Reframing women's risk: social inequalities and HIV infection

Condom Use at Last Sex and Sexual Negotiation Among Young African American Women in North Carolina: Context or Personal Agency

African American women are 10.8 times more likely to be diagnosed with HIV compared with White women. This descriptive study fills a gap by examining associations among social and contextual factors and sexual communication, condom use, and safer sex negotiation among African American women. Study participants between 18 and 25 years of age and who reported recent substance use were recruited from three North Carolina counties. A risk behavior survey was administered via audio computer-assisted self-interview, and logistic regression analyses were conducted to assess associations between social and contextual variables and condom use at last sex with a main partner. Education (AOR: 2.078; 95% CI: 1.214, 3.556), sexual communication with a main partner (AOR: 1.079; 95% CI: 1.050, 1.109), and condom use relationship scale (AOR: 1.059; 95% CI: 1.023, 1.098) were positively associated with condom use at last sex, whereas living with a main partner (AOR: 0.447; 95% CI: 0.210, 0.950) and the alcohol and drug problem scale (AOR: 0.971; 95% CI: 0.944, 0.998) were negatively associated with condom use (p < 0.05). The study findings show that among young African American women at risk for HIV, contextual and personal factors may influence condom use. A socio-ecological approach combining personal empowerment, interpersonal, structural, and biobehavioral strategies is necessary in implementing holistic gender-focused HIV prevention programs.

Toward a Theory of Nature Experience and Health

This article presents an integrated theoretical framework to study the socioenvironmental attributes of the nature experience as a basic health behavior. After first reviewing existing literature on theories behind nature exposure, we discuss social cognitive theory (SCT) to explain individual nature experience through the model's triadic dynamic of environment, cognitions, and behaviors. We then expand beyond SCT's focus on the individual to examine structural and societal spheres of influence on nature experience found in ecological systems theory and ecosocial theory. In moving from proximal to distal influences, we identify the core constructs of each theory that may reinforce or deter decisions inclining individuals toward nature engagement. In synthesizing aspects of these three theories, we propose an integrated theoretical framework of nature experience distinguished by three ideas. First, individual-level formative influences in nature pervade higher level ecologies as a learned social behavior. Second, nature experience happens within multiple systems and timepoints. Third, social relationships within historical processes shape contextual factors of the nature experience, resulting in disparities in nature access and nature responses that manifest heterogeneously. Theorizing behind nature experience can inform why this occurs. We offer suggestions for further research to build on the groundwork put forth here: for hypothesizing around present observations, for collecting data to confirm and/or refute parts of the theory, and for further hypothesis generation inspired by the theory to inform the research agenda. In conclusion, we consider the practical implications of theory underlying nature experience as a health behavior relevant to research, interventions, and policy.

Addressing Women’s Needs with Human Immunodeficiency Virus (HIV) and Enhancing the Visibility of Pharmacists in the Public Health Arena

Human Immunodeficiency Virus (HIV) continues to have a staggering effect on women’s lives in the United States (U.S.). Women Living With HIV (WLWH) face many challenges, such as mental health disorders, compared to their male counterparts. These diagnoses make women more disproportionally affected, and meaningful healthcare interventions must address these conditions. This review has three foci: WLWH in the U.S., their access to care and staying in care once antiretroviral treatment has been initiated, coping with mental health, and the role of the U.S. pharmacists in access to the treatment. Pharmacists are the most easily accessible healthcare profession in the U.S. For example, 93% of American customers live within 5 miles of a community pharmacy. Pharmacists are the last healthcare provider with whom the patient interacts before a medication is dispensed; thus, they are in an ideal position to intervene. Engaging pharmacists to provide care for patients with chronic disease states such as HIV has resulted in positive outcomes. Although there are global and U.S. studies that emphasize the role of pharmacists in directing care for persons living with HIV, there is a lack of studies conducted about the role of pharmacists in managing mental health. Future research must address WLWH and mental health conditions to develop targeted interventions from an interdisciplinary team perspective.

Lack of full citizenship rights linked to heightened client condom refusal among im/migrant sex workers in Metro Vancouver (2010-2018)

In Canada, im/migrant sex workers face stigma, health access barriers, and overlapping marginalisation, with end-demand law reforms in 2014 postulated to exacerbate these inequities. Yet, little quantitative evidence on how immigration status shapes HIV/STI risk exists. Drawing on community-based longitudinal cohort data (AESHA, 2010-2018), we used multivariable confounder models with logistic regression to model (1) the independent effect of precarious immigration status (any status revocable under criminal charges: permanent residency/temporary residency/undocumented) on client condom refusal, and (2) the moderating effect of precarious status on the relationship between condom refusal and exposure to end-demand law reform (2015-2018). Over this 8-year study involving 758 sex workers in Metro Vancouver, 16.0% were im/migrants, of whom 57% had precarious immigration status at baseline. 16.5% of participants experienced client condom refusal. Precarious immigration was associated with increased odds of facing condom refusal (adjusted odds ratio [AOR] 2.53, 95% confidence interval [CI] 1.37-4.68), and these odds were heightened post-end-demand law reforms (AOR 4.35, 95%CI 1.21-15.66). Our findings suggest that lack of citizenship rights may enhance barriers to safer sex negotiation and increase HIV/STI risk among sex workers, highlighting the need for sex work and immigration policy reforms.

Leveraging Technology to Blend Large-Scale Epidemiologic Surveillance With Social and Behavioral Science Methods: Successes, Challenges, and Lessons Learned Implementing the UNITE Longitudinal Cohort Study of HIV Risk Factors Among Sexual Minority Men in the United States

The use of digital technologies to conduct large-scale research with limited interaction (i.e., no in-person contact) and objective endpoints (i.e., biological testing) has significant potential for the field of epidemiology, but limited research to date has been published on the successes and challenges of such approaches. We analyzed data from a cohort study of sexual minority men across the United States, collected using digital strategies during a 10-month period from 2017 to 2018. Overall, 113,874 individuals were screened, of whom 26,000 were invited to the study, 10,691 joined the study, and 7,957 completed all enrollment steps, including return of a human immunodeficiency virus-negative sample. We examined group differences in completion of the steps towards enrollment to inform future research and found significant differences according to several factors, including age and race. This study adds to prior work to provide further proof-of-concept for this limited-interaction, technology-mediated methodology, highlighting some of its strengths and challenges, including rapid access to more diverse populations but also potential for bias due to differential enrollment. This method has strong promise, and future implementation research is needed to better understand the roles of burden, privacy, access, and compensation, to enhance representativeness and generalizability of the data generated.

