Reframing research on sexual behavior and HIV

In Their Own Voices

This study qualitatively examines the intersections of risk for intimate partner violence (IPV) and HIV infection in South Africa. Eighteen women seeking services for relationship violence were asked semistructured questions regarding their abusive experiences and HIV risk. Participants had experienced myriad forms of abuse, which reinforced each other to create a climate that sustained abuse and multiplied HIV risk. Male partners having multiple concurrent sexual relationships, and poor relationship communication compounded female vulnerability to HIV and abuse. A social environment of silence, male power, and economic constraints enabled abuse to continue. “Breaking the silence” and women's empowerment were suggested solutions.

Assessing base rates of sexual behavior using the unmatched count technique

Estimating the prevalence of sexual behaviors is difficult because of self-report biases. This is particularly relevant in assessing high-risk sexual behaviors for the purpose of reducing the transmission and acquisition of sexually transmitted infections (STIs) and HIV/AIDS. The present study employed the unmatched count technique (UCT), which provides estimates of the prevalence of risky sexual behaviors without requiring participants to confess to socially undesirable or stigmatized behaviors. Compared to a standard, anonymous self-report questionnaire, the UCT protocol revealed that people were less likely to notify their partners about STIs or discuss their history of sexual experiences. Effects were particularly large in women suggesting that women may be more likely to misrepresent their sexual behaviors. The findings suggest that conventional, anonymous self-report questionnaire data of base rates of risky sexual behavior and sexual communication are consistently inaccurate. These discrepant base rates suggest that the UCT might provide a better estimate of the frequency of these behaviors. Results suggest that inconsistent sexual behavior is more rampant than anonymous questionnaires suggest. They also underscore the need for improvements in the anonymity of assessment of sexual behaviors, which could in turn improve the targeting of prevention efforts. Results have important public health implications because accurate assessment of sexual behaviors is crucial for developing effective STI prevention interventions among target populations.

Effectiveness of a community-based positive prevention intervention for people living with HIV who are not receiving antiretroviral treatment: a prospective cohort study

In Mombasa, Kenya, a community-based HIV risk-reduction intervention effectively reached people living with HIV who were not receiving antiretroviral treatment (ART)—a difficult-to-reach population because they often fall outside the ambit of health care services—and succeeded in reducing reported risky sex behavior and increasing ART uptake.

Background: We report effectiveness of an HIV-prevention intervention delivered by community health workers (CHWs) in Mombasa, Kenya, to PLHIV who have not initiated or who have discontinued ART—an often difficult-to-reach population because they fall outside the ambit of health care and prevention services.

Methods: A 2-arm cohort study assessed a structured risk-reduction intervention involving at least 4 one-to-one counseling sessions and personalized support. The control group received standard prevention services. CHWs recruited treatment-naïve people living with HIV (PLHIV) or those who had previously taken antiretroviral drugs. Data were analyzed using a Propensity Score Matched (PSM)-sample to control for baseline differences between the groups.

Results: 634 PLHIV were recruited and followed for 6 months. Median age was 35 years, and 74.3% were female. Participants in the intervention group reported reduced risky sexual behaviors both at endline compared with baseline and compared with the control group. At endline, in the PSM analysis, participants in the intervention arm were less likely than participants in the control group to report unprotected sex with a spouse (Odds Ratio [OR] = 0.08, 95% confidence interval [CI] = 0.03-0.24), and they reported fewer unprotected sex acts (12.3% versus 46.0%, respectively; OR = 0.16, 95% CI = 0.09-0.29; P<0.001). Further, 92.4% of participants in the intervention group reported zero unsafe sex acts (with partners of negative or unknown HIV status) compared with 70.8% in the control group (P<0.001), and more participants in the intervention arm were receiving ART (34.3% versus 12.7%, respectively; P<0.001).

Conclusion: CHWs effectively reached PLHIV who had never received or who had discontinued ART, and they delivered a risk-reduction intervention that led to declines in reported sexual risk behaviors, as well as to increases in ART uptake. A scaled-up intervention warrants consideration.

