Non-adherence to antiretroviral treatment among migrating fishermen in western Kenya's islands: a rapid qualitative study

Fishing communities in many Sub-Saharan African countries are a high-risk population group disproportionately affected by the HIV epidemic. The association of migration with HIV and AIDS in sub-Saharan Africa is well documented. Frequent mobility, high consumption of alcohol, multiple sexual partners, transactional and commercial sex, poor health infrastructure and limited access to health services are reported among the main factors shaping the HIV epidemic in fishing communities. Moreover, studies have been conducted in sub-Saharan Africa on adherence to antiretroviral treatment (ART) among fishers; however, non-adherence to ART remains poorly understood among migrating fishermen in the western Kenya islands. This qualitative study investigated factors contributing to non-adherence among fishermen in the western Kenya islands. This study utilised 51 in-depth interviews and six focus group discussions to highlight factors contributing to non-adherence to ART by mobile fishermen. Data were analysed using a contextualised thematic analysis. Results show that migration, alcohol consumption and ART sharing contributed to non-adherence. Adherence to ART is a powerful predictor of survival for individuals living with HIV and AIDS. The Kenyan government can use lessons from this study to target fishermen to achieve the UNAIDS 2025 recommendations on people-centred and context-specific service responses to AIDS as this would move Kenya closer to the 90% reduction in annual infections by 2030. This article contributes to a deeper understanding of how and why fishermen from the islands in western Kenya struggle to adhere to treatment even though they can access ARTs through the public health care system. Longitudinal studies should be conducted to explore how the factors associated with non-adherence correlate with other key health outcomes such as drug resistance.

Extreme weather events and HIV: development of a conceptual framework through qualitative interviews with people with HIV impacted by the California wildfires and their clinicians

BACKGROUND

People with HIV (PWH) are disproportionately vulnerable to the impacts of wildfires, given the need for frequent access to healthcare systems, higher burden of comorbidities, higher food insecurity, mental and behavioral health challenges, and challenges of living with HIV in a rural area. In this study, we aim to better understand the pathways through which wildfires impact health outcomes among PWH.

METHODS

From October 2021 through February 2022, we conducted individual semi-structured qualitative interviews with PWH impacted by the Northern California wildfires and clinicians of PWH who were impacted by wildfires. The study aims were to explore the influence of wildfires on the health of PWH and to discuss measures at the individual, clinic, and system levels that helped to mitigate these impacts.

RESULTS

We interviewed 15 PWH and 7 clinicians. While some PWH felt that surviving the HIV epidemic added to their resilience against wildfires, many felt that the wildfires compounded the HIV-related traumas that they have experienced. Participants outlined five main routes by which wildfires negatively impacted their health: (1) access to healthcare (medications, clinics, clinic staff), (2) mental health (trauma; anxiety, depression, or stress; sleep disturbances; coping strategies), (3) physical health (cardiopulmonary, other co-morbidities), (4) social/economic impacts (housing, finances, community), and (5) nutrition and exercise. The recommendations for future wildfire preparedness were at the (1) individual-level (what to have during evacuation), (2) pharmacy-level (procedural, staffing), and (3) clinic- or county-level (funds and vouchers; case management; mental health services; emergency response planning; other services such as telehealth, home visits, home laboratory testing).

CONCLUSIONS

Based on our data and prior research, we devised a conceptual framework that acknowledges the impact of wildfires at the community-, household-, and individual-level with implications for physical and mental health outcomes among PWH. These findings and framework can help in developing future interventions, programs, and policies to mitigate the cumulative impacts of extreme weather events on the health of PWH, particularly among individuals living in rural areas. Further studies are needed to examine health system strengthening strategies, innovative methods to improve access to healthcare, and community resilience through disaster preparedness.

TRIAL REGISTRATION

N/A.

Migration, personal physical safety and economic survival: drivers of risky sexual behaviour among rural–urban migrant street youth in Kampala, Uganda

Background

Despite the vulnerabilities associated with the youth migration process, knowledge on the drivers of risky sexual behaviour among migrant street youth is limited. This study sought to explore the pathways driving risky sexual behaviour among rural–urban migrant street youth in Kampala, Uganda.

Methods

We conducted 11 focus-group discussions composed of 8–10 participants each, and 15 in-depth interviews with urban street adolescents and youth aged 12–24 years. We purposively recruited street youth who had migrated from other districts to Kampala, Uganda, and who identified themselves as street youth. Data were analysed thematically using an inductive approach facilitated by Dedoose software.

Results

The migration journey acted as a catalyst for risky sexual behaviour among the adolescents and youth moving from rural districts to Kampala. Three primary pathways were found to drive risky sexual behaviour of street youth: 1) rural–urban migration itself, through sexual exploitation of and violence toward street youth especially young girls during movement, 2) economic survival through engaging in casual jobs and sex work upon arrival in the city, and 3) personal physical safety through friendships and networks, which consequently lead to having multiple sexual partners and unprotected sex. Engagement in risky sexual behaviour, especially sex work, was found to be an adaptation to the challenging and complex street life within the city.

Conclusions

This study highlights the migration process, personal physical safety and economic survival as major pathways driving risky sexual behaviour among rural–urban street youth in Kampala. Interventions to improve sexual health, physical safety and protection of street youth during the migration process and within the city spaces should be prioritised.

Migration and Mobility: Correlates of Recent HIV Testing Among Substance Using Female Sex Workers at the Mexico-Guatemala Border

The goal of this paper is to determine the association between traveling to engage in sex work in another country and recent access to HIV testing among substance-using female sex workers (FSWs) in the Mexico-Guatemala border region. From 2012 to 2015, through modified time-location sampling and peer referral, 255 FSWs were recruited at Mexico's southern border. Participants completed questionnaires on sociodemographics, migration and mobility experiences, work environment factors, and substance use. A conceptual framework, as depicted by a directed acyclic graph (DAG), guided our analysis. Crude and adjusted logistic regression models were used to evaluate the relationships between mobility experiences and HIV testing in the past year. Overall HIV testing was low (41%); after considering relevant covariates (i.e., interaction with health services and organizations, and sex work characteristics) traveling to engage in sex work in another country was found to be positively associated with HIV testing in the past year. Future efforts need to consider voluntary and non-stigmatizing prevention HIV services and focus on reaching out to less mobile women.

