From first love to marriage and maturity: a life-course perspective on HIV risk among young Swazi adults

Context, Types, and Consequences of Violence Across the Life Course: A Qualitative Study of the Lived Experiences of Transgender Women Living With HIV

Violence is a known driver of HIV vulnerability among transgender (trans) women, who are disproportionately impacted by HIV globally. Violence is also a barrier to accessing HIV prevention, treatment, and support. Yet, little is known about the everyday experiences of violence faced by trans women living with HIV, who live at the intersection of a marginalized gender identity and physical health condition. To address this gap, this study draws on semi-structured, individual interviews conducted 2017-2018 with a purposive sample (selected based on diverse identities) of trans women living with HIV (n = 11) participating in a large, community-based cohort study in three Canadian provinces. Framework analysis was used to identify key themes, patterns within themes between participants, and patterns across themes among participants. Findings showed that trans women living with HIV experience specific contexts of violence shaped at the intersection of stigma based on gender identity, gender expression, and HIV status, among other identities/experiences. Violence experienced in childhood (e.g., familial rejection, bullying) increased trans women's likelihood of being exposed to a violent social context in young adulthood (e.g., state violence perpetuated by the police, interpersonal violence perpetuated by sexual partners, and community violence perpetuated by society-at-large/the general public), which increased trans women's HIV vulnerability; once living with HIV trans women were subjected to discursive violence from healthcare providers. These multiple forms of violence have serious consequences for trans women living with HIV's ongoing social, mental, and physical well-being. The findings suggest that interventions are urgently needed to reduce violence against trans women in childhood and young adulthood, in addition to reducing violence against trans women living with HIV perpetuated by healthcare providers in adulthood, to both proactively and responsively promote their safety, health, and well-being.

The perpetuating cycle of unplanned pregnancy: underlying causes and implications in Eswatini

Unplanned pregnancies constitute a major health problem globally carrying negative social, economic and health consequences for individuals and families. In this study, we explored the underlying causes and implications of this phenomenon in Eswatini, a country with high rates of unplanned pregnancy. Three focus group discussions were conducted in January 2018 with female health workers called mentor mothers, chosen because they offer a twofold perspective, being both Swati women and health workers in socially and economically disadvantaged settings. Using inductive thematic analysis, we identified five sub-themes and an overarching theme called 'the perpetuating cycle of unplanned pregnancy' in the data. A social-ecological model was used to frame the results, describing how factors at the individual, relationship, societal and community levels interact to influence unplanned pregnancy. In this setting, factors such as perceived low self-esteem as well as poor conditions in the community drove young women to engage in transactional relationships characterised by abuse, gender inequality and unprotected sex, resulting in unplanned pregnancy. These pregnancies led to neglected and abandoned children growing up to become vulnerable, young adults at risk of becoming pregnant unintendedly, thus creating an iterative cycle of unplanned childbearing.

Development and Validation of the Couple Sexual Satisfaction Scale for HIV and Sexual Health Research

Sexual satisfaction is an important dimension of relationship quality with implications for sexual and reproductive health (SRH), and HIV prevention, care, and treatment. We developed and validated the Couple Sexual Satisfaction Scale (CSSS) with heterosexual couples in sub-Saharan Africa. Using data from qualitative interviews with 94 partnered women and men in Swaziland and Malawi, we generated a 22-item scale and administered it to 211 couples with at least one partner living with HIV in Malawi. We performed an exploratory factor analysis (EFA) to identify and confirmatory factor analysis (CFA) to test the factor structure. To assess validity, we tested for associations between the CSSS and relationship quality, consistent condom use, and intimate partner violence (IPV) using generalized estimating equations. The EFA yielded two factors, general sexual satisfaction (13-item CSSS-Gen subscale, e.g., "I am satisfied with the sweetness of sex in our relationship") and HIV-specific sexual satisfaction (4-item CSSS-HIV subscale, e.g., "My appetite for sex has gone down due to HIV"), accounting for 78% of the shared variance. The CFA supported the two-factor solution: χ²(118) = 203.60; CFI = 0.909; SRMR = 0.057; RMSEA = 0.058. Participants with higher CSSS-Gen scores reported higher coital frequency and relationship quality (intimacy, trust, unity, equality, relationship satisfaction, commitment, partner social support), and less consistent condom use, physical IPV, and emotional IPV. Participants with higher CSSS-HIV scores reported higher coital frequency and relationship quality (trust, partner support), and less consistent condom use, and sexual IPV. The CSSS demonstrated good psychometric properties and provides new opportunities to study sexual reproductive health and HIV-related health behaviors among couples in sub-Saharan Africa.

