Gender inequity norms are associated with increased male-perpetrated rape and sexual risks for HIV infection in Botswana and Swaziland

Social scripts of violence among adolescent girls and young women in Zambia: Exploring how gender norms and social expectations are activated in the aftermath of violence

Adolescent girls and young women ages 15-24 experience high rates of gender-based violence (GBV), underpinned by gender and social norms that shape their transitions to adulthood. For interventions that seek to leverage and build on existing infrastructure for health service provision, it is important to understand how gender norms operate in the background and how they shape service engagement or non-engagement. In formative work for our project, Screen & Support, outside of Lusaka, Zambia, we engaged in community conversations with adolescent girls and young women to understand common types and experiences of violence, perceptions of what causes violence, and pathways to post-violence service access. This manuscript explores emerging findings surrounding social and gender norms. We engaged n = 12 adolescent girls and young women ages 15-24, including survivors of GBV, young women living with HIV, and young married women in separate conversations conducted in a mix of Nyanja, Bemba, and English. Arts-based activities accompanied guided focus group discussions. Translated transcripts were coded and thematically analysed by two authors using Dedoose software. Key themes emerged around two major themes-understanding the norms underpinning violence, and observing how these norms were activated in the aftermath of violence. Sub-themes focused on power differentials supporting violence, social expectations and community-enacted sanctions, and understanding dominant norms and assumptions. Considering what unfolded in the aftermath of violence, young women participants considered key reference groups upholding norms, explored the contexts where norms may be contested or become more complicated, and described how accepting silence was a common means of closure. We discuss the implications of these findings for programme design, delivery, and evaluation, as well as the potential, and roadmap, for shifting norms that negative affect adolescent girls and young women.

Misperception of Norms About Intimate Partner Violence as a Driver of Personal IPV Attitudes and Perpetration: A Population-Based Study of Men in Rural Uganda

Intimate partner violence (IPV) against women is a global public health problem. Conceptual frameworks suggest misperceived norms around IPV might drive perpetration of violence against women in southern and eastern Africa. We conducted a cross-sectional, population-based survey of all men residing in a rural parish in southwest Uganda, eliciting their endorsement of IPV in five hypothetical scenarios and their reported frequency of perpetration of violence against their wife/main partner. They also reported their perceptions about the extent to which most other men in their villages endorsed and/or perpetrated IPV, which we compared against the population data to measure the primary explanatory variable of interest: whether individuals misperceived norms around IPV. We fitted multivariable Poisson regression models specifying personal IPV endorsement and IPV perpetration as the outcomes. Overall, 765 men participated in the study (90% response rate): 182 (24%) personally endorsed IPV, and 78 of 456 partnered men (17%) reported perpetrating one or more acts of IPV at least once per month. Although most men neither endorsed nor reported perpetrating IPV, 342 (45%) men mistakenly thought that most other men in their villages endorsed IPV and 365 (48%) men mistakenly thought that most other men perpetrate IPV at least monthly. In multivariable regression models, men who misperceived most men to endorse IPV were more likely to endorse IPV themselves (adjusted relative risk [aRR] = 2.44; 95% CI [1.66, 3.59]; p < .001). Among partnered men, those who misperceived IPV perpetration to be normative were more likely to perpetrate IPV themselves (aRR = 4.38; [2.53, 7.59]; p < .001). Interventions to correct misperceived norms about IPV may be a promising method for reducing violence against women in rural Uganda.

How men influence young women taking PrEP: perspectives from young women, male partners, and male peers in Siaya county, Western Kenya

BACKGROUND

Daily oral pre-exposure prophylaxis (PrEP) is an effective HIV prevention option for those who are most vulnerable to HIV infection, especially young women (YW). Objection by or lack of support from male sexual partners has been shown to impact YW's ability to take PrEP consistently. We explored the views of YW, and male partners and male peers of YW in Siaya County, Western Kenya, to illustrate how men influence, and can support, YW in using PrEP.

METHODS

We used Photovoice to capture the views of YW ages 18-24 who were currently or previously enrolled in the DREAMS program and with current or previous experience taking PrEP. We also captured the views of YW's sexual partners and male peers. The YW completed eight photo assignments that focused on identifying factors influencing their PrEP use, and male participants completed four photo assignments focused on identifying ways men support or hinder YW's PrEP use. Photographs were presented and discussed in same- and mixed-gender groups using the SHOWeD method. YW also participated in in-depth interviews. The analysis focused on identifying themes that described men's influence on YW's PrEP adherence and persistence.

RESULTS

Among YW, a restricting male influence on PrEP use emerged in the majority of photo assignments such that YW's photographs and discussions revealed that men were more often viewed as barriers than supporters. YW perceived that they had little autonomy over their sexual lives and choice to use PrEP. YW's PrEP use was perceived to be hindered by stigmatizing community narratives that influenced men's support of PrEP use among women. Male participants suggested that men would support YW's PrEP use if PrEP was better promoted in the community and if men were more knowledgeable about its benefits.

CONCLUSIONS

A lack of support from male partners and peers and stigmatizing community narratives influence YW's PrEP use. Community-based programs should include education about PrEP specifically for male partners and peers of YW to positively influence PrEP use among YW.

Qualitative Evaluation of Treatment Partners for People With HIV in Botswana: Current Healthcare Provider Practices and Recommendations for Improvement

Botswana has an adult HIV prevalence of 20.8% and annual incidence of 0.2%. We aimed to evaluate current practices and advance recommendations for treatment partners (informal adherence supporters) for people with HIV in Botswana. In January-February 2020, we conducted seven focus groups with 36 healthcare providers at seven HIV clinics in Gaborone, Botswana. Providers perceived treatment partners to be critical for quality patient care. They shared that in the new era of universal antiretroviral therapy (ART) initiation immediately after diagnosis ("test-and-treat"), providers no longer require patients to select treatment partners at ART initiation. Providers suggested a renewed emphasis on treatment partners. They believed that standard guidance for providers around treatment partner selection would ensure that providers cover similar topics across patients and endorsed implementation of workshops to educate treatment partners on how to support patients. However, streamlined ART initiation policies require innovative strategies, including eHealth interventions, to engage treatment partners.

