HIV risk assessment and risk reduction strategies in the context of prevailing gender norms in rural areas of Cabo Delgado, Mozambique

OUP accepted manuscript

Background

Sexually transmitted infections (STIs) affect individuals of all ages, but adolescent girls and young women are disproportionately affected. We examined the prevalence and factors associated with self-reported STIs (SR-STIs) among adolescent girls and young women in sub-Saharan Africa (SSA).

Methods

Demographic and Health Survey data of 27 sub-Saharan African countries were used for the study. The sample size comprised 68944 adolescent girls and young women (15–24 y of age). The outcome variable was SR-STIs. Multilevel binary logistic regression analysis was performed to identify factors associated with SR-STIs.

Results

On average, the prevalence of SR-STIs among adolescent girls and young women in SSA was 6.92%. The likelihood of SR-STIs was higher among young women aged 20–24 y (adjusted odds ratio [aOR] 1.36 [confidence interval {CI} 1.27 to 1.46]), those not married (aOR 1.64 [CI 1.51 to 1.79]), those working (aOR 1.20 [CI 1.12 to 1.27]), those whose age at first sex was ≤19 y (aOR 1.99 [CI 1.80 to 2.20]), those with two or more sex partners (aOR 1.56 [CI 1.35 to 1.80]), those who listened to radio (aOR 1.26 [CI 1.17 to 1.35]), those in urban areas (aOR 1.42 [CI 1.30 to 1.51]) and those with a wealth index of rich (aOR 1.28 [CI 1.17 to 1.40]) compared with their counterparts. In contrast, those with a primary (aOR 0.86 [CI 0.78 to 0.94]) or secondary/higher level of education (aOR 0.83 [CI 0.75 to 0.92]) compared with those with no formal education and those who were exposed to television (aOR 0.90 [CI 0.84 to 0.98]) compared with those who were not exposed were less likely to report STIs.

Conclusions

Our findings demonstrate the need for countries in SSA to commit towards reducing the incidence of STIs. Community-based health educational programs are required to intensify the awareness of STIs and their prevention in various sub-Saharan African countries considering the factors that expose adolescent girls and young women to STIs.

'I married when I was 16… due to poverty, I had no other way': multi-level factors influencing HIV-related sexual risk behaviours among adolescent girls in Zambézia, Mozambique

This paper explores individual, interpersonal- and household-level factors influencing HIV-related sexual risk behaviour among adolescent girls who participated in an intervention to reduce HIV risk in a rural setting in Mozambique. Twenty-eight adolescent girls ages 13-19, 30 heads of household, and 53 influential men participated in in-depth interviews at two time points. Comparative analysis compared girls who reported reducing risk behaviours over time to girls who did not and identified factors that respondents described as influential to behaviour change. Among the twenty girls self-reporting sexual risk at the first time point, half had reduced these behaviours one year later. Changes in girls' behaviours were contingent upon household- and interpersonal-level factors, particularly households' economic stability and family members' financial support. Future interventions with adolescents in similar settings should evaluate and leverage household and family support to achieve sexual risk reduction.

High proportion of unknown HIV exposure status among children aged less than 2 years: An analytical study using the 2015 National AIDS Indicator Survey in Mozambique

Background

Determination of the human immunodeficiency virus (HIV) exposure status in infants and young children is required to guarantee timely diagnosis and access to appropriate care. HIV prevalence among Mozambican women aged 15–49 years is 15%, and vertical transmission rate is still high. The study investigated HIV exposure in children aged less than 2 years in Mozambique and the factors associated with unknown HIV exposure and with HIV exposure status in this population.

Methods

This was a cross-sectional analytical study using data from the 2015 Survey of Indicators on Immunization, Malaria and HIV/AIDS in Mozambique. A total of 2141 mothers (15–49 years) with children aged less than 2 years were interviewed. The dependent variables were “known HIV exposure status in a child” and “HIV-exposed child,” and the explanatory variables were mother’s social, demographic, economic, and reproductive health characteristics. We used binary and logistic regression, adjusted for complex sampling, to determine the association between variables.

Results

HIV exposure status was unknown in 27% of children (95% CI, 25.1–28.9). Mothers residing in the North (AOR, 4.41; 95% CI, 2.18–8.91), in rural area (AOR, 2.44; 95% CI, 1.33–4.35), with no education (AOR, 2.72; 95% CI, 1.38–5.36), and not having utilized any health services in the last pregnancy (AOR, 1.9; 95% CI, 1.42–2.55) were more likely to have a child with unknown HIV exposure status. Six percent of children were HIV-exposed (95% CI, 5–7). Children were less likely to be HIV-exposed if the head of the household was a male (AOR, 0.26; 95% CI, 0.08–0.86), if the mother was residing in the North (AOR, 0.41; 95% CI, 0.26–0.66) and did not utilize any health services in her last pregnancy (AOR, 0.52; 95% CI, 0.32–0.83).

