HandiVIH--A population-based survey to understand the vulnerability of people with disabilities to HIV and other sexual and reproductive health problems in Cameroon: protocol and methodological considerations

Burden of and risk factors for sexual violence among women with and without disabilities in two sub-Saharan African countries

Background

Available data suggest that women with disabilities have an increased risk of sexual violence, but little is known about the situation of those women living in resource-limited settings.

Objectives

To assess the burden and examine the drivers of sexual violence among women with disabilities.

Methods

This is a pooled analysis of two population-based surveys conducted in Cameroon and Burundi. Adults with and without disabilities were randomly recruited from the general population. Structured interviews were conducted at both sites to collect data on participants’ functional limitations, life-course history of sexual violence, education, employment, and resources. Only women with disabilities whose impairments started before the age of 10 years (n = 359) and women without disabilities (n = 720) are included in this analysis. The age-adjusted prevalence of violence was computed, and risk factors were assessed using a discrete survival regression and mediation analysis.

Results

At both sites, the participants with disabilities had a lower education level and had an increased risk of food insecurity. The pooled age-adjusted prevalence of lifetime sexual violence was 19.8% (95%CI:15.3–24.3) among women with disabilities and 11.7% (95%CI:9.3–14.1) among those without disabilities (OR_ap: 2.0, 95%CI:1.4–2.8). Women with cognitive limitations and those with visual impairments had the highest risk of sexual violence (OR_ap: 3.5 (95%CI:2.0–6.3) and 2.7 (95%CI:1.4–5.0), respectively). Over the life course, the risk of sexual violence was especially high among women with disabilities who had lived with an intimate partner before the age of 25 years (p < 0.001). Education level mediated approximately one-third of the total association between disability and sexual violence (p = 0.001). There was no evidence of an indirect effect through food insecurity.

Conclusion

This study provides evidence of the high burden of sexual violence among women with disabilities who live in urban African contexts. The social environment and access to education may be key contributors to this vulnerability.

People with disabilities in Cabo Verde, an unresolved issue: HIV prevalence, knowledge, attitudes and practices

This article provides evidence about profile of persons with disabilities in Cabo Verde, their Knowledge, attitudes and practice and their bio-behavioural vulnerability to HIV/AIDS. The Cape verdian population was estimated to be 537,661 inhabitants in 2020, with an HIV prevalence of about 0.6% in the general population. Data were collected from 5 islands and 8 municipalities with a proportion of people with disabilities greater than or equal to 5%. A total of 682 persons participated in the study, and 653 People with Disabilities (PwDs) were tested for HIV. The HIV prevalence rate was 2.3% (3.5% in men; 1.7% in women), and the most prevalent type of virus is HIV1. Over 90% PwDs have access to information about HIV. Most of PwDs (85.8%) have had sex and known protection methods against HIV, although there are some misconceptions and beliefs. About 80.0% never participated in HIV/AIDS prevention activities, and 96.3% said that their participation gave them a better understanding about HIV and AIDS. About 79% were unaware of the existence of HIV care, support and prevention facilities, and 36.7% do not know of any place for HIV screening. This first study in Cabo Verde highlights the reality about PwDs social and environmental situation.

Prevalence and risk factors of HIV infection among people with disabilities in Burkina Faso

This study aimed to determine the prevalence and risk factors of HIV infection among people with disabilities (PWDs) in Burkina Faso. We carried out a cross-sectional study on level 3 and/or 4 disabled people. Identification of PWDs aged 15-69 years was done in households using the Washington Group (WG) Short questionnaire, following by HIV behavioural survey and HIV testing. Multi-level binary logistics Bayesian analysis was done to identify factor associated with HIV. In total, 973 PWDs were included in this study. HIV prevalence was 4.6% (3.3-6.1%). Independent factors associated with HIV infection were aged 35-44 years old (AOR: 8.93; 95% CrI: 3.57-18.89), had visual or hearing impairments (AOR: 6.38; 95%CrI: 1.95-15.44), no income (AOR:6.11; 95% CrI: 2.49-12.48), and had casual sex partners (AOR: 6.28; 95% CrI: 3.27-11.13). HIV prevalence is high compared to the general population. These data suggest a need for comprehensive and specific HIV prevention among people with disabilities, including awareness for safer sexual behaviours.

The compounding effect of having HIV and a disability on child mortality among mothers in South Africa

BACKGROUND

Previous research on the association between maternal HIV status and child mortality in sub-Saharan Africa was published between 2005-2011. Findings from these studies showed a higher child mortality risk among children born to HIV-positive mothers. While the population of women with disabilities is growing in developing countries, we found no research that examined the association between maternal disability in HIV-positive mothers, and child mortality in sub-Saharan Africa. This study examined the potential compounding effect of maternal disability and HIV status on child mortality in South Africa.