Development and psychometric evaluation of a Risky Sexual Behaviour Scale for Married Women (RSBS-MW) in Iran: a mixed-method study

A valid and reliable culture-based scale for the evaluation of risky sexual behaviours for married Iranian women is lacking. This study aimed to develop, and psychometrically test, a risky sexual behaviour scale for married Iranian women. A mixed-method sequential exploratory design was conducted from 2016 to 2020 in Tehran, Iran. First, a qualitative study was employed to define the concept of risky sexual behaviour using 16 semi-structured individual interviews and 10 focus group discussions (n = 100). Then, an item pool was generated, and the scale was developed. Finally, in the quantitative study, the psychometric properties of the scale were evaluated by validity and reliability tests. A maximum likelihood extraction with promax rotation was performed on 400 sexually active married women to assess the construct validity. The six components: (i) 'quality of sexual relations'; (ii) 'unusual pleasures in sexual relations'; (iii) 'sexual coercion'; (iv) 'verbal violence in sexual relations'; (v) 'self-care in sexual relations'; and (vi) 'concealment in sexual relations' could explain 57.49% of the total observed variance. The findings showed that the 27-item Risky Sexual Behaviour Scale (RSBS-MW) for married women in Iran has excellent internal consistency (α = 0.94) and stability (ICC = 0.98). Health care providers can use it to access risky sexual behaviours in married Iranian women.

Older men, younger women: blesser-blessee relationships among university students in Durban, South Africa

In sub-Saharan Africa, sexual relationships between younger women and older men have been shown to pose a risk of HIV transmission. In South Africa, there has been growing interest in blesser-blessee relationships. This study explores perceptions of these relationships among university students in Durban, South Africa. The study draws on 15 in-depth interviews with students. Participants suggest that older men engage in these relationships for sexual gratification and younger women do so for monetary or material gain. Interviews revealed that participants believed that these relationships are common with both men and women engaging in them and putting themselves at risk of HIV infection. It is imperative to explore the context and motivation for these relationships because of their broader social and health implications. In addition, greater effort should be geared towards addressing the underlying factors that facilitate blesser-blessee relationships.

Hold the phone! A cross-national analysis of Women's education, mobile phones, and HIV infections in low- and middle-income countries, 1990-2018

Despite remarkable progress in the fight against HIV, the number of new infections remains unacceptably high, epidemics continue to grow in certain communities, and therefore AIDS continues to be one of the deadliest pandemics of our times. This study analyzes the rate of new HIV infections over almost 30 years in low- and middle-income countries. Previous research identifies two critical ways to address HIV prevention in developing countries: educating women and using mobile phones to improve health literacy and access to virtual healthcare. Our study bridges these literatures by evaluating how women's education and mobile technology work together to support the goals of HIV prevention in low- and middle-income countries. Using two-way panel fixed effects regression models of HIV incidence across 76 developing countries, we find that both increasing access to women's education and increasing access to mobile phones are associated with fewer HIV infections over time. Furthermore, we discover that women's education moderates the relationship between mobile phones and HIV. More specifically, mobile phones seem to be more beneficial for HIV prevention in cases where rates of formal schooling are low. However, at higher levels of women's education, the impact of mobile phones on new HIV infections is substantially reduced. Our findings have important policy implications for Information and Communications for Development (ICT4D) programs.

Development of the Gender Roles and Male Provision Expectations Scale

Existing composite measures assess the extent to which women and men support masculinity ideals concerning the expectation that men should provide for their partners and families. In many contexts across sub-Saharan Africa, the male provider role is taken as given. This core masculinity tenet may be associated with related gender role expectations that result in increasing young women's risk of HIV, especially within the context of transactional sex relationships. Extant literature points to five domains potentially associated with male provider role expectations: male authority, men's sexual decision-making control, women's sexual agency, women's economic dependence, and love. The goal of this study was to develop the Gender Roles and Male Provision Expectations (GRMPE) scale toward understanding whether beliefs attached to male provider role expectations increase HIV risk. We developed the GRMPE across three research phases with young women (ages 15-24) in Central Uganda that (1) used qualitative data to refine domains and develop scale items; (2) cognitively tested the refined items; and (3) pilot tested a 26-item scale across five domains with 108 young women. Using confirmatory factor analyses, we retained 15 items across four factors, corresponding to the domains of male authority, sexual decision-making, women's sexual agency, and love; which we then modeled as indicators in a single second-order factor model. The GRMPE demonstrated initial reliability and validity, and tests of criterion validity found significant associations with known HIV risk behaviors. The GRMPE scale shows promise for better examining the determinants of HIV risk and assessing gender norm change interventions.

An agent-based model of binge drinking, inequitable gender norms and their contribution to HIV transmission, with application to South Africa

BACKGROUND

Binge drinking, inequitable gender norms and sexual risk behaviour are closely interlinked. This study aims to model the potential effect of alcohol counselling interventions (in men and women) and gender-transformative interventions (in men) as strategies to reduce HIV transmission.

METHODS

We developed an agent-based model of HIV and other sexually transmitted infections, allowing for effects of binge drinking on sexual risk behaviour, and effects of inequitable gender norms (in men) on sexual risk behaviour and binge drinking. The model was applied to South Africa and was calibrated using data from randomized controlled trials of alcohol counselling interventions (n = 9) and gender-transformative interventions (n = 4) in sub-Saharan Africa. The model was also calibrated to South African data on alcohol consumption and acceptance of inequitable gender norms. Binge drinking was defined as five or more drinks on a single day, in the last month.

RESULTS

Binge drinking is estimated to be highly prevalent in South Africa (54% in men and 35% in women, in 2021), and over the 2000-2021 period 54% (95% CI: 34-74%) of new HIV infections occurred in binge drinkers. Binge drinking accounted for 6.8% of new HIV infections (0.0-32.1%) over the same period, which was mediated mainly by an effect of binge drinking in women on engaging in casual sex. Inequitable gender norms accounted for 17.5% of incident HIV infections (0.0-68.3%), which was mediated mainly by an effect of inequitable gender norms on male partner concurrency. A multi-session alcohol counselling intervention that reaches all binge drinkers would reduce HIV incidence by 1.2% (0.0-2.5%) over a 5-year period, while a community-based gender-transformative intervention would reduce incidence by 3.2% (0.8-7.2%) or by 7.3% (0.6-21.2%) if there was no waning of intervention impact.