The Evolution of Dignity: An Intervention Model to Engage and Retain HIV-Positive Black Women in Care

The Black community is currently battling two pandemics, one is HIV, and the other is COVID-19. Similarly, as with HIV, COVID-19 has shone a spotlight on our healthcare system's structural failings and revealed the disproportionate impact on the Black community, particularly Black women. Black women accounted for the largest proportion of new HIV diagnoses (58 %) among all women in 2018 and represented about one-quarter of new HIV diagnoses among all Black Americans. Additionally, Black women's exposure to an abundance of misinformation about the COVID-19 infection resulted in an increased risk of complications and death from the COVID-19 virus compared to other racial and ethnic groups. Factors that increase HIV transmission risks for Black women include living in poverty, intimate partner violence, and stigma associated with HIV. Moreover, environmental, physical, cultural, financial, social, and psychological barriers are identified as unique challenges for this population's cohort. After being diagnosed with HIV, Black often were unable to access quality HIV care. Access and retention in care are tantamount to the overall well-being of women who are HIV positive. Frequently healthcare providers may attempt to engage and retain patients using only clinical measures. Our non-clinical intervention, The Evolution of Dignity, supports medical outcomes by creating a process that empowers women to motivate themselves toward improved health outcomes while ensuring their engagement and retention in care. Thus, by implementing our comprehensive intervention, all of the necessary elements contributing and promoting improved service utilization and medical adherence are integrated.

Development of the Canadian Women-Centred HIV Care Model Using the Knowledge-to-Action Framework

In Canada, women make up 25% of the prevalent HIV cases and represent an important population of those living with HIV, as a high proportion are racialized and systemically marginalized; furthermore, many have unmet healthcare needs. Using the knowledge-to-action framework as an implementation science methodology, we developed the "Women-Centred HIV Care" (WCHC) Model to address the needs of women living with HIV. The WCHC Model is depicted in the shape of a house with trauma- and violence-aware care as the "foundation". Person-centred care with attention with attention to social determinants of health and family make up the "first" floor. Women's health (including sexual and reproductive health and rights) and mental and addiction health care are integrated with HIV care, forming the "second" floor. Peer support, leadership, and capacity building make up the "roof". To address the priorities of women living with HIV in all their diversity and across their life course, the WCHC Model should be flexible in its delivery (e.g., single provider, interdisciplinary clinic or multiple providers) and implementation settings (e.g., urban, rural).

Multilevel influences of women's empowerment and economic resources on risky sexual behaviour among young women in Zomba district, Malawi

Gender disparities are pronounced in Zomba district, Malawi. Among women aged 15-49 years, HIV prevalence is 16.8%, compared with 9.3% among men of the same age. Complex structural factors are associated with risky sexual behaviour leading to HIV infection. This study's objective was to explore associations between multilevel measures of economic resources and women's empowerment with risky sexual behaviour among young women in Zomba. Four measures of risky sexual behaviour were examined: ever had sex, condom use and two indices measuring age during sexual activity and partner history. Multilevel regression models and regression models with cluster-robust standard errors were used to estimate associations, stratified by school enrolment status. Among the schoolgirl stratum, the percentage of girls enrolled in school at the community level had protective associations with ever having sex (OR = 0.76; 95% CI: 0.60, 0.96) and condom use (OR = 1.06; 95% CI: 1.01, 1.11). Belief in the right to refuse sex was protective against ever having sex (OR = 0.76; 95% CI: 0.60, 0.96). Participants from households with no secondary school education had higher odds of ever having sex (OR = 1.59; 95% CI: 1.14, 2.22). Among the dropout stratum, participants who had not achieved a secondary school level of education had riskier Age Factor and Partner History Factor scores (β = 0.51; 95% CI: 0.23, 0.79, and β = 0.24; 95% CI: 0.07, 0.41, respectively). Participants from households without a secondary school level of education had riskier Age Factor scores (β = 0.26; 95% CI: 0.03, 0.48). Across strata, the most consistent variables associated with risky sexual behaviour were those related to education, including girl's level of education, highest level of education of her household of origin and the community percentage of girls enrolled in school. These results suggest that programmes seeking to reduce risky sexual behaviour among young women in Malawi should consider the role of improving access to education at multiple levels.

The effect of gender inequality on HIV incidence in Sub-Saharan Africa

OBJECTIVE

We aimed to quantify the extent to which country-level trends in HIV incidence in Sub-Saharan Africa (SSA) were influenced by gender inequalities, measured by gender gaps in educational attainment, income, and a Gender Inequality Index (GII).

STUDY DESIGN

We examined the relation between gender inequality and HIV incidence using country-level panel data from 24 SSA countries for the period between 2000 and 2016.

METHODS

Our goal was to estimate the relation between within-country changes in gender inequality and HIV incidence. We compared results from fixed effects and random effects models for estimating the effect of gender inequalities on changes in HIV incidence. Based on the results of the Hausman test, the fixed effects model was selected as the preferred approach.

RESULTS

HIV incidence decreased by nearly one-half over the period from 2000 to 2016. We estimated that a one percent increase in the GII was associated with a 1.6 percent increase in HIV incidence (95% confidence interval = [0.21%; 3.00%]), after adjusting by country-level socio-economic and governance variables.

CONCLUSIONS

Our study suggests that addressing gender inequalities is a potential strategy to reduce HIV incidence in the SSA region. To control HIV infection, policymakers and public health practitioners should support relevant interventions for promoting gender equality. Further work is needed to identify specific interventions to improve gender inequality and to examine their impacts on changes in HIV incidence.

Towards ending the US HIV epidemic by 2030: Understanding social determinants of health and HIV in Mississippi

The disproportionate burden of HIV-related inequities borne by African Americans in the US South amplifies the role of social determinants of health (SDH) in shaping social patterning of illness. Despite some attention, SDH remain overlooked in a biomedically oriented, federal HIV policy. Mississippi is the poorest state with the worst HIV outcomes, nationally. Using qualitative methods, we investigated how primarily African American, HIV-positive Mississippians experienced SDH and health inequities in their daily lives. Employing grounded theory and in-depth interviews (n = 25) in an urban and rural site in 2015 yielded these findings: (1) absence of an enabling structural environment; (a) HIV-stigma constructed via social discourse; (b) lack of psycho-social support and HIV education; (c) insufficient economic and social support resources; and (2) presence of family support for coping. Due to stigma, being HIV-positive seemed to lead to further status loss; diminished social position; reduced life chances; and contractions in particular freedoms. Stigma further compounded existing inequalities - contributing to the moral, social experience of those living with HIV. Trump's plan to end HIV by 2030 creates the opportunity to rethink the biomedical-paradigm and fully engage SDH - using social science theory and methods that address multi-level social determinants in ways that are also policy-responsive.

HIV Stigma and Its Relation to Mental, Physical and Social Health Among Black Women Living with HIV/AIDS

Black women living with HIV/AIDS (LWHA) are a subgroup with the highest growing rates of HIV infection in the United States. Stigma and co-occurring mental and physical health problems have been reported among Black women LWHA, and research on the benefits of social and religious support, often major protective factors among Black women, has been met with mixed findings. The current study examined the relation between anticipated HIV stigma and mental and physical health symptoms and risk and protective factors (discrimination, coping, social support) among Black women LWHA (N = 220). Results showed that greater anticipated stigma was significantly related to poorer mental health status, greater discrimination, and greater use of negative coping strategies. Stigma was not related to physical health, perceived social support or use of positive coping strategies. This study lends support to the need for psychosocial interventions that reduce anticipated stigma among individuals LWHA, particularly Black women LWHA.