Factors determining sexual behaviour amongst siddi tribe migrating to Udupi district, India: A cross-sectional study

Background

Afro-Indians, locally known as Siddi, are the tribal community descended from the Bantu populace from eastern Africa found in Goa, Gujarat and Karnataka along the Indian west coast. This study determines knowledge, attitude and sexual behaviour amongst the Siddi population in the Udupi district.

Materials and Methods

A cross-sectional study was conducted from October 2018 to September 2019; men and women aged above 18 years who lived in the locality at the time of the survey were included in the study.

Results

A total of 108 Siddi individuals participated in this study. The mean age of the respondents was 31.8 ± 9.5 years. More than half (51.8%) of the respondents received information on sexual matters through friends. Awareness regarding the usage of condoms and other preventive measures was poor (34.7%). Around 65.7% of the respondents felt that sex education in school encourages sex amongst youngsters. The mean age at the first sexual intercourse amongst men and women was 20.3 years and 16.2 years, respectively. About 18.7% of the respondents had sex with a new partner in the migrated place within the last 1 month, of which 80% were married. Only 5% of the respondents used condoms while indulging in sex with a new partner at the migrated place. Factors such as age at marriage, age at the first sexual act and attitude towards sexual activity were significantly associated with a new sex partner at the arrival site.

Conclusion

There is a high prevalence of unsafe sexual practices amongst the migrated Siddi tribe at the place of destination. This poses the risk of sexually transmitted infections amongst the migrant tribes and local communities at the place of destination and the location of origin. The study finding shows that measures should be taken to create awareness, and change in attitude towards sexual matter should be channelised at an early age amongst the Siddi population.

The Synergistic Relationship Between Climate Change and the HIV/AIDS Epidemic: A Conceptual Framework

Climate change and HIV/AIDS represent two of the greatest threats to human health in the 21st century. However, limitations in understanding the complex relationship between these syndemics continue to constrain advancements in the prevention and management of HIV/AIDS in the context of a rapidly changing climate. Here, we present a conceptual framework that identifies four pathways linking climate change with HIV/AIDS transmission and health outcomes: increased food insecurity, increased prevalence of other infectious diseases, increased human migration, and erosion of public health infrastructure. This framework is based on an in-depth literature review in PubMed and Google Scholar from June 6 to June 27, 2019. The pathways linking climate change with HIV transmission and health outcomes are complex with multiple interacting factors. Food insecurity emerged as a particularly important mediator by driving sexual risk-taking behaviours and migration, as well as by increasing susceptibility to infections that are common among people living with HIV (PLWHIV). Future interventions should focus on decreasing carbon dioxide emissions globally and increasing education and investment in adaptation strategies, particularly in those areas of sub-Saharan Africa and southeast Asia heavily impacted by both HIV and climate change. Environmentally sustainable interventions such as urban gardening and investing in sustainable agriculture technologies also have significant health co-benefits that may help PLWHIV adapt to the environmental consequences of climate change.

Mobility and its Effects on HIV Acquisition and Treatment Engagement: Recent Theoretical and Empirical Advances

PURPOSE OF REVIEW

We reviewed literature across multiple disciplines to describe issues with the measurement of population mobility in HIV research and to summarize evidence of causal pathways linking mobility to HIV acquisition risks and treatment engagement, with a focus on sub-Saharan Africa.

RECENT FINDINGS

While the literature on mobility and HIV remains hampered by problems and inconsistency in measures of mobility, the recent research reveals a turn towards a greater attentiveness to measurement and gender. Theoretical and heuristic models for the study of mobility and HIV acquisition and treatment outcomes have been published, but few studies have used longitudinal designs with clear ascertainment of exposures and outcomes for measurement of causal pathways. Notwithstanding these limitations, evidence continues to accumulate that mobility is linked to higher HIV incidence, and that it challenges optimal treatment engagement. Gender continues to be important: while men are more mobile than women, women's mobility particularly heightens their HIV acquisition risks. Recent large-scale efforts to find, test, and treat the individuals in communities who are most at risk of sustaining local HIV transmission have been severely challenged by mobility. Novel interventions, policies, and health systems improvements are urgently needed to fully engage mobile individuals in HIV care and prevention. Interventions targeting the HIV prevention and care needs of mobile populations remain few in number and urgently needed.

Spousal migration and married adults' psychological distress in rural China: The roles of intimacy, autonomy and responsibility

Spousal separation due to migration is a prevalent phenomenon in the developing world, but its psychological consequences for left-behind partners are largely understudied. Using data from 2010, 2012 and 2014 China Family Panel Studies (CFPS), this paper first examined whether spousal migration causes rural married adults any psychological distress; this finding was then advanced by testing the mechanisms that could potentially explain the linkage between these two variables. Inverse Probability Weighting (IPW) for multivalued treatment effect models and paired Propensity Score Matching (PSM) have been used to correct the potential selection bias of spousal migration. The results show that prolonged spousal separation through migration increases the depressive symptoms of married adults in rural China, and the detrimental effects on left-behind spouses' psychological well-being can be explained by the reduced level of emotional intimacy between husband and wife, and partially by women becoming the master of the household. Considering that being the master of the household is accompanied by elevated stress levels associated with increasing family responsibilities, further examination showed that economic resources can buffer the negative effect associated with being the master of the household when the spouse migrates. However, we did not find that time use is an effective mechanism to link spousal migration and left-behind spouses' well-being.