CONCLUSIONS

Although binge drinking and inequitable gender norms contribute substantially to HIV transmission in South Africa, recently-trialled alcohol counselling and gender-transformative interventions are likely to have only modest effects on HIV incidence. Further innovation in developing locally-relevant interventions to address binge drinking and inequitable gender norms is needed.

"Men Rule… this is the Normal Thing. We Normalise it and it's Wrong": Gendered Power in Decision-Making Around Sex and Condom Use in Heterosexual Relationships Amongst Adolescents and Young People in South Africa

We examined power and decision-making in heterosexual relationships amongst South African adolescents and young people. A survey conducted with 515 adolescent girls and young women (AGYW) included items from the Sexual Relationship Power Scale (SRPS) adapted for South African women. Qualitative interviews with fifty AGYW aged between 15 and 24, and nine males aged 18 years and above, explored decision-making in heterosexual relationships, particularly relating to timing of sex and condom use. Theories of gendered power, sexual relationship power and sexual scripting were used in interpreting the data. Findings showed that the power AGYW have in sexual relationships determines their ability to use condoms, and that males generally control condom use and timing of sex. Both survey and interview data suggest that male control over female partners' behaviour also extends beyond the sexual domain. Although while male power is pervasive and enduring, it is simultaneously contested and negotiated. Despite some young people believing that gendered power in decision-making should be equal, it is not always possible for AGYW to enact agency in the dyadic context of heterosexual relationships. Whilst adolescents and young people in South Africa move away from traditional cultural gendered expectations, relationship power inequity and hegemonic masculinities continue to legitimise men's power over women, constraining the sexual agency of adolescent girls and young women and discouraging them from taking control of their own sexual interests and sexual health.

Intimate partner violence among young women in Ibadan, Nigeria: are there slum and non-slum differences?

This study determined the past-year prevalence of physical, sexual and psychological intimate partner violence (IPV) and associated factors among young women in urban slums and non-slums of Ibadan, Nigeria.A cross-sectional study, using a multistage cluster sampling method was used to select 1050 ever-partnered young women aged between 18 and 24 years from the five Local Government Areas (LGAs) in Ibadan municipal. All localities were classified into slums and non-slums using the UN-Habitat 2003 criterion. Independent variables were respondents' and partners' characteristics. Dependent variables were physical, sexual and psychological IPV. Data were analysed using descriptive statistics and binary logistic regression model (α0.05).Prevalence of physical (31.4%, 13.4%), sexual (37.1%, 18.3%), and psychological IPV (58.6%, 31.5%) were significantly higher in the slum than non-slum communities. Multivariate analysis showed that secondary education (aOR:0.45, 95%CI: 0.21 - 0.92) reduced IPV experience while being unmarried (aOR:2.83, 95%CI: 1.28 - 6.26), partner's alcohol use (aOR:1.97, 95%CI: 1.22 - 3.18), and partner's relationship with other women (aOR:1.79, 95%CI: 1.10 -2.91) increased IPV experience in slum communities. In non-slum communities, having children (aOR:2.99, 95%CI: 1.05-8.51), non-consensual sexual debut (aOR: 1.88, 95%CI: 1.07-3.31) and witness of abuse in childhood (aOR:1.82: 95%CI: 1.01 - 3.28) increased experience of IPV. Acceptance of IPV and partner's witness of abuse in childhood increased experience of IPV in both settings.This study confirms that IPV is common among young women in Ibadan, Nigeria, but higher among women in slum communities. Findings also showed different factors associated with IPV in slum and non-slum communities. Therefore, targeted interventions for each urban stratum are recommended.

Intimate partner violence perpetration and sexual risk behaviour: Identifying shared determinants among young men in Tanzania

In this study we examined factors that predict involvement in different patterns of sexual risk behavior and IPV perpetration among young men in Tanzania (n = 979), with a focus on identifying factors that distinguish men who engage in both behaviours from those who do not. Risk factors were drawn from three domains thought to be upstream drivers of both IPV and sexual risk: poverty, adverse childhood experiences, and inequitable gender norms. A three-step latent class analysis was used to assess whether and how factors from each domain distinguished subgroups of men whose behaviour patterns were characterised as comorbid (involvement in IPV and sexual risk behaviour), IPV-only, sexual risk only, and normative (low risk). Consistent with expectations, greater food insecurity, adverse childhood experiences, and inequitable gender norms related to violence and sexual behaviour predicted increased risk of membership in the comorbid group compared to other sub-groups. Findings support the promise of integrated prevention programmes targeting the common causes of IPV perpetration and sexual risk behaviour.

How gender norms and 'good girl' notions prevent adolescent girls and young women from engaging with PrEP: qualitative insights from Zimbabwe

BACKGROUND

Pre-exposure prophylaxis, or PrEP, has been hailed for its promise to provide women with user-control. However, gender-specific challenges undermining PrEP use are beginning to emerge. We explore the role of gender norms in shaping adolescent girls and young women's (AGYW) engagement with PrEP.

METHODS

We draw on qualitative data from 12 individual interviews and three focus group discussions with AGYW from eastern Zimbabwe. Interviews were transcribed and thematically coded in NVivo 12. Emerging themes were further investigated using Connell's notion of 'emphasised femininity'.

RESULTS

Participants alluded to the patriarchal society they are part of, with 'good girl' notions subjecting them to direct and indirect social control. These controls manifest themselves through the anticipation of intersecting sexuality- and PrEP-related stigmas, discouraging AGYW from engaging with PrEP. AGYW recounted the need for permission to engage with PrEP, forcing them to consider engaging with PrEP in secrecy. In addition, limited privacy at home, and fear of disclosure of their health clinic visits, further heightened their fear of engaging with PrEP. PrEP is not simply a user-controlled HIV prevention method, but deeply entrenched within public gender orders.