Conclusion

The high proportion of children with unknown HIV exposure status and the associated socioeconomic factors suggests that HIV retesting of eligible women throughout breastfeeding should be intensified and identifies the urgent need to reach women without prior access to health care using a multisectoral approach.

Risk factors for HIV infection among married couples in Rakai, Uganda: a cross-sectional study

BACKGROUND

Although married couples can be at an elevated risk of HIV infection, few studies have explored the risk factors for HIV infection at the couple-level. We explored the risk factors for HIV infection among married couples in settings with differing HIV prevalence levels in Rakai, Uganda.

METHODS

This was a cross-sectional study conducted among 664 heterosexual couples living in three HIV prevalence strata (low: 9-11.2%; medium: 11.4-20% or high HIV prevalence: 21-43%) in Rakai District, south-western Uganda, between November 2013 and February 2014. Data were collected on socio-demographic and behavioural characteristics from all consenting adults and aggregated to allow for couple-level analyses. We conducted bivariate and multivariable Logistic regression to assess the factors that were independently associated with HIV infection among married couples. Data were analysed using STATA statistical software (version 14.1).

RESULTS

Of the 664 couples, 6.4% (n = 42) were in HIV-discordant relationships; 5.8% (n = 39) were in concordant HIV-positive relationships while 87.8% (n = 583) were in concordant HIV-negative relationships. At the bivariate analysis, we found that residing in a high HIV prevalence stratum, reporting extra-marital relations, age difference between partners and number of previous marriages were significantly associated with being part of an HIV infected couple. After adjusting for potential cofounders, living in a high HIV prevalence stratum (Adjusted OR [AOR] =2.31, 95% CI: 1.52, 3.52), being in a third or higher order relationship (AOR = 3.80, 95% CI: 2.30, 6.28), and engagement in extra-marital relations (AOR = 1.75; 95% CI: 1.19, 2.59) were associated with couple HIV infection. Individuals that had stayed together for six or more years had 28% odds of being part of an HIV infected couple (AOR = 0.28; 95%CI: 0.18, 0.43).

CONCLUSION

Living in a high HIV prevalence stratum, engagement in extra-marital relations and having a higher number of previous marriages were significant risk factors for HIV infection among married couples. Long marital duration was associated with reduced risk of HIV infection. Interventions that increase marital stability and those that promote pre-marital couples' HIV testing before marital formation can reduce HIV transmission risk among married couples in this setting.

Cultural practices, gender inequality and inconsistent condom use increase vulnerability to HIV infection: narratives from married and cohabiting women in rural communities in Mpumalanga province, South Africa

BACKGROUND

Women in sub-Saharan Africa bear the brunt of the human immunodeficiency virus (HIV) epidemic, and older married women and those in cohabiting relationships are regarded as the largest HIV risk group. Although preventing HIV infection in married or stable relationships is an international HIV prevention priority, little is known about the influence of sociocultural contexts on safe-sex practice by women, particularly older women in rural communities in South Africa.

OBJECTIVES

This study aimed to examine how older women in a rural patriarchal society negotiate safer sex within marital and long-term cohabitation relationships, and their perceptions and experiences of barriers that influence condom use.

METHODS

Focus group discussions were conducted with married and cohabiting women aged 40-60 years recruited from primary health facilities in a rural district in Mpumalanga province, South Africa. A thematic analysis approach was used to analyse the data.

RESULTS

We found that although women reported negotiating safe sex in their relationships, they dreaded the possible consequences of suggesting condom use with their partners. Many factors made negotiating safe sex complex for these women: living in a patriarchal society where women play no part in sexual decision making, the fear of possible consequences of insisting on condom use, women's inferior social position in marital relationships, cultural practices such as bride price, and gender inequality were the main barriers to practising safer sex.

CONCLUSIONS

Older married and cohabiting women dreaded negotiating safer sex in this patriarchal society where women's subordination is legitimized. The findings suggest that the women were at high risk of HIV infection because of their inability to negotiate condom use, or to reject forced sex and non-consensual sex. There is a need for interventions targeting older married and cohabiting couples and key stakeholders within communities to create awareness about cultural practices and beliefs that undermine women and HIV prevention efforts.

