Prevalence and correlates of intimate partner violence in HIV-positive women engaged in transactional sex in Mombasa, Kenya

Correlates of Intimate Partner Violence Among Young Women Engaged in Sex Work in Southern Uganda

Intimate partner violence (IPV) is a significant global public health problem that results in high social and economic costs to individuals and communities. Compared to women in the general population, women engaged in sex work (WESW) are more likely to experience physical, emotional, and sexual IPV. This study examines the correlates of IPV among young WESW with their intimate partners in Southern Uganda. We used baseline data from the Kyaterekera project, a 5 year NIH-funded longitudinal study aimed at reducing HIV risks among 542 WESW in Southern Uganda. To examine the factors associated with IPV, we fitted three separate multi-level Poisson regression models for physical, emotional, and sexual IPV, respectively. Average age was 31.4 years, and 54% of the women reported being victims of at least one form of IPV from their intimate partners. Model one assessed correlates of sexual IPV. Being married women (β = .71, 95% CI [0.24, 1.17]), divorced/separated/widowed (β = .52, [0.02, 1.02]), depressed (β = .04, [0.02, 0.05]), and having any sexually transmitted infections (STIs) (β = .58, [0.14, 1.01]) were associated with sexual IPV. Model two assessed correlates of physical IPV. Experience of childhood sexual abuse (β = .12, [0.04, 0.19]) was associated with an increase in physical IPV, and increasing age reduced its occurrence (β = -.02, [-0.04, -0.001]). Finally, model three assessed emotional IPV. Women with higher education (β = .49, [0.14, 0.85]) and symptoms of depression (β = .02, [0.001, 0.04]) had higher risks for emotional IPV. For WESW, IPV presents an additional potential pathway for HIV and STIs acquisition and transmission through a lack of negotiating power for safe sex. Efforts to reduce violence against WESW should be prioritized as a strategy for enhancing the well-being of WESW.

Intimate partner violence and associated factors among HIV positive women attending antiretroviral therapy clinics in Gondar city, Northwest Ethiopia

INTRODUCTION

Intimate partner violence against women is a behavior within an intimate relationship that causes sexual, physical, or psychological harm to the women. It occurs among all socioeconomic, religious, and cultural groups in all settings, and affects the health of women, families, and the community at large. Determining the magnitude and determinants of intimate partner violence against HIV positive women could help to design preventive and control strategies. However, there is a dearth of information regarding the magnitude and determinants of intimate partner violence against HIV positive women in Ethiopia. Thus, this study aimed to assess the magnitude and associated factors of intimate partner violence against HIV positive women in Gondar city, Northwest Ethiopia.

METHOD

A facility-based cross-sectional study was carried out from February to May 2021 in selected public health facilities of Gondar city among 626 HIV positive women. A systematic random sampling technique was used to select study participants. Data were analyzed using Statistical Package of Social Science (SPSS) version 20 software. Bivariable and Multivariable logistic regression models were done. Adjusted odds ratio (AOR) with a 95% confidence interval (CI) was used to identify determinants of intimate partner violence. Statistical significance was considered at a p value < 0.05.

RESULTS

The overall prevalence of intimate partner violence against HIV positive women within the last 12 months was 64.2% (95% CI 60.4, 68.2). Physical violence was the most common type (54.8%), followed by sexual (51.1%) and emotional (48.9%) violence. Intimate partner violence among HIV positive women was associated with women's age 19-24 (AOR = 0.13, 95% CI 0.02, 0.79), monthly income of 500-2500 (AOR = 6.5, 95% CI 1.72, 25.0), urban residence (AOR = 0.35, 95% CI 0.13, 0.91), partner drink alcohol (AOR = 2.14, 95% CI 1.42, 4.06), and a husband with no multiple sexual partners (AOR = 0.75, 95% CI 0.34, 0.94).

CONCLUSION

The result of this study revealed that intimate partner violence against HIV positive women was found to be high. Thus, protective measures that could increase the community's and women's awareness about the consequences of various forms of violence, and women empowerment are paramount. Priorities in programs of gender-based violence prevention should involve women from rural residences, older age, and males who consume alcohol.

Harmful Alcohol Use and Associated Socio-Structural Factors among Female Sex Workers Initiating HIV Pre-Exposure Prophylaxis in Dar es Salaam, Tanzania

Harmful alcohol use is an important risk factor for premature mortality and morbidity and associated with increased HIV risk and lower uptake of and adherence to HIV interventions. This study aimed to assess the extent of harmful alcohol use and associated socio-structural vulnerability factors among female sex workers in Dar es Salaam, Tanzania, a key population in the HIV epidemic. Data from a study of female sex workers initiating pre-exposure prophylaxis (PrEP) recruited through respondent driven sampling were used. We assessed harmful alcohol use with the Alcohol Use Disorders Identification Test (AUDIT) defined as having an AUDIT score ≥ 16. Associations between harmful alcohol use and socio-structural factors were assessed using logistic regression with marginal standardization. Of the 470 women recruited, more than one third (37.3%) had a drinking pattern suggestive of harmful alcohol use. Such use was independently associated with sex work-related mobility (aPR: 1.36, 95% CI: 1.11-1.61), arrest/incarceration (aPR: 1.55, 95% CI: 1.27-1.84) and gender-based violence (aPR: 1.31, 95% CI: 1.06-1.56). The high prevalence of harmful alcohol use and the interconnectedness with socio-structural factors indicate a need for a holistic programmatic approach to health for female sex workers. Programming should not solely direct attention to individual behavior but also include strategies aiming to address socio-structural vulnerabilities.