CONCLUSION

AGYW face significant limitations in their autonomy to initiate and engage with PrEP. Those considering PrEP face the dilemma of Scylla and Charybdis: The social risks of stigmatisation or risks of HIV acquisition. Efforts to make PrEP available must form part of a combination of social and structural interventions that challenge harmful gender norms.

Gender, Power, and Health: Measuring and Assessing Sexual Relationship Power Equity Among Young Sub-Saharan African Women and Men, a Systematic Review

Gender inequity, including low sexual relationship power (SRP), is an important determinant of intimate partner violence (IPV) and negative sexual, reproductive, and mental health. Different versions of the Sexual Relationship Power Scale (SRPS) are commonly used within youth studies to examine how gender inequities, including controlling behaviors, in heterosexual relationships impact the lives of young people in sub-Saharan Africa. This review aims to (1) describe definitions and measures of SRP within sub-Saharan African youth studies and (2) review and summarize associations between SRP equity, IPV, and sexual, reproductive, and mental health. After searching Pubmed, Ovid Med, Psych info, Web of Science, Google Scholar, and relevant research forums, 304 papers were identified, of which 29 papers based on 15 distinct studies (published 2004-2019) met our criteria for being youth-specific, conducted in sub-Saharan Africa, and including a quantitative measure of SRP. Details of each SRPS are described, including any adaptations and psychometric properties, as well as associations with IPV, sexual, reproductive, and mental health behaviors and outcomes. Results indicate that there are variations to the SRPS, and a paucity of evidence has detailed the psychometric properties of such measures within sub-Saharan African youth studies. Measures of SRP equity are associated with experiences (among women) and perpetration of (among men) IPV as numerous pathways to HIV risk; however, the evidence remains mixed. In order to address overlapping epidemics of violence against women and HIV, efforts are needed to ensure that measures, including the SRPS, are valid and reliable among highly affected populations.

Defining Power and Agency in Gender Relations in El Salvador: Consequences for Intimate Partner Violence and Women's Mental Health

Intimate partner violence (IPV) affects thousands of women around the world and is prevalent in the Global South. Unequal social structures perpetuate hierarchies and maintain women’s vulnerability to violence. Difficulties women face in accessing education, economic resources, and employment diminish their power in intimate relationships, increasing the likelihood of IPV. These factors can also have a significant effect on women’s mental health. However, some studies show that economic empowerment does not necessarily translate into greater agency for women if they cannot use the resources they earn to pursue whatever goals or values they regard as important in life. Agency is women’s ability to identify their life goals and act upon them through critical evaluation (intrinsic agency) and autonomous decision-making (instrumental agency). In this article, we aim to analyze the relationship between women’s power (educational and economic) and agency and their influence on intimate partner violence and on women’s mental health in the context of El Salvador. Currently, El Salvador has one of the highest percentages of femicide worldwide. We used data from the first national survey on violence against women in El Salvador to determine empowerment indicators and investigated their influence on intimate partner violence and women’s mental health. Results from a representative sample of 1,274 women aged between 15 and 64 years old and, using a structural equation modeling revealed that education was a protective factor against IPV, but economic power appeared to put women at greater risk of IPV. Education was positively related to both intrinsic and instrumental agency, but only instrumental agency was negatively associated with the likelihood of being a victim of IPV. Finally, both intrinsic and instrumental agencies were positively related to women’s mental health. We discuss the importance of identifying specific factors related to women’s power and agency to prevent IPV and mental health problems and to promote more gender equity in the Global South.

Gender-Based Violence and Factors Associated with Victimization among Female Entertainment Workers in Cambodia: A Cross-Sectional Study

Women working in the entertainment industry are confronted with various forms of gender-based violence (GBV). However, their vulnerability remains understudied, particularly in resource-limited settings. This study aims to examine the prevalence of GBV among female entertainment workers (FEWs) in Cambodia and identify factors associated with victimization. We conducted a cross-sectional study in November 2018 for the impact evaluation of a randomized controlled trial. We used a stratified random sampling method to recruit 600 FEWs from different entertainment venues in the capital city and three other provinces. Female data collectors administered a structured questionnaire, and we performed multiple logistic regression analyses. Of the total, 60.5% had experienced a form of GBV during their lifetime; of whom, 37.5% experienced the GBV in the past 6 months. The prevalence of emotional abuse, forced substance use, physical abuse, and forced sex was 51.5%, 25.0%, 20.6%, and 2.9%, respectively. Forced substance use and forced sex were mainly perpetrated by clients, physical abuse by intimate partners, and emotional abuse by others such as entertainment establishment owners or managers. FEWs victimized by clients (relative risk ratio [RRR] = 0.19, 95% confidence interval [CI] = [0.07, 0.53]) and others (RRR = 0.11, 95% CI = [0.03, 0.44]) were less likely to be married compared with victims of intimate partner violence. Factors associated with sexual harassment were working in beer gardens (adjusted odds ratio [aOR] = 2.39, 95% CI = [1.20, 4.73]) and restaurants/cafés (aOR = 1.65, 95% CI = [1.01, 2.69]), and having higher acceptance of violence against women (aOR = 1.12, 95% CI = [1.01, 1.24]). FEWs in Cambodia experience high levels and unique forms of GBV as they are confronted with different types of perpetrators. Interventions need to be tailored to fit the specific needs of FEWs. Interventions aimed at reducing client-perpetrated violence should specifically focus on forced substance use and forced sex, while physical abuse by intimate partners should also be addressed.

Examining Mediators of the Relationship Between Community Mobilization and HIV Incidence Among Young South African Women Participating in the HPTN 068 Study Cohort

We previously demonstrated that village community mobilization (CM) was associated with reduced HIV incidence among adolescent girls and young women (AGYW) in South Africa. Little remains known about the mechanisms linking CM to HIV incidence. Using longitudinal data from 2292 AGYW in the HPTN 068 cohort (2011-2017), we examined whether school attendance, pro-social engagement, and hope for the future mediated the relationship between CM and HIV incidence. CM was measured at the village-level via two population-based surveys (2012 and 2014). Mediators and incident HIV infection were measured through HPTN 068 surveys and HIV testing. Mediation analyses were conducted using Mplus 8.5, adjusting for village-level clustering and covariates. Hope for the future mediated the relationship between CM and HIV incidence (indirect effect-RR 0.98, bias-corrected 95% CI 0.96, 0.99). Pro-social engagement and school attendance did not demonstrate indirect effects. CM reduces AGYW's HIV acquisition risk, in part, by engendering hope.

