Variations in condom use by type of partner in 13 sub-Saharan African countries

Development and calibration of a mathematical model of HIV outcomes among Rwandan adults: informing equitable achievement of targets in Rwanda

Background

We developed and calibrated the Central Africa-International epidemiology Databases to Evaluate AIDS (CA-IeDEA) HIV policy model to inform equitable achievement of global goals, overall and across sub-populations, in Rwanda.

Methods

We created a deterministic dynamic model to project adult HIV epidemic and care continuum outcomes, overall and for 25 subpopulations (age group, sex, HIV acquisition risk, urbanicity). Data came from the Rwanda cohort of CA-IeDEA, 2004-2020; Rwanda Demographic and Health Surveys, 2005, 2010, 2015; Rwanda Population-based HIV Impact Assessment, 2019; and the literature and reports. We calibrated the model to 47 targets by selecting the 50 best-fitting parameter sets among 20,000 simulations. Calibration targets reflected epidemic (HIV prevalence, incidence), global goals (percentage on antiretroviral therapy (ART) among diagnosed, percentage virally suppressed among on ART) and other (number on ART, percentage virally suppressed) indicators, overall and by sex. Best-fitting sets minimized the summed absolute value of the percentage deviation (AVPD) between model projections and calibration targets. Good model performance was mean AVPD ≤5% across the 50 best-fitting sets and/or projections within the target confidence intervals; acceptable was mean AVPD >5% and ≤15%.

Results

Across indicators, 1,841 of 2,350 (78.3%) model projections were a good or acceptable fit to calibration targets. For HIV epidemic indicators, 256 of 300 (85.3%) projections were a good fit to targets, with the model performing better for women (83.3% a good fit) than for men (71.7% a good fit). For global goals indicators, 96 of 100 (96.0%) projections were a good fit; model performance was similar for women and men. For other indicators, 653 of 950 (68.7%) projections were a good or acceptable fit. Fit was better for women than for men (percentage virally suppressed only) and when restricting targets for number on ART to 2013 and beyond.

Conclusions

The CA-IeDEA HIV policy model fits historical data and can inform policy solutions for equitably achieving global goals to end the HIV epidemic in Rwanda. High-quality, unbiased population-based data, as well as novel approaches that account for calibration target quality, are critical to ongoing use of mathematical models for programmatic planning.

Small-area estimation and analysis of HIV/AIDS indicators for precise geographical targeting of health interventions in Nigeria. a spatial microsimulation approach

BACKGROUND

Precise geographical targeting is well recognised as an indispensable intervention strategy for achieving many Sustainable Development Goals (SDGs). This is more cogent for health-related goals such as the reduction of the HIV/AIDS pandemic, which exhibits substantial spatial heterogeneity at various spatial scales (including at microscale levels). Despite the dire data limitations in Low and Middle Income Countries (LMICs), it is essential to produce fine-scale estimates of health-related indicators such as HIV/AIDS. Existing small-area estimates (SAEs) incorporate limited synthesis of the spatial and socio-behavioural aspects of the HIV/AIDS pandemic and/or are not adequately grounded in international indicator frameworks for sustainable development initiatives. They are, therefore, of limited policy-relevance, not least because of their inability to provide necessary fine-scale socio-spatial disaggregation of relevant indicators.

METHODS

The current study attempts to overcome these challenges through innovative utilisation of gridded demographic datasets for SAEs as well as the mapping of standard HIV/AIDS indicators in LMICs using spatial microsimulation (SMS).

RESULTS

The result is a spatially enriched synthetic individual-level population of the study area as well as microscale estimates of four standard HIV/AIDS and sexual behaviour indicators. The analysis of these indicators follows similar studies with the added advantage of mapping fine-grained spatial patterns to facilitate precise geographical targeting of relevant interventions. In doing so, the need to explicate socio-spatial variations through proper socioeconomic disaggregation of data is reiterated.

CONCLUSIONS

In addition to creating SAEs of standard health-related indicators from disparate multivariate data, the outputs make it possible to establish more robust links (even at individual levels) with other mesoscale models, thereby enabling spatial analytics to be more responsive to evidence-based policymaking in LMICs. It is hoped that international organisations concerned with producing SDG-related indicators for LMICs move towards SAEs of such metrics using methods like SMS.