Prevalence and correlates of intimate partner violence among women with HIV in serodifferent relationships in Nairobi, Kenya

Background

Intimate partner violence (IPV) is a major public health problem and is the most common form of violence against women. Women with HIV in serodifferent relationships may be at an increased risk of IPV compared to women without HIV, hindering their ability to adhere to antiretroviral therapy, clinic appointments, and condom use during sex. This study assessed the prevalence and correlates of IPV in the past year among women with HIV in serodifferent relationships in Nairobi, Kenya.

Methods

This cross-sectional study included women with HIV in serodifferent relationships who were at least 18 years old and provided written informed consent. Their experience of physical, sexual, or emotional violence in the past year by the current partner was assessed using 13 questions adapted from the World Health Organization survey on violence against women. Standardized instruments were used to assess sociodemographic and behavioral factors. Associations between intimate partner violence and other variables were evaluated using log binomial regression models.

Results

Of the 159 women enrolled, 47 (29.6%, 95% CI 22.9–37.2%) reported IPV in the past year. Of these, 32 (68.1%) reported emotional, 27 (57.4%) physical, and 27 (57.4%) sexual violence. In the multivariate model, pregnancy (adjusted prevalence ratio [aPR] 2.14, 95% CI 1.09–4.20), alcohol use (minimal drinking aPR 1.91, 95% CI 1.10–3.33; moderate/severe drinking aPR 1.17, 95% CI 0.53–2.59), male partner controlling behavior (aPR 2.09, 95% CI 1.24–3.51), and past physical violence (aPR 1.93, 95% CI 1.22–3.05) remained significantly associated with a higher prevalence of IPV in the past year.

Conclusion

This study identified a high prevalence of IPV in the past year among women with HIV in serodifferent relationships. Pregnant women and women who had experienced prior violence had a higher prevalence of IPV. These data highlight the need to screen for IPV during clinic visits, and to offer evidence based interventions to support women in serodifferent relationships who have experienced IPV.

Partner and Relationship Characteristics Determining Intimate Partner Violence Among Women Living with HIV in Ruili, China

Intimate partner violence (IPV) in China is a largely understudied, major health risk among women living with HIV. Using structured face-to-face interviews, this research examined partner and couple relationship characteristics associated with physical and sexual IPV among 219 HIV-positive women living with a male partner in Ruili, China. Twenty-nine women (13%) reported past-year occurrences of physical IPV, and 24 (11%) reported sexual IPV. Physical IPV was more common when the woman's partner was of Jingpo ethnicity, drank weekly, or learned of her HIV status indirectly from a third person. Reduced risk of physical IPV was associated with a woman's perceived confidant support that was available through either her partner or a minimum of 2 non-partner confidants. Sexual IPV was more often reported among women with a partner who drank frequently or was concurrently HIV-positive, or in situations where the woman was employed and the partner was not. Sexual IPV was less likely with a partner of Dai ethnicity than Han, the major ethnicity in China. Identifying determinants of IPV vulnerability among women living with HIV may help future interventions to achieve greater impact in similar settings.

A systematic review of substance use and substance use disorder research in Kenya

Objectives

The burden of substance use in Kenya is significant. The objective of this study was to systematically summarize existing literature on substance use in Kenya, identify research gaps, and provide directions for future research.

Methods

This systematic review was conducted in line with the PRISMA guidelines. We conducted a search of 5 bibliographic databases (PubMed, PsychINFO, Web of Science, Cumulative Index of Nursing and Allied Professionals (CINAHL) and Cochrane Library) from inception until 20 August 2020. In addition, we searched all the volumes of the official journal of the National Authority for the Campaign Against Alcohol & Drug Abuse (the African Journal of Alcohol and Drug Abuse). The results of eligible studies have been summarized descriptively and organized by three broad categories including: studies evaluating the epidemiology of substance use, studies evaluating interventions and programs, and qualitative studies exploring various themes on substance use other than interventions. The quality of the included studies was assessed with the Quality Assessment Tool for Studies with Diverse Designs.

Results

Of the 185 studies that were eligible for inclusion, 144 investigated the epidemiology of substance use, 23 qualitatively explored various substance use related themes, and 18 evaluated substance use interventions and programs. Key evidence gaps emerged. Few studies had explored the epidemiology of hallucinogen, prescription medication, ecstasy, injecting drug use, and emerging substance use. Vulnerable populations such as pregnant women, and persons with physical disability had been under-represented within the epidemiological and qualitative work. No intervention study had been conducted among children and adolescents. Most interventions had focused on alcohol to the exclusion of other prevalent substances such as tobacco and cannabis. Little had been done to evaluate digital and population-level interventions.

Conclusion

The results of this systematic review provide important directions for future substance use research in Kenya.

Systematic review registration

PROSPERO: CRD42020203717.

Strategies for Optimising Uptake of Assisted Partner Notification Services Among Newly Diagnosed HIV Positive Adults at Ndirande Health Centre, Malawi

UNAIDS Fast-Track goals for 2025 include ensuring that 95% of the people with HIV know their HIV status. In 2019, the Malawi Ministry of Health introduced its approach for achieving this: an active index testing (AIT) policy with assisted partner notification services (APNS). Under this policy, health centers can actively reach out to a contact of newly-diagnosed HIV positive client (the index) to offer voluntary HIV testing services. However, APNS uptake has been sub-optimal at many health facilities. This qualitative study considers strategies to optimize the uptake of APNS among newly-diagnosed HIV positive clients at Ndirande Health Center in Blantyre, Malawi. We conducted in-depth interviews, between February and April 2020, with 24 participants, including new HIV positive index clients, their sexual partners, and key health workers. We employ a maximum variation purposive sampling technique. Thematic inductive and deductive data analysis was done manually according to the social-ecological model. Interviewees discussed various strategies for optimizing APNS uptake among newly diagnosed HIV-infected clients. Interpersonal strategies included maximizing the use of client profiling techniques and sensitization on APNS to create demand. Institutional-level strategies were also suggested, such as providing transportation for home visits, strengthening referral notification approaches, and additional training for health workers. Policy-level recommendations included introducing home-based partner testing and intensifying use of partner notification slips. APNS is a key strategy to maximize HIV case identification. However, achieving optimal APNS in Malawi requires strengthening existing strategies and conducting additional research to identify other APNS strategies tailored to the local context.