Nativity Homogeneity in Social Networks and Prostitution Patronage Among Male Migrant Laborers

Previous studies have repeatedly found the association between network homogeneity based on native-place and sexual risk behaviors among migrants. However, it remains unclear why such a simple numerical property of network composition can be correlated with a sexual risk behavior. Using a dataset (n = 1591) with detailed information on the sexual behaviors among male migrant laborers in the two Chinese provinces with the highest migrant inflows, we confirmed network homogeneity is significantly associated with prostitution patronage. With structural equation modeling, we further found that half of network homogeneity’s impact on prostitution patronage is mediated by three factors: peer deviance, family bonds, and hedonistic subcultural beliefs. In addition, network homogeneity’s association with hedonistic subcultural beliefs is fully mediated by peer deviance. Although the nativity homogeneity in social networks is still associated with prostitution patronage, more proximate psycho-social factors are found responsible for the network effect. Health policies seeking to integrate migrant laborers, removing the policy barriers against family bonds, and providing alternative sources of social support are highly promising for reducing sexual risk behavior among this population.

Male Migration, Women Left Behind, and Sexually Transmitted Diseases in Armenia

The effect of male circular labor migration on risks of sexually transmitted diseases (STDs) among women left behind has not been well studied. Our study examines this effect using data from a survey of 1,240 married women in rural Armenia, where international male labor migration has traditionally been very common. A multivariate comparison of women married to migrants and women married to non-migrants finds that the former, ceteris paribus, reported more STD symptoms, on average, and were more likely to report diagnosed STDs than the latter. However, in the case of STD symptoms, this effect is moderated by household income, as the predicted number of STD symptoms reported by migrants’ wives increases as income rises. The findings illustrate the complex tradeoffs that migration entails for left-behind women and are interpreted in the context of the literature on gender, migration, and STDs.

Temporary Migration and the Spread of STDs/HIV in China: Is There a Link?

Using data from the literature and a specially designed community-level survey, this article examines the link between temporary migration and the spread of HIV/STDs in China. The results suggest that temporary migrants not only are overrepresented among people with STD/HIV risk-taking behaviors, but also account for disproportionately more STD patients and persons infected with HIV. It is imperative that STD and AIDS prevention intervention and education programs in China target temporary migrants. More research is needed that focuses on the underlying mechanisms by which the process of temporary migration renders migrants vulnerable to STD/HIV risk-taking behaviors.

Population mobility associated with higher risk sexual behaviour in eastern African communities participating in a Universal Testing and Treatment trial

INTRODUCTION

There are significant knowledge gaps concerning complex forms of mobility emergent in sub-Saharan Africa, their relationship to sexual behaviours, HIV transmission, and how sex modifies these associations. This study, within an ongoing test-and-treat trial (SEARCH, NCT01864603), sought to measure effects of diverse metrics of mobility on behaviours, with attention to gender.

METHODS

Cross-sectional data were collected in 2016 from 1919 adults in 12 communities in Kenya and Uganda, to examine mobility (labour/non-labour-related travel), migration (changes of residence over geopolitical boundaries) and their associations with sexual behaviours (concurrent/higher risk partnerships), by region and sex. Multilevel mixed-effects logistic regression models, stratified by sex and adjusted for clustering by community, were fitted to examine associations of mobility with higher-risk behaviours, in past 2 years/past 6 months, controlling for key covariates.

RESULTS

The population was 45.8% male and 52.4% female, with mean age 38.7 (median 37, IQR: 17); 11.2% had migrated in the past 2 years. Migration varied by region (14.4% in Kenya, 11.5% in southwestern and 1.7% in eastern and Uganda) and sex (13.6% of men and 9.2% of women). Ten per cent reported labour-related travel and 45.9% non-labour-related travel in past 6 months-and varied by region and sex: labour-related mobility was more common in men (18.5%) than women (2.9%); non-labour-related mobility was more common in women (57.1%) than men (32.6%). In 2015 to 2016, 24.6% of men and 6.6% of women had concurrent sexual partnerships; in past 6 months, 21.6% of men and 5.4% of women had concurrent partnerships. Concurrency in 2015 to 2016 was more strongly associated with migration in women [aRR = 2.0, 95% CI(1.1 to 3.7)] than men [aRR = 1.5, 95% CI(1.0 to 2.2)]. Concurrency in past 6 months was more strongly associated with labour-related mobility in women [aRR = 2.9, 95% CI(1.0 to 8.0)] than men [aRR = 1.8, 95% CI(1.2 to 2.5)], but with non-labour-related mobility in men [aRR = 2.2, 95% CI(1.5 to 3.4)].

CONCLUSIONS

In rural eastern Africa, both longer-distance/permanent, and localized/shorter-term forms of mobility are associated with higher-risk behaviours, and are highly gendered: the HIV risks associated with mobility are more pronounced for women. Gender-specific interventions among mobile populations are needed to combat HIV in the region.

The effect of mobility on HIV-related healthcare access and use for female sex workers: A systematic review