Measuring gender and reproductive health in Africa using demographic and health surveys: the need for mixed-methods research

Understanding gender in Africa is essential to creating policy and designing interventions to address key reproductive-health issues such as HIV/AIDS and maternal mortality that are particularly pressing for the continent and are strongly related to gender inequality. The addition of questions to capture women's empowerment and autonomy on the MEASURE/Demographic and Health Surveys (DHS) in the late-1990s expanded opportunities to examine the relationship between gender and reproductive health. These questions provide valuable information on trends and individual-level associations between gender inequality and health. Given that women's empowerment, status and autonomy are largely dependent on contextually-specific gender systems, however, supplementary qualitative studies to validate and contextualise these data would strengthen analyses significantly. This paper provides examples of how such mixed-methods work would improve understandings of gender and reproductive health in Africa by validating survey questions, providing insights into how to analyse and interpret DHS data and illuminating the processes and mechanisms behind gendered experiences. Additionally, this work could help improve future survey research on gender and reproductive health.

Lifting the curtain on the conditions of sexual initiation among youth in Ethiopia

PURPOSE

Deriving accurate estimates of the level of sexual coercion is challenging because of the stigma that is attached to the experience. This study examines the effectiveness of a nonverbal response-card method to reduce social desirability bias in reports of the conditions of sexual initiation among youth in southwestern Ethiopia.

METHODS

The conditions surrounding sexual initiation are examined using data from a pilot survey and a final survey of youth aged 13-24 years. Half of the respondents in each survey were randomly assigned to a nonverbal response-card method for sensitive questions on sexual attitudes and behavior, and the other half of the respondents were assigned to a control group that provided verbal responses. Responses for the two groups to questions regarding the conditions of sexual initiation are compared.

RESULTS

Respondents who used the nonverbal response card were more likely to report pressure from friends or a partner, having sex for money or another gain, and rape as conditions of sexual initiation than those who provided verbal responses. Among sexually experienced youth, 29.3% of respondents who used the card method reported some form of coercion during sexual initiation compared with 19.4% of respondents who gave verbal responses.

CONCLUSIONS

The nonverbal response card provides an effective method for reducing social desirability bias when soliciting responses to sensitive questions in the context of an interviewer-administered survey. The analysis also suggests that coerced sexual initiation is underreported by youth in interviewer-administered surveys that use conventional verbal responses.

Sexual behavior of HIV-positive adults not accessing HIV treatment in Mombasa, Kenya: Defining their prevention needs

BACKGROUND

HIV spread continues at high rates from infected persons to their sexual partners. In 2009, an estimated 2.6 million new infections occurred globally. People living with HIV (PLHIV) receiving treatment are in contact with health workers and therefore exposed to prevention messages. By contrast, PLHIV not receiving ART often fall outside the ambit of prevention programs. There is little information on their sexual risk behaviors. This study in Mombasa Kenya therefore explored sexual behaviors of PLHIV not receiving any HIV treatment.

RESULTS

Using modified targeted snowball sampling, 698 PLHIV were recruited through community health workers and HIV-positive peer counsellors. Of the 59.2% sexually-active PLHIV, 24.5% reported multiple sexual partners. Of all sexual partners, 10.2% were HIV negative, while 74.5% were of unknown HIV status. Overall, unprotected sex occurred in 52% of sexual partnerships; notably with 32% of HIV-negative partners and 54% of partners of unknown HIV status in the last 6 months. Multivariate analysis, controlling for intra-client clustering, showed non-disclosure of HIV status (AOR: 2.38, 95%CI: 1.47-3.84, p < 0.001); experiencing moderate levels of perceived stigma (AOR: 2.94, 95%CI: 1.50-5.75, p = 0.002); and believing condoms reduce sexual pleasure (AOR: 2.81, 95%CI: 1.60-4.91, p < 0.001) were independently associated with unsafe sex. Unsafe sex was also higher in those using contraceptive methods other than condoms (AOR: 5.47, 95%CI: 2.57-11.65, p < 0.001); or no method (AOR: 3.99, 95%CI: 2.06-7.75, p < 0.001), compared to condom users.

CONCLUSIONS

High-risk sexual behaviors are common among PLHIV not accessing treatment services, raising the risk of HIV transmission to discordant partners. This population can be identified and reached in the community. Prevention programs need to urgently bring this population into the ambit of prevention and care services. Moreover, beginning HIV treatment earlier might assist in bringing this group into contact with providers and HIV prevention services, and in reducing risk behaviors.