A Prospective Study of Depressive Symptoms, Condomless Sex, and HIV Viral Load in HIV-Positive Female Sex Workers in Kenya

The relationships between depressive symptoms, viral suppression, and condomless sex were examined in a prospective cohort study of 369 HIV-positive Kenyan female sex workers. Participants were screened for depressive symptoms at baseline and every six months until completion of the study (up to 66 months). HIV viral load (VL) was measured every six months and prostate specific antigen (PSA) testing in vaginal secretions was performed quarterly. Mild or greater depressive symptoms were found in 100 (27.1%) women and were associated with increased risk of detectable VL (aRR 1.41, 95%CI 0.97-2.07, p-value = 0.07), but were not associated with detectable PSA. The co-occurrence of PSA detection and detectable VL at the same visit suggests the potential for HIV transmission but was uncommon (2.4% of visits). The prevalence of depressive symptoms and the association with detectable VL suggests the need for screening and treatment of depression for comprehensive HIV care in this population.

Mapping the evidence of intimate partner violence among women living with HIV/AIDS in sub-Saharan Africa: a scoping review

OBJECTIVES

The present study undertakes a scoping review aimed to map the evidence of intimate partner violence (IPV) against women living with HIV/AIDS in Africa.

DESIGN

We used the online database to identify papers published from 1 January 2009 to 1 April 2019, from which we selected 21 articles from Uganda, Nigeria, Kenya, South Africa, Zambia, Ethiopia, Cameroon, Tanzania and Swaziland that used IPV as an outcome variable among women living with HIV/AIDS.

DATA SOURCES

PubMed, MEDLINE, EBSCO host, Google Scholar.

ELIGIBILITY CRITERIA

We included women who were aged 15 years and above, living with HIV/AIDS in sub-Saharan Africa.

DATA EXTRACTION AND SYNTHESIS

We conducted the abstract screening with two independent reviewers. We also performed full-text screening. We used the six methodological frameworks proposed by Arksey and O'Malley. The Mixed Method Appraisal Tool was used to determine the quality of the studies. We used NVIVO software V.12 to undertake a thematic analysis.

RESULTS

Of the studies, the majority, 57.1%, reported cross-sectional results. In comparison, 23.8% examined qualitative studies, 9.5% were clinical trials, 4.8% were cohort studies and the remaining 4.8% covered grey literature. This review revealed evidence of IPV experience among women with HIV/AIDS, evidence of how HIV status disclosure influences IPV, proof of the association of sociodemographic characteristics with IPV and implications for practice. Moreover, the review revealed that following the serostatus disclosure, there is evidence of heightened risk for IPV.

CONCLUSIONS

This study found evidence of IPV among women living with HIV/AIDS. The HIV-positive women were at considerable risk of IPV after disclosure of their serostatus to a male partner. Therefore, further research is needed to promote action to reduce IPV among HIV-positive and HIV-negative women and to determine healthcare workers' IPV screening experience.

Brief Report: Incidence and Correlates of Pregnancy in HIV-Positive Kenyan Sex Workers

INTRODUCTION

The incidence of pregnancy in female sex workers (FSWs) living with HIV is not well characterized.

METHODS

Current and former FSWs living with HIV and enrolled in a prospective cohort study in Mombasa, Kenya, were followed monthly to ascertain sexual behavior and underwent quarterly pregnancy testing. Pregnancies were considered planned, mistimed, or unwanted according to fertility desires and pregnancy intentions. Cox proportional hazards models were used to estimate hazard ratios (HRs) of the association between characteristics and incident pregnancy.

RESULTS

Two hundred seventy-nine FSWs were eligible (October 2012-April 2017). Most women had a nonpaying, regular partner (83.2%, 232/279), were not using modern nonbarrier contraception (69.5%, 194/279), and did not desire additional children (70.6%, 197/279). Of 34 first incident pregnancies [5.8/100 person-years (p-y); 95% confidence interval (CI): 4.1 to 8.0], 91.2% (n = 31) were unintended. The incidences of planned (5.7/100 p-y, n = 3), mistimed (10.4/100 p-y, n = 9), and unwanted pregnancies (4.9/100 p-y, n = 22) were similar (P = 0.15). In univariable analysis, oral contraceptive pill use (versus no contraception), having a nonpaying, regular partner, transactional sex, vaginal washing, condomless sex, and higher sex frequency were associated with an increased pregnancy risk. Older age was associated with a lower pregnancy risk. In multivariable analysis, having a nonpaying, regular partner (adjusted HR 4.0, 95% CI: 1.2 to 14.1) and age ≥40 years (aHR 0.2, 95% CI: 0.0 to 0.9) remained significantly associated with a higher and lower pregnancy risk, respectively.

CONCLUSION

In this cohort of HIV-positive FSWs, most pregnancies were unintended. Identifying FSWs' fertility desires and pregnancy intentions could facilitate efforts to increase contraceptive use and implement safer conception strategies.