Female sex workers (FSW) experience a high HIV burden and are often mobile. FSW access to HIV-related healthcare is essential for equitable welfare and to reduce new HIV infections. We systematically reviewed the literature on mobility and HIV-related healthcare access and use among FSW. Outcome measures included: HIV/STI testing, STI treatment, PrEP (initiation or adherence), and ART (initiation or adherence). We summarised the results with a narrative synthesis. From 7417 non-duplicated citations, nine studies from Canada (3), Guatamala, Honduras (2), India, South Africa, and Vietnam were included. Only one of the studies was designed to address mobility and healthcare access, and only six reported adjusted effect estimates. Mobility was measured over four time-frames (from 'current' to 'ever'), as having lived or worked elsewhere or in another town/province/country. Three studies from Canada, Guatemala, and India found mobility associated with increased odds of poor initial access to healthcare (adjusted odds ratios (AOR) from 1.33, 95% CI 1.02, 1.75, to 2.27, 95% CI 1.09, 4.76), and one from Vietnam found no association (odds ratio (OR): 0.92, 95% CI 0.65, 1.28). The study from South Africa found no association with initiating ART (risk ratio: 0.86, 95% CI 0.65, 1.14). Two studies from Canada and Honduras found increased odds of ART interruption (AOR 2.74, 95% CI 0.89, 8.42; 5.19, 95% CI 1.38, 19.56), while two other studies from Canada and Honduras found no association with detectable viral load (OR 0.84, 95% CI 0.08, 8.33; AOR 0.79, 95% CI 0.41, 1.69). We found that mobility is associated with reduced initial healthcare access and interruption of ART, consistent with literature from the general population. Discordance between effects on adherence and viral load may be due to measurement of mobility. Future research should carefully construct measures of mobility and consider a range of HIV-related healthcare outcomes.

Health Selection, Migration, and HIV Infection in Malawi

Despite its importance in studies of migrant health, selectivity of migrants-also known as migration health selection-has seldom been examined in sub-Saharan Africa (SSA). This neglect is problematic because several features of the context in which migration occurs in SSA-very high levels of HIV, in particular-differ from contextual features in regions that have been studied more thoroughly. To address this important gap, we use longitudinal panel data from Malawi to examine whether migrants differ from nonmigrants in pre-migration health, assessed via SF-12 measures of mental and physical health. In addition to overall health selection, we focus on three more-specific factors that may affect the relationship between migration and health: (1) whether migration health selection differs by destination (rural-rural, rural-town, and rural-urban), (2) whether HIV infection moderates the relationship between migration and health, and (3) whether circular migrants differ in pre-migration health status. We find evidence of the healthy migrant phenomenon in Malawi, where physically healthier individuals are more likely to move. This relationship varies by migration destination, with healthier rural migrants moving to urban and other rural areas. We also find interactions between HIV-infected status and health: HIV-infected women moving to cities are physically healthier than their nonmigrant counterparts.

High Mobility and HIV Prevalence Among Female Market Traders in East Africa in 2014

BACKGROUND

The contribution of women's mobility to the HIV/AIDS epidemic in Africa is poorly understood, despite women's high mobility and evidence that it is associated with higher-risk sexual behavior. We sought to measure levels of mobility, HIV prevalence, and related risk behaviors among female traders in Kisumu, Kenya.

METHODS

We used global positioning system mapping to develop a probability-based sample and recruited 305 female market traders for participation in a survey and voluntary HIV counseling and testing in 2014. We estimated HIV prevalence and fitted logistic regression models to measure associations between mobility, risk behaviors, and HIV infection.

RESULTS

HIV prevalence was 25.6% (95% confidence interval: 21.0 to 30.8); 11.5% had migrated (changed residence, over county, or national boundary) in the past year and 39.3% in the past 5 years. More than one-third (38.3%) spent nights away from main residence in the past month, with 11.4% spending more than a week away. Multiple partners were reported by 13.1% of women in the last year; 16% of married women reported a concurrent partnership. Mobility was not significantly associated with HIV prevalence, although recent short-term mobility was significantly correlated with higher numbers of sexual partners in the past year.

CONCLUSIONS

Female market traders were highly mobile, and HIV prevalence among traders was higher than in the general population of women of reproductive age in Kisumu (15.3% in 2013), and Nyanza Province, Kenya (16.1% in 2012). High HIV prevalence and risk behavior among women in this study warrant accelerated attention to HIV prevention and care needs of mobile women, including market traders.

Changing spatial patterns and increasing rurality of HIV prevalence in the Democratic Republic of the Congo between 2007 and 2013

The Democratic Republic of the Congo (DRC) has one of the lowest HIV prevalence in sub-Saharan Africa, estimated at 1.1% [0.9-1.3] of adults aged 15-49 in 2013 (UNAIDS). Within the 2 million km(2) country, however, there exists spatial variation in HIV prevalence, with the highest HIV prevalence observed in the large cities of Kinshasa and Lubumbashi. Globally, HIV is an increasingly rural disease, diffusing outwards from urban centers of high HIV prevalence to places where HIV was previously absent or present at very low levels. Utilizing data collected during Demographic and Health Surveillance (DHS) in 2007 and 2013 in the DRC, we sought to update the map of HIV prevalence in the DRC as well as to explore whether HIV in the DRC is an increasingly rural disease or remains confined to urban areas. Bayesian kriging and regression indicate that HIV prevalence in rural areas of the DRC is higher in 2013 than in 2007 and that increased distance to an urban area is no longer protective against HIV as it was in 2007. These findings suggest that HIV education, testing and prevention efforts need to diffuse from urban to rural areas just as HIV is doing.

Mapping divided households and residency changes: the effect of couple separation on sexual behavior and risk of HIV infection

Using census data we identify geographic patterns in residency changes in Lesotho over a decade. Using kriging to spatially interpolate data from 8,510 households we identify regions where households have members temporarily living away from home (divided households). Further, using a multivariate analysis and data from 2,026 couples we determine whether a partners’ absence increases the likelihood of having extramarital partners and/or risk of HIV infection. Approximately 40% of individuals moved between 2001 and 2011; mainly to, and within, urbanized regions. Many households are divided: ~40% have members elsewhere in Lesotho, ~30% in South Africa (SA). Geographic patterns are apparent; they differ based on where the household member is living. Many couples were temporarily separated: ~50% of wives, ~20% of husbands. Separation was not a risk factor for HIV. Only men were more likely to have extramarital partners if their spouse was away: ~1.5 times if in Lesotho, ~3 times if in SA. The high degree of geographic mixing necessitates synchronizing interventions within Lesotho, and with SA, to successfully reduce transmission. It will be challenging to reduce concurrency in men with wives away from home. Our results are generalizable to other sub-Saharan countries where residency changes are common.