Superstition, witchcraft and HIV prevention in sub-Saharan Africa: the case of Ghana

Belief in superstition and witchcraft is central to many African conceptions of illness, disease causation and etiology. While a number of anthropological studies have alluded to a theoretical link between such beliefs and HIV prevention in particular, there is limited empirical assessment of the association. Using data from the 2008 Ghana Demographic and Health Survey and applying random-effects logit models, we investigate whether the belief that AIDS can spread through witchcraft associates with the sexual decision making of never-married men and women. The results show that men who believed AIDS can spread through witchcraft and other supernatural means were less likely to have used condoms at last sexual intercourse, controlling for other socioeconomic and cultural variables. Women with similar beliefs were more likely to have experienced sexual intercourse but less likely to have used condoms at last sex. For women, however, the relationship between such superstitious beliefs and condom use was somewhat attenuated after controlling for ethnicity and region of residence. From a policy perspective, the findings suggest that local beliefs regarding AIDS causation must be considered in designing HIV/AIDS programmes and interventions.

Making sense of abstinence: social representations in young Africans' HIV-related narratives from six countries

Despite the prominence of abstinence promotion in HIV prevention for young Africans, there is little documentation concerning its reception and interpretation. With the purpose of informing programmatic practice, we examined how young Africans from six countries with contrasting HIV prevalence rates make sense of abstinence. 'Scenarios from Africa' scriptwriting contests invite young people to contribute ideas for short films about HIV. Using thematic narrative-based approaches, we analyzed a stratified random sample of these narratives written in 2005 by young women and men aged 10-24 years from Senegal, Burkina Faso, South-East Nigeria, Kenya, Namibia and Swaziland. Abstinence was considerably more prominent as a theme in the samples from SE Nigeria, Kenya and Swaziland. It was articulated in relation to conservative Christian sexual morality and in opposition to condom use with particular intensity in SE Nigeria, with stigmatising implications for non-abstainers. However, cross-national commonalities were more striking than differences. Examples of non-stigmatising pro-abstinence messaging highlighted the appeal of discourses of romantic love and future plans across countries and demographic characteristics. The analysis yielded contextual understanding, youth-driven ideas and recommendations to inform comprehensive HIV-prevention efforts.

Reporting on first sexual experience: The importance of interviewer-respondent interaction

Survey methodologists typically seek to improve data on sensitive topics by standardizing surveys and avoiding the use of human interviewers. This study uses data collected from 90 never-married young adults in rural Malawi to compare reports on first sexual encounters between a standard survey and an in-depth interview. A significant fraction of young women who claimed in the survey to have never been sexually active affirmed sexual experience during the in-depth interview, fielded shortly thereafter. Two elements of the in-depth interview, flexibility and reciprocal exchange, foster trust and more truthful reporting. The findings contradict the long-standing presumption that face-to-face interviews are inherently threatening when the topic is sex.

Gender and HIV testing in Burkina Faso: an exploratory study

This study investigated the utilization of services around HIV testing in Burkina Faso through a survey that combined quantitative and qualitative data from 14 selected sites and 299 questionnaires. While some attitudes and behaviors towards HIV testing were similar for women and men, we found lower use of services by men, greater concerns about testing and disclosure on the part of women, and differences between men and women in motivations to test, and the experience of testing and its consequences. The results are discussed in the context of Burkina Faso and in terms of their implications for efforts to improve access to services around HIV.

How young is "too young"? Comparative perspectives on adolescent sexual, marital, and reproductive transitions

This study puts forth three criteria for assessing the extent to which the timing of sexual, marital, and reproductive transitions among male and female adolescents could be considered "too young": (1) the physiological maturation of the body; (2) the cognitive capacity for making safe, informed, and voluntary decisions; and (3) institutionalized concepts of "old enough" for consent to sexual intercourse and marriage as reflected in legal frameworks and international standards. Expansion of the age grouping of adolescence is proposed, from the customary 15-19 into three age categories--early adolescence (ages 10-14, or 10-11 and 12-14), middle adolescence (15-17), and late adolescence (18-19)--to better capture the age-specific variations in the trajectories of male and female sexual, marital, and reproductive events. An application of the three adolescent development criteria to the timing of transitions observed in Demographic and Health Surveys in 64 developing countries leads to the conclusion that boys and girls aged 14 and younger are universally "too young" to make safe and consensual transitions; that 15-17-year-olds may or may not be too young, depending on their circumstances; and that 18-year-olds are generally "old enough." Policies and programs should focus on capacity building and the creation of an enabling environment for making safe and voluntary transitions among all age groups, but particularly among 10-14-year-olds, whose sexual and reproductive health and rights are so clearly at stake.