Racism, African American Women, and Their Sexual and Reproductive Health: A Review of Historical and Contemporary Evidence and Implications for Health Equity

Background: The sexual and reproductive health of African American women has been compromised due to multiple experiences of racism, including discriminatory healthcare practices from slavery through the post-Civil Rights era. However, studies rarely consider how the historical underpinnings of racism negatively influence the present-day health outcomes of African American women. Although some improvements to ensure equitable healthcare have been made, these historical influences provide an unexplored context for illuminating present-day epidemiology of sexual and reproductive health disparities among African American women. Methods: To account for the unique healthcare experiences influenced by racism, including healthcare provision, we searched online databases for peer-reviewed sources and books published in English only. We explored the link between historical and current experiences of racism and sexual and reproductive health outcomes. Results: The legacy of medical experimentation and inadequate healthcare coupled with social determinants has exacerbated African American women's complex relationship with healthcare systems. The social determinants of health associated with institutionalized and interpersonal racism, including poverty, unemployment, and residential segregation, may make African American women more vulnerable to disparate sexual and reproductive health outcomes. Conclusions: The development of innovative models and strategies to improve the health of African American women may be informed by an understanding of the historical and enduring legacy of racism in the United States. Addressing sexual and reproductive health through a historical lens and ensuring the implementation of culturally appropriate programs, research, and treatment efforts will likely move public health toward achieving health equity. Furthermore, it is necessary to develop interventions that address the intersection of the social determinants of health that contribute to sexual and reproductive health inequities.

Population risk factors for late-stage presentation of cervical cancer in sub-Saharan Africa

BACKGROUND

Cervical cancer is the most prevalent malignancy in sub-Saharan Africa (SSA) with many women only seeking professional help when they are experiencing symptoms, implying late-stage malignancy and higher mortality rates. This ecological study assesses population-level exposures of SSA women to the numerous risk factors for HPV infection and cervical cancer, against late-stage presentation of cervical cancer.

MATERIALS AND METHOD

A literature review revealed the relevant risk factors in SSA. Open-access databases were mined for variables closely representing each risk factor. A proxy for late-stage presentation was used (ratio of incidence-to-mortality, IMR), and gathered from IARC's GLOBOCAN 2012 database. Variables showing significant correlation to the IMR were used in stepwise multiple regression to quantify their effect on the IMR.

RESULTS

Countries with high cervical cancer mortality rates relative to their incidence have an IMR nearer one, suggesting a larger proportion of late-stage presentation. Western Africa had the lowest median IMR (1.463), followed by Eastern Africa (IMR = 1.595) and Central Africa (IMR = 1.675), whereas Southern Africa had the highest median IMR (1.761). Variables selected for the final model explain 65.2% of changes seen in the IMR. Significant predictors of IMR were GDP (coefficient = 2.189 × 10^-6, p = 0.064), HIV infection (-1.936 × 10^-3, p = 0.095), not using a condom (-1.347 × 10^-3, p = 0.013), high parity (-1.744 × 10^-2, p = 0.008), and no formal education (-1.311 × 10^-3, p < 0.001).

CONCLUSION

Using an IMR enables identification of factors predicting late-stage cervical cancer in SSA including: GDP, HIV infection, not using a condom, high parity and no formal education.

Behavioral HIV Prevention Interventions Among Latinas in the US: A Systematic Review of the Evidence

Compared to White women, Latinas are 4 times more likely to contract HIV. In an effort to determine the overall state of the science meant to address this disparity, we reviewed the current HIV prevention intervention literature for U.S. Latinas. We searched 5 online electronic databases from their inception through July, 2014, for HIV prevention interventions including a majority sample of Latinas. Of 1041 articles identified, 20 studies met inclusion criteria. We documented study designs, participant characteristics, outcomes, theories used, and other intervention characteristics. Overall, HIV knowledge and attitudes were the predominant outcome; a small minority of studies included self-reported condom use or STD incidence. Strategies used to address cultural factors specific to Latinas and HIV included; lay health advisors, using ethnographic narratives, or using the Theory of Gender and Power, however few of the interventions adopted these strategies. This study identified several gaps in the intervention literature that need to be addressed. In addition to including more direct measures of decreased HIV risk (ex. condom use), more systematic use of strategies meant to address gender and cultural factors that may place Latinas at increased risk (e.g., gender inequity, traditional gender role norms such as machismo and marianismo, and relationship power dynamics).

Challenges and opportunities for gender-affirming healthcare for transgender women in prison

Purpose The purpose of this paper is to briefly address three interrelated areas of concerns - victimization, housing placement and healthcare provision - related to the health and welfare of transgender women in jails, prisons and other types of detention facilities. Design/methodology/approach Drawing on a growing body of research on health risks for transgender women who are detained in facilities in California and elsewhere, the authors provide recommendations for policy and practice that constitutes gender-affirming healthcare for transgender women behind bars. Findings Policymakers, correctional leaders, and prison-based clinicians have a number of opportunities to address the welfare of transgender women in jails, prisons and other types of detention facilities. Originality/value This policy brief offers concrete steps government officials can take to better meet their professional and constitutional obligations, provide higher quality care for transgender women involved in the criminal justice system, and effectuate positive changes in transgender women's health and welfare both inside and outside of carceral environments.

Southern Women at Risk: Narratives of Familial and Social HIV Risk in Justice-Involved U.S. Women in Alabama

Justice-involved HIV-positive women, particularly those in the U.S. South, are a hidden, understudied population. Little work has explored their psychosocial histories in relation to their HIV risk. We conducted a content analysis of their life history narratives from childhood to present, via in-depth interviews with 24 such women in 2 Alabama cities. Findings included the following: (a) In childhood/adolescence, consistent HIV risk factors were present, beginning with early sexual abuse and induction into alcohol/substance use; (b) By early adulthood, HIV and incarceration risks were compounded in social settings, through cyclical substance use, revictimization, and reoffending;

Capturing the Social Location of African American Mothers Living With HIV: An Inquiry Into How Social Determinants of Health Are Framed

BACKGROUND

The disparate health outcomes of African American mothers living with HIV are considerable. Multidimensional approaches are needed to address the complex social and economic conditions of their lives, collectively known as the social determinants of health.

OBJECTIVES

The purpose of this study was to explore the social determinants of health for African American mothers living with HIV by examining how mothers describe their social location at the intersection of gender, race, and class inequality; HIV-related stigma; and motherhood. How they frame the impact of their social location on their health experiences is explored.

METHODS

This exploratory study included in-depth, semistructured interviews with 18 African American mothers living with HIV at three time points. We used an intersectional framework and frame analysis to explore the meaning of these constructs for participants.