Maternal migration and child health: An analysis of disruption and adaptation processes in Benin

Children of migrant mothers have lower vaccination rates compared to their peers with non-migrant mothers in low-income countries. Explanations for this finding are typically grounded in the disruption and adaptation perspectives of migration. Researchers argue that migration is a disruptive process that interferes with women's economic well-being and social networks, and ultimately their health-seeking behaviors. With time, however, migrant women adapt to their new settings, and their health behaviors improve. Despite prominence in the literature, no research tests the salience of these perspectives to the relationship between maternal migration and child vaccination. We innovatively leverage Demographic and Health Survey data to test the extent to which disruption and adaptation processes underlie the relationship between maternal migration and child vaccination in the context of Benin-a West African country where migration is common and child vaccination rates have declined in recent years. By disaggregating children of migrants according to whether they were born before or after their mother's migration, we confirm that migration does not lower children's vaccination rates in Benin. In fact, children born after migration enjoy a higher likelihood of vaccination, whereas their peers born in the community from which their mother eventually migrates are less likely to be vaccinated. Although we find no support for the disruption perspective of migration, we do find evidence of adaptation: children born after migration have an increased likelihood of vaccination the longer their mother resides in the destination community prior to their birth.

DOES RURAL-TO-URBAN MIGRATION PLACE ADOLESCENTS AT RISK OF DELETERIOUS SEXUAL AND REPRODUCTIVE HEALTH OUTCOMES? EVIDENCE FROM HAITI

This study examines the links between migration and sexual and reproductive health among rural-to-urban migrant youth in Haiti. It evaluates behavioural, knowledge and attitudinal components from the perspective of three competing explanations for migrants' behaviours: adaptation, disruption and selection. Discrete-time event history analysis is employed to compare these hypotheses using Haiti Demographic and Health Survey data (N=1215 adolescent girls, N=829 adolescent boys). Multi-level models are used to compare changes in knowledge and attitudes in individuals using data from the Haiti Youth Transitions Study (N=223). The findings reveal that disruption is the most plausible explanation for the timing of migration and first sex among girls. However, contrary to the assumption that migrant youth risk experiencing first sex earlier, girls are less likely to experience first sex near the time they migrate, and rural-to-urban migrant boys may experience first sex at later ages. The high aspirations of migrant youth provide a likely explanation for these findings. Furthermore, male migrants accumulate less protective knowledge, which is consistent with the disruption hypothesis, and migrants endorse premarital sex similarly to non-migrants. Sexual and reproductive health curricula should be adapted to the unique needs of migrant youth, and youth should be targeted before they migrate.

Brief report: Mobility and circular migration in Lesotho: implications for transmission, treatment, and control of a severe HIV epidemic

We analyzed georeferenced data on mobility and HIV infection from the 2009 Demographic and Health Survey of Lesotho. We found ∼50% of the population traveled in the preceding year. By constructing gender-specific mobility maps, we discovered that travel is highest in the urban areas bordering South Africa and in the mountainous interior of the country. For both genders, increased mobility was associated with increased levels of "recent" sexual behavior. Notably, mobility was only associated with an increased risk of HIV infection for men who traveled frequently. We discuss the implications of our results for designing effective treatment programs and HIV interventions.

Impact of migration on fertility and abortion: evidence from the household and welfare study of Accra

Over the last few decades, total fertility rates, child morbidity, and child mortality rates have declined in most parts of sub-Saharan Africa. Among the most striking trends observed are the rapid rate of urbanization and the often remarkably large gaps in fertility between rural and urban areas. Although a large literature has highlighted the importance of migration and urbanization within countries' demographic transitions, relatively little is known regarding the impact of migration on migrants' reproductive health outcomes in general and abortion in particular. In this article, we use detailed pregnancy and migration histories collected as part of the Household and Welfare Study of Accra (HAWS) to examine the association between migration and pregnancy outcomes among women residing in the urban slums of Accra, Ghana. We find that the completed fertility patterns of lifetime Accra residents are remarkably similar to those of residents who migrated. Our results suggest that recent migrants have an increased risk of pregnancy but not an increased risk of live birth in the first years post-move compared with those who had never moved. This gap seems to be largely explained by an increased risk of miscarriage or abortion among recent migrants. Increasing access to contraceptives for recent migrants has the potential to reduce the incidence of unwanted pregnancies, lower the prevalence of unsafe abortion, and contribute to improved maternal health outcomes.

Rural-to-urban migration and sexual debut in Thailand

Migration from one's parents' home and sexual debut are common features of the transition to adulthood. Although many studies have described both of these features independently, few have examined the relationship between migration and sexual debut in a systematic manner. In this study, we explore this link for young adults in Thailand. With relatively high rates of internal migration, rapid modernization, a moderate HIV epidemic, and a declining average age of sexual debut, Thailand presents an instructive environment in which to examine migration and sexual debut. We use two waves of a longitudinal data set (2005 and 2007) that includes a subsample of young adults who migrated to urban areas during that period. We identify characteristics and behaviors associated with sexual debut and examine the role of migration on debut. Our approach reduces several common sources of bias that hamper existing work on both migration and sexual debut: (1) the longitudinal nature of the data enables us to examine the effects of characteristics that predate both behaviors of interest; (2) the survey on sexual behavior employed a technique that reduces response bias; and (3) we examine differences in debut by marital status. We find that migrants have a higher likelihood of sexual debut than nonmigrants.