METHODS

We analyzed data for women age 15-49 years from South Africa, using the nationally representative 2016 South Africa Demographic and Health Survey. We estimated unadjusted and adjusted risk ratios of child mortality indicators by maternal disability and maternal HIV using modified Poisson regressions.

RESULTS

Children born to disabled mothers compared to their peers born to non-disabled mothers were at a higher risk for neonatal mortality (RR = 1.80, 95% CI:1.31-2.49), infant mortality (RR = 1.69, 95% CI:1.19-2.41), and under-five mortality (RR = 1.78, 95% CI:1.05-3.01). The joint risk of maternal disability and HIV-positive status on the selected child mortality indicators is compounded such that it is more than the sum of the risks from maternal disability or maternal HIV-positive status alone (RR = 3.97 vs. joint RR = 3.67 for neonatal mortality; RR = 3.57 vs. joint RR = 3.25 for infant mortality; RR = 6.44 vs. joint RR = 3.75 for under-five mortality).

CONCLUSIONS

The findings suggest that children born to HIV-positive women with disabilities are at an exceptionally high risk of premature mortality. Established inequalities faced by women with disabilities may account for this increased risk. Given that maternal HIV and disability amplify each other's impact on child mortality, addressing disabled women's HIV-related needs and understanding the pathways and mechanisms contributing to these disparities is crucial.

Determinants of knowledge, attitudes, and practices in relation to HIV/AIDS and other STIs among people with disabilities in North-Shewa zone, Ethiopia

INTRODUCTION

People with disabilities face socioeconomic disadvantages and they have limited access to sexual and reproductive health information. They are highly vulnerable to sexual abuse which places them at increased risk of HIV and STI infection. At present, however, little is known about the knowledge, attitude and practice of sexually transmitted diseases including HIV/AIDS and other STIs in Ethiopia. This study aimed to identify which individual factors best predict knowledge, attitudes, and practices in relation to HIV/AIDS and other STIs among people with disabilities in North-shewa zone, Ethiopia.

METHODS

A cross-sectional study was conducted from June to October 2019. A total of 397 respondents were interviewed using a structured and pre-tested questionnaire. A systematic sampling technique was employed to select the respondents. Logistic regression was performed to analyze the data. A significant association was declared at a p-value of less than 0.05.

RESULTS

Nearly half of the study participants were knowledgeable in relation to HIV/AIDS (47.3%) and STIs (46.9%). Sixty-two percent of respondents had good attitude towards evidence of HIV/AIDS while sixty-nine percent of participants had good attitude towards helpful facts of STIs. Twenty-three percent of study participants had been ever tested for HIV infections. Being married (AOR = 2.23; 95% CI = 1.92, 10.72) was associated with having good knowledge of STI. Males were 1.6 times more knowledgeable about HIV/AIDS than females (AOR = 1.60; 95% CI = 1.21, 9.12).

CONCLUSIONS

In this study, knowledge, attitudes, and practices of people with disabilities in relation to HIV/AIDS and other STIs were relatively low. This is clear evidence that HIV programs need to ensure that people with disabilities can access basic knowledge about HIV/AIDS and STIs.

A comparative analysis of disability measures in Cameroonian surveys

Background

Although identifying vulnerable groups is an important step in shaping appropriate and efficient policies for targeting populations of disabled people, it remains a challenge. This study aims to evaluate for the first time the comparability of the different disability measurements used in Cameroon. This is done by comparing them with the international standards proposed by the Washington Group (WG). It also evaluates the consistency of the association between the disability as measured by these surveys and the sociodemographic characteristics.

Method

We used data from the third Cameroonian Population and Housing Census (3RGPH) of 2005, the third Cameroonian Household survey (ECAM3) of 2007, the Demographic Health and Multiple Indicator Cluster Survey (DHS-MICS) of 2011 and a survey conducted on adults in Yaoundé (HandiVIH) in 2015 with the WG tool. The proportion and their confidence intervals, chi-square tests and multivariate logistic regressions are used for analyses.