Prevalence of Consistent Condom Use and Associated Factors among Serodiscordant Couples in Ethiopia, 2020: A Mixed-Method Study

BACKGROUND

Heterosexual transmission within serodiscordant relationships is the core source of new HIV infections. Although consistent condom use can significantly reduce HIV transmission risk among serodiscordant couples, it has not been extensively studied in Ethiopia. Consequently, the current study looked at the proportion of serodiscordant couples in Ethiopia who used condoms consistently and the factors associated with that.

METHODS

A cross-sectional was conducted from October 2019 to June 2020. For the quantitative findings to be more robust and reliable, a qualitative design was incorporated. An interviewer-administered questionnaire was used to collect the data. Qualitative data were collected using gender-matched four focus group discussions. Multivariable logistic regression was conducted to identify factors associated with consistent condom use. The statistical significance of the variables was declared at a P value of less than 0.05.

RESULTS

This study confirmed that the proportion of consistent condom use was 58.4% [95% CI: 53.1-63.1%]. After controlling for all other variables, unmarried partners, adjusted odds ratio (AOR) = 0.44 [95% CI: 0.229-0.877] and students and employees, AOR = 0.33 [95% CI: 0.130-0.846] and AOR = 0.39 [95% CI: 0.165-0.939], respectively, were less likely consistently use condoms, whereas couples living together, AOR = 1.86 [95% CI: 1.197-2.195], receiving counseling about condom use, AOR = 1.90 [95% CI: 1.182-3.076], and having more knowledge about HIV, AOR = 1.61 [95% CI: 1.031-2.525] were more likely to use condoms consistently.

CONCLUSION

Despite its importance, the proportion of consistent condom use among serodiscordant couples was significantly low. To improve condom use consistently, planners, policymakers, and health care practitioners should consider the factors listed above when making decisions. There should be an increased focus on student and employee intervention as well.

What About Methods for Men? A Qualitative Analysis of Attitudes Toward Male Contraception in Burkina Faso and Uganda

CONTEXT

Male contraceptive options are limited; however, product development efforts tend to focus on female methods. Research on attitudes toward methods for men-particularly in regions of low contraceptive prevalence, such as Sub-Saharan Africa-could inform the development of new male methods.

METHODS

Qualitative data were taken from focus group discussions with 80 men aged 23-67 and 398 women aged 15-50 conducted in Burkina Faso and Uganda in 2016. Transcripts were analyzed thematically to explore support among men and women for male contraceptive methods, and to extract suggestions about ideal method characteristics.

RESULTS

Male and female participants in both countries expressed support for new male contraceptive options; more positive attitudes were expressed in Uganda than in Burkina Faso. Participants of both sexes recognized that male methods could reduce the family planning burden on women and offer men greater control over their fertility; however, some had concerns about side effects and thought that men would not use contraceptives. Relationship characteristics, such as polygamous unions, were cited as possible challenges. In both countries, various delivery methods (e.g., creams or jellies, injections and implants) and durations (from short-acting to permanent) were proposed.

CONCLUSIONS

The acceptability of new male methods among most participants in the two countries indicates a potential demand for male contraceptives. Options should include a variety of method characteristics to maximize choice, engage men, and support men and women's contraceptive needs.

Dual protection to address the global syndemic of HIV and unintended pregnancy in Brazil

BACKGROUND

Syndemic HIV and unintended pregnancy is prevalent in Brazil, where 79% of female HIV cases occur in women of reproductive age and 55% of all pregnancies are unintended. Although increasing condom use to prevent HIV may decrease non-barrier contraception and increase unintended pregnancy, few studies focus on dual protection or dual methods (condoms with another modern contraceptive).

AIM

To describe the correlates of dual method use and consistent condom use in women of reproductive age in Brazil.

METHOD

Data are from the 2006 Pesquisa Nacional de Demografia e Saúde da Mulher e da Criança, a decennial nationally representative household survey of women of reproductive age in Brazil. Multivariate logistic regression models identify the socio-demographic, sexual debut, fertility and relationship factors associated with dual method use and consistent condom use.