Evaluating the implementation of the Reproductive Life Plan in disadvantaged communities: A mixed-methods study using the i-PARIHS framework

Introduction

The Reproductive Life Plan (RLP) is a clinical tool to help clients find strategies to achieve their reproductive goals. Despite much research on the RLP from high-income countries, it has never been studied in low- or middle income countries. Together with health workers called Mentor Mothers (MMs), we used a context-adapted RLP in disadvantaged areas in Eswatini. Our aim was to evaluate the implementation of the RLP in this setting.

Methodology

MMs participated in focus group discussions (FGDs, n = 3 MMs n = 29) in January 2018 and at follow-up in May 2018 (n = 4, MMs n = 24). FGDs covered challenges in using the RLP, how to adapt it, and later experiences from using it. We used a deductive qualitative thematic analysis with the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, creating themes guided by its four constructs: facilitation, innovation, recipients and context. The MMs also answered a questionnaire to assess the implementation process inspired by normalization process theory.

Results

The RLP intervention was feasible and acceptable among MMs and fit well with existing practices. The RLP questions were perceived as advantageous since they opened up discussions with clients and enabled reflection. All except one MM (n = 23) agreed or strongly agreed that they valued the effect the RLP has had on their work. Using the RLP, the MMs observed progress in pregnancy planning among their clients and thought it improved the quality of contraceptive counselling. The clients’ ability to form and achieve their reproductive goals was hampered by contextual factors such as intimate partner violence and women’s limited reproductive health and rights.

Discussion

The RLP was easily implemented in these disadvantaged communities and the MMs were key persons in this intervention. The RLP should be further evaluated among clients and suitable approaches to include partners are required.

Re-conceptualising gender and power relations for sexual and reproductive health: contrasting narratives of tradition, unity, and rights

Sexual and reproductive health interventions in sub-Saharan Africa will be most effective if grounded in emic (insider) perspectives of gender and power in intimate relationships. We conducted eight focus group discussions with 62 young adults in Malawi to explore conceptions of gender and power relations and areas of tension between different perspectives. We framed our enquiry according to the three social structures of the Theory of Gender and Power: the sexual division of labour, the sexual division of power, and social norms and affective attachments around femininity and masculinity. Young adults drew on interrelated and competing narratives to describe the state of gender relations, which we named tradition, unity, and rights. Participants used tradition narratives most frequently to describe patriarchal gender roles, norms and ideals. Some participants challenged this predominant discourse using unity and rights narratives. Unity narratives illustrated how love and couple reciprocity were essential sources of 'power with' as opposed to 'power over'. Rights narratives were more contested than other narratives, with some participants acknowledging that women's rights were important to the family's survival and others viewing women's rights as problematic for gender relations. Gender-responsive interventions should consider the tensions and intersections between multiple narratives on gender and power, including unity as a gender-equitable form of power.

Navigating intimate sexual partnerships in an era of HIV: dimensions of couple relationship quality and satisfaction among adults in Eswatini and linkages to HIV risk

Couple relationship functioning impacts individual health and well-being, including HIV risk, but scant research has focused on emic understandings of relationship quality in African populations. We explored relationship quality and satisfaction in Eswatini (formerly Swaziland) using data from 148 in-depth interviews (117 life-course interviews with 28 adults and 31 interviews with 29 marriage counselors and their clients) and 4 focus group discussions. Love, respect, honesty, trust, communication, sexual satisfaction, and sexual faithfulness emerged as the most salient characteristics of good relationships, with both men and women emphasising love and respect as being most important. Participants desired relationships characterised by such qualities but reported relationship threats in the areas of trust, honesty, and sexual faithfulness. The dimensions of relationship quality identified by this study are consistent with research from other contexts, suggesting cross-cultural similarities in conceptions of a good relationship. Some relationship constructs, particularly respect, may be more salient in a Swazi context.