Psychosocial Factors, Condomless Sex, and Detectable Viral Load in HIV-Positive Women in Serodiscordant Couples in Nairobi, Kenya

This prospective study of HIV-positive Kenyan women in serodiscordant couples examined relationships between psychosocial factors, viral suppression, and condomless sex. Participants were screened for alcohol use disorders and intimate partner violence (IPV) annually and depressive symptoms every 6 months. Prostate specific antigen (PSA) detection was used as a marker for condomless sex. A total of 151 participants contributed 349 person-years of follow-up. Hazardous/harmful alcohol use was associated with increased risk of detecting PSA in vaginal secretions (aRR 1.99, 95%CI 1.08-3.66, χ2 = 4.85 (1)), while IPV and depression were not. Events representing HIV transmission potential, where there was biological evidence of condomless sex at a visit with a detectable plasma viral load, were observed at 2% of visits. The high prevalence of IPV and association between alcohol use and sexual risk suggest the need for monitoring and support for these conditions as part of comprehensive HIV care for women.

Prevalence and patterns of gender-based violence across adolescent girls and young women in Mombasa, Kenya

Background

We sought to estimate the prevalence and describe heterogeneity in experiences of gender-based violence (GBV) across subgroups of adolescent girls and young women (AGYW).

Methods

We used data from a cross-sectional bio-behavioural survey among 1299 AGYW aged 14–24 in Mombasa, Kenya in 2015. Respondents were recruited from hotspots associated with sex work, and self-selected into one of three subgroups: young women engaged in casual sex (YCS), young women engaged in transactional sex (YTS), and young women engaged in sex work (YSW). We compared overall and across subgroups: prevalence of lifetime and recent (within previous year) self-reported experience of physical, sexual, and police violence; patterns and perpetrators of first and most recent episode of physical and sexual violence; and factors associated with physical and sexual violence.

Results

The prevalences of lifetime and recent physical violence were 18.0 and 10.7% respectively. Lifetime and recent sexual violence respectively were reported by 20.5 and 9.8% of respondents. Prevalence of lifetime and recent experience of police violence were 34.7 and 25.8% respectively. All forms of violence were most frequently reported by YSW, followed by YTS and then YCS. 62%/81% of respondents reported having sex during the first episode of physical/sexual violence, and 48%/62% of those sex acts at first episode of physical/sexual violence were condomless. In the most recent episode of violence when sex took place levels of condom use remained low at 53–61%. The main perpetrators of violence were intimate partners for YCS, and both intimate partners and regular non-client partners for YTS. For YSW, first-time and regular paying clients were the main perpetrators of physical and sexual violence. Alcohol use, ever being pregnant and regular source of income were associated with physical and sexual violence though it differed by subgroup and type of violence.

Conclusions

AGYW in these settings experience high vulnerability to physical, sexual and police violence. However, AGYW are not a homogeneous group, and there are heterogeneities in prevalence and predictors of violence between subgroups of AGYW that need to be understood to design effective programmes to address violence.

Knowledge of HIV Status Is Associated With a Decrease in the Severity of Depressive Symptoms Among Female Sex Workers in Uganda and Zambia

BACKGROUND

Knowledge of HIV-positive status may result in depressive symptoms, which may be a concern to scaling novel HIV testing interventions that move testing outside the health system and away from counselor support.

SETTING

Uganda and Zambia.

METHODS

We used longitudinal data from 2 female sex worker (FSW) cohorts in Uganda (n = 960) and Zambia (n = 965). Over 4 months, participants had ample opportunity to HIV testing using standard-of-care services or self-tests. At baseline and 4 months, we measured participants' perceived knowledge of HIV status, severity of depressive symptoms (continuous PHQ-9 scale, 0-27 points), and prevalence of likely depression (PHQ-9 scores ≥10). We estimated associations using individual fixed-effects estimation.

RESULTS

Compared with unknown HIV status, knowledge of HIV-negative status was significantly associated with a decrease in depressive symptoms of 1.06 points in Uganda (95% CI -1.79 to -0.34) and 1.68 points in Zambia (95% CI -2.70 to -0.62). Knowledge of HIV-positive status was significantly associated with a decrease in depressive symptoms of 1.01 points in Uganda (95% CI -1.82 to -0.20) and 1.98 points in Zambia (95% CI -3.09 to -0.88). The prevalence of likely depression was not associated with knowledge of HIV status in Uganda but was associated with a 14.1% decrease with knowledge of HIV-negative status (95% CI -22.1% to -6.0%) and a 14.3% decrease with knowledge of HIV-positive status (95% CI -23.9% to -4.5%) in Zambia.

CONCLUSIONS

Knowledge of HIV status, be it positive or negative, was significantly associated with a decrease in depressive symptoms in 2 FSW populations. The expansion of HIV testing programs may have mental health benefits for FSWs.

Alcohol Misuse and Illicit Drug Use Among Occupational Groups at High Risk of HIV in Sub-Saharan Africa: A Systematic Review

Key occupational groups in sub-Saharan Africa (SSA) are at increased risk of HIV, and may be at increased risk of substance use. In January 2018, we systematically searched for studies reporting prevalence of, and risk factors for alcohol misuse or illicit drug use and their association with HIV incidence or prevalence among fisherfolk, uniformed personnel, truckers, miners, motorcycle taxi riders and sex workers in SSA. Seventy-one studies published between 1983 and 2017 were included: 35 reported on alcohol misuse (19 using AUDIT, 5 using CAGE) and 44 on illicit drug use (eight reported both). Median prevalence of alcohol misuse based on AUDIT/CAGE was 32.8% (IQR 20.8-48.5%). Prevalence of illicit drug use ranged from 0.1% (95% CI: 0.0-0.2%) for injection drug use to 97.1% (95% CI: 85.1-99.9%) for khat (among uniformed personnel). Among papers examining associations between substance use and HIV incidence (n = 3) or prevalence (n = 14), nine papers (53%) reported a significant positive association (2 with incidence, 7 with prevalence). Harm reduction interventions in occupational settings are urgently required to prevent new HIV infections.