RESULTS

Two-thirds of contracepting women in Brazil used dual protection (40% exclusive condoms, 27% dual methods). Consistent condom use in the past year occurred among 61% of exclusive condom users and 27% of dual method users. Dual methods (vs exclusive condoms) was associated with some high school education [relative risk ratio (RRR)=1.69, p<0.05], living in the Southern region (RRR=1.59, p<0.01), and number of children (RRR=1.22, p<0.01), net of other factors. Consistent condom use was associated with condom use at sexual debut [adjusted odds ratio (AOR)=1.84, p<0.001], wants no (more) children (AOR=1.86, p<0.001), single/separated relationship status (AOR=2.77/2.45, p<0.001) and using exclusive condoms (vs dual methods: AOR=0.19, p<0.001).

CONCLUSIONS

Findings highlight that targeting and delivering integrated HIV and family planning services should focus on completed/large families. single/separated individuals, and promoting dual protection at sexual debut.

Sexual behaviour of women in rural South Africa: a descriptive study

Background

Sexual behaviour is a core determinant of the HIV and sexually transmitted infection (STI) epidemics in women living in rural South Africa. Knowledge of sexual behaviour in these areas is limited, but constitutes essential information for a combination prevention approach of behavioural change and biomedical interventions.

Methods

This descriptive study was conducted in rural Mopani District, South Africa, as part of a larger study on STI. Women of reproductive age (18–49 years) who reported sexual activity were included regardless of the reason for visiting the facility. Questionnaires were administered to 570 women. We report sexual behaviour by age group, ethnic group and self-reported HIV status.

Results

Young women (<25 years) were more likely to visit bars, practice fellatio, have concurrent sexual partners and report a circumcised partner than older women (>34 years); there was no difference for condom use during last sex act (36 % overall). Sotho women were more likely to report concurrent sexual partners whereas Shangaan women reported more frequent intravaginal cleansing and vaginal scarring practice in our analysis. HIV-infected women were older, had a higher number of lifetime sexual partners, reported more frequent condom use during the last sex act and were more likely to have a known HIV-infected partner than women without HIV infection; hormonal contraceptive use, fellatio, and a circumcised partner were less often reported.

Conclusions

This study provides insight into women’s sexual behaviour in a rural South African region. There are important differences in sexual behaviour by age group and ethnicity and HIV status; these should be taken into account when designing tailor-made prevention packages.

Attitudes Toward Intimate Partner Violence and Associations With Condom Use Among Men in Haiti: An Analysis of the Nationally Representative Demographic Health Survey

Although men have substantial decision-making power regarding condom use, the majority of HIV knowledge and prevention studies in the general Haitian population have been conducted among youth and women. We investigated attitudes toward intimate partner violence, knowledge of, and use of condoms among 9493 men in Haiti using data from the 2012 nationally representative Demographic and Health Survey. Only 36% of HIV-negative and 44% of HIV-positive men reported using a condom the last time they had had sex. Logistic regression revealed that believing it was justified for a man to hit or beat his wife if she refuses to have sex with him was associated with a lower odds of condom use. The odds of using a condom during last sex was higher among men who reported knowing condoms can prevent HIV and who had been tested for HIV. Given the low rate of condom use among men in Haiti, these findings suggest that interventions promoting HIV knowledge, HIV testing, and gender-violence prevention among men may also increase condom use.

"If You Are Not Circumcised, I Cannot Say Yes": The Role of Women in Promoting the Uptake of Voluntary Medical Male Circumcision in Tanzania

Voluntary Medical Male Circumcision (VMMC) for HIV prevention in Tanzania was introduced by the Ministry of Health and Social Welfare in 2010 as part of the national HIV prevention strategy. A qualitative study was conducted prior to a cluster randomized trial which tested effective strategies to increase VMMC up take among men aged ≥20 years. During the formative qualitative study, we conducted in-depth interviews with circumcised males (n = 14), uncircumcised males (n = 16), and participatory group discussions (n = 20) with men and women aged 20–49 years in Njombe and Tabora regions of Tanzania. Participants reported that mothers and female partners have an important influence on men’s decisions to seek VMMC both directly by denying sex, and indirectly through discussion, advice and providing information on VMMC to uncircumcised partners and sons. Our findings suggest that in Tanzania and potentially other settings, an expanded role for women in VMMC communication strategies could increase adult male uptake of VMMC services.

