The theory of masculinity in studies on HIV. A systematic review

Epidemiological Characteristics and Factors Associated with Repeat Sexually Transmitted Infections in Barcelona, Spain Over a Decade

In the last few years, the frequency of sexually transmitted infections (STI) has increased, as has the number of people with multiple infections. The aim of our study was to describe the epidemiological characteristics of persons with repeated bacterial STI and to determine the risk factors for these episodes in persons living in Barcelona during the period 2007-2018. We studied all cases of bacterial STI included in the STI registry of Barcelona. Repeated STI were defined as a diagnosis of gonorrhea, syphilis, or lymphogranuloma venereum (LGV) after a first episode of one of these infections. Analysis was stratified by sex and place of birth. The factors associated with time to reinfection were determined by Kaplan-Meier estimates, while the factors associated with risk of infection were determined by a Cox proportional hazards model. Of 9927 persons with a diagnosis of bacterial STI, 1690 (17.0%) had at least two episodes of STI during the study period. On multivariate analysis, repeat STI were independently associated with male sex assigned at birth (HR: 3.45; 95%CI 2.22-5.36), age less than 34 years (HR: 1.22; 95%CI 1.10-1.35); gay, bisexual, and other men who have sex with men, and transgender o transsexual woman (GBSMS/Trans) (HR: 4.03; 95%CI 3.24-5.03), having gonorrhea as first diagnosis (HR:1.49, 95%CI 1.34-1.66) or LGV (HR:1.75; 95%CI 1.47-2.08) and coinfection with HIV (HR:1.98; 95%CI 1.78-2.21). Sexual health programs should be strengthened to prevent STI and reinfection in key populations.

County-level variations in linkage to care among people newly diagnosed with HIV in South Carolina: A longitudinal analysis from 2010 to 2018

BACKGROUND

Timely linkage to care (LTC) is key in the HIV care continuum, as it enables people newly diagnosed with HIV (PNWH) to benefit from HIV treatment at the earliest stage. Previous studies have found LTC disparities by individual factors, but data are limited beyond the individual level, especially at the county level. This study examined the temporal and geographic variations of county-level LTC status across 46 counties in South Carolina (SC) from 2010 to 2018 and the association of county-level characteristics with LTC status.

METHODS

All adults newly diagnosed with HIV from 2010 to 2018 in SC were included in this study. County-level LTC status was defined as 1 = "high LTC (≥ yearly national LTC percentage)" and 0 = "low LTC (< yearly national LTC percentage)". A generalized estimating equation model with stepwise selection was employed to examine the relationship between 29 county-level characteristics and LTC status.

RESULTS

The number of counties with high LTC in SC decreased from 34 to 21 from 2010 to 2018. In the generalized estimating equation model, six out of 29 factors were significantly associated with LTC status. Counties with a higher percentage of males (OR = 0.07, 95%CI: 0.02~0.29) and persons with at least four years of college (OR = 0.07, 95%CI: 0.02~0.34) were less likely to have high LTC. However, counties with more mental health centers per PNWH (OR = 45.09, 95%CI: 6.81~298.55) were more likely to have high LTC.

CONCLUSIONS

Factors associated with demographic characteristics and healthcare resources contributed to the variations of LTC status at the county level. Interventions targeting increasing the accessibility to mental health facilities could help improve LTC.

Prevalence and risk factors for transactional sex among Swedish-born and foreign-born MSM in Sweden

BACKGROUND

Little is known about transactional sex (TS) (selling and buying sex) among men who have sex with men (MSM) in Sweden, especially among foreign-born MSM. This study aims to assess the prevalence and risk factors of TS (ever and in the previous five years) among MSM living in Sweden and to determine if there is a difference between Swedish-born MSM and foreign-born MSM.

METHODS

Swedish data from a multicountry online banner survey (EMIS-2017) was used (n = 4443). Multivariable regression analysis was applied to analyse the data.