A quantitative analysis of food insecurity and other barriers associated with ART nonadherence among women in rural communities of Eswatini

BACKGROUND

Eswatini has the highest global prevalence of HIV despite decades of universal access to free antiretroviral therapy (ART). We conducted a mixed methods study to investigate barriers to ART adherence among women living with HIV (WLHIV) in rural communities of Eswatini. Qualitative findings were reported in our previous publication. This subsequent paper expands on our qualitative analysis to examine the magnitude to which identified barriers impacted ART adherence among WLHIV in the same communities.

METHODS

We used an exploratory sequential design to collect data from WLHIV (n = 166) in rural Eswatini. Quantitative data were collected using interviewer-administered survey questionnaires between October and November 2017. ART adherence was measured using the CASE Adherence Index, with scores less than 10 indicating nonadherence. Log-binomial regression models were used to examine the extent to which critical barriers affected ART adherence among study participants.

RESULTS

A majority of the women in our study (56%) were nonadherent to ART. Of the barriers identified in our prior qualitative analysis, only eight were found to be significantly associated with ART nonadherence in our quantitative analysis. These include, with adjusted risk ratios (ARR) and 95% confidence intervals (95% CI): household food insecurity (ARR: 3.16, 95% CI: 1.33-7.52), maltreatment by clinic staff (ARR: 2.67, 95% CI: 1.94-3.66), forgetfulness (ARR: 1.80, 95% CI: 1.41-2.31), stress (ARR: 1.47, 95% CI: 1.14-1.88), gossip (ARR: 1.57, 95% CI: 1.21-2.04), mode of transport (ARR: 0.59, 95% CI: 0.44-0.79), age (ARR: 0.98, 95% CI: 0.97-0.99), and lack of community support (ARR: 0.55, 95% CI: 0.35-0.85).

CONCLUSIONS

Among numerous barriers identified in our study, food insecurity was found to be a significant contributor toward ART nonadherence among women living with HIV in rural Eswatini. Future strategies aimed at improving ART adherence in Eswatini should include programs which provide food and nutrition support for people living with HIV, particularly rural women living in poverty.

Intersections of financial agency, gender dynamics, and HIV risk: A qualitative study with adolescent girls and young women in Zambia

Objectives: Recent research demonstrates that economic interventions may positively effect HIV risk among adolescent girls and young women (AGYW) in sub-Saharan Africa. Some evidence reveals potential associations between financial decision-making and bargaining power in sexual relationships. However, this evidence is mixed, nuanced, and limited. This paper explores how AGYW in Zambia understand financial agency and its effect on intimate relationships. Methods: In-depth qualitative interviews were conducted with 30 females aged 15-24 years residing in Kalingalinga, a low income, high-density residential area in Lusaka. Data were analysed using thematic content analysis. Results: Participants spoke of the ability to earn and spend money as reality for some and aspirational for many others, intrinsic to cultural and religious caveats influencing perceptions of agency for women. The transfer of financial independence to sexual agency within relationships was viewed as a mechanism for HIV risk reduction; however, male sexual privilege was an obstacle irrespective of financial decision-making. Conclusions: Programmes aiming to enhance financial agency for AGYW have the potential to reduce HIV sexual risk. Yet, to be most effective, integration with gender-transformative programmes is needed to address norms of male dominance that keep AGYW in positions of vulnerability.

Qualitative Study on the Acceptability of and Adherence to a Vaginal Ring for HIV Prophylaxis Among Adolescent Girls

OBJECTIVE

This study aims to assess the product-related, relationship-related, and sex-related factors that act as facilitators and barriers to the acceptability of a vaginal ring (VR) for HIV prevention among adolescent girls.

DESIGN

Qualitative study.

METHODS

Ninety-six girls aged 15-17 years from 6 urban US sites were enrolled in MTN-023/IPM 030, a 24-week randomized controlled trial, for assessing the safety and acceptability of a dapivirine VR for HIV prevention. At week 24, 21 girls were randomly selected to participate in in-depth interviews. Interviews were transcribed verbatim and data analyzed using a thematic analysis approach. Facilitators and barriers to VR acceptability related to participants' relationships, sexual activity, and characteristics of the VR product were identified.

RESULTS

Factors related to relationships rarely seemed to act as barriers to VR acceptability; most participants disclosed VR use to sexual partners, and positive reactions from sexual partners, which were common, seemed to facilitate VR acceptability. Emotional and/or physical discomfort surrounding VR use during sex was mentioned occasionally as a barrier to VR acceptability. Product characteristics were most frequently mentioned as barriers to VR acceptability. Many participants reported concerns about the large size of the VR on first impression. Although most found the VR comfortable, some reported pain with VR insertion. Several participants were concerned about VR cleanliness, particularly during menstruation.

CONCLUSION

Product considerations, specifically size and use during menstruation, were the most commonly reported barriers to VR acceptability in this study. Adolescent girls may require additional counseling to assuage product concerns regarding a VR for HIV prevention.

Intimate partner violence against adolescents and young women in sub-Saharan Africa: who is most vulnerable?

BACKGROUND

Intimate partner violence (IPV) is a global public health and human rights issue that affects millions of women and girls. While disaggregated national statistics are crucial to assess inequalities, little evidence exists on inequalities in exposure to violence against adolescents and young women (AYW). The aim of this study was to determine inequalities in physical or sexual IPV against AYW and beliefs about gender based violence (GBV) in sub-Saharan Africa (SSA).

METHODS

We used data from the most recent Demographic and Health Surveys (DHS) conducted in 27 countries in SSA. Only data from surveys conducted after 2010 were included. Our analysis focused on married or cohabiting AYW aged 15-24 years and compared inequalities in physical or sexual IPV by place of residence, education and wealth. We also examined IPV variations by AYW's beliefs about GBV and the association of country characteristics such as gender inequality with IPV prevalence.