Have the educated changed HIV risk behaviours more in Africa?

Theory predicts that when new health information becomes available, more educated individuals may adopt healthy behaviours sooner, resulting in lower morbidity and mortality among the highly educated. This may be the case for HIV in sub-Saharan Africa: Recent empirical work shows that incidence is falling and the reduction is concentrated in more educated populations. However, it is unclear whether the educated have indeed adopted HIV risk-reducing behaviours to a greater extent than the less educated. I used two rounds of demographic and health surveys (DHS) in eight African countries to examine whether HIV-related behavioural change over time is greater among the more highly educated. I examined changes in condom use, age of marriage, number of partners, extramarital partnerships, and HIV testing. Results showed that education has a robust positive association with condom use and HIV testing, but also with having more sexual partners. I found that the probability of HIV testing increased more between rounds among the more educated, relative to the less educated. More educated men also appeared to have larger reductions in the number of sexual partners and there was evidence that younger, more educated women may be marrying earlier than their predecessors did. The education gradient did not change significantly over time for condom use. These changes in behaviour may signal a shift in the future burden of the epidemic towards more marginalised and less educated populations.

Sex workers, condoms, and mobility among men in Uzbekistan: implications for HIV transmission

Uzbekistan has one of the fastest growing HIV epidemics in the world. In this study, men who reported mobility were compared to non-mobile men in regard to paying for sex and condom use during paid sex. The sample included 2333 men between the ages of 15 and 59 in Uzbekistan. Generalised linear models were used to assess the relationship between mobility, paid sex, and condom use while adjusting for possible confounders. Of the total sample, 103 (4.4%) reported engaging in paid sex and 43 (42%) reported using condoms while engaging in paid sex. Mobile men were found to have more than three times the odds of paid sex than non-mobile men (OR: 3.209; 95% CI: 2.481, 4.150; p < 0.001). Mobile men were not significantly different from non-mobile men in terms of condom use; however, unmarried men were found to have six times the odds of not using a condom when compared to married men during paid sex (OR: 6.411; 95% CI: 2.502, 16.425; p = 0.004). Only one of the men who reported paid sex also reported using a condom with their spouses at last intercourse. The findings contribute to understanding mobility and HIV risk, and have important implications for HIV prevention interventions.

HIV prevention and marriage: peer group effects on condom use acceptability in rural Kenya

The twofold function of condom use - contraception and sexually transmitted disease protection - should be taken into account when understanding attitudes towards this practice. Emphasis on the interpretation of condom use as a protective practice conflicts with the norms of fidelity and trust, which regulate marriage. The alternative interpretation of condom use as a contraceptive method may be less problematic. This paper analyzes the extent to which the attitude of married men and women towards condom use with their spouses, and their actual use of condoms within marriage, are affected by their expectations about the dominant attitudes and behaviors in their peer group. I expect that a social consensus on understanding condom use as an HIV-preventive behavior will not make this practice more acceptable within marriage, while social acceptance of modern contraception and, more specifically, of the use of condoms for contraceptive purposes will. Two waves of a longitudinal survey from 1996 to 1999 in rural Kenya are analyzed using fixed-effects regression. Social support for each function of condom use is measured with indicators of the proportion of individuals in the peer group that use condoms for a particular purpose or have a positive attitude towards each of the uses, according to the respondent. The results support the hypothesis for men, but are inconclusive for women.

Men's attitudes on gender equality and their contraceptive use in Uttar Pradesh India

BACKGROUND

Men play crucial role in contraceptive decision-making, particularly in highly gender-stratified populations. Past research examined men's attitudes toward fertility and contraception and the association with actual contraceptive practices. More research is needed on whether men's attitudes on gender equality are associated with contraceptive behaviors; this is the objective of this study.