Brief Report: Intimate Partner Violence and Antiretroviral Therapy Initiation Among Female Sex Workers Newly Diagnosed With HIV in Zambia: A Prospective Study

Supplemental Digital Content is Available in the Text.

Background:

Intimate partner violence (IPV) is common among female sex workers (FSW) globally. Here, we prospectively assessed the relationship between IPV and engagement in HIV care in a cohort of FSW who had been newly diagnosed with HIV.

Methods:

Data arose from the Zambian Peer Educators for HIV Self-Testing study, a randomized controlled trial of HIV self-test distribution among FSW in 3 transit towns in Zambia. Participants were self-reported to be HIV-uninfected or unaware of their status at baseline. IPV in the previous 12 months was assessed at baseline. At 4 months, participants were asked the results of their last HIV test and those who reported testing positive were asked whether they had engaged in HIV-related care and started antiretroviral therapy (ART).

Results:

Of 964 participants, 234 (24.3%) reported that they were living with HIV at 4 months. Of these 234 participants, 142 (60.7%) reported a history of IPV (past 12 months) at baseline and at 4 months, 152 (65.0%) reported that they were in HIV-related care, and 132 (56.7%) reported that they had initiated ART. Participants who reported IPV had significantly reduced odds of engagement in care (adjusted odds ratio = 0.48, 95% confidence interval: 0.26 to 0.91) and ART initiation (adjusted odds ratio = 0.40, 95% confidence interval: 0.22 to 0.72).

Conclusions:

FSW living with HIV in Zambia reported very high rates of IPV. Structural and individual interventions for violence prevention are urgently needed to better protect this population. Given the strong negative relationship between IPV and engagement in HIV-related care, such interventions could also substantially improve HIV-related health outcomes.

Intimate partner violence among HIV-positive women in Nairobi, Kenya

Purpose

This study was conducted to identify the prevalence and sociodemographic factors associated with four forms of intimate partner violence (IPV) among HIV-positive women attending the Comprehensive Care Centre at the Kenyatta National Hospital in Nairobi, Kenya.

Methods

A cross-sectional study was conducted among 600 sexually active HIV-positive women aged 18–69 years from May to August of 2012. A structured questionnaire including questions pertaining to sociodemographic characteristics, health care decisions, and forms of IPV (controlling behavior, emotional abuse, physical violence, and sexual violence) was administered to each woman.

Results

All women reported experiencing emotional abuse; 20%, 17%, and 15% experienced controlling behavior, physical violence, and sexual violence, respectively. Women who reported low/below average socioeconomic status (SES) had a greater likelihood of experiencing controlling behavior than women with high/average SES (adjusted odds ratio [aOR] =1.62, 95% CI 1.05–2.51). Women who were unemployed had greater odds of experiencing physical violence than those who were employed (aOR =2.35, 95% CI 1.31–4.23). Non-Christian women had higher odds of experiencing controlling behavior, physical violence, and sexual violence than Christian women (aOR =4.41, 95% CI 1.81–10.76 and aOR =3.33, 95% CI 1.43–7.80).

Conclusion

Based on the prevalence of IPV and the sociodemographic factors identified to be associated with IPV among women in this study it may be beneficial to include IPV screening as part of routine clinic visits for HIV-positive and other women. Furthermore, women who report emotional abuse or controlling behavior from spouse should not be overlooked, as these two forms of IPV may precede or accompany physical and sexual IPV. Women who report experiencing IPV during clinic visits may be referred to organizations and resources available to battered women in Kenya. Increased funding for anti-IPV programs and changes in policy may also contribute to a reduction in IPV among HIV-positive and other women in Kenya.

Unseen, unheard and unprotected: prevalence and correlates of violence among female sex workers in Mozambique

Violence against women, including female sex workers, is a public health concern worldwide. This is the first study in Mozambique to estimate the prevalence of and factors associated with physical and sexual violence against female sex workers. We used data collected from 1,250 women recruited using respondent-driven sampling in the cities of Maputo, Beira and Nampula in 2011-12. Participants were 15 years of age and reported having had sex for money in the preceding six months. Prevalence of physical or sexual violence (defined as being hit or battered or raped or forced to have sex within the last 6 months) ranged from 10.0% to 25.6%. Strangers (37.0%) and acquaintances (31.2%) were reported to be the most frequent perpetrators of sexual violence. Among participants who experienced sexual violence, 65.9% and 87.0% did not seek medical care and police assistance, respectively. Physical or sexual violence was associated with city (adjusted odds ratio [AOR] 2.6 and 2.0 Nampula and Beira vs Maputo), age (AOR 1.9, aged 15-24 years vs aged 25 and older), unprotected sex with last client (AOR 1.6) and self-reported sexually transmitted infections (AOR 2.1). The high prevalence of violence found confirms the need for interventions to mitigate this problem.

Prevalence and correlates of physical violence and rape among female sex workers in Ethiopia: a cross-sectional study with respondent-driven sampling from 11 major towns

OBJECTIVE

This study examined the prevalence and correlates of physical violence and rape among female sex workers (FSWs) in Ethiopia.

DESIGN

A cross-sectional study using respondent-driven sampling technique.

SETTING

Eleven major towns in Ethiopia.

PARTICIPANTS

4900 FSWs.

MAIN OUTCOME MEASURES

The prevalence of experiences of physical beating and rape.