Starting young: sexual initiation and HIV prevention in early adolescence

The rising numbers of new HIV infections among young people ages 15-24 in many developing countries, especially among young women, signal an urgent need to identify and respond programmatically to behaviors and situations that contribute to the spread of HIV and other sexually transmitted infections in early adolescence. Quantitative and qualitative studies of the sexual knowledge and practices of adolescents age 14 and younger reveal that substantial numbers of boys and girls in many countries engage in unprotected heterosexual vaginal intercourse--by choice or coercion--before their 15th birthdays. Early initiation into male-male or male-female oral and/or anal sex is also documented in some populations. Educational, health, and social programs must reach 10-14-year-olds as well as older adolescents with the information, skills, services, and supplies (condoms, contraceptives) they need to negotiate their own protection from unwanted and/or unsafe sexual practices and to respect the rights of others.

Young people's sexual partnerships in KwaZulu-Natal, South Africa: patterns, contextual influences, and HIV risk

Certain sexual partnering practices, such as multiple, concurrent, or age-discrepant partnerships, are known to increase HIV risk. Yet the underlying dynamics of young people's relationships are less clearly understood. Using household survey and qualitative data, this study examines partnership dynamics and characteristics in the context of HIV risk, including number of partners, age differences, partnership duration and concurrency, and frequency of contact among young people aged 15-24 in rural KwaZulu-Natal, South Africa. One-third of the men surveyed reported multiple and/or concurrent partnering, and one-fourth of the women had partners who were five years older than they were. Nonparticipation in civic organizations or school was correlated with higher-risk partnerships for women but not for men. On average, relationships lasted more than a year for the women and men surveyed, and were frequently characterized as "serious." Qualitative findings pointed to the sequential and overlapping nature of relationships, however, with distance and mobility being important influences. These fluid partnership patterns are an important feature of young people's sexual risk in the context of South Africa's severe HIV epidemic.

Sexual risk behaviour and HAART: a comparative study of HIV-infected persons on HAART and on preventive therapy in Kenya

Unprotected sex (UPS) among persons receiving highly active antiretroviral therapy (HAART) remains a concern because of the risk of HIV-transmission. A cross-sectional study comparing the sexual risk behaviour of 179 people living with HIV/AIDS (PLHA) receiving HAART with that of 143 PLHA receiving preventive therapy (PT) with cotrimoxazole/isoniazid was conducted in Mombasa, Kenya. Forty-five percent of all participants were sexually active in the last six months. Participants receiving PT were more likely to report > or =2 partners (13% vs.1%; P = 0.006). Participants receiving PT reported more UPS with regular partners (odds ratio [OR]: 3.9; 95% confidence interval [CI]: 1.8-8.4) and also more sexually transmitted infections (STI) symptoms (OR: 1.7; 95% CI: 1.0-2.8; P = 0.059). More than 40% of all participants did not know the HIV-status of regular partners. Therefore, HAART was not associated with increased sexual risk behaviours though considerable risk of HIV-transmission remains. HIV-care services need to emphasize partner testing and consistent condom use with all partners.

The sexual ethics of HIV testing and the rights and responsibilities of partners

The discourse of much of the international AIDS community champions the rights of individuals in low-income countries to "just say no" to routine HIV testing in health-care settings and, if tested and found positive, not to inform their sexual partner(s) if such disclosure could result in substantial personal harm. This study contends that the right of individuals to refuse testing ignores the right of their sexual partners--male or female, regular or casual--to be informed of the health risks to which they may be exposed on entering or continuing a sexual relationship or engaging in particular sexual acts. If, as the UN has declared, all persons have the right to decide freely and responsibly on matters relating to their sexuality, including their sexual and reproductive health, free from coercion, discrimination, and violence, then all persons have the right and the responsibility to know their own and their partner's serostatus and to protect themselves and their partner(s) from sexually transmitted infections (STIs). Support by AIDS activists for policies of routine STI/HIV testing, counseling, and disclosure between both partners in a sexual relationship would help to promote an ethic of equal rights and shared responsibility for sexual behavior and its consequences.