METHODS

This study uses baseline data of the Measurement, Learning, and Evaluation (MLE) Project for the Urban Health Initiative in Uttar Pradesh, India. Data were collected from a representative sample of 6,431 currently married men in four cities of the state. Outcomes are current use of contraception and contraceptive method choice. Key independent variables are three gender measures: men's attitudes toward gender equality, gender sensitive decision making, and restrictions on wife's mobility. Multivariate analyses are used to identify the association between the gender measures and contraceptive use.

RESULTS

Most men have high or moderate levels of gender sensitive decision-making, have low to moderate levels of restrictions on wife's mobility, and have moderate to high levels of gender equitable attitudes in all four cities. Gender sensitive decision making and equitable attitudes show significant positive association and restrictions on wife's mobility showed significant negative relationship with current contraceptive use.

CONCLUSION

The study demonstrates that contraceptive programs need to engage men and address gender equitable attitudes; this can be done through peer outreach (interpersonal communication) or via mass media. Engaging men to be more gender equal may have an influence beyond contraceptive use in contexts where men play a crucial role in household decision-making.

Correlates of condom use among males in North Sudan

Objectives In sub-Saharan Africa countries, HIV infections are transmitted primary through heterosexual contact. Correct and consistent condom use has been promoted as a method to prevent sexually transmissible infections, including HIV. The aim of this study was to assess and determine the factors influencing condom use in Khartoum, Sudan.

MATERIALS AND METHODS

Out of the 45 voluntary counselling and testing centres in Khartoum region, 10 centres were selected. A random sample of 804 respondents aged 20-40 years was selected. Stepwise multiple logistic regression analysis was used to investigate the predictors of condom use.

RESULTS

About 12% of respondents reported using condoms consistently, 41.5% used them sporadically and 46.3% were nonusers. Most of the participants had problems with condom use (81.9%) and friends were the main source of condoms (72%). Knowledge about AIDS transmission, knowing someone who is infected with or had died of AIDS, experiencing condom problems, type of sexual partners, purchase embarrassment and education were the main predictors of condom use.

CONCLUSIONS

Condom use among the Sudanese is low. Strategies to promote condom use should focus on price support for condoms by the government, expanded private sector condom distribution and the integration of sex education in school curriculums or via frequent discussion on television.

Effect of media use on HIV/AIDS-related knowledge and condom use in sub-Saharan Africa: a cross-sectional study

It is known that the level of HIV/AIDS-related knowledge and the degree of condom use varies by socioeconomic status (SES). However, there is limited research on the effect of mass media use on HIV/AIDS-related cognitive and behavioral outcomes in low-income countries and how it might influence the association between SES and HIV-related outcomes. We investigated the moderating effect of media use on the relationship between SES and HIV/AIDS-related knowledge and condom use in sub-Saharan Africa in terms of communication inequalities. Cross-sectional data from the Demographic Health Surveys from 13 sub-Saharan countries (2004–10) were pooled. Gender-stratified multivariable poisson regression of 151,209 women and 68,890 men were used to calculate adjusted relative ratios and 95% confidence intervals for the associations between SES, media use, HIV-related outcomes, and condom use. We found significant disparities in mass media use among people from different SES groups as well as among countries. Education and wealth are strongly and positively associated with awareness of HIV/AIDS and knowledge about transmission and prevention of HIV/AIDS and are significantly associated with condom use. These associations are attenuated when the use of various types of mass media is added to the models, with newspapers showing the strongest effect. The findings of this study suggest that media use has the potential to blunt the impact of socioeconomic status though not completely eliminate it. Thus, we need to pay attention to reducing communication inequalities among social groups and countries to moderate the effect of wealth and SES on HIV/AIDS.

Disclosure, knowledge of partner status, and condom use among HIV-positive patients attending clinical care in Tanzania, Kenya, and Namibia

We describe the frequency of and factors associated with disclosure, knowledge of partner's HIV status, and consistent condom use among 3538 HIV-positive patients attending eighteen HIV care and treatment clinics in Kenya, Namibia, and Tanzania. Overall, 42% of patients were male, and 64% were on antiretroviral treatment. The majority (80%) had disclosed their HIV status to their partners, 64% knew their partner's HIV status, and 77% reported consistent condom use. Of those who knew their partner's status, 18% reported their partner was HIV negative. Compared to men, women were significantly less likely to report disclosing their HIV status to their sex partner(s), to knowing their partner's HIV status, and to using condoms consistently with HIV-negative partners. Other factors negatively associated with consistent condom use include nondisclosure, alcohol use, reporting a casual sex partner, and desiring a pregnancy. Health care providers should target additional risk reduction counseling and support services to patients who report these characteristics.