RESULTS

Findings from 48 interviews include a description of the intersecting social determinants functioning as systems of inequality and the heterogeneous social locations. Three frames of social location were used to organize and explain how African American mothers living with HIV may understand their social determinants of health: (a) an emancipatory frame, marked by attempts to transcend the negative social connotations associated with HIV and socially constructed identities of race, gender, and class; (b) a maternal frame, marked by a desire to maintain a positive maternal identity and maternal-child relations; and (c) an internalized frame, marked by an emphasis on the deleterious and stigmatizing effects of HIV, racial, gender, and class inequality.

DISCUSSION

The findings offer knowledge about the heterogeneity in how demographically similar individuals frame their social location as well as how the intersections of social determinants influence participant's health experiences. Potential health implications and interventions are suggested for the three frames of social location used to describe intersecting social determinants of health. The study offers an analytic approach for capturing the complexity inherent in intersectional methodologies examining the role of social determinants in producing health inequities.

Advice for prevention from HIV-positive African-American women: 'My story is not just a story'

Large disparities in HIV incidence, prevalence and mortality exist for African-American women, especially in the southern region of the USA. Based on the culture-centric health promotion model, HIV-positive African American women can use their stories to support primary prevention. The purpose of this study was to document advice from HIV-positive African-American women (n = 25) to young African-American women, as described in their own cultural narratives collected through qualitative interviews. Content analysis of women's advice identified five common themes revolving broadly around: (1) advice for prevention, (2) support systems for prevention, (3) education, (4) empowerment/self-care and (5) potential barriers to prevention. Advice reflected recommendations based on personal experience and highlighted social determinants linked to HIV, such as stigma, access to education and healthcare, social support, and gender and power dynamics. Women also offered advice for coping with an HIV-positive diagnosis. Communication with parents, family and friends regarding education and social support emerged as an important interpersonal factor for participants, as were interactions with sexual/romantic partners. Stigma, at the community level, was consistently discussed as a hindrance to prevention. Narratives of HIV-positive women as community health agents of change can enhance the effectiveness of HIV prevention interventions for young US African-American women.

“The Ball was Always in His Court”: An Exploratory Analysis of Relationship Scripts, Sexual Scripts, and Condom Use among African American Women

This qualitative study explored the association between African American women's interpersonal relationship and sexual scripts and condom use with primary partners. Participants were 14 lower to middle-income women between the ages of 22 and 39 involved in emotionally and sexually intimate heterosexual relationships. Relationship types included those that were: stable, emotionally committed; casual, primarily sexual; and unstable, emotionally imbalanced and/or conflict-ridden. Respondents completed a semi-structured interview and a questionnaire about their relationships, sexual, and condom use behaviors. Data analyses identified 3 interpersonal relationship scripts (i.e., men control relationships, women sustain relationships, infidelity is normative) and 2 interpersonal sexual scripts (i.e., men control sexual activity; women want to use condoms, but men control condom use) that may indirectly or directly decrease African American women's condom use with primary partners, and in turn increase their HIV risk. We discuss these interpersonal scripts within the context of sociocultural factors relevant to African American women, heterosexual relationships, and communities.

What explains gender inequalities in HIV/AIDS prevalence in sub-Saharan Africa? Evidence from the demographic and health surveys

BACKGROUND

Women are disproportionally affected by human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) in sub-Saharan Africa (SSA). The determinants of gender inequality in HIV/AIDS may vary across countries and require country-specific interventions to address them. This study aimed to identify the socio-demographic and behavioral characteristics underlying gender inequalities in HIV/AIDS in 21 SSA countries.

METHODS

We applied an extension of the Blinder-Oaxaca decomposition approach to data from Demographic and Health Surveys and AIDS Indicator Surveys to quantify the differences in HIV/AIDS prevalence between women and men attributable to socio-demographic factors, sexual behaviours, and awareness of HIV/AIDS. We decomposed gender inequalities into two components: the percentage attributable to different levels of the risk factors between women and men (the "composition effect") and the percentage attributable to risk factors having differential effects on HIV/AIDS prevalence in women and men (the "response effect").

RESULTS

Descriptive analyses showed that the difference between women and men in HIV/AIDS prevalence varied from a low of 0.68 % (P = 0.008) in Liberia to a high of 11.5 % (P < 0.001) in Swaziland. The decomposition analysis showed that 84 % (P < 0.001) and 92 % (P < 0.001) of the higher prevalence of HIV/AIDS among women in Uganda and Ghana, respectively, was explained by the different distributions of HIV/AIDS risk factors, particularly age at first sex between women and men. In the majority of countries, however, observed gender inequalities in HIV/AIDS were chiefly explained by differences in the responses to risk factors; the differential effects of age, marital status and occupation on prevalence of HIV/AIDS for women and men were among the significant contributors to this component. In Cameroon, Guinea, Malawi and Swaziland, a combination of the composition and response effects explained gender inequalities in HIV/AIDS prevalence.

CONCLUSIONS

The factors that explain gender inequality in HIV/AIDS in SSA vary by country, suggesting that country-specific interventions are needed. Unmeasured factors also contributed substantially to the difference in HIV/AIDS prevalence between women and men, highlighting the need for further study.

Is Intimate Partner and Client Violence Associated with Condomless Anal Intercourse and HIV Among Male Sex Workers in Lima, Peru?

Violence experience can increase HIV risk behaviors; however, literature is scarce on violence among male sex workers (MSWs) globally. In 2014, 210 Peruvian MSWs (median age 24.9) were interviewed about their experience of physical, emotional, and sexual violence and condom use with non-paying intimate partners and clients and were tested for HIV. Multivariable models examined relationships between violence in the past 6 months, condomless anal intercourse (CLAI) in the past 3 months and HIV infection. HIV infection (24 %), CLAI (43 %), being a violence victim (42 %) and perpetrator (39 %) were common. In separate multivariable models, being a violence victim [adjusted prevalence ratio aPR = 1.49 (95 % CI 1.09-2.03)] and perpetrator [aPR = 1.39 (1.03-1.87)] were associated with CLAI. Further, being a victim [aPR = 1.65 (1.04-2.62)] was associated with HIV infection. Violence, which was significantly associated with CLAI and HIV infection, is common among Peruvian MSWs, reinforcing the importance of violence awareness and prevention as HIV risk-reduction strategies.

Another Look at HIV in African American Women: The Impact of Psychosocial and Contextual Factors

This study tested a conceptual model that integrates structural and psychological determinants of HIV prevention for African American women. The sample consisted of African American mothers (N = 129) of children in Head Start programs. Higher levels of perceived stress were associated with higher levels of HIV risk; higher levels of perceived racism were related to higher HIV prevention behavior. A combined psychological functioning score, representing levels of depression and anger, significantly moderated the relationships of perceived stress and racism to prevention behavior. This study confirms the importance of interactions between sociostructural factors and psychological factors as predictors of health behavioral outcomes and reinforces the need to examine the impact of structural factors on psychological functioning, perceived HIV risk, and HIV prevention behavior in African American women.