RESULTS

The prevalence of ever-selling sex among all MSM participants was 13.2% and 5.9% in the previous five years. Selling sex ever and in the previous five years was higher among foreign-born MSM (16% and 8.4%, respectively) than Swedish-born MSM (12.7% and 5.4%, respectively). Among all participants, younger age (aOR:3.19, 95% CI:1.57-6.45) and really struggling to live on current income (aOR:3.37, 95% CI:2.29-4.96) increased the odds of selling sex. Being foreign-born MSM (aOR:1.33, 95% CI:1.02-1.73) and having had sex with a woman in the previous 12 months increased the odds of selling sex (aOR:1.44, 95% CI:1.00-2.07). The prevalence of ever buying sex among MSM participants in Sweden was 10.8% and 6.7% in the previous five years, with the same trend among foreign-born MSM (11.6% and 6.9%, respectively) and Swedish-born MSM (10.7% and 6.6%, respectively). Higher education and not having a current partner increased the odds of buying sex. Younger age was protective for buying sex (aOR:0.05, 95% CI:0.02-0.14). Among the foreign-born MSM, the length of stay in Sweden decreased the odds of buying sex (aOR: 0.98, 95% CI: 0.96-0.99).

CONCLUSIONS

The comparatively high prevalence of TS among MSM participants in Sweden, where buying sex is illegal, with a higher prevalence among foreign-born MSM participants, calls for sexual and reproductive health and rights interventions in this population. Increased attention, including HIV prevention programming and education, should be aimed at younger MSM, MSM struggling with their current income, and foreign-born MSM, as they are more likely to report selling sex.

"I think it's communication and trust and sharing everything": Qualitative evidence for a model of healthy intimate relationships in Black women living with HIV and men in KwaZulu-Natal, South Africa

In South Africa, couple-based interventions (CBIs) have been used to increase HIV testing, reduce HIV transmission, and shift relationship dynamics. To understand local definitions of healthy relationships, this study sought to collect qualitative data on a model of healthy relationships in a semi-rural area of KwaZulu-Natal, South Africa. We conducted semi-structured qualitative interviews with HIV-positive women (n = 15) and men of mixed HIV status (n = 15) who were in heterosexual, monogamous relationships (not with each other). Thematic analyses guided coding. Three primary healthy relationship behaviour themes emerged, labelled open communication, couple-level problem-solving, and active relationship building, which were related to various relationship facets (trust, support, respect, commitment, and connection). We purposively explored contextual themes, namely the role of HIV, positive community involvement, and power dynamics, to better situate the healthy relationship behaviour themes. HIV was not central to relationship conceptualisations and three different power structures (shared power/flexible gender norms, shared power/traditional gender norms, male-dominated power/traditional gender norms) were described as being healthy. This model of healthy relationships is similar to observed definitions in other African countries and in high-income settings. Findings can inform HIV programming content for couples in KwaZulu-Natal, particularly the active relationship building component.

De-problematizing masculinity among heterosexual African, Caribbean, and Black male youth and men

Objectives

The dominant discourse in literature often constructs heterosexual African, Caribbean, and Black (ACB) masculinity as inherently problematic and in need of “correction, repair, or rescue.” This discourse privileges hegemonic male standards and conceals the power relations that shape racialized masculinities. Our study of self-identified heterosexual ACB men and male youth examines how performative and perceptual attenuations of hegemonic masculinity can moderate social and behavioural vulnerabilities in the context of HIV prevention, transmission, and survival.

Methods

We used descriptive qualitative methods informed by community-based participatory research. Individual in-depth interviews and focus group discussions were conducted with 63 ACB men and male youth (aged 16 and above) residing in Ottawa, Canada, including community leaders, HIV service providers, and decision makers. The interviews were transcribed verbatim, and thematically analyzed with NVivo software. Member-checking, peer debriefing, and external audit ensured trustworthiness of data.

Results

ACB men and male youth define masculinity by their ability to provide for, protect, love, and lead their families. Within ACB cultures, men demonstrate their masculinity through their traditional role as family breadwinners, and are expected to be strong, bold, and responsible. This positive view of masculinity is potentially beneficial to the well-being of ACB men and male youth, and challenges mainstream notions of Black masculinity as uncontrolled, risky, toxic, or even predatory.

Conclusion

A positive view of masculinity among ACB heterosexual men and youth could support future practice and policy interventions aimed at strengthening community responses to HIV and health.