The effect of marriage and HIV risks on condom use acceptability in rural Malawi

A large and increasing proportion of HIV transmissions in sub-Saharan Africa occur within marriage. Condom use within marriage could, therefore, be an important prevention strategy, but there is considerable debate about whether married couples would be willing to use condoms. This paper contributes to this debate by identifying key factors that affect the acceptability of condom use within marriage and actual condom use among men and women in rural Malawi, using three waves of longitudinal data from 2004, 2006 and 2008. Specifically, we focused on the effect of (1) entry into first marriage, (2) respondent's HIV status, HIV perceptions, and risk behaviors, and (3) spouse's HIV characteristics on condom use acceptability within marriage and actual condom use with a spouse or steady partner. Using fixed-effects regression, we found that getting married coincides with a pronounced attitudinal shift regarding the acceptability of condom use within marriage that cannot be explained by differences in fertility status or selection into marriage. In addition, we found that, for women, perceived HIV status of the respondent and spouse generally had greater influence than actual HIV status on the acceptability of condom use within marriage and actual condom use with a spouse or steady partner, even after HIV status is known; while actual HIV status and HIV risk behaviors are generally more important among men. Although condom use within marriage remained low, these findings suggest that attitudes about and use of condoms are susceptible to change and that both marital status and perceptions of risk are important influences on condom use.

The association between remarriage and HIV infection in 13 sub-Saharan African countries

Separated, divorced, and widowed individuals in Africa are at significantly increased risk for HIV infection. Using nationally representative data from 13 sub-Saharan African countries, this study confirms that finding and goes further by examining those who have experienced a marital dissolution and are now remarried. Results show that remarried individuals form a large portion of the population and have a higher-than-average HIV prevalence. HIV-positive remarried individuals are at risk of transmitting the infection to their spouse, because many of the couples are serodiscordant. The large number of high-risk remarried individuals is a source of vulnerability and further infection, and should be acknowledged and taken into account by prevention strategies that rarely address this population.

Consistent condom use among men with non-marital partners in four sub-Saharan African countries

Data from the Demographic and Health Surveys for Namibia, Swaziland, and Zambia and the AIDS Indicator Survey from Tanzania were used to examine the influence of marital status and number of partners on consistent condom use among men with casual sexual partnerships in four generalized HIV epidemic settings. We restrict the sample to the 26% (Zambia), 29% (Tanzania), 35% (Swaziland), and 42% (Namibia) of men, who, in the last 12 months before the survey, had any non-marital/non-cohabiting (i.e., casual) sexual partners. We use "condom always used with any partner in the last 12 months" as a dichotomous-dependent measure of consistent condom use. Analyses were stratified by country. Of men with casual partners, 41% (Zambia) to 70% (Namibia) used a condom every time with at least one partner. The majority of men were unmarried/non-cohabiting with one casual partner in the last year. In Swaziland and Zambia, multivariate results suggest that unmarried/non-cohabiting men with one casual partner had significantly lower odds than married/cohabiting men with casual partners to use condoms consistently (odds ratio [OR]=0.56, p=0.01 and OR=0.41, p<0.001, respectively.). In Namibia, unmarried/non-cohabiting men with two or more casual partners had significantly greater odds than married/cohabiting men with casual partners to use condoms consistently (OR=2.80, p<0.01). With some exceptions by country, higher education, religious group, wealth, having no children, knowing HIV results, having an STI, having one lifetime partner, and positive condom knowledge and beliefs also were significantly associated with using a condom every time with any partner. We conclude that consistent condom use remains an elusive goal even among men with casual sexual relationships. Condom use messages should be refined and targeted to men based on their number and types of relationships and combined with other messages to decrease concurrent relationships.