RESULTS

Among FSWs, 17.5% reported physical beating within the last year and 15.2% reported rape since they started selling sex. FSWs aged 35+ years (AOR 0.59, 95% CI 0.38 to 0.92) were less exposed to physical beating than those aged 15-24 years. FSWs working on the street (AOR 1.92, 95% CI 1.53 to 2.39), in red-light houses (AOR 1.63, 95% CI 1.12 to 2.38) and in local drinking houses (AOR 1.35, 95% CI 1.02 to 1.78) experienced more physical beating than FSWs working in bars/hotels. FSWs who consumed alcohol four or more days in a week (AOR 1.92, 95% CI 1.21 to 3.04), and who chewed khat frequently experienced more physical violence. Rape was associated with having a low monthly income, drinking alcohol four or more days per week (AOR 2.33, 95% CI 1.47 to 3.7), experience of heavy episodic drinking in a month (AOR 1.71, 95% CI 1.24 to 2.38) and chewing khat 3-4 days per week (AOR 2.15, 95% CI 1.55 to 2.98). Condom breakage was more frequent among FSWs who reported both physical beating (AOR 1.51, 95% CI 1.25 to 1.84) and rape (AOR 1.26, 95% CI 1.03 to 1.55).

CONCLUSION

FSWs in Ethiopia are vulnerable to physical and sexual violence, and the risk increases when they are younger, street-based and high consumers of alcohol or khat. Therefore, targeted efforts are needed for prevention and harm reduction.

Prevalence and predictors of unmet contraceptive need in HIV-positive female sex workers in Mombasa, Kenya

OBJECTIVES

Female sex workers (FSWs) in sub-Saharan Africa are a key population for HIV prevention and treatment interventions, but less attention is given to their family planning needs. We evaluated the prevalence and predictors of unmet contraceptive need in HIV-positive FSWs.

STUDY DESIGN

This cross-sectional analysis used data from an existing longitudinal study of FSWs in Mombasa, Kenya. This analysis included women who were HIV positive, age ≥18 years, pre-menopausal, not currently pregnant or desiring pregnancy, and reported exchanging sex for cash or in-kind payment at the time of enrollment. Unmet contraceptive need was defined as non-use of modern non-barrier contraceptives and not currently trying to become pregnant. Poisson regression was used to identify factors independently associated with unmet contraceptive need.

RESULTS

Among 346 HIV-positive FSWs, 125 (36.1%) reported modern non-barrier contraceptive use, leaving 221 (63.9%, 95%CI 58.8-68.9%) with unmet contraceptive need. Condom use was the only form of contraception for 129 (37.3%) participants. In unadjusted analyses, unmet contraceptive need was associated with physical abuse in the past year by someone other than a regular partner (PR 1.2, 95%CI 1.0-1.5), desire for (more) children (PR 1.3, 95%CI 1.1-1.5), and having 2-3 previous pregnancies compared to 0-1 prior pregnancies (PR 0.8, 95%CI 0.6-0.9). In adjusted analyses, lower number of previous pregnancies and having desire for future children remained significantly associated with a higher prevalence of unmet contraceptive need.

CONCLUSIONS

Unmet need for modern non-barrier contraception was found in two-thirds of HIV-positive FSWs who reported that they were not currently trying to become pregnant, and was higher in women with the lowest number of prior pregnancies (0-1 prior pregnancies) and in those reporting desire for (more) children in the future. These findings highlight the need for concerted efforts to identify and eliminate barriers to contraceptive use in FSWs living with HIV.

What determines violence among female sex workers in an intimate partner relationship? Findings from North Karnataka, south India

Background

Like other women in India, female sex workers (FSWs) frequently experience violence from their intimate partners (IPs)-a reality that increases their risk of acquiring HIV or other sexually transmitted infections. Less is known about the nature of these intimate relationships or what aspect of the relationship increases the risk of IP violence (IPV). We measured the prevalence and determinants of IPV on FSWs in the context of north Karnataka, India, characterized by high HIV-prevalence and extreme poverty.

Methods

Overall 620 FSWs with an IP participated in a baseline survey conducted for an on-going cluster-randomised controlled trial aiming to evaluate the impact of a multi-level intervention on IPV reduction. We characterize the nature of intimate relationships and explored determinants of severe physical and/or sexual IP violence using univariable and multivariable analyses.

Results

The median age of participants was 35 years with 10 years of duration in an intimate relationship. Though most relationships originated from a sex work encounter, 84% stated that IPs did not know they were currently practicing sex work. In past 6 months, the experience of emotional violence was 49% (95%CI:45.2–53.2), physical 33% (95%CI:29.5–37.1) and sexual violence 7% (95%CI:4.8–8.9), while 24% (95%CI:21.0–27.9) FSWs experienced recent severe physical and/or sexual violence from IPs. Factors associated with recent IPV included experience of physical and/or sexual violence from their clients in last 6 months (AOR 2.20; 95%CI: 1.29–3.75), sexual intercourse in the past 1 month when their IP was under the influence of alcohol (AOR 2.30; 95%CI: 1.47–3.59) and providing financial support to their IP (AOR 2.07; 95%CI: 1.28–3.34).

Conclusions

The association between increased risk of violence and provision of financial support to an IP is indicative of gendered power dynamics as men remain dominant irrespective of their financial dependency on FSWs. Interventions are needed that address inequitable gender norms which makes FSWs tolerate violence even though she is not financially dependent on IP. Higher likelihood of violence in presence of alcohol use and FSWs’ previous experience of workplace violence linked to IPV call for strengthening the crisis management systems within community-based organisations that can address all forms of violence and associated risk factors.