Gender Moderates Results of a Randomized Clinical Trial for the Khanya Intervention for Substance Use and ART Adherence in HIV Care in South Africa

Little is known about gender effects of alcohol and drug use (AOD) among people living with HIV (PLWH) in resource-limited settings. Using multilevel models, we tested whether gender moderated the effect of Khanya, a cognitive-behavioral therapy-based intervention addressing antiretroviral (ART) adherence and AOD reduction. We enrolled 61 participants from HIV care and examined outcomes at 3- and 6-months compared to enhanced treatment as usual (ETAU). Gender significantly moderated the effect of Khanya on ART adherence (measured using electronically-monitored and biomarker-confirmed adherence), such that women in Khanya had significantly lower ART adherence compared to men in Khanya; no gender differences were found for AOD outcomes. Exploratory trajectory analyses showed men in Khanya and both genders in ETAU had significant reductions in at least one AOD outcome; women in Khanya did not. More research is needed to understand whether a gender lens can support behavioral interventions for PLWH with AOD.

Trial registry ClinicalTrials.gov identifier: NCT03529409. Trial registered on May 18, 2018.

Self-Reported Anxiety in Spain: A Gendered Approach One Year After the Start of COVID-19 Pandemic

The COVID-19 pandemic has an impact on mental health. However, there is little evidence on how different axes of social inequity influence mental health from a gender perspective and over time. Our aim is to analyze anxiety according to gender identity and other axes of social inequities (migration status, sexual orientation, age, and employment conditions) one year after the start of the COVID-19 pandemic in Spain. We conducted a cross-sectional study among adults living in Spain with an online survey from April 8 to May 28, 2021. The main variable was anxiety measured by Generalized Anxiety Disorder Scale (GAD-7). Sex-stratified multivariate logistic regression models were constructed to assess the association between axes of inequities and anxiety. Our findings (N = 2,053) suggest that women have greater anxiety risk than men (35.2 vs. 28.2%, respectively). We observe in both genders that there is a clear age gradient, with anxiety decreasing as age increases; and that there is an association between worsening employment status and anxiety risk, although there is a difference between women by education level. Additionally, not having Spanish nationality is also associated with greater anxiety risk in women. In men, identifying as non-heterosexual is associated with a higher risk of anxiety. The axes of inequities have different effects according to gender identity. These differences in anxiety risk by population subgroup must be taken into account in order to sensibly and equitably treat the surge in mental health disorders brought on by the COVID-19 pandemic.

Sex differences in HIV testing among elders in Sub-Saharan Africa: a systematic review protocol

BACKGROUND

Elders (age 50+) HIV demographic (age and sex) data are essential to better understand their HIV service utilization and develop appropriate evidence-based responses and policies. Despite a significant prevalence rate of HIV and growing numbers of this population group, data are still scarce, and studies have neglected them in Sub-Saharan Africa. The aim of this protocol is to outline the methodological process of a systematic review that will gather qualitative and quantitative data to critically examine sex differences in HIV testing among elders (age 50+) in Sub-Saharan Africa.

METHODS

This protocol adheres to the PRISMA-P reporting guidelines. We will conduct a systematic database search to retrieve all observational and qualitative studies. Electronic search strategies will be developed for MEDLINE, EMBASE, Web of Science, Global Health, and CINAHL for studies reporting HIV data. Two reviewers will independently screen all citations, full-text articles, and abstract data. The search strategy will consist of free-text and Medical Subject Headings (MeSH) terms. Search terms for elders (50+) will include the following: "elders", "older adults", "aged", "geriatric" and "seniors". The primary outcome of interest is sex differences in the uptake of HIV counselling and testing (HCT). The study methodological quality (or bias) will be appraised using appropriate tools. Screening, data extraction, and assessments of risk of bias will be performed independently by two reviewers. Narrative synthesis will be conducted with studies that are compatible based on population and outcome. As it will be a systematic review, without human participants' involvement, there will be no requirement for ethical approval.