Women's roles in voluntary medical male circumcision in Nyanza Province, Kenya

Women are an important audience for voluntary medical male circumcision (VMMC) communication messages so that they know that VMMC provides only partial protection against HIV. They may also be able to influence their male partners to get circumcised and practice other HIV protective measures after VMMC. This study was conducted in two phases of qualitative data collection. Phase 1 used in-depth interviews to explore women’s understanding of partial protection and their role in VMMC. Phase 2 built on the findings from the Phase 1, using focus groups to test VMMC communication messages currently used in Nyanza Province and to further explore women’s roles in VMMC. Sixty-four sexually active women between the ages of 18 and 35 participated. In Phase 1, all women said they had heard of partial protection, though some were not able to elaborate on what the concept means. When women in Phase 2 were exposed to messages about partial protection, however, participants understood the messages well and were able to identify the main points. In Phases 1 and 2, many participants said that they had discussed VMMC with their partner, and for several, it was a joint decision for the man to go for VMMC. These findings suggest that current VMMC messaging is reaching women, though communications could more effectively target women to increase their ability to communicate about partial HIV protection from VMMC. Also, women seem to be playing an important role in encouraging men to get circumcised, so reaching out to women could be a valuable intervention strategy for increasing VMMC uptake and promoting use of other HIV protective measures after VMMC.

Evolving strategies, opportunistic implementation: HIV risk reduction in Tanzania in the context of an incentive-based HIV prevention intervention

BACKGROUND

Behavior change communication (BCC) interventions, while still a necessary component of HIV prevention, have not on their own been shown to be sufficient to stem the tide of the epidemic. The shortcomings of BCC interventions are partly due to barriers arising from structural or economic constraints. Arguments are being made for combination prevention packages that include behavior change, biomedical, and structural interventions to address the complex set of risk factors that may lead to HIV infection.

METHODS

In 2009/2010 we conducted 216 in-depth interviews with a subset of study participants enrolled in the RESPECT study - an HIV prevention trial in Tanzania that used cash awards to incentivize safer sexual behaviors. We analyzed community diaries to understand how the study was perceived in the community. We drew on these data to enhance our understanding of how the intervention influenced strategies for risk reduction.

RESULTS

We found that certain situations provide increased leverage for sexual negotiation, and these situations facilitated opportunistic implementation of risk reduction strategies. Opportunities enabled by the RESPECT intervention included leveraging conditional cash awards, but participants also emphasized the importance of exploiting new health status knowledge from regular STI testing. Risk reduction strategies included condom use within partnerships and/or with other partners, and an unexpected emphasis on temporary abstinence.

CONCLUSIONS

Our results highlight the importance of increasing opportunities for implementing risk reduction strategies. We found that an incentive-based intervention could be effective in part by creating such opportunities, particularly among groups such as women with limited sexual agency. The results provide new evidence that expanding regular testing of STIs is another important mechanism for providing opportunities for negotiating behavior change, beyond the direct benefits of testing. Exploiting the latent demand for STI testing should receive renewed attention as part of innovative new combination interventions for HIV prevention.

HIV prevalence and sexual behaviour at older ages in rural Malawi

Research on HIV infection and sexual behaviour in sub-Saharan Africa typically focuses on individuals aged 15-49 years under the assumption that both become less relevant for older individuals. We test this assumption using data from rural Malawi to compare sexual behaviour and HIV infection for individuals aged 15-49 with individuals aged 50-64 and 65 and over years. Although general declines with age were observed, levels of sexual activity and HIV remained considerable: 26.7% and 73.8% of women and men aged 65+ reported having sex in the last year, respectively; men's average number of sexual partners remained above one; and HIV prevalence is significantly higher for men aged 50-64 (8.9%) than men aged 15-49 (4.1%). We conclude that older populations are relevant to studies of sexual behaviour and HIV risk. Their importance is likely to increase as access to antiretrovirals in Africa increases. We recommend inclusion of adults aged over 49 years in African HIV/AIDS research and prevention efforts.

Proximate context of gender-unequal norms and women's HIV risk in sub-Saharan Africa

OBJECTIVE

To determine whether the proximate context of gender-unequal norms about violence against women undermines women's ability to negotiate condom use in sexual relationships.