Trial registration

Clinical Trials NCT02807259

Intimate Partner Violence and Self-Reported Pre-exposure Prophylaxis Interruptions Among HIV-Negative Partners in HIV Serodiscordant Couples in Kenya and Uganda

BACKGROUND

Oral pre-exposure prophylaxis (PrEP) is effective for HIV prevention, and PrEP delivery studies are investigating ways to deliver PrEP with high adherence. However, in many settings with high HIV burden, intimate partner violence (IPV) is reported often and could be a barrier to the effective PrEP use. We examined the association between IPV and interruptions in PrEP use.

METHODS

We analyzed data from 1013 serodiscordant heterosexual couples enrolled in a large PrEP demonstration project in Kenya and Uganda, the Partners Demonstration Project. At quarterly study visits, HIV-negative participants receiving PrEP were asked about interruptions in their PrEP use and experiences with IPV. The association between IPV and PrEP interruptions was analyzed using multivariable generalized estimating equations.

RESULTS

At baseline and follow-up, there were 53 visits with reports of abuse by 49 HIV-negative partners, including physical, economic, and verbal IPV. Interruptions in PrEP use were reported at 328 visits (7.1% of all visits) by 249 people. The median length of PrEP interruption was 28 days (interquartile range: 7-45). The frequency of PrEP interruptions among those reporting IPV was 23.8% and those without IPV was 6.9%. PrEP interruption was significantly associated with IPV after adjustment for age and frequency of sexual intercourse (adjusted odds ratio = 2.6, 95% confidence interval: 1.2 to 6.0).

CONCLUSIONS

IPV was more likely to be reported at visits when PrEP interruptions were also reported, which may have implications for sustained adherence to PrEP. Within PrEP delivery programs, there may be opportunities to assess individual safety and well-being to bolster adherence.

'You already drank my beer, I can decide anything': using structuration theory to explore the dynamics of alcohol use, gender-based violence and HIV risk among female sex workers in Tanzania

Female sex workers experience high rates of gender-based violence and HIV. Alcohol has been shown to facilitate women's risk of both gender-based violence and HIV; however, little research has explored how aspects of the sex work environment shape this risk. Drawing on structuration theory, this study explored how social conduct is patterned across time and space within the sex work environment to influence alcohol consumption, gender-based violence and HIV risk among female sex workers. Qualitative in-depth interviews were conducted with 24 female sex workers enrolled in an ongoing community randomised controlled trial of a combination HIV prevention intervention in Iringa, Tanzania. Data were analysed using both inductive and deductive approaches. Findings reveal how routine interactions between female sex workers and their clients occur at three moments of time and space during the sex exchange process to facilitate alcohol consumption and increase women's risk of gender-based violence and HIV. Findings also highlight how sex workers utilise collective agency to address aspects of the sex work environment that place them at risk of alcohol abuse, gender-based violence and HIV. Implications for future interventions to prevent gender-based violence and HIV among female sex workers in Tanzania and similar contexts are discussed.

Sexual and physical violence and associated factors among female sex workers in Rwanda: a cross-sectional survey

Female sex workers (FSWs) frequently face violence in their working place. This study assessed the physical and sexual violence and associated factors among FSWs in Rwanda. A cross-sectional study was conducted among FSWs in Rwanda in 2015. Venue-Day-Time sampling method was used for recruitment. Descriptive analyses and logistic regression models were computed to assess factors associated with violence. In total, 1978 FSWs were recruited. A large proportion (18.3%) had been sexually abused outside of the family circle, and 37.8% had faced physical violence before 15 years of age. Clients were most often reported (67.0%) as perpetrators of physical violence in sex work. Being aged 25 years old and above, and having sexually transmitted infections (STIs) were positively associated with sexual violence (aOR = 2.1[95%CI: 1.80-2.39]) and (aOR = 3.0[95%CI: 1.01-2.14], respectively). Being aged 25 years old and above (aOR = 0.8[95%CI: 0.76-0.89]) and drinking alcohol every day (aOR = 0.6[95%CI: 0.42-0.87]) were negatively associated with physical violence. Sexual and physical violence was common among FSWs in Rwanda. Single FSWs are the most vulnerable to sexual violence. Alcohol consumption and having STIs are associated with violence against FSWs. Human rights and social protection as well as health promotion among FSWs is needed.

A Prospective Cohort Study of Fertility Desire, Unprotected Sex, and Detectable Viral Load in HIV-Positive Female Sex Workers in Mombasa, Kenya

BACKGROUND

Little is known about fertility desire in HIV-positive female sex workers. Fertility desire could increase HIV transmission risk if it was associated with condomless sex or lower adherence to antiretroviral therapy.

METHODS

A prospective cohort study was conducted among 255 HIV-positive female sex workers in Mombasa, Kenya. Using generalized estimating equations, fertility desire was evaluated as a risk factor for semen detection in vaginal secretions by prostate-specific antigen (PSA) test, a biomarker of condomless sex, detectable plasma viral load (VL), and HIV transmission potential, defined as visits with positive PSA and detectable VL.

RESULTS

The effect of fertility desire on PSA detection varied significantly by nonbarrier contraception use (P-interaction < 0.01). At visits when women reported not using nonbarrier contraception, fertility desire was associated with higher risk of semen detection [82/385, 21.3% vs. 158/1007, 15.7%; adjusted relative risk (aRR) 1.58, 95% confidence interval (CI): 1.12 to 2.23]. However, when women used nonbarrier contraception, fertility desire was associated with lower risk of PSA detection (10/77, 13.0% vs. 121/536, 22.6%; aRR 0.58, 95% CI: 0.35 to 0.94). Fertility desire was not associated with detectable VL (31/219, 14.2% vs. 128/776, 16.5%; aRR 0.82, 95% CI: 0.46 to 1.45) or higher absolute risk of transmission potential (10/218, 4.6% vs. 21/769, 2.7%; adjusted risk difference = 0.011, 95% CI -0.031 to 0.050).