Results

In the city of Yaoundé and for the 15–49 age group, disability prevalence was estimated at 3.6% (CI = [2.5, 5.1]), 2.7% CI = [2.1, 3.5]), 2.6% (CI = [2.4, 2.7]) and 1.0% (CI = [1.0, 1.10]), according to DHS-MICS, ECAM3, HandiVIH and 3RGPH, respectively. The prevalence of severe motor and mental disabilities in DHS-MICS (0.4% CI = [0.2, 0.8], 1.1% CI = [0.7, 1.8] and 0.5% CI = [0.2, 1.1], respectively) are not significantly different from the findings of HandiVIH (0.3% CI = [0.2, 0.3], 0.8% CI = [0.7, 0.9] and 0.5% CI = [0.5, 0.6], respectively). Only motor disability prevalence in ECAM3 (0.8%, CI = [0.5, 1.2]) is not different from that of HandiVIH. When the WG screening tool is used in HandiVIH, disability is positively associated with age, negatively associated with educational level, being in a union and socioeconomic status (SES) and it is not associated with sex. Severe disability, for its part, is not associated with SES and is positively associated with being a male. A different association trend is observed with 3RGPH, ECAM3 and DHS-MICS.

Conclusion

None of the instruments used in the nationally representative Cameroonian surveys produced both disability prevalence and association trends that are exactly similar to those obtained when using the WG disability screening tool, thus highlighting the necessity to include the WG questions in nationally representative surveys.

Disability and Access to Sexual and Reproductive Health Services in Cameroon: A Mediation Analysis of the Role of Socioeconomic Factors

There is growing evidence showing that people with disabilities face more frequently socioeconomic inequities than their non-disabled peers. This study aims to examine to what extent socioeconomic consequences of disability contribute to poorer access to sexual and reproductive health (SRH) services for Cameroonian with disabilities and how these outcomes vary with disabilities characteristics and gender. It uses data from a population-based survey conducted in 2015 in Yaounde, Cameroon. Mediation analysis was performed to determine how much of the total association between disability and the use, satisfaction and difficulties to access SRH services was mediated by education level, material wellbeing lifetime work participation and availability of social support. Overall, disability was associated with deprivation for all socioeconomic factors assessed though significant variation with the nature and severity of the functional limitations was observed. Lower education level and restricted lifetime work mediated a large part of the association between disability and lower use of HIV testing and of family planning. By contrast, while people with disabilities reported more difficulties to use a SRH service, no mediating was identified. In conclusion, Cameroonians with disabilities since childhood have restricted access to SRH services resulting from socioeconomic factors occurring early during the life-course.

Young women with disabilities and access to HIV/AIDS interventions in Uganda

Sexual health and autonomy, and the often violent ways in which these are suppressed, are critical women's human rights issues. The process of ensuring that women enjoy their sexual and reproductive rights, including sexual health and freedom from HIV, is particularly challenging for persons with disabilities and most especially women with disabilities. This paper applies a human rights and gender lens to the sexuality and HIV-related vulnerabilities of young women with disabilities in Uganda. Widespread misperceptions about the sexual behaviours of women with disabilities, exposure to violence and exclusion from health promotion activities and health services, render women with disabilities, particularly young women with disabilities, disproportionately vulnerable to HIV and impede the full realisation of their sexual and reproductive health and rights. While limited protections exist for people with disabilities in Uganda, and some efforts have been made to provide appropriate services, the availability, accessibility, acceptability and quality of health services for this population group remains low, with a deleterious impact on their health and rights. This article calls for measures that strengthen the ability of young women with disabilities to prevent HIV infection and that promote responsiveness of the health system (as well as services in other sectors) to the sexual and reproductive health needs of this population.

HIV/AIDS knowledge, attitudes and behaviour of persons with and without disabilities from the Uganda Demographic and Health Survey 2011: Differential access to HIV/AIDS information and services

Uganda is among the first to use the Washington Group Short Set of Questions on Disability to identify persons with disabilities in its Demographic and Health Survey. In this paper, we review the HIV Knowledge, Attitudes and Behaviour component of the 2011 Ugandan Demographic and Health Survey, analysing a series of questions comparing those with and without disabilities in relation to HIV/AIDS knowledge, attitudes and practices. We found comparable levels of knowledge on HIV/AIDS for those with and those without disabilities in relation to HIV transmission during delivery (93.89%, 93.26%) and through breastfeeding (89.91%, 90.63%), which may reflect increased attention to reaching the community of persons with disabilities. However, several gaps in the knowledge base of persons with disabilities stood out, including misconceptions of risk of HIV infection through mosquito bites and caring for a relative with HIV in own household (34.39%, 29.86%; p<0.001; 91.53%, 89.00%; p = 0.001, respectively). The issue is not just access to appropriate information but also equitable access to HIV/AIDS services and support. Here we found that persons with multiple disabilities were less likely than individuals without disabilities to return to receive results from their most recent HIV test (0.60[0.41-0.87], p<0.05). HIV testing means little if people do not return for follow-up to know their HIV status and, if necessary, to be connected to available services and supports. Additional findings of note were that persons with disabilities reported having a first sexual encounter at a slightly younger age than peers without disabilities; and persons with disabilities also reported having a sexually transmitted disease (STD) within the last 12 months at significantly higher rates than peers without disabilities (1.38[1.18-1.63], p<0.01), despite reporting comparable knowledge of the need for safer sex practices. This analysis is among the first to use HIV/AIDS-related questions from Demographic Health Surveys to provide information about persons with disabilities in Uganda in comparison to those without disabilities. These findings present a more complex and nuanced understanding of persons with disabilities and HIV/AIDS. If persons with disabilities are becoming sexually active earlier, are more likely to have an STD within the preceding 12 month period and are less likely to receive HIV test results, it is important to understand why. Recommendations are also made for the inclusion of disability measures in Uganda's AIDS Indicator Survey to provide cyclical and systematic data on disability and HIV/AIDS, including HIV prevalence amongst persons with disabilities.