The Case for Gender Equity in Health Research

Attention to health equity on the basis of economic class, caste or race has not spilled over to an effective consideration ofgender. Yet, social bias not only heavily influences health outcomes between women and men, it also affects our very understanding of biological differences with implications for understanding gender equity. Hence, when considering biological differences or special gender needs, it is necessary to be aware that biological 'givens' can also mask social norms that sanction discrimination and perpetuate health inequities. It is, therefore, particularly crucial to understand the nuances found in a gender and health equity approach and the consequences of not taking gender seriously in health research. These include the neglect of certain areas through resounding silences, the existence of misdirected or partial approaches, and the poor recognition of interactive pathways in terms of co-morbidity and multi ple social processes. After detailing this background we review the literature on the gender paradox' in health from an equity perspective. Finally, we discuss how research can contribute to improving gender equity and health by being conscious of potential biases in data, methodology and clinical research.

Women's Sexual Health: The Need for Feminist Analyses in Public Health in the Decade of Behavior

Women's sexual health is directly affected by women's low status in society. This low status, and subsequent lack of sexual autonomy not only increases risk for sexual health problems, it also decreases ability to obtain treatment and support when a sexual health concern arises. This has clearly been demonstrated in the HIV epidemic within the U.S. Earlier in the epidemic, women were simply ignored by public health research and practice. Once they could no longer be ignored, they were blamed and viewed as vectors. Current seroprevalence rates among men reveal that women are not significant vectors. In contrast, rates among women indicate that infection from men is the primary mechanism by which women are contracting HIV, and male-controlled sexual decision-making, male partner violence against women, and histories of sexual assault all contribute to increased HIV risk for women. Once infected, women are not given the support and resources they need as mothers and caretakers of HIV-positive partners and/or children. These findings are especially true for marginalized women such as women of color, poor women, women addicted to alcohol or drugs, and women who exchange sex for drugs or money. Findings from this review demonstrate the need for feminist approaches in understanding and addressing this issue in the Decade of Behavior. Such approaches must include an understanding of the needs of diverse women. An empowerment approach is needed to better contend with the sexual health needs of women; this must include the goal of ensuring women's control of their own bodies.

Individual and Partner-Level Factors Associated with Condom Non-Use Among African American STI Clinic Attendees in the Deep South: An Event-Level Analysis

The US HIV/AIDS epidemic is concentrated in the Deep South, yet factors contributing to HIV transmission are not fully understood. We examined relationships between substance use, sexual partnership characteristics, and condom non-use in an African American sample of STI clinic attendees in Jackson, Mississippi. We assessed condom non-use at last intercourse with up to three recent sexual partners reported by participants between January and June 2011. Participant- and partner-level correlates of condom non-use were examined using generalized estimating equations. The 1295 participants reported 2880 intercourse events, of which 1490 (51.7 %) involved condom non-use. Older age, lower educational attainment, reporting financial or material dependence on a sex partner, sex with a primary partner, and higher frequency of sex were associated with increased odds of condomless sex. HIV prevention efforts in the South should address underlying socioeconomic disparities and structural determinants that result in partner dependency and sexual risk behavior.

A Social Ecological Model of Syndemic Risk affecting Women with and At-Risk for HIV in Impoverished Urban Communities

Syndemic risk is an ecological construct, defined by co-occurring interdependent socio-environmental, interpersonal and intrapersonal determinants. We posited syndemic risk to be a function of violence, substance use, perceived financial hardship, emotional distress and self-worth among women with and at-risk for HIV in an impoverished urban community. In order to better understand these interrelationships, we developed and validated a system dynamics (SD) model based upon peer-reviewed literature; secondary data analyses of a cohort dataset including women living with and at-risk of HIV in Bronx, NY (N = 620); and input from a Bronx-based community advisory board. Simulated model output revealed divergent levels and patterns of syndemic risk over time across different sample profiles. Outputs generated new insights about how to effectively explore multicomponent multi-level programs in order to strategically develop more effective services for this population. Specifically, the model indicated that effective multi-level interventions might bolster women's resilience by increasing self-worth, which may result in decreased perceived financial hardship and risk of violence. Overall, our stakeholder-informed model depicts how self-worth may be a major driver of vulnerability and a meaningful addition to syndemic theory affecting this population.

Perspectives on safer conception practices and preconception counseling among women living with HIV

Pregnancies are frequently unplanned, and higher rates of unplanned pregnancies occur among HIV-infected women. Reviewers examined reproductive decision making, conception practices, and patient-provider communication among women living with HIV. Qualitative interviews were conducted with 19 HIV-infected sexually active women aged 18-45 in southern Florida, USA. Using thematic analysis, we found decisions to conceive were influenced by women and partners; knowledge and use of safer conception practices were low. Discussion and support from partners, family, and providers was limited and diminished by stigma and nondisclosure. Preconception counseling discussions in HIV care should be comprehensive and initiated frequently by all health care providers.

Substance use, mental illness, and familial conflict non-negotiation among HIV-positive African-Americans: latent class regression and a new syndemic framework

We evaluated a synergistic epidemic (syndemic) of substance use, mental illness, and familial conflict non-negotiation among HIV-positive injection drug users (IDU). Baseline BEACON study data was utilized. Latent class analyses identified syndemic classes. These classes were regressed on sex, viral suppression, and acute care non-utilization. Females were hypothesized to have higher syndemic burden, and worse health outcomes than males. Nine percent of participants had high substance use/mental illness prevalence (Class 4); 23 % had moderate levels of all factors (Class 3); 25 % had high mental illness (Class 2); 43 % had moderate substance use/mental illness (Class 1; N = 331). Compared to Classes 1-3, Class 4 was mostly female (p < .05), less likely to achieve viral suppression, and more likely to utilize acute care (p < .05). Interventions should target African-American IDU females to improve their risk of negative medical outcomes. Findings support comprehensive syndemic approaches to HIV interventions, rather than singular treatment methods.

Male Contraception: Research, New Methods, and Implications for Marginalized Populations

The majority of research on contraception has focused on manipulating the female reproductive system. Recent studies have identified novel contraceptives for males, including hormonal- and nonhormonal-based therapeutics. Although these new contraceptives are still undergoing clinical trials, their development and potential future use in society necessitate serious consideration of their implications for reproductive health. Through my analysis of the research conducted on male contraception over time and the current therapeutics available, it is clear that male contraception has the potential to shift societal gender dynamics and provide males with greater control over their own reproduction. This article also identifies the implications of these novel contraceptives for marginalized populations, especially men of color and men of lower socioeconomic positions. To overcome barriers to contraception among these populations, public policy efforts are needed in order to motivate the development of programs that facilitate coverage of these new male contraceptives by health plans and to increase their availability to underserved communities. Health care providers will be responsible for educating patients about these novel male contraception options and the need to continue using existing methods (e.g., condoms) in order to prevent sexually transmitted infections. This article analyzes the research conducted on male contraception and identifies the implications of these novel therapeutics for marginalized groups of men in the United States to identify the interventions that will be necessary to help ensure that all men have access to these promising scientific innovations.