CONCLUSIONS

Fertility desire was associated with higher risk of biological evidence of semen exposure when women were not using nonbarrier contraceptives. Low HIV transmission potential regardless of fertility desire suggests that the combination of condoms and antiretroviral therapy adherence was effective.

The intersection of intimate partner violence and HIV risk among women engaging in transactional sex in Ugandan fishing villages

Intimate partner violence (IPV) may increase risk for HIV/AIDS among women engaging in transactional sex in Ugandan fishing communities. In this cross-sectional study, 115 women reporting engaging in transactional sex in Lake Victoria fishing communities completed a computerized interview. We tested associations between IPV and other HIV risk factors, with unprotected sex and HIV status, and tested moderators of the IPV-HIV risk relationship. Women reporting recent sexual IPV reported 3.36 times more unprotected sex acts (AdjExp[B] = 3.36, 95% CI = 1.29-8.69, p = 0.07). The effect of sexual IPV on sexual risk was significantly greater among alcohol and fish sellers compared to sex workers (interaction: Exp[B] = 12.29, 95% CI = 5.06-29.85, p < 0.001). Women reporting any sexual IPV were nearly four times more likely to report being HIV positive than women reporting no sexual IPV (AOR = 3.94, 95% CI = 1.22-12.66, p = 0.02). Integrated IPV and HIV interventions are needed in this context, especially among alcohol and fish sellers engaging in transactional sex.

Forced sexual intercourse and its association with HIV status among people attending HIV Voluntary Counseling and Testing in a healthcare center in Kinshasa (DRC)

INTRODUCTION

Sexual violence, an HIV determinant, is an integrated behavior in the D.R.Congo. We aimed to analyze the prevalence of forced sexual intercourse (FSI) among people receiving HIV Voluntary Counseling and Testing in a hospital in Kinshasa, and its association with socio-demographics, behaviors and HIV status.

METHODOLOGY

Case-control study (2010-2012). Two-hundred and seventy-four cases with a new HIV+ test and 1,340 controls with an HIV- test were interviewed about HIV-related knowledge, attitudes and behaviors, including FSI.

RESULTS

Thirty-four percent of the participants declared having had FSI (38% of women and 32% of men). Being a woman, aged 25-49 and reporting multiple sexual partners were associated with reporting FSI. For men, being single was protective against FSI; and cohabiting, having a high socioeconomic status, and alcohol consumption increased the odds. For women, being single, divorced/separated and widow was associated with reporting FSI. A significant positive association was found between FSI and an HIV positive test.

CONCLUSION

Among our Congolese population, FSI was strongly associated with HIV infection and it was also associated with alcohol consumption and multiple sexual partnerships, other key HIV determinants. These behaviors need to be identified as potential risk factors of FSI during counseling interventions. Researchers, practitioners and decision-makers should work together to get violence prevention integrated into health, social and educational policies.

Alcohol Use and Associations With Biological Markers and Self-Reported Indicators of Unprotected Sex in Human Immunodeficiency Virus-Positive Female Sex Workers in Mombasa, Kenya

BACKGROUND

Studies of alcohol use and sexual behavior in African populations have primarily been cross-sectional, used nonvalidated measures of alcohol use, or relied on self-reported sexual risk endpoints. Few have focused on human immunodeficiency virus (HIV)-positive women.

METHODS

Longitudinal data were collected from a cohort of HIV-positive Kenyan female sex workers. At enrollment and annual visits, participants were asked about past-year alcohol use using the Alcohol Use Disorders Identification Test (AUDIT). The primary endpoint was detection of prostate-specific antigen (PSA) in vaginal secretions at quarterly examinations. Associations between hazardous/harmful alcohol use (AUDIT score ≥7), PSA detection, and secondary measures of sexual risk were evaluated using generalized estimating equations with a log binomial regression model.

RESULTS

A total of 405 women contributed 2750 vaginal samples over 606 person-years of follow-up. Hazardous/harmful alcohol use was reported at 16.6% of AUDIT assessments and was associated with higher risk of PSA detection (relative risk 1.50; 95% confidence interval, 1.11-2.01) relative to no alcohol use. This association was attenuated and no longer statistically significant, after adjusting for age, work venue, intimate partner violence, depression, and partnership status (adjusted relative risk, 1.13; 95% confidence interval, 0.82-1.56). In exploratory analyses, alcohol use was associated with self-report of unprotected sex and with sexually transmitted infection acquisition.

CONCLUSIONS

Although hazardous/harmful alcohol use was not associated with detection of PSA in adjusted analysis, associations with secondary outcomes suggest that alcohol use is at least a marker of sexual risk behavior.

A Prospective Study of Intimate Partner Violence as a Risk Factor for Detectable Plasma Viral Load in HIV-Positive Women Engaged in Transactional Sex in Mombasa, Kenya

We conducted a prospective cohort study to evaluate intimate partner violence (IPV) as a risk factor for detectable plasma viral load in HIV-positive female sex workers (FSWs) on antiretroviral therapy (ART) in Kenya. IPV in the past year was defined as ≥1 act of physical, sexual, or emotional violence by the index partner (i.e. boyfriend/husband). The primary outcome was detectable viral load (≥180 copies/ml). In-depth interviews and focus groups were included to contextualize results. Analyses included 195 women (570 visits). Unexpectedly, IPV was associated with significantly lower risk of detectable viral load (adjusted relative risk 0.21, 95 % CI 0.05-0.84, p-value = 0.02). Qualitative findings revealed that women valued emotional and financial support from index partners, despite IPV. IPV was not a major barrier to ART adherence. The observed association between IPV and lower risk of detectable viral load in FSWs may be due to unmeasured personal and relationship factors, warranting further research.