RESULTS

The proportion of AYW reporting IPV in the year before the survey ranged from 6.5% in Comoros to 43.3% in Gabon, with a median of 25.2%. Overall, reported IPV levels were higher in countries in the Central Africa region than other sub-regions. Although the prevalence of IPV varied by place of residence, education and wealth, there was no clear pattern of inequalities. In many countries with high prevalence of IPV, a higher proportion of AYW from rural areas, with lower education and from the poorest wealth quintile reported IPV. In almost all countries, a greater proportion of AYW who approved wife beating for any reason reported IPV compared to their counterparts who disapproved wife beating. Reporting of IPV was weakly correlated with the Gender Inequality Index and other societal level variables but was moderately positively correlated with adult alcohol consumption (r = 0.48) and negative attitudes towards GBV (r = 0.38).

CONCLUSION

IPV is pervasive among AYW, with substantial variation across and within countries reflecting the role of contextual and structural factors in shaping the vulnerability to IPV. The lack of consistent patterns of inequalities by the stratifiers within countries shows that IPV against women and girls cuts across socio-economic boundaries suggesting the need for comprehensive and multi-sectoral approaches to preventing and responding to IPV.

Social and Behavioral Correlates of Adolescent Sexual Experience and Intention to Use Condoms in Northwestern Botswana

Adolescent sexual behavior is shaped by individual, social, and structural factors that can increase HIV-risk, unwanted pregnancy, and sexually transmitted disease. To inform the development of a comprehensive sexuality education program, 239 secondary school adolescents ages 14–19 in Maun, Botswana, completed a survey of sexual and reproductive health knowledge, attitudes, and behaviors in February–March 2020. Bivariate and multivariate analyses examined factors associated with sexual experience and perceived ability to insist on condoms. Approximately 21% of respondents reported having had sexual intercourse. More than half felt able to insist on condoms. Sources of information about human reproduction, alcohol use, attitudes about when sex is acceptable, and perceived sexual activity by one’s peers were predictive of sexual experience. Age, confidence in correct condom use, perceived acceptability of adolescent sex with condoms, and endorsement of prevailing gender norms were significantly associated with perceived ability to insist on condom use.

Egalitarian Values and Sexual Behavior-The Role of Country Level Values in Shaping Individual Level Behaviors in Africa, South America and Asia

Objective The aim of this study is to investigate the relationship between country level egalitarian values (broadly speaking emancipatory values/structural gender equality) and sexual behavior among youth. Methods: Comparative individual level data on sexual activity and condom use were collected from the Global School-based Student Health Survey, resulting in a final sample of 23 countries, analyzed utilizing multilevel logistic regression analysis. Results: Egalitarian values were significantly associated with sexual activity and condom use. Conclusions: Egalitarian values have a relationship with adolescents' sexual activity and condom use, and thus contribute to sexual health and well-being in Africa, South America and Asia.

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.

Violence against older women: A systematic review of qualitative literature

The majority of the existing evidence-base on violence against women focuses on women of reproductive age (15–49), and globally there is sparse evidence concerning patterns of and types of violence against women aged 50 and older. Improved understanding of differing patterns and dynamics of violence older women experienced is needed to ensure appropriate policy or programmatic responses. To address these gaps in the evidence, we conducted a systematic review of qualitative literature on violence against older women, including any form of violence against women, rather than adopting a specific theoretical framework on what types of violence or perpetrators should be included from the outset, and focusing specifically on qualitative studies, to explore the nature and dynamics of violence against older women from the perspective of women. Following pre-planned searches of 11 electronic databases, two authors screened all identified titles, abstracts and relevant full texts for inclusion in the review. We extracted data from 52 manuscripts identified for inclusion, and conducted quality assessment and thematic synthesis from the key findings of the included studies. Results indicated that the vast majority of included studies were conducted in high-income contexts, and did not contain adequate information on study setting and context. Thematic synthesis identified several central themes, including the intersection between ageing and perceptions of, experiences of and response to violence; the centrality of social and gender norms in shaping older women’s experiences of violence; the cumulative physical and mental health impact of exposure to lifelong violence, and that specific barriers exist for older women accessing community supports and health services to address violence victimization. Our findings indicated that violence against older women is prevalent and has significant impacts on physical and mental well-being of older women. Implications for policy and programmatic response, as well as future research directions, are highlighted.

Individual and contextual predictors of comprehensive HIV and AIDS knowledge among young females in Ghana

Sub-Saharan Africa is a region that is severely affected by the HIV and AIDS pandemic with females disproportionately affected. Having accurate and comprehensive knowledge about HIV and AIDS is a major strategy in the fight against the pandemic. This study sought to examine the individual and contextual predictors of comprehensive HIV and AIDS knowledge among young women in Ghana. The study used the females' file from the 2014 Ghana Demographic and Health Survey dataset. A total of 1 407 young women were used for the analysis. Both bivariate and multivariate analyses were done. The results showed that about 22% of the respondents had comprehensive HIV and AIDS knowledge. Young women with secondary and higher levels of education (AOR = 2.85, p < 0.01) and those from the Upper East Region (AOR = 7.15, p < 0.001) had higher odds of comprehensive HIV and AIDS knowledge. However, those cohabiting (AOR = 0.57, p < 0.01) and those who do not watch TV at all (AOR = 0.50, p < 0.01) had lower odds of comprehensive HIV and AIDS knowledge. Comprehensive HIV and AIDS knowledge is low among young women in Ghana and the predictors are both individual (marital status and education) and contextual (region, watching television and listening to radio). A concerted effort is needed to improve the HIV and AIDS knowledge of young people. Mass media campaigns aimed at improving comprehensive HIV and AIDS knowledge should appreciate the individual and contextual factors that influence the comprehensive HIV & AIDS knowledge of young women.