The 100% Condom Use Program: a demonstration in Wuhan, China

The 100% Condom Use Program (100% CUP) was evaluated in Wuhan, China. The program sought to increase knowledge of STI/HIV transmission, increase condom use rates, and reduce the prevalence of sexually transmitted infections (STIs) among sex workers (commercial sex workers (CSWs)), via condom availability and use policies in entertainment establishments and STI services including education and counseling. Entertainment establishment owners and CSWs participated in educational sessions and multiple community sectors were involved in the program. At baseline, 170 female CSWs were assessed, and 102 CSWs were assessed at the final 21-month follow-up. At 6-month follow-up, 95% of entertainment establishments were in compliance with 100% CUP policies. At 15 months, condoms were readily available in retail outlets, and condom use rates rose by 94.5%. Refractive rates of chlamydia and methodological limitations of the evaluation leave unanswered questions about the effectiveness of the program. Nonetheless, outcomes suggest that the 100% CUP may be a promising approach to HIV prevention in China.

Perceived risks and benefits of sex work among transgender women of color in San Francisco

Prior research has shown that male-to-female (MTF) transgender women of color in the United States have a high rate of HIV infection and often engage in sex work for economic survival. With the exception of studies on HIV prevalence and behavioral risk, little research exists to elucidate the social context and determinants of sex work and related health risks among these women. Through a qualitative analysis of seven focus groups with 48 transgender women of color, we examined why and how participants became involved in sex work, documented risks associated with sex work, and explored what motivated participants to remain in sex work. Participants reported on how social networks and cultural norms, immigration issues, and experiences of racism, sexism, and transphobia influenced their decisions to enter and the risks encountered in sex work. Findings revealed that transgender women of color who engage in sex work have unique needs and experiences that must be addressed through structural and social network-based interventions to minimize their vulnerability to social and public health harms.

The utilization of testing and counseling for HIV: a review of the social and behavioral evidence

Against the background of debates about expanding HIV testing and counseling, we summarize the evidence on the social and behavioral dimension of testing and its implications for programs. The discrepancy between acceptance of testing and returning for results and the difficulties of disclosure are examined in light of research on risk perceptions and the influence of gender and stigma. We also summarize the evidence on the provision of testing and counseling, the implementation of practices regarding confidentiality and consent, and the results of interventions. We demonstrate that social factors have a considerable impact on testing, show that the services linked to testing are key determinants of utilization, and consider the implications of these findings for HIV testing programs.

Assisting or compromising intervention? The concept of 'culture' in biomedical and social research on HIV/AIDS

This paper addresses how the notion of 'culture' has been understood and employed by both epidemiologists and anthropologists with respect to the literature on HIV/AIDS in Sub-Saharan Africa. It examines the shift towards non-biomedical understandings of the epidemic. The concept of 'culture' has been 'bandied about' [Schoepf, B.G. (2004). AIDS, history and struggles over meaning. In E. Kalipeni, S. Craddock, J.R. Oppong, & J. Ghosh (Eds.), HIV and AIDS in Africa: Beyond epidemiology. Oxford: Blackwell.], and yet no authors in the literature reviewed here attempt a more systematic account of the 'bandying about' itself. This paper thus attempts to address and close this gap. For biomedical researchers and epidemiologists, broadly speaking, 'culture' appears to compromise intervention, whilst for medical anthropologists, 'culture' is often seen as having the potential to assist intervention. 'Culture' comes to be multifaceted and laden with varying assumptions, which range from 'culture' being bounded and timeless, to 'culture' being linked to macro-processes, historically shaped, and contested. In turn, 'culture' has variously been understood as both the cause of, and solution to, the epidemic. It is also understood as having structured local interpretations of, and responses to, the epidemic. At the same time as noting the apparent dichotomy between the biomedical and social approaches, however, the models may inadvertently share certain assumptions about 'culture' as an essentializing signifier of difference. To this extent HIV/AIDS research could be improved by incorporating wider anthropological debates about the problems of the 'culture' concept.