DISCUSSION

The systematic review will present key evidence on sex differences in HIV testing among elders in Sub-Saharan Africa. The findings will be used to inform program developers, policymakers, and other stakeholders to enhance sex disaggregated HIV data to improve access to HIV counselling and testing service for elders in Sub-Saharan Africa. The final manuscript will be disseminated through a peer-reviewed journal and scientific conferences.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42020172737 .

Attitudes Toward Gender-Based Violence Among Sexually Active Adult Men at High Risk for HIV in Rustenburg, South Africa

Gender-based violence (GBV) toward women is widespread and has been associated with increased HIV risk. We investigated attitudes toward GBV among men living in Rustenburg, South Africa, who were enrolled in a longitudinal HIV incidence study. Participants were 18 to 49 years old, reported high risk sexual activity in the last 3 months, and were HIV-uninfected. Attitudes toward GBV were evaluated using responses to a five-item standardized questionnaire about men perpetrating physical violence on a female spouse; responses to each item were scaled from 1 (no agreement) to 4 (strong agreement) and summed. Total scores >10 were considered permissive toward GBV. Among the 535 men analyzed, nearly half (N = 229, 42.8%) had a GBV score >10. Being young (18-24 years) (adjusted odds ratio [aOR] = 1.53, 95% confidence interval [CI] [1.06, 2.22]), having less years of education (aOR = 1.61, 95% CI [1.11, 2.32]), and reporting no current sexual partner at baseline (aOR = 2.10, 95% CI [1.06, 4.14]) were independently associated with permissive attitudes toward GBV. The following behaviors reported in the last 3 months were also associated with high GBV scores: having a new female partner (aOR = 1.78, 95% CI [1.02, 3.10]), and having had an STI (aOR = 1.85, 95% CI [1.15, 2.99]). Consuming alcohol prior to sex in the last month (aOR = 1.59, 95% CI [1.09, 2.31]) was also associated with high GBV scores. A large proportion of South African HIV-uninfected men in this analysis reported permissive attitudes toward GBV. These attitudes were associated with HIV risk behavior. Integrating GBV and HIV prevention programs is essential.

Clinical progression of COVID-19 coinfection in people living with the human immunodeficiency virus: scoping review

OBJECTIVES

to map the production of scientific knowledge on the clinical progression of COVID-19 coinfection in people living with the human immunodeficiency virus (HIV).

METHODS

scoping review, with search strategies in MEDLINE, Scopus, Embase, Web of Science, and LILACS. Dual independent data extraction and analysis of the material with similarity compilation and narrative synthesis.

RESULTS

sample consisted of 35 articles. Fever, cough, and dyspnea were the most prevalent signs/symptoms. Recurrent complications involved desaturation/worsening of oxygen desaturation and pneumonia. No standard pharmacological treatment was identified, and the main interventions involved the provision of supplemental oxygen and mechanical ventilation. The studies recommended preventive, care, and pharmacological practices.

CONCLUSIONS

the clinical manifestations, complications, and treatments/assistance care for people coinfected with SARS CoV-2/HIV are similar to those of the general population. Coinfection, overall, does not infer a worse prognosis.

Identifying "What Matters Most" to Men in Botswana to Promote Resistance to HIV-Related Stigma

Despite a comprehensive national program of free HIV services, men living with HIV in Botswana participate at lower rates and have worse outcomes than women. Directed content analysis of five focus groups (n = 38) and 50 in-depth interviews with men and women with known and unknown HIV status in Gaborone, Botswana in 2017 used the "what matters most" (WMM) and "structural vulnerability" frameworks to examine how the most valued cultural aspects of manhood interact with HIV-related stigma. WMM for manhood in Botswana included fulfilling male responsibilities by being a capable provider and maintaining social status. Being identified with HIV threatened WMM, which fear of employment discrimination could further exacerbate. Our findings indicate how cultural and structural forces interact to worsen or mitigate HIV-related stigma for urban men in Botswana. These threats to manhood deter HIV testing and treatment, but interventions could capitalize on cultural capabilities for manhood to promote stigma resistance.