Health service use and social vulnerability in a community-based sample of women on probation and parole, 2011–2013

Background

Most women involved in the criminal justice system are not incarcerated, but rather on probation or parole. We examined the receipt of health services and social vulnerability among women on parole or probation in the past year.

Methods

In a community-based sample of 776 women who use crack cocaine or injection drugs, we compared those who had been on probation or parole in the past year with those who had no criminal justice involvement in the past year.

Results

Women recently on probation or people were no more likely have health insurance, or to receive most health services, than women not in the criminal justice system. In addition, we found social vulnerabilities that contribute to poor health to be significantly more prevalent among women on probation or parole.

Conclusions

There is a missed opportunity to address health and social needs of women on probation or parole.

Rejection Sensitivity, Perceived Power, and HIV Risk in the Relationships of Low-Income Urban Women

The psychological processes associated with HIV infection in long-term relationships differ from those operative in casual sexual encounters, and relatively little research has considered the aspects of personality applicable in the ongoing heterosexual relationships in which women are at greatest risk. Sensitivity to rejection has been linked with efforts to prevent rejection at a cost to the self and, therefore, may be relevant to the health risks that many women incur in relationships. We examined the association of rejection sensitivity with women's sexual risk behavior in a sample of women at heightened risk for HIV exposure. Women in long-term heterosexual relationships (N = 159) were recruited for study participation in the hospital emergency room serving a low-income neighborhood in New York City, in 2001-2003. Rejection sensitivity and known HIV risk factors were assessed using verbally administered questionnaires. Rejection sensitivity was associated with lower perceived relationship power and, in turn, more frequent unprotected sex with a partner perceived to be at risk for HIV. These results held when controlling for other HIV risk factors including partner violence, economic dependence, and substance use. Understanding the association of rejection concerns with lower perceived personal power in relationships may be important for HIV prevention.

Female and male differences in AIDS diagnosis rates among people who inject drugs in large U.S. metro areas from 1993 to 2007

PURPOSE

We estimated female and male incident AIDS diagnosis rates (IARs) among people who inject drugs (PWID) in U.S. metropolitan statistical areas (MSAs) over time to assess whether declines in IARs varied by sex after combination antiretroviral therapy (cART) dissemination.

METHODS

We compared IARs and 95% confidence intervals for female and male PWID in 95 of the most populous MSAs. To stabilize estimates, we aggregated data across three-year periods, selecting a period immediately preceding cART (1993-1995) and the most recent after the introduction of cART for which data were available (2005-2007). We assessed disparities by comparing IAR 95% confidence intervals for overlap, female-to-male risk ratios, and disparity change scores.

RESULTS

IARs declined an average of 58% for female PWID and 67% for male PWID between the pre-cART and cART periods. Among female PWID, IARs were significantly lower in the later period relative to the pre-cART period in 48% of MSAs. Among male PWID, IARs were significantly lower over time in 86% of MSAs.

CONCLUSIONS

IARs among female PWID in large U.S. MSAs have declined more slowly than among male PWID. This suggests a need for increased targeting of prevention and treatment programs and for research on MSA level conditions that may drive differences in declining AIDS rates among female and male PWID.

Using an intersectional approach to study the impact of social determinants of health for African American mothers living with HIV

Heightened awareness of the social determinants of health by health scientists and clinicians has failed to translate into significant progress in the amelioration of those social determinants contributing to health inequities. The purpose of this article is to broaden the discussion about conceptual approaches nurse scientists can use to address health and health inequities. We will apply an intersectional approach to the study of the social determinants of health for African American mothers living with human immunodeficiency virus and through this explore the utility of an intersectional approach to generate knowledge in nursing.

Resilience among women with HIV: Impact of silencing the self and socioeconomic factors

In the U.S., women account for over a quarter of the approximately 50,000 annual new HIV diagnoses and face intersecting and ubiquitous adversities including gender inequities, sexism, poverty, violence, and limited access to quality education and employment. Women are also subjected to prescribed gender roles such as silencing their needs in interpersonal relationships, which may lessen their ability to be resilient and function adaptively following adversity. Previous studies have often highlighted the struggles encountered by women with HIV without focusing on their strengths. The present cross-sectional study investigated the relationships of silencing the self and socioeconomic factors (education, employment, and income) with resilience in a sample of women with HIV. The sample consisted of 85 women with HIV, diverse ethnic/racial groups, aged 24 - 65 enrolled at the Chicago site of the Women's Interagency HIV Study in the midwestern region of the United States. Measures included the Connor-Davidson Resilience Scale -10 item and the Silencing the Self Scale (STSS). Participants showed high levels of resilience. Women with lower scores on the STSS (lower self-silencing) reported significantly higher resilience compared to women with higher STSS scores. Although employment significantly related to higher resilience, silencing the self tended to predict resilience over and above the contributions of employment, income, and education. Results suggest that intervention and prevention efforts aimed at decreasing silencing the self and increasing employment opportunities may improve resilience.

Youth, violence and non-injection drug use: nexus of vulnerabilities among lesbian and bisexual sex workers

Despite increasing evidence of enhanced HIV risk among sexual minority populations, and sex workers (SWs) in particular, there remains a paucity of epidemiological data on the risk environments of SWs who identify as lesbian or bisexual. Therefore, this short report describes a study that examined the individual, interpersonal and structural associations with lesbian or bisexual identity among SWs in Vancouver, Canada. Analysis drew on data from an open prospective cohort of street and hidden off-street SWs in Vancouver. Bivariate and multivariable logistic regressions were used to examine the independent relationships between individual, interpersonal, work environment and structural factors and lesbian or bisexual identity. Of the 510 individuals in our sample, 95 (18.6%) identified as lesbian or bisexual. In multivariable analysis, reporting non-injection drug use in the last six months (adjusted odds ratio [AOR] = 2.89; 95% confidence intervals [CI] = 1.42, 5.75), youth ≤24 years of age (AOR = 2.43; 95% CI = 1.24, 4.73) and experiencing client-perpetrated verbal, physical and/or sexual violence in the last six months (AOR = 1.85; 95% CI = 1.15, 2.98) remained independently associated with lesbian/bisexual identity, after adjusting for potential confounders. The findings demonstrate an urgent need for evidence-based social and structural HIV prevention interventions. In particular, policies and programmes tailored to lesbian and bisexual youth and women working in sex work, including those that prevent violence and address issues of non-injection stimulant use are required.