Predictors and Patterns of Transactional Sex with Casual Partners Among Adult Men Living in an Informal Urban Area, South Africa

Few studies have explored the relationship between transactional sex and HIV in adult men, with even fewer exploring the predictors of providing money or goods in exchange for sex. This study aimed to characterise the predictors and patterns of transactional sex in adult men in an urban informal area in South Africa. We used baseline, cross-sectional data from a study of 2406 men aged 18-40 years from an urban informal area. Past year transactional sex was assessed through questions adapted from those used previously. Controlling behaviour was measured using an adapted Sexual Relationship Power Scale. Multivariable logistic regression was used to determine associations between transactional sex and other potential explanatory variables. Nearly half (47%) of respondents who had ever had sex reported at least one type of transactional sex with a casual partner in the past year. A third of men provided support or money for a sex partner's family, 30% provided cash and 28% provided somewhere to stay. Controlling for other factors, men with higher levels of controlling behaviour had nearly double the odds of engaging in transactional sex. Men reporting three or more sexual partners had significantly higher odds of engaging in transactional sex. Hazardous drinkers had 33% higher odds of engaging in transactional sex. Men's provision of money or goods in exchange for sex with women is related to other high-risk behaviours, such as multiple sexual partners, hazardous drinking and controlling behaviour. To address transactional sex-related HIV risks, programming should address harmful masculinities, including relationship control.

Creating HIV risk profiles for men in South Africa: a latent class approach using cross-sectional survey data

INTRODUCTION

Engaging at-risk men in HIV prevention programs and services is a current priority, yet there are few effective ways to identify which men are at highest risk or how to best reach them. In this study we generated multi-factor profiles of HIV acquisition/transmission risk for men in Durban, South Africa, to help inform targeted programming and service delivery.

METHODS

Data come from surveys with 947 men ages 20 to 40 conducted in two informal settlements from May to September 2017. Using latent class analysis (LCA), which detects a small set of underlying groups based on multiple dimensions, we identified classes based on nine HIV risk factors and socio-demographic characteristics. We then compared HIV service use between the classes.

RESULTS

We identified four latent classes, with good model fit statistics. The older high-risk class (20% of the sample; mean age 36) were more likely married/cohabiting and employed, with multiple sexual partners, substantial age-disparity with partners (eight years younger on-average), transactional relationships (including more resource-intensive forms like paying for partner's rent), and hazardous drinking. The younger high-risk class (24%; mean age 27) were likely unmarried and employed, with the highest probability of multiple partners in the last year (including 42% with 5+ partners), transactional relationships (less resource-intensive, e.g., clothes/transportation), hazardous drinking, and inequitable gender views. The younger moderate-risk class (36%; mean age 23) were most likely unmarried, unemployed technical college/university students/graduates. They had a relatively high probability of multiple partners and transactional relationships (less resource-intensive), and moderate hazardous drinking. Finally, the older low-risk class (20%; mean age 29) were more likely married/cohabiting, employed, and highly gender-equitable, with few partners and limited transactional relationships. Circumcision (status) was higher among the younger moderate-risk class than either high-risk class (p < 0.001). HIV testing and treatment literacy score were suboptimal and did not differ across classes.

CONCLUSIONS

Distinct HIV risk profiles among men were identified. Interventions should focus on reaching the highest-risk profiles who, despite their elevated risk, were less or no more likely than the lower-risk to use HIV services. By enabling a more synergistic understanding of subgroups, LCA has potential to enable more strategic, data-driven programming and evaluation.

Sexual Relationship Power and Socio-demographic Factors Predicting Contraceptive Use, Antenatal Visits and Sick Child Health Service Use in Northern Togo

INTRODUCTION

Implementation of community-based healthcare services offering effective contraception, antenatal care (ANC), and treatment for symptomatic children under five has reduced maternal and child mortality in Togo. However, understanding if women are utilizing these services differentially based on social or demographic factors is important. This study identifies whether sexual relationship and socio-demographic factors are associated with healthcare utilization in four health facility catchment areas.

METHODS

We conducted a cross-sectional household survey of women aged 15-49 in four health facility catchment areas in 2016 (three rural sites, one urban site). We used multivariable Poisson regression to test whether socio-demographic factors and a validated sexual relationship power scale were associated with contraceptive use, ANC visits, and seeking treatment for symptomatic children under five.

RESULTS

Among women not pregnant or desiring pregnancy, older age, lower education, and single relationship status were associated with lower use of effective contraception. Among women who gave birth in two years preceding survey, low relationship power and low wealth quintile were associated with being less likely to attend at least four ANC visits. Women in rural sites were slightly more likely than women in the urban site to report seeking treatment for child under five with malaria, pneumonia, and/or diarrhea symptoms in last 2 weeks.

DISCUSSION

Interventions in low-resource settings should explore ways to reach women with low health-service utilization to improve contraceptive use, ANC visits, and treatment for sick children. Furthermore, age, education, marital status, wealth status and sexual relationship power must be considered when targeting maternal health behaviors.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03773913; Date of registration: 12 Dec. 2018.

Sexual Relationship Power and Socio-demographic Factors Predicting Contraceptive Use, Antenatal Visits and Sick Child Health Service Use in Northern Togo

INTRODUCTION

Implementation of community-based healthcare services offering effective contraception, antenatal care (ANC), and treatment for symptomatic children under five has reduced maternal and child mortality in Togo. However, understanding if women are utilizing these services differentially based on social or demographic factors is important. This study identifies whether sexual relationship and socio-demographic factors are associated with healthcare utilization in four health facility catchment areas.

METHODS

We conducted a cross-sectional household survey of women aged 15-49 in four health facility catchment areas in 2016 (three rural sites, one urban site). We used multivariable Poisson regression to test whether socio-demographic factors and a validated sexual relationship power scale were associated with contraceptive use, ANC visits, and seeking treatment for symptomatic children under five.

RESULTS

Among women not pregnant or desiring pregnancy, older age, lower education, and single relationship status were associated with lower use of effective contraception. Among women who gave birth in two years preceding survey, low relationship power and low wealth quintile were associated with being less likely to attend at least four ANC visits. Women in rural sites were slightly more likely than women in the urban site to report seeking treatment for child under five with malaria, pneumonia, and/or diarrhea symptoms in last 2 weeks.