Family instability and early initiation of sexual activity in Western Kenya

Epidemiological, economic, and social forces have produced high levels of volatility in family and household structure for young people growing up in sub-Saharan Africa in recent decades. However, scholarship on the family to date has not examined the influence of this family instability on young people's well-being. The current study employs unique life history calendar data from Western Kenya to investigate the relationship between instability in caregiving and early initiation of sexual activity. It draws on a body of work on parental union instability in the United States, and examines new dimensions of family change. Analyses reveal a positive association between transitions in primary caregiver and the likelihood of early sexual debut that is rapidly manifested following caregiver change and persists for a short period. The association is strongest at early ages, and there is a cumulative effect of multiple caregiver changes. The results highlight the importance of studying family stability in sub-Saharan Africa, as distinct from family structure, and for attention to dimensions such as age and recency.

Dimensions of Rural-to-Urban Migration and Premarital Pregnancy in Kenya

Rural-to urban migration is increasingly common among youth and could affect sexual activities. We use life history calendar data collected in Kisumu, Kenya, to investigate how the timing and number of rural-to-urban moves are associated with premarital pregnancy. Among sexually experienced young women aged 18-24 (N=226), 39 percent have experienced a premarital pregnancy and 60 percent experienced a move in the last 10 years. Results of the event history analysis show that those who experienced one or two moves or whose most recent move occurred in the last seven to 12 months are at increased risk of premarital pregnancy compared to nonmovers. Those whose last move occurred at age 13 or younger were also at an elevated risk. Migration brings about specific needs for youth, including the need for sexual and reproductive health education and services, which should be made available and accessible to new urban residents.

Migration, marital change, and HIV infection in Malawi

Research on the relationship between migration and HIV infection in sub-Saharan Africa often suggests that migrants are at higher risk of HIV infection because they are more likely to engage in HIV risk behaviors than nonmigrants, and they tend to move to areas with a relatively higher HIV prevalence. Although migration may be a risk factor for HIV infection, I instead focus on the possibility that the HIV positive are more likely to migrate. Using a longitudinal data set of permanent rural residents and migrants from Malawi, I find that migrants originating from rural areas are indeed more likely than nonmigrants to be HIV positive and to have engaged in HIV risk behaviors. The increased HIV risk among migrants may be due to the selection of HIV-positive individuals into migration; I find that HIV-positive individuals are more likely to migrate than those who are HIV negative. The explanation for this phenomenon appears to be marital instability, which occurs more frequently among HIV-positive individuals and leads to migration after marital change.

Implications of mobility patterns and HIV risks for HIV prevention among migrant market vendors in Kazakhstan

OBJECTIVES

We examined the relationships between mobility characteristics and sexual risk behaviors among male and female migrant market vendors in Almaty, Kazakhstan.

METHODS

Participants completed a structured interview covering sociodemographics, mobility characteristics, sexual behaviors, and biomarkers for HIV, HCV, and syphilis. We used multivariate analyses to examine associations between mobility patterns and HIV risks after adjusting for sociodemographics.

RESULTS

Longer duration of a participant's last trip outside Almaty increased the odds of reporting multiple sexual partners. More frequent travel to visit family or friends was associated with multiple sexual partners and unprotected sex with steady partners. More frequent travel to buy goods in the past year was associated with multiple sexual partners. Men who traveled more often to buy goods were more likely to have purchased sex within the previous 90 days.

CONCLUSIONS

Relationships between mobility patterns and sexual risk behaviors underscore the need for HIV-prevention strategies targeting the specific transmission dynamics that migrant vendors are likely to present.

Men's multiple sexual partnerships in 15 Sub-Saharan African countries: sociodemographic patterns and implications

Men's multiple sexual partnerships contribute to the spread of HIV in sub-Saharan Africa, but the social determinants of these relationships remain poorly understood. Prevailing wisdom suggests that men's institutionalized authority over women and their control of economic resources are key facilitators of multiple partnerships in this region. Men's exposure to or freedom from social control mechanisms embedded in family and village life may also play a role. This article provides insight into these issues by examining sociodemographic correlates of men's multiple sexual partnerships using data from recent Demographic and Health Surveys in 15 sub-Saharan African countries. The prevalence of self-reported multiple partnerships varies widely among countries. Sociodemographic patterns of such partnerships confirm the importance of men's control of economic resources and suggest that men's freedom from social control mechanisms may be more important than their authority over their wives.

Linking migration, mobility and HIV

Population mobility is commonly identified as a key driver of the HIV epidemic, both linking geographically separate epidemics and intensifying transmission through inducing riskier sexual behaviours. However, beyond the well-known case studies of South African miners and East African truck drivers, the evidence on the links between HIV and mobility is nuanced, contradictory and inconclusive and is in part attributed to the abstract definitions of mobility used in different studies. This problematic conception of mobility, with no reference to who moves, their motivations for moving, or the characteristics of sending and receiving areas, can have a dramatic impact on how one understands the influence which this structural factor has on HIV risk in different settings. Future research on mobility and HIV transmission must incorporate an understanding of migration and mobility as dynamic processes and link different patterns and forms of mobility with location-specific sexual networks and HIV epidemiology.

Spatial mobility, alcohol use, sexual behavior and sexual health among males in India

This paper examines the linkages of permanent migration, temporary mobility and alcohol consumption with risky sexual behavior and sexually transmitted infections (STIs) including HIV infection among males in India using a nationally representative dataset. The study shows that non-migrant men and migrant men do not differ significantly in any indicator of risky sexual behavior and STIs. Temporary long duration mobile men reported significantly more often than the non-mobile men or short duration mobile men that they had sex with multiple sex partners during their lifetime as well as sex with a high risk partner and had paid sex in the 12 months preceding the survey. Males who drank alcohol almost every day notwithstanding with their migration or mobility status were most prone to lifelong as well as more recent sexual risk behavior. Controlling for sociodemographic characteristics long duration mobile men and men who used alcohol almost daily had higher sexual risk behaviors and STI infections. Further migration and mobility did not show any significant relationship with tested HIV prevalence among males in India, controlling for sociodemographic characteristics. Males who had lifetime multiple sex partners were at the highest risk of tested HIV infection controlling for sociodemographic characteristics, migration, mobility, alcohol use and STI infection. Interventions focusing on HIV prevention in India need to target both non-migrant and migrant men, particularly those who drink alcohol more frequently or daily. Targeted interventions are required for temporary mobile men, particularly for those mobile men who have to stay away from their homes continuously for a longer duration. Long duration mobile men are most prone to regular alcohol use and risky sexual behavior.

