in 255 (44%) of them. The median age for female participants was 35 years and 42 years for men. Reported condom use at last sex with spouse increased over time (p<0.001) with the largest increases found among couples where the positive participant never received ART during the study(an increase from 68.8% at enrollment to 97.1% at 24 months). Male participants reported reductions in the number of concurrent sexual partners (p<0.001), increase in the knowledge of the HIV serostatus of these partners (p = 0.001) and a trend towards improved condom-use among non-primary partners (p = 0.070). Reported reduced risky behaviors did not wane over the study period. Conclusion Couples counselling resulted in increased condom use among all participants and among men the intervention resulted in reductions in risk behaviour with concurrent sexual partners. Routine counselling for serodiscordant couples should be integrated in routine ART care programs.
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Affiliation(s)
- Rachel King
- University of California San Francisco, Kampala, Uganda
- * E-mail:
| | - Jeong Min
- British Colombia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | | | | | - Katherine A. Muldoon
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | | | - Pontiano Kaleebu
- Uganda Virus Research Institute/ Medical Research Council Research Unit on AIDS, Entebbe, Uganda
| | - David M. Moore
- British Colombia Centre for Excellence in HIV/AIDS, Vancouver, Canada
- Faculty of Medicine, University of British Colombia, Vancouver, Canada
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Muldoon KA, Duff PK, Birungi J, Ngolobe MH, Min JE, King R, Nyonyintono M, Chen Y, Shannon K, Khanakwa S, Moore D. Decisions, decisions: the importance of condom use decision making among HIV sero-discordant couples in a prospective cohort study in Uganda. Sex Transm Infect 2014; 90:408-12. [PMID: 24695989 DOI: 10.1136/sextrans-2013-051326] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES We examined sexual decision making type among couples in HIV sero-discordant partnerships in Uganda, and investigated how sexual decision making type changed over time and its effect on condom use. METHODS Data were drawn from a longitudinal cohort of HIV sero-discordant couples, recruited through the AIDS Support Organisation in Jinja, Uganda. Sexual decision making was measured using the Sexual Relationship Power Scale, and couples' individual self-report answers were matched to assess agreement for decision making type and condom use. Generalised linear mixed effects modelling was used to assess statistically significant differences in time trend of sexual decision making type, and to investigate the independent association of decision making type on condom use status over time. RESULTS Of the 533 couples included in this analysis, 345 (65%) reported using condoms at last sex at study enrolment. In the time trend analysis of decision making, the proportion of couples who decided together increased over time while the proportions of couples who reported that one partner decided or no one decided/did not use condoms, decreased over time (overall p<0.001). Compared with couples who decided together, those who disagreed (adjusted OR=0.42, 95% CI 0.28 to 0.64) and those where one partner decided (adjusted OR=0.20, 95% CI 0.12 to 0.34) had significantly lower odds of condom use at last sex, even after controlling for confounders. CONCLUSIONS Couples who disagreed on decision making, or agreed that one partner decides alone, had significantly lower odds of reporting condom use compared with couples who decided together. HIV counselling interventions that encourage joint sexual decision making may improve condom use within this population.
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Affiliation(s)
- Katherine A Muldoon
- British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, British Columbia, Canada School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Putu K Duff
- British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, British Columbia, Canada School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Jeong Eun Min
- British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Rachel King
- University of California, San Francisco, California, USA Karolinska Institute, Stockholm, Sweden
| | | | - Yalin Chen
- British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Kate Shannon
- British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, British Columbia, Canada School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada Department of Medicine, University of British Columbia, St Paul's Hospital, Vancouver, British Columbia, Canada
| | | | - David Moore
- British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, British Columbia, Canada Department of Medicine, University of British Columbia, St Paul's Hospital, Vancouver, British Columbia, Canada
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Gnauck K, Ruiz J, Kellett N, Sussman A, Sullivan MA, Montoya M, Levin N, Tomedi A, Mwanthi MA. Economic empowerment and AIDS-related stigma in rural Kenya: a double-edged sword? CULTURE, HEALTH & SEXUALITY 2013; 15:851-865. [PMID: 23668536 DOI: 10.1080/13691058.2013.789127] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Economic empowerment, HIV risk and AIDS-related stigma appear intricately intertwined for women in Kenya. Their interaction must be understood in order to implement effective economic interventions that also decrease HIV risk and stigma. We conducted a qualitative study amongst women in a rural Kamba-speaking community of southeastern Kenya to pursue whether engagement in an economic empowerment initiative (a basket weaving cooperative) influences women's perspectives and experiences with HIV risk and AIDS-related stigma. We conducted seven women's focus groups: participants in the local basket-weaving cooperative comprised four focus groups and non-participants comprised the remaining three groups. The HIV status of the women was not known. Three dominant themes emerged from the focus groups: empowerment, pervasive vulnerability and unanticipated social paradoxes. Contradictions found in these themes suggest that economic empowerment can become a double-edged sword. Economic empowerment enhanced perceived individual, domestic and social community status. However, this enhancement was not protective of domestic violence and perceived HIV risk. Social perceptions may have paradoxically contributed barriers to HIV testing and treatment putting women at greater HIV risk. In conclusion, economic empowerment initiatives for women in developing countries in the context of the HIV epidemic should be coupled with peer mediated support and HIV-risk education.
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Affiliation(s)
- Katherine Gnauck
- University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque, NM, USA.
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Cuca YP, Onono M, Bukusi E, Turan JM. Factors associated with pregnant women's anticipations and experiences of HIV-related stigma in rural Kenya. AIDS Care 2012; 24:1173-80. [PMID: 22799618 DOI: 10.1080/09540121.2012.699669] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Pregnant women who fear or experience HIV-related stigma may not get care for their own health or medications to reduce perinatal transmission of HIV. This study examined factors associated with anticipating and experiencing HIV-related stigma among 1777 pregnant women attending antenatal care clinics in rural Kenya. Women were interviewed at baseline, offered HIV testing and care, and a sub-set was re-interviewed at 4-8 weeks postpartum. Women who were older, had less education, whose husbands had other wives, and who perceived community discrimination against people with HIV had significantly greater adjusted odds of anticipating HIV stigma. Over half of the HIV-positive women interviewed postpartum reported having experienced stigma, much of which was self-stigma. Women experiencing minor depression, and those whose family knew of their HIV status had significantly greater adjusted odds of experiencing stigma. Lack of women's empowerment, as well as depression, may be important risk factors for HIV-related stigma and discrimination.
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Affiliation(s)
- Yvette P Cuca
- Department of Social and Behavioral Sciences, University of California, San Francisco (UCSF), San Francisco, CA, USA.
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