Health profiles and associated service use among adults with HIV and intellectual and developmental disabilities

OBJECTIVE(S)

Owing to the commonly held notion that individuals with intellectual and developmental disabilities (IDD) have low risk of HIV acquisition, we compared the prevalence of HIV infection among people with and without IDD. We also examined health status and health service use among the HIV-infected group.

DESIGN

Population-based cohort study using linked administrative health and social services databases.

METHODS

We compared HIV prevalence between Ontario adults with IDD (n = 64 008) and a 20% random sample of Ontario adults without IDD. Among the HIV-infected group, we compared adults with and without IDD in terms of comorbid chronic physical conditions and mental health disorders, as well as use of overall health services, mental health services, and HIV-specific services.

RESULTS

HIV prevalence per 100 000 population did not differ for adults with IDD [163.38 (95% confidence interval: 132.27, 199.6)] and without IDD [172.45 (95 confidence interval: 167.48, 177.53)]. Among the HIV-infected group, those with IDD had more comorbid chronic physical conditions and mental health disorders. They also had greater use of overall health services and mental health services. Likelihood of use of HIV-specific services also differed for those with and without IDD.

DISCUSSION

A similar prevalence of HIV among adults with and without IDD accentuates a need for strategies for individuals with IDD to be included in HIV prevention efforts. High prevalence of chronic physical and mental health comorbidity and health service use among the HIV-infected group with IDD highlight a need for comprehensive and coordinated treatment plans to optimize outcomes for this complex patient group.

Prevalence of HIV infection among people with disabilities: a population-based observational study in Yaoundé, Cameroon (HandiVIH)

BACKGROUND

In resource-limited settings, people with disabilities have been left behind in the response to HIV. In the HandiVIH study, we estimate and compare HIV prevalence and associated risk factors between people with and without disabilities.

METHODS

In this cross-sectional, population-based, observational study, we used two-phase random sampling to recruit adults with disabilities and a control group matched for age, sex, and residential location from households of the general population. We used the Washington Group Short Set of Questions on Disability to identify people with disabilities. We administered an HIV test and a life-course history interview to participants. The primary outcome was the prevalence of HIV among participants with and without disabilities.

FINDINGS

Between Oct 2, 2014, and Nov 30, 2015, we recruited 807 people with disabilities and 807 participants without disabilities from Yaoundé, Cameroon. 28 of 716 people in the control population had a positive HIV test result (crude prevalence 3·9%, 95% CI 2·9-5·3) compared with 50 of 739 people with disabilities (6·8%, 5·0-8·6; conditional odds ratio [OR] 1·7; p=0·04). Women with disabilities were more often involved in paid sexual relationships than were women without disabilities (2·5% vs 0·5%, p=0·05). People with disabilities were also at increased risk of sexual violence than were women without disabilities (11·0% vs 7·5%, OR 1·5; p=0·01). Sexual violence and sex work were strongly associated with increased risk of HIV infection among participants with disabilities but not among controls (OR 3·0, 95% CI 1·6-5·6 for sexual violence and 12·3, 4·4-34·6 for sex work). Analyses were done in men and women.

INTERPRETATION

The higher prevalence of HIV infection in people with disabilities than people without disabilities reflects a higher exposure to HIV infection as well as the presence of disability-associated HIV infection. The susceptibility of people with disabilities to HIV infection seems to be shaped by social and environmental factors. Research is needed to inform firm recommendations on how to protect this vulnerable population.

FUNDING

Agence nationale de recherches sur le sida et les hépatites virales (ANRS-Inserm) and the 5% Initiative.