Exploring new tendencies of gender and health in university students

In light of the impact of gender roles on health, the aims of the present study are (1) to assess the associations between femininity/masculinity and gender typologies, and health indicators (mental health, wellbeing, and self-perceived health) and (2) to identify patterns of gender roles and health indicators, thus exploring new tendencies in gender and health in Spanish university students in the framework of the androgyny model. The sample was made up of 795 university students from Madrid and Toledo. Data collection was completed during 2019. Measures of self-rated health, mental health (GHQ12), and wellbeing (MHC-SF) were considered as health indicators, while the Bem Sex Roles Inventory (BSRI) was used to measure gender roles. Multilevel analysis was employed to value associations between masculinity and femininity and gender typologies with self-rated health, mental health, and wellbeing. Furthermore, cluster analysis was used to explore general tendencies in gender roles and health, while also considering biological sex composition. The best predictor of mental health was found to be masculinity, rather than femininity. Cluster analysis showed a dominance of androgyny and undifferentiated typologies with proportionally similar biological sex composition. Results confirmed the androgyny model, highlighting the role of androgyny and masculinity as protective factors of mental health. Cluster analysis suggested less gender-typed individuals and more flexible ways of adapting to gender roles in university students. Health systems, governments, and public institutions must take these results into account when designing health prevention and intervention policies. Social agents, educators, and the media must also collaborate in the achievement of equalitarian gender roles, which could result in a minimization of gender-related health differences.

Ten-year attrition and antiretroviral therapy response among HIV-positive adults: a sex-based cohort analysis from eight West African countries

INTRODUCTION

Sex differences have already been reported in sub-Saharan Africa for attrition and immunological response after antiretroviral therapy (ART) initiation, but follow-up was usually limited to the first two to three years after ART initiation. We evaluated sex differences on the same outcomes in the 10 years following ART initiation in West African adults.

METHODS

We used cohort data of patients included in the IeDEA West Africa collaboration, who initiated ART between 2002 and 2014. We modelled no-follow-up and 10-year attrition risks, and immunological response by sex using logistic regression analysis, survival analysis with random effect and linear mixed models respectively.

RESULTS

A total of 71,283 patients (65.8% women) contributed to 310,007 person-years of follow-up in 16 clinics in eight West African countries. The cumulative attrition incidence at 10-year after ART initiation reached 75% and 68% for men and women respectively. Being male was associated with an increased risk of no follow-up after starting ART (5.1% vs. 4.0%, adjusted Odds Ratio: 1.25 [95% CI: 1.15 to 1.35]) and of 10-year attrition throughout the 10-year period following ART initiation: adjusted Hazard Ratios were 1.22 [95% CI: 1.17 to 1.27], 1.08 [95% CI: 1.04 to 1.12] and 1.04 [95% CI: 1.01 to 1.08] during year 1, years 2 to 4 and 5 to 10 respectively. A better immunological response was achieved by women than men: monthly CD4 gain was 30.2 and 28.3 cells/mL in the first four months and 2.6 and 1.9 cells/μL thereafter. Ultimately, women reached the average threshold of 500 CD4 cells/μL in their sixth year of follow-up, whereas men failed to reach it even at the end of the 10-year follow-up period. The proportion of patients reaching the threshold was much higher in women than in men after 10 years since ART initiation (65% vs. 44%).

CONCLUSIONS

In West Africa, attrition is unacceptably high in both sexes. Men are more vulnerable than women on both attrition and immunological response to ART in the 10 years following ART initiation. Innovative tracing strategies that are sex-adapted are needed for patients in care to monitor attrition, detect early high-risk groups so that they can stay in care with a durably controlled infection.

'Too old to test?': A life course approach to HIV-related risk and self-testing among midlife-older adults in Malawi

BACKGROUND

Despite the aging HIV epidemic, increasing age can be associated with hesitancy to test. Addressing this gap is a critical policy concern and highlights the urgent need to identify the underlying factors, to improve knowledge of HIV-related risks as well as uptake of HIV testing and prevention services, in midlife-older adults.

METHODS

We conducted five focus group discussions and 12 in-depth interviews between April 2013 and November 2016 among rural and urban Malawian midlife-older (≥30 years) men and women. Using a life-course theoretical framework we explored how age is enacted socially and its implications on HIV testing and sexual risk behaviours. We also explore the potential for HIV self-testing (HIVST) to be part of a broader strategy for engaging midlife-older adults in HIV testing, prevention and care. Thematic analysis was used to identify recurrent themes and variations.