What lies behind gender inequalities in HIV/AIDS in sub-Saharan African countries: evidence from Kenya, Lesotho and Tanzania

Within sub-Saharan Africa, women are disproportionately at risk for acquiring and having human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). It is important to clarify whether gender inequalities in HIV prevalence in this region are explained by differences in the distributions of HIV risk factors, differences in the effects of these risk factors or some combination of both. We used an extension of the Blinder-Oaxaca decomposition approach to explain gender inequalities in HIV/AIDS in Kenya, Lesotho and Tanzania using data from the demographic and health and AIDS indicator surveys. After adjusting for covariates using Poisson regression models, female gender was associated with a higher prevalence of HIV/AIDS in Kenya [prevalence ratio (PR) = 1.73, 95% confidence interval (CI) = 1.33, 2.23 in 2003] and Lesotho (PR = 1.39, 95% CI = 1.20, 1.62 in 2004/05), but not in Tanzania. Decomposition analyses demonstrated two distinct patterns over time. In Tanzania, the gender inequality in HIV/AIDS was explained by differences in the distributions of HIV risk factors between men and women. In contrast, in Kenya and Lesotho, this inequality was partly explained by differences in the effects across men and women of measured HIV/AIDS risk factors, including socio-demographic characteristics (age and marital status) and sexual behaviours (age at first sex); these results imply that gender inequalities in HIV/AIDS would persist in Kenya and Lesotho even if men and women had similar distributions of HIV risk factors. The production of gender inequalities may vary across countries, with inequalities attributable to the unequal distribution of risk factors among men and women in some countries and the differential effect of these factors between groups in others. These different patterns have important implications for policies to reduce gender inequalities in HIV/AIDS.

Income inequality and sexually transmitted in the United States: who bears the burden?

Three causal processes have been proposed to explain associations between group income inequality and individual health outcomes, each of which implies health effects for different segments of the population. We present a novel conceptual and analytic framework for the quantitative evaluation of these pathways, assessing the contribution of: (i) absolute deprivation - affecting the poor in all settings - using family income; (ii) structural inequality - affecting all those in unequal settings - using the Gini coefficient; and (iii) relative deprivation - affecting only the poor in unequal settings - using the Yitzhaki index. We conceptualize relative deprivation as the interaction of absolute deprivation and structural inequality. We test our approach using hierarchical models of 11,183 individuals in the National Longitudinal Study of Adolescent Health (Add Health). We examine the relationship between school-level inequality and sexually transmitted infections (STI) - self-reported or laboratory-confirmed Chlamydia, Gonorrhoea or Trichomoniasis. Results suggest that increased poverty and inequality were both independently associated with STI diagnosis, and that being poor in an unequal community imposed an additional risk. However, the effects of inequality and relative deprivation were confounded by individuals' race/ethnicity.

HIV-positive and in jail: race, risk factors, and prior access to care

Black individuals represent 13 % of the US population but 46 % of HIV positive persons and 40 % of incarcerated persons. The national EnhanceLink project evaluated characteristics of HIV-positive jail entrants at ten sites and explored associations between race and HIV disease state. Between 1/2008 and 10/2011, 1,270 study participants provided demographic and clinical data. Adjusted odds ratios (aORs) were calculated for advanced HIV disease (CD4 < 200 cells/mm(3)) and uncontrolled viremia (viral load > 400 copies/ml) for Black (n = 807) versus non-Black (n = 426) participants. Sixty-five percent of HIV-positive jail participants self-identified as Black. Among all participants, fewer than half had a high school diploma or GED, the median number of lifetime arrests was 15, and major mental illness and substance abuse were common. Black participants were more likely to be older than non-Black participants, and less likely to have health insurance (70 vs 83 %) or an HIV provider (73 vs 81 %) in the prior 30 days. Among all male study participants (n = 870), 20 % self-identified as homosexual or bisexual. Black male participants were more likely to be homosexual or bisexual (22 vs 16 %) and less likely to have a history of injection drug use (20 vs 50 %) than non-Black male participants. Advanced HIV disease was associated with self-identification as Black (aOR = 1.84, 95 % CI 1.16-2.93) and time since HIV diagnosis of more than two years (aOR = 3.55, 95 % CI 1.52-8.31); advanced disease was inversely associated with age of less than 38 years (aOR = 0.41, 95 % CI 0.24-0.70). Uncontrolled viremia was inversely associated with use of antiretroviral therapy (ART) in the prior 7 days (aOR = 0.25, 95 % CI 0.15-0.43) and insurance coverage in the prior 30 days (aOR = 0.46, 95 % CI 0.26-0.81).

CONCLUSIONS

The racial disparities of HIV and incarceration among Black individuals in the US are underscored by the finding that 65 % of HIV-positive jail participants self-identified as Black in this ten-site study. Our study also found that 22 % of Black male participants self-identified as men who have sex with men (MSM). We believe these findings support jails as strategic venues to reach heterosexual, bisexual, and homosexual HIV-positive Black men who may have been overlooked in the community. Among HIV-positive jail entrants, Black individuals had more advanced HIV disease. Self-identification as Black was associated with a lower likelihood of having health insurance or an HIV provider prior to incarceration. HIV care and linkage interventions are needed within jails to better treat HIV and to address these racial disparities.

Client demands for unsafe sex: the socioeconomic risk environment for HIV among street and off-street sex workers

OBJECTIVE

Among sex workers (SWs) in Vancouver, Canada, this study identified social, drug use, sex work, environmental-structural, and client-related factors associated with being offered and accepting more money after clients' demand for sex without a condom.

DESIGN

Cross-sectional study using baseline (February 2010 to October 2011) data from a longitudinal cohort of 510 SWs.

METHODS

A 2-part multivariable regression model was used to identify factors associated with 2 separate outcomes: (1) being offered more money for sex without a condom in the last 6 months; and (2) accepting more money, among those who had been offered more money.

RESULTS

The sample included 490 SWs. In multivariable analysis, being offered more money for sex without a condom was more likely for SWs who used speedballs, had higher average numbers of clients per week, had difficulty accessing condoms, and had clients who visited other SWs. Accepting more money for sex without a condom was more likely for SWs self-reporting as a sexual minority and who had experienced client violence and used crystal methamphetamine less than daily (versus none) and less likely for SWs who solicited mainly indoors for clients (versus outdoor/public places).

CONCLUSIONS

These results highlight the high demand for sex without a condom by clients of SWs. HIV prevention efforts should shift responsibility toward clients to reduce offers of more money for unsafe sex. Programs that mitigate the social and economic risk environments of SWs alongside the removal of criminal sanctions on sex work to enable condom use within safer indoor workspaces are urgently required.

Identifying programmatic gaps: inequities in harm reduction service utilization among male and female drug users in Dar es Salaam, Tanzania

Introduction

Current estimates suggest an HIV prevalence of 42% among people who inject drugs (PWIDs) in Dar es Salaam, while HIV prevalence is estimated to be 8.8% among the general population in the city. To address the HIV epidemic in this population, the government of Tanzania began establishing HIV prevention, treatment and care services including outreach and medication assisted treatment (MAT) for PWIDs in 2010. We assessed gender inequities in utilization of outreach and MAT services and evaluated differences in HIV risk behaviors between female and male PWIDs.

Materials and Methods

Routine outreach data between December 2010 to mid-August 2012 and baseline data on clients enrolling in methadone from February 2011 to August 2012 were utilized. Binomial regression was used to estimate adjusted relative risk estimates comparing females to males.