Behavioural risks for HIV infection among Quebec residents of Haitian origin

Quebecers of Haitian origin (QHO) have the highest HIV prevalence of all immigrant groups in the province. We conducted a study among QHO to document the behavioural risk factors for HIV transmission. Male respondents were significantly more likely than female respondents to have at least one casual heterosexual partner in the past 12 months (39.7 vs. 18.8%, p < 0.001). Males were more likely to have used a condom at last sexual intercourse with a casual partner (78.9 vs. 53.7%; p = 0.002). However, among men who never, casually, or rarely used condoms with their regular female partner, 27.3% did not use a condom at last sexual intercourse with a casual partner. In the multivariable logistic regression analysis, having at least one casual heterosexual partner in the past 12 months was associated with being younger than 29 years, being male, being single, and being a second-generation QHO. This study allows us to identify subgroups whose behaviours can result in greater vulnerability to HIV infection and other STIs.

The Orthodoxy of Gender Mainstreaming

Gender mainstreaming has itself become something of a mainstream practice in much development work. As the theory and practice of mainstreaming has developed so too have a range of debates over what exactly gender mainstreaming can contribute to development. This article reflects on a gender mainstreaming intervention in the East African region to explore the role that gender mainstreaming can play in achieving the Millennium Development Goals. In this article we discuss how gender mainstreaming has, at times, functioned as a retreat from women's equality and is used to render feminist perspectives more palatable to those who resist them. Far from being a simple critique of gender mainstreaming this reflects the broader tensions and debates that are shaping what gender has come to mean in different contexts. This brings difficult tensions over who develops a gender mainstreaming agenda and who claims to have expertise on gender. We explore how much is at stake in claims to represent the ‘beneficiary’ groups and the ways that donor relationships with NGOs function in this regard. Gender mainstreaming has clearly offered a mechanism for legitimating attention to gender inequality that is sufficiently flexible to account for local contexts. However, this flexibility also means that gender mainstreaming can be co-opted for conservative means and the struggles over ownership of gender mainstreaming can just as easily hamper the achievement of gender equality as envisaged in the MDGs.

HIV risk behaviours among contracted and non-contracted male migrant workers in India: potential role of labour contractors and contractual systems in HIV prevention

OBJECTIVE(S)

To assess the HIV risk behaviours of male migrant contracted and non-contracted labourers in India and to understand the role of contract labour systems for use in HIV prevention efforts.

METHODS

Cross-sectional surveys (N = 11 219) were conducted with male migrant workers, aged 18-49 years from 21 districts in four high HIV prevalence states of India. Analyses involved data from the subsample of contracted labour (n = 3880; 35% of total sample) to assess the prevalence of HIV risk behaviours and sexually transmitted infection (STI) symptoms and further comparisons with non-contracted labourers.

RESULTS

Contracted male labourers are largely young; 70% were between the ages of 18 and 29 years. Over half (55%) were married, and a third (34%) resided away from their wives because of migrant work. More than one in six contract labourers (17%) reported having sex with a sex worker, and two-fifths of these reported an inconsistent use of condoms. One in 10 reported sex with both sex workers and non-spousal unpaid female partners in the past year in the places they had migrated to, and 31% reported sex with either a sex worker or non-spousal unpaid female partner in their places of origin over the past 2 years. After adjustment for sociodemographic characteristics, the contracted labourers were significantly more likely to report alcohol use and HIV risk behaviours than non-contracted labourers.

CONCLUSION

The existence of a wide network of labour contractors and a structured infrastructure of the contract system provides opportunities for effective and sustained worksite HIV prevention programmes among contracted male migrant workers in India.

Determinants of Zambian men's extra-marital sex: a multi-level analysis

Research interest in extra-marital sex has increased as scholars have become aware of its role in sustaining epidemics of STDs in sub-Saharan Africa and elsewhere. While most research has used the socioeconomic and demographic features of individuals as determinants of extra-marital sexual behavior, this study examined the role played by community characteristics. Using data from the 2003 Zambian Sexual Behavior Survey for a sample of 1,118 men aged 15-59 and multilevel logistic regression techniques, the study analyzed the effects of community social and demographic characteristics on involvement in extra-marital sex while controlling for the men's individual-level characteristics. Men's involvement in extra-marital sex was found to vary with the characteristics of communities. The chances of men's involvement in extra-marital sex increased with community-level ethnic heterogeneity and urbanization, decreased in commercial centers, and in communities with a demographic surplus of males, health workers active in AIDS prevention, and access to the mass media. These results show that scholars trying to understand the motivations for extra-marital sex must pay attention to the characteristics of both individuals and communities.

Barriers and missed opportunities to HIV testing among injection drug users in two Mexico--US border cities

INTRODUCTION AND AIMS

Despite increasing HIV prevalence in cities along the Mexico--US border, HIV testing among high-risk populations remains low. We sought to identify barriers associated with HIV testing among injection drug users (IDUs) in Tijuana and Ciudad Juarez, the two largest Mexican border cities located across from San Diego, California and El Paso, Texas, respectively.

DESIGN AND METHODS

In 2005, 222 IDUs in Tijuana and 205 IDUs in Ciudad Juarez were recruited by respondent-driven sampling and administered a questionnaire to collect socio-demographic, behavioural and HIV testing history data. Blood samples were provided for serological testing of HIV, hepatitis C virus (HCV) and syphilis.