RESULTS

Midlife-older adults (30-74 years of age) associated their age with respectability and identified HIV as "a disease of youth" that would not affect them, with age protecting them against infidelity and sexual risk-taking. HIV testing was felt to be stigmatizing, challenging age norms, threatening social status, and implying "lack of wisdom". These norms drove self-testing preferences at home or other locations deemed age and gender appropriate. Awareness of the potential for long-standing undiagnosed HIV to be carried forward from past relationships was minimal, as was understanding of treatment-as-prevention. These norms led to HIV testing being perceived as a threat to status by older adults, contributing to low levels of recent HIV testing compared to younger adults.

CONCLUSIONS

Characteristics associated with age-gender norms and social position encourage self-testing but drive poor HIV-risk perception and unacceptability of conventional HIV testing in midlife-older adults. There is an urgent need to provide targeted messages and services more appropriate to midlife-older adults in sub-Saharan Africa. HIVST which has often been highlighted as a tool for reaching young people, may be a valuable tool for engaging midlife-older age groups who may not otherwise test.

Provider love in an informal settlement: Men's relationships with providing women and implications for HIV in Kampala, Uganda

Uganda has made progress in controlling the HIV epidemic since it first emerged in the 1980s. While new infections in the country are higher among women, men in urban areas face a higher risk of AIDS-related mortality due to starting treatment later and taking medication inconsistently. While gender analyses have been used to describe women's HIV vulnerability, less is known about how masculinity, and especially different forms of masculinity, affect men's vulnerability. This study reports on data from an ethnography (2016-2019) with low-income men in urban Uganda. This study uses gender and power theory to describe how men's relationships with female sex workers in an informal settlement in urban Kampala, Uganda are characterized by female providers ("provider love") and male dependents. Young men in this sample, largely jobless, rely on their relationships for daily survival. As gender roles reverse, young men find themselves unable to attain masculine ideals as expected of Baganda men. Instead, men in this sample face less power in their relationships, a loss of masculine respectability, and diminished reputations in the community. These intersections of gender, economic struggle, power, and intimacy reconfigure men's HIV vulnerability in this setting. Public health programming on HIV/AIDS for men should consider different patterns of masculinity, power, and economic struggle and how they impact HIV outcomes.

Gender-based approach on the social impact and mental health in Spain during COVID-19 lockdown: a cross-sectional study

OBJECTIVE

Lockdown has impacts on people's living conditions and mental health. The study aims to assess the relations between social impact and mental health among adults living in Spain during COVID-19 lockdown measures, taking a gender-based approach into account.

DESIGN, SETTING AND PARTICIPANTS

We conducted a cross-sectional study among adults living in Spain during the lockdown of COVID-19 with an online survey from 8 April to 28 May 2020. The main variable was mental health measured by Generalized Anxiety Disorder Scale for anxiety and the Patient Health Questionnaire for depression. Sex-stratified multivariate ordinal logistic regression models were constructed to assess the association between social impact variables, anxiety and depression.

RESULTS

A total of 7053 people completed this survey. A total of 31.2% of women and 17.7% of men reported anxiety. Depression levels were reported in 28.5% of women and 16.7% of men. A higher proportion of anxiety and depression levels was found in the younger population (18-35 years), especially in women. Poorer mental health was mainly related to fear of COVID-19 infection, with higher anxiety levels especially in women (adjusted ordinal OR (aOR): 4.23, 95% CI 3.68 to 4.87) and worsened economy with higher levels of depression in women (aOR: 1.51, 95% CI 1.24 to 1.84), and perceived inadequate housing to cope with lockdown was especially associated with anxiety in men (aOR: 2.53, 95% CI 1.93 to 3.44).

CONCLUSION

The social impact of the lockdown is related to gender, age and socioeconomic conditions. Women and young people had worse mental health outcomes during lockdown. It is urgent to establish strategies for public health emergencies that include mental health and its determinants, taking a gender-based approach into account, in order to reduce health inequities.