Results

From December 2010 to August 2012, 8,578 contacts were made to drug users; among them 1,898 were injectors. A total of 453 injectors were eligible and referred to MAT, of which, 443 enrolled in treatment. However, regarding total outreach contacts, outreach to PWID, referral to MAT and enrollment in MAT, 8% or less of drug users accessing services were women. In contrast, weighted estimations from surveys suggest that 34% of PWIDs are female, and this approximation is similar to recent population size estimations. Overall, 43% of traditional outreach workers conducting outreach with drug users were female. Though reporting higher levels of condom usage, female PWID were more likely to report multiple sex partners, anal sex, commercial sex work and struggle under a higher burden of addiction, mental disorders and abuse.

Conclusions

Services have not been mobilized adequately to address the clear needs of females who inject drugs. A clear and urgent need exists for women-centered strategies that effectively engage female PWID into HIV prevention services.

The impact of social context on self-management in women living with HIV

HIV self-management is central to the health of people living with HIV and is comprised of the daily tasks individuals employ to manage their illness. Women living with HIV are confronted with social context vulnerabilities that impede their ability to conduct HIV self-management behaviors, including demanding social roles, poverty, homelessness, decreased social capital, and limited access to health care. We examined the relationship between these vulnerabilities and HIV self-management in a cross-sectional secondary analysis of 260 women living with HIV from two U.S. sites. All social context variables were assessed using validated self-report scales. HIV Self-Management was assessed using the HIV Self-Management Scale that measures daily health practices, HIV social support, and the chronic nature of HIV. Data were analyzed using appropriate descriptive statistics and multivariable regression. Mean age was 46 years and 65% of participants were African-American. Results indicated that social context variables, particularly social capital, significantly predicted all domains of HIV self-management including daily health practices (F = 5.40, adjusted R(2) = 0.27, p < 0.01), HIV social support (F = 4.50, adjusted R(2) = 0.22, p < 0.01), and accepting the chronic nature of HIV (F = 5.57, adjusted R(2) = 0.27, p < 0.01). We found evidence to support the influence of the traditional social roles of mother and employee on the daily health practices and the chronic nature of HIV domains of HIV self-management. Our data support the idea that women's social context influences their HIV self-management behavior. While social context has been previously identified as important, our data provide new evidence on which aspects of social context might be important targets of self-management interventions for women living with HIV. Working to improve social capital and to incorporate social roles into the daily health practices of women living with HIV may improve the health of this population.

Experiences of racial discrimination and relation to sexual risk for HIV among a sample of urban black and African American men

This study aimed to examine racial discrimination and relation to sexual risk for HIV among a sample of urban black and African American men. Participants of this cross-sectional study were black and African American men (N = 703) between the ages of 18 and 65 years, recruited from four urban clinical sites in the northeast. Multivariate logistic regression models were used to analyze the relation of reported racial discrimination to the following: (1) sex trade involvement, (2) recent unprotected sex, and (3) reporting a number of sex partners in the past 12 months greater than the sample average. The majority of the sample (96%) reported racial discrimination. In adjusted analyses, men reporting high levels of discrimination were significantly more likely to report recent sex trade involvement (buying and/or selling) (adjusted odds ratio (AOR) range = 1.7-2.3), having recent unprotected vaginal sex with a female partner (AOR = 1.4, 95% confidence interval (CI), 1.1-2.0), and reporting more than four sex partners in the past year (AOR = 1.4, 95% CI, 1.1-1.9). Findings highlight the link between experiences of racial discrimination and men's sexual risk for HIV.

Gender based violence as a risk factor for HIV-associated risk behaviors among female sex workers in Armenia

This cross-sectional study identified the prevalence of gender based violence (GBV) and examined its association with sexual risk behavior among female sex workers (FSWs). Among 120 participants between ages 20 and 52, a total of 56.7 % reported lifetime GBV. Multivariate analyses revealed that GBV was significantly associated with inconsistent condom use, unprotected sex, condom misuse, fear of client reaction to requests of condom use, self-reported history of STIs, and earlier age of initiation of sex work. GBV must be considered an urgent public health priority among FSWs in Armenia. Interventions addressing FSWs, in addition to targeting skill-based, sexual risk reduction must also introduce a discourse among FSWs, sexual partners, clients and community members about the role of GBV in HIV-associated risk behaviors and infection. Structural level initiatives must address economic opportunities for women, health-sector policies and responses to FSWs' health needs, law enforcement training and societal norms toward women.

Measuring socioeconomic inequality in the incidence of AIDS: rural-urban considerations

Low socioeconomic status (SES) influences the risk of acquiring human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and thus should be considered when analyzing HIV/AIDS surveillance data. Most surveillance systems do not collect individual level SES data but do collect residential ZIP code. We developed SES deprivation indices at the ZIP code tabulation area and assessed their predictive validity for AIDS incidence relative to individual neighborhood-level indicators in Florida using reliability analysis, factor analysis with principal component factorization, and structural equation modeling. For urban areas an index of poverty performed best, although the single factor poverty also performed well. For rural areas no index performed well, but the individual indicators of no access to a car and crowding performed well. In rural areas poverty was not associated with increased AIDS incidence. Users of HIV/AIDS surveillance data should consider urban and rural areas separately when assessing the impact of SES on AIDS incidence.

Sex inequality, high transport costs, and exposed clinic location: reasons for loss to follow-up of clients under prevention of mother-to-child HIV transmission in eastern Uganda - a qualitative study

BACKGROUND

In Iganga, Uganda, 45% of women who tested HIV-positive during antenatal care between 2007 and 2010 were lost to follow-up (LTFU). We explored reasons for LTFU during prevention of mother-to-child transmission (PMTCT) from a client perspective in eastern Uganda, where antiretroviral therapy (ART) awareness is presumably high.

METHODS

Seven key informant interviews and 20 in-depth interviews, including both clients who had been retained under PMTCT care and those LTFU during PMTCT were held. Ten focus-group discussions involving a total of 112 participants were also conducted with caretakers/ relatives of the PMTCT clients. Content analysis was performed to identify recurrent themes.

RESULTS

Our findings indicate that LTFU during PMTCT in eastern Uganda was due to sex inequality, high transport costs to access the services, inadequate posttest counseling, lack of HIV status disclosure, and the isolated/exposed location of the ART clinic, which robs the clients of their privacy.

CONCLUSION

There is a need for approaches that empower women with social capital, knowledge, and skills to influence health-seeking practices. There is also a need to train low-ranking staff and take PMTCT services closer to the clients at the lower-level units to make them affordable and accessible to rural clients. Posttest counseling should be improved to enable PMTCT clients to appreciate the importance of PMTCT services through increasing the number of staff in antenatal care to match the client numbers for improved quality. The counseling should emphasize HIV status disclosure to partners and encourage partner escort for antenatal care visits for further counseling. The exposed and isolated ART clinic should be integrated with the other regular outpatient services to reduce the labeling stigma.