RESULTS

Only 38% and 30% of respondents in Tijuana and Ciudad Juarez, respectively, had ever had an HIV test. The factors independently associated with never having been tested for HIV differed between the two sites, except for lack of knowledge on HIV transmission, which was independently associated in both locales. Importantly, 65% of those who had never been tested for HIV in both cities experienced at least one missed opportunity for voluntary testing, including medical visits, drug treatment and spending time in jail.

DISCUSSION AND CONCLUSIONS

Among this high-risk IDU population we found HIV testing to be low, with voluntary testing in public and private settings utilised inadequately. These findings underscore the need to expand voluntary HIV education and testing and to integrate it into services and locales frequented by IDUs in these Mexico--US border cities.

Deportation along the U.S.-Mexico border: its relation to drug use patterns and accessing care

Since migration has been linked to new drug trends and risky behaviors, and deported individuals face unique economic and social stressors, we investigated behaviors of injection drug users (IDUs) from Tijuana, Mexico in relation to deportation history. In 2005, IDUs > or =18 years old who injected within the prior month were recruited by respondent-driven sampling, administered a questionnaire, and underwent antibody testing for HIV, HCV, and syphilis. Logistic regression compared IDUs who reported coming to Tijuana due to deportation from the U.S. versus others in the study. Of 219 participants, 16% were deportees. Prevalence of HIV, HCV and syphilis was 3, 95 and 13%, respectively. Deportees had lived in Tijuana for a shorter time (median: 2 vs. 16 years), were more likely to inject multiple times/day (OR: 5.52; 95%CI: 1.62-18.8), but less likely to have smoked/inhaled methamphetamine (OR: 0.17; 95%CI: 0.17-0.86). Deportation history was inversely associated with receiving drug treatment (OR: 0.41; 95%CI: 0.19-0.89), recent medical care (OR: 0.37; 95%CI: 0.13-1.00), or HIV testing (OR: 0.44; 95%CI: 0.19-1.02). Deportees had different drug use patterns and less interaction with public health services than other study participants. Our study is an indication that migration history might relate to current risk behaviors and access to health care. More in-depth studies to determine factors driving such behaviors are needed.

Estimated numbers of men and women infected with HIV/AIDS in Tijuana, Mexico

Tijuana, Mexico, just south of San Diego, California, is located by the busiest land border crossing in the world. Although UNAIDS considers Mexico to be a country of "low prevalence, high risk," recent surveillance data among sentinel populations in Tijuana suggests HIV prevalence is increasing. The aim of this study was to estimate the number of men and women aged 15 to 49 years infected with HIV in Tijuana. Gender and age-specific estimates of the Tijuana population were obtained from the 2000 Mexican census. Population and HIV prevalence estimates for at-risk groups were obtained from published reports, community based studies, and data from the Centro Nacional para la Prevención y Control del VIH/SIDA (CENSIDA). Age-specific fertility rates for Mexico were used to derive the number of low and high-risk pregnant women. Numbers of HIV-positive men and women were estimated for each at-risk group and then aggregated. A high growth scenario based on current HIV prevalence and a conservative, low growth estimate were determined. A total of 686,600 men and women in Tijuana were aged 15 to 49 years at the time of the 2000 census. Considering both scenarios, the number of infected persons ranged from 1,803 to 5,472 (HIV prevalence: 0.26 to 0.80%). The majority of these persons were men (>70%). The largest number of infected persons were MSM (N = 1,146 to 3,300) and IDUs (N = 147 to 650). Our data suggest that up to one in every 125 persons aged 15-49 years in Tijuana is HIV-infected. Interventions to reduce ongoing spread of HIV are urgently needed.

Access to HIV care among migrant Africans in Britain. What are the issues?

In the UK, substantial numbers of new HIV diagnoses are within migrant communities, especially African communities. Current surveillance shows that despite health promotion efforts and advances in therapy these communities are accessing HIV care late. This paper explores the issues influencing the access and uptake of HIV care by migrant Africans in Britain. Using Kleinman's model of health care systems (Kleinman, 1980) as a theoretical framework, we highlight the importance of placing health within its broader context if we are to make significant improvement to the health of HIV-infected Africans in Britain.

Migration and the Diffusion of Modern Contraceptive Knowledge and Use in Rural Guatemala

This article uses the concept of social networks as it is employed in the research literature on family planning and migration to explore the impact of out-migration on modern contraceptive knowledge and use in rural Guatemala. Data for this study come from the 1995 Guatemalan Survey of Family Health. Results from multilevel regression models indicate that urban migration experience, having migrant kin in urban or international destinations, and living in a community where urban migration is common are all associated with greater contraceptive knowledge. Social ties to urban or international migrants are also associated with a greater likelihood of modern contraceptive use among married women, but this association works primarily through increased contraceptive knowledge. The findings of significant diffusion effects provide support for recent theories of fertility decline that emphasize the role of social interactions.

Migrants' risky sexual behaviours in India and at home in far western Nepal

OBJECTIVE

To examine Nepali migrants' vulnerability to HIV/sexually transmitted infections (STIs) and their possible role in causing the epidemic in far western Nepal.

METHODS

From August to October 2000, we conducted six focus group discussions among 53 returned migrants from India, mainly from Mumbai. Data were analysed by interpretative thematic analysis.

RESULTS

Migrants commonly had multiple sexual encounters, changed partners, and used condoms infrequently both in India and at home. Several factors influenced them to practice high-risk sexual behaviours. In India, these included peer norms and pressures, cheaper sex, lack of family restraint, drinking alcohol, and low perceived vulnerability to HIV/STIs. In Nepal, these factors included the migrants' new status, frequent local festivals, and low perceived vulnerability to HIV/STIs. Participants displayed substantial deficits in their knowledge of HIV/STIs.

CONCLUSIONS

This study revealed Nepali migrants' high-risk sexual behaviours both abroad and at home. Understanding these realities will assist in the development of culturally appropriate HIV/STI interventions necessary to halt the spread of HIV/STIs in Nepal.