VULNERABILIDADES DE GÊNERO, PRÁTICAS CULTURAIS E INFECÇÃO PELO HIV EM MAPUTO

RESUMOA construção social do gênero feminino em Moçambique está baseada na submissão ao homem, influenciando a vulnerabilidade de gênero à infecção pelo HIV. Objetivou-se analisar a percepção de pessoas vivendo com HIV/aids (PVHA) e de profissionais de saúde (PS), da cidade de Maputo, em relação à vulnerabilidade de gênero e infecção pelo HIV. Participaram 33 PVHA e 15 PS, selecionados por conveniência, mediante a realização de grupos focais e de entrevistas semiestruturadas. Dois eixos temáticos nortearam a análise: vulnerabilidade de gênero e práticas culturais tradicionais. A análise de conteúdo dos relatos verbais permitiu concluir que a vulnerabilidade feminina é maior, segundo a quase totalidade dos participantes, delineando categorias como submissão da mulher, dificuldade para negociar o uso do preservativo e influência das práticas culturais. O estudo possibilitou compreender melhor o contexto de vulnerabilidades que afetam cidadãos de Maputo, em especial as mulheres, em um país de prevalência elevada da epidemia.

Poor clinical outcomes for HIV infected children on antiretroviral therapy in rural Mozambique: need for program quality improvement and community engagement

INTRODUCTION

Residents of Zambézia Province, Mozambique live from rural subsistence farming and fishing. The 2009 provincial HIV prevalence for adults 15-49 years was 12.6%, higher among women (15.3%) than men (8.9%). We reviewed clinical data to assess outcomes for HIV-infected children on combination antiretroviral therapy (cART) in a highly resource-limited setting.

METHODS

We studied rates of 2-year mortality and loss to follow-up (LTFU) for children <15 years of age initiating cART between June 2006-July 2011 in 10 rural districts. National guidelines define LTFU as >60 days following last-scheduled medication pickup. Kaplan-Meier estimates to compute mortality assumed non-informative censoring. Cumulative LTFU incidence calculations treated death as a competing risk.

RESULTS

Of 753 children, 29.0% (95% CI: 24.5, 33.2) were confirmed dead by 2 years and 39.0% (95% CI: 34.8, 42.9) were LTFU with unknown clinical outcomes. The cohort mortality rate was 8.4% (95% CI: 6.3, 10.4) after 90 days on cART and 19.2% (95% CI: 16.0, 22.3) after 365 days. Higher hemoglobin at cART initiation was associated with being alive and on cART at 2 years (alive: 9.3 g/dL vs. dead or LTFU: 8.3-8.4 g/dL, p<0.01). Cotrimoxazole use within 90 days of ART initiation was associated with improved 2-year outcomes Treatment was initiated late (WHO stage III/IV) among 48% of the children with WHO stage recorded in their records. Marked heterogeneity in outcomes by district was noted (p<0.001).

CONCLUSIONS

We found poor clinical and programmatic outcomes among children taking cART in rural Mozambique. Expanded testing, early infant diagnosis, counseling/support services, case finding, and outreach are insufficiently implemented. Our quality improvement efforts seek to better link pregnancy and HIV services, expand coverage and timeliness of infant diagnosis and treatment, and increase follow-up and adherence.

Determinants of prevalent HIV infection and late HIV diagnosis among young women with two or more sexual partners in Beira, Mozambique

Background

The prevalence and determinants of HIV and late diagnosis of HIV in young women in Beira, Mozambique, were estimated in preparation for HIV prevention trials.

Methods

An HIV prevalence survey was conducted between December 2009 and October 2012 among 1,018 women aged 18–35 with two or more sexual partners in the last month. Participants were recruited in places thought by recruitment officers to be frequented by women at higher-risk, such as kiosks, markets, night schools, and bars. Women attended the research center and underwent a face-to-face interview, HIV counseling and testing, pregnancy testing, and blood sample collection.

Results

HIV prevalence was 32.6% (95% confidence interval (CI) 29.7%–35.5%). Factors associated with being HIV infected in the multivariable analysis were older age (p<0.001), lower educational level (p<0.001), self-reported genital symptoms in the last 3 months (adjusted odds ratio (aOR) = 1.4; CI 1.1–2.0), more than one lifetime HIV test (aOR = 0.4; CI 0.3–0.6), and not knowing whether the primary partner has ever been tested for HIV (aOR = 1.7; CI 1.1–2.5). About a third (32.3%) of participants who tested HIV-positive had a CD4 lymphocyte count of <350 cells/µl at diagnosis. Factors associated with late diagnosis in multivariable analyses were: not knowing whether the primary partner has ever been tested for HIV (aOR = 2.2; CI 1.1–4.2) and having had a gynecological pathology in the last year (aOR = 3.7; CI 1.2–12.0).

Conclusions

HIV prevalence and late diagnosis of HIV infection were high in our study population of young women with sexual risk behavior in Beira, Mozambique. HIV prevention programs should be strengthened, health care providers should be sensitized, and regular HIV testing should be encouraged to enroll people living with HIV into care and treatment programs sooner.