DESIGN

Secondary analysis of cross-sectional data pooled from 22 Demographic and Health Surveys conducted in sub-Saharan Africa.

METHODS

Each of the 22 surveys employed a multistage stratified design with probabilistic sampling and was designed to be nationally representative of reproductive-age women. The outcome was self-reported condom use at last sexual intercourse. The primary explanatory variable of interest was a scale consisting of five questions about whether the respondent agreed with the appropriateness of wife beating under five different scenarios. To measure the proximate context of norms about violence against women, this scale was aggregated to the level of the primary sampling unit. We fit logistic regression models with cluster-correlated robust standard errors and adjustment for country-level fixed effects and sociodemographic characteristics.

RESULTS

Our analysis sample included data from 198,806 sexually active women living in 22 sub-Saharan African countries. The wife-beating scale was internally consistent (Cronbach's α = 0.84), and factor analysis confirmed the presence of a single factor. Condom use was associated with gender-unequal contextual norms about violence against women (adjusted odds ratio = 0.88; 95% confidence interval, 0.85-0.92; P < 0.001). The estimated association was robust to adjustment for sociodemographic characteristics and several sensitivity analyses.

CONCLUSIONS

The proximate context of gender-unequal norms about violence against women is associated with lack of condom use among women in sub-Saharan Africa.

Is food insecurity associated with HIV risk? Cross-sectional evidence from sexually active women in Brazil

BACKGROUND

Understanding how food insecurity among women gives rise to differential patterning in HIV risks is critical for policy and programming in resource-limited settings. This is particularly the case in Brazil, which has undergone successive changes in the gender and socio-geographic composition of its complex epidemic over the past three decades. We used data from a national survey of Brazilian women to estimate the relationship between food insecurity and HIV risk.

METHODS AND FINDINGS

We used data on 12,684 sexually active women from a national survey conducted in Brazil in 2006-2007. Self-reported outcomes were (a) consistent condom use, defined as using a condom at each occasion of sexual intercourse in the previous 12 mo; (b) recent condom use, less stringently defined as using a condom with the most recent sexual partner; and (c) itchy vaginal discharge in the previous 30 d, possibly indicating presence of a sexually transmitted infection. The primary explanatory variable of interest was food insecurity, measured using the culturally adapted and validated Escala Brasiliera de Segurança Alimentar. In multivariable logistic regression models, severe food insecurity with hunger was associated with a reduced odds of consistent condom use in the past 12 mo (adjusted odds ratio [AOR] = 0.67; 95% CI, 0.48-0.92) and condom use at last sexual intercourse (AOR = 0.75; 95% CI, 0.57-0.98). Self-reported itchy vaginal discharge was associated with all categories of food insecurity (with AORs ranging from 1.46 to 1.94). In absolute terms, the effect sizes were large in magnitude across all outcomes. Underweight and/or lack of control in sexual relations did not appear to mediate the observed associations.

CONCLUSIONS

Severe food insecurity with hunger was associated with reduced odds of condom use and increased odds of itchy vaginal discharge, which is potentially indicative of sexually transmitted infection, among sexually active women in Brazil. Interventions targeting food insecurity may have beneficial implications for HIV prevention in resource-limited settings.

Condom use within marriage: an assessment of changes in South Africa and Uganda

The aim of the study is to measure trends in condom use in marital and cohabiting relationships in South Africa and Uganda. The data for the study come from two cross sectional surveys conducted in 1998 and 2008 among adult men and women and their partners in KwaZulu-Natal, South Africa and the Jinja district, Uganda. The findings suggest that consistent condom use has risen substantially in both countries. The percentage reporting consistent condom use in the South African sample of husbands increased from 2.5% in 1998 to 12% in 2008 and from 5.5 to 12.5% among wives. In Uganda, the corresponding trends are 1.1-8.3% for husbands and 4-8.6% for wives. In both countries, condom use was considerably higher among the minority of couples where one or both partners were thought to be HIV positive. Increasingly, in both countries condoms are also used for contraceptive purposes. Condoms play a role in preventing HIV infection but the challenge is for prevention programs to broaden their focus toward meeting the needs of married and cohabiting couples.