Love matters: exploring conceptions of love in Rwanda and Swaziland and relationship to HIV and intimate partner violence

Health risks such as intimate partner violence (IPV) and HIV infection often occur within intimate sexual relationships, yet the study of love and intimacy is largely absent from health research on African populations. This study explores how women and men in Rwanda and Swaziland understand and represent love in their intimate sexual partnerships. In Rwanda, 58 in-depth interviews with 15 couples, 12 interviews with activists, and 24 focus group discussions were carried out during formative and evaluative research of the Indashyikirwa programme, which aims to reduce IPV and support healthy couple relationships. In Swaziland, 117 in-depth, life-course interviews with 14 women and 14 men focused on understanding intimate sexual partnerships. We analysed these qualitative data thematically using a Grounded Theory approach. Participants described love as being foundational to their intimate sexual partnerships. Women and men emphasised that love is seen and expressed through actions and tangible evidence such as gifts and material support, acts of service, showing intentions for marriage, sexual faithfulness, and spending time together. Some participants expressed ambivalent narratives regarding love, gifts, and money, acknowledging that they desired partners who demonstrated love through material support while implying that true love should be untainted by desires for wealth. IPV characterised many relationships and was perceived as a threat to love, even as love was seen as a potential antidote to IPV. Careful scholarship of love is critical to better understand protective and risk factors for HIV and IPV and for interventions that seek to ameliorate these risks.

Agency as a mediator in the pathway from transactional sex to HIV among pregnant women in Swaziland: a multigroup path analysis

Introduction: Transactional sex is a structural driver of HIV for women and girls in sub-Saharan Africa. In transactional relationships, sexual and economic obligations intertwine and may have positive and negative effects on women’s financial standing and social status. We conducted a clinic-based survey with pregnant women in Swaziland using a locally validated transactional sex scale to measure the association between subjective social status, transactional sex, and HIV status, and to assess whether this association differed according to a woman’s agency within her relationship.

Methods: We recruited a convenience sample of 406 pregnant women at one rural and one urban public antenatal clinic in Swaziland and administered a behavioural survey that was linked to participant HIV status using clinic records. We then conducted a multigroup path analysis to test three hypotheses: (1) that more engagement in transactional sex is associated with decreased condom use and increased subjective social status; (2) that subjective social status mediates the relationship between transactional sex and HIV status; and (3) that these relationships are different across groups according to whether or not a woman reported any indicator of constrained agency within her relationship.

Results: The amount and value of material goods received from a sexual partner was significantly and positively associated with higher subjective social status among all participants. As the amount of material goods received from a partner increased, women who reported no indicators of constrained agency were less likely to use condoms. Conversely, there was no relationship between transactional sex and condom use among women who reported any indicator of constrained relationship agency. Among women who reported any indicator of constrained agency, HIV was significantly associated with lower subjective social status.

Conclusions: Relationship agency likely plays a key role in determining which mechanisms create HIV risk for women in transactional relationships. Interventions to mitigate these risks must address social forces that penalize women who engage in sexual relationships as well as structural drivers of gendered economic disparity that reduce women’s agency within their sexual and romantic relationships.

'Behaving well': the transition to respectable womanhood in rural South Africa

Few studies of the transition to adulthood in Africa analyse young people's own definitions of the events that confer adult status, and how adulthood is actually attained. This paper examines the experience of transitioning to womanhood in rural Mpumalanga Province, South Africa, drawing on interviews with 18 women aged 18-39. Three primary experiences characterised this transition: puberty and emerging body awareness, spending time with boys, and having a child. More important than the timing of these experiences, however, was whether women 'behaved well' and maintained respectability as they transitioned to adulthood. Behavioural standards reinforcing ideal femininity were focused on dress, manner and talk, and were particularly stringent for mothers. Findings emphasise the value of emic models of adulthood for understanding how youth experience this transition and provide an important counter-narrative to the literature focused primarily on the risk African youth face during this period of change in the life course.

Using Qualitative Methods to Validate and Contextualize Quantitative Findings: A Case Study of Research on Sexual Behavior and Gender-Based Violence Among Young Swazi Women

Nesting qualitative data collection methods within quantitative studies improves results by assessing validity and providing depth and context. Using data from 3 sources from Swaziland, we triangulate qualitative and quantitative findings to highlight how different methodologies produce discrepant data regarding risky sexual behaviors among young women. We found that women reported similar numbers of lifetime sex partners in all sources, but the proportion reporting multiple and concurrent partnerships was several times higher in qualitative interviews. In addition, qualitative data can provide deeper understanding of how participants, such as those experiencing gender-based violence, understood the experiences behind the quantitative statistics.