DISCUSSION

Interventions in low-resource settings should explore ways to reach women with low health-service utilization to improve contraceptive use, ANC visits, and treatment for sick children. Furthermore, age, education, marital status, wealth status and sexual relationship power must be considered when targeting maternal health behaviors.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03773913; Date of registration: 12 Dec. 2018.

Individual, household, and community level barriers to ART adherence among women in rural Eswatini

Background

Despite access to free antiretroviral therapy (ART) for all people living with human immunodeficiency virus (HIV), noncompliance to treatment continues to be a significant challenge in Eswatini. Yet studies investigating barriers to ART adherence in Eswatini are scarce. Most notably, there is a lack of research regarding rural women in Eswatini, who are currently the country’s most vulnerable to HIV infection. Therefore, the objective of the study is to investigate individual, household, and community level barriers to ART adherence among rural women living with HIV.

Methods

We conducted a qualitative study to investigate individual, household, and community level barriers to ART adherence. We conducted focus group discussions with HIV-infected women (n = 4) from rural villages in Eswatini, and in-depth interviews with healthcare workers (n = 8) serving the area clinics. Open and axial coding techniques were used for data analysis and interpreted within a social ecological framework.

Results

Our findings revealed several individual level barriers including hunger, side effects of ART, personal stress, lack of disclosure of HIV status, alcohol use, and forgetting to take ART. Lack of food, unemployment and scarcity of financial resources were identified as critical barriers at the household level. Community and institutional barriers encompassed factors related to health delivery such as lack of privacy, travel time, transportation costs, excessive alcohol use by healthcare workers, maltreatment, public and self-stigma, gossip, and long waits at clinics.

Conclusions

Rural women living with HIV face multilevel barriers to ART adherence. Support programs aimed at increasing ART adherence among this vulnerable population need to develop targeted polices to alleviate challenges rural women face, beginning with expanding qualifications for food assistance programs.

The extent of child sexual abuse in Botswana: hidden in plain sight

Introduction

Child Sexual Abuse (CSA) is a worldwide persisting public health problem which has generated interesting discussions within child protection scholarship. Globally as well as in Botswana, CSA estimates prove challenging to establish. This study sought to establish the extent of CSA in Botswana by use of existing data as well as narratives from key informants.

Methods

CSA existing data was extracted from the Botswana police services records and Botswana statistics for the year 2013, 2014, 2015 & 2016. In-depth interviews, semi-structured interviews, were used to collect data from policymakers, child protection practitioners, and caregivers respectively. The study sites were Gaborone city and Letlhakeng village. Qualitative data were analysed using NVivo qualitative data analysis computer software. Whereas the quantitative data I analysed using the excel Microsoft office 365.

Findings

According to CSA existing data, in 2013 defilement among children was 97 (0.2%). Whereas 901 children were reported pregnant in 2013, almost ten times more than defilement cases. In the same year, there was a high number (1058) of children who stayed away from school. Participants' narratives reported CSA to be an escalating problem in Botswana.

Conclusion

The finding that teenage pregnancy statistics are higher than defilement statistics needs further research to categorise and inform child sexual abuse programming in Botswana.

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

OBJECTIVE

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

STUDY DESIGN

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

HIV Risk Among Displaced Adolescent Girls in Ethiopia: the Role of Gender Attitudes and Self-Esteem

Adolescent girls in sub-Saharan Africa have been deemed one of the most critical populations to address in the campaign for an HIV-free generation. Experiences of intimate partner violence (IPV), harmful gender norms, diminished personal agency, and age-disparate sex have been identified as factors in the increasing rate of new infections among this population. Using baseline data from a cluster-randomized controlled trial in three refugee camps in Benishangul-Gumuz Regional State in Ethiopia, our study quantitatively examined the associations between HIV risk factors, attitudes on gender inequality, IPV acceptability, and self-esteem for female adolescent refugees primarily from Sudan and South Sudan (n = 919). In multivariate models, adjusting for age and education, results showed girls who were more accepting of gender inequitable norms and IPV had greater odds of ever experiencing forced (OR 1.40, CI 1.15-1.70; OR 1.66, CI 1.42-1.94) or transactional sex (OR 1.28, CI 1.05-1.55; OR 1.59, CI 1.37-1.85) compared to girls who demonstrated less approval. Higher self-esteem was associated with increased odds of condom use (OR 1.13, CI 1.02-1.24) as well as decreased odds of adolescent marriage (OR 0.93, CI 0.90-0.95), age-disparate sex (OR 0.90, CI 0.86-0.94), and transactional sex (OR 0.96, CI 0.93-0.99). The findings suggest acceptance of inequitable gender norms (including those that perpetuate violence against women) and low self-esteem to be associated with common HIV risk factors among refugee adolescents living in Ethiopia. Greater attention towards the intersections of gender equality and self-valuation is needed when seeking to understand HIV risk among refugee adolescent girls in sub-Saharan Africa.

A syndemic of psychosocial and mental health problems in Liberia: Examining the link to transactional sex among young pregnant women

Transactional sex may be a driver of the rising HIV epidemic in Liberia, especially among young women. The goal of this study was to explore the independent and additive effects of psychosocial conditions on engagement in transactional sex among 191 pregnant women in Monrovia, Liberia. Between March and August 2016, women receiving prenatal services completed a cross-sectional structured questionnaire. These data were used to examine the independent and additive effects of exposure to trauma, depression, post-traumatic stress disorder symptoms, and intimate partner violence on transactional sex. Overall, the results are in support of our hypothesis that these psychosocial conditions cluster together and are independently associated with transactional sex. Multivariate logistic regression analysis demonstrated an additive effect of the number of psychosocial conditions experienced on transactional sex. Women experiencing 2 psychosocial conditions had 5.96 greater odds of engaging in transactional sex compared to women reporting 0 conditions (AOR: 5.96, 95% CI: 2.22-15.99), and women experiencing 3 or 4 psychosocial conditions had 11.91 greater odds of engaging in transactional sex compared to women report 0 conditions (AOR: 11.91, 95% CI: 4.12-34.45). Our results demonstrate the need for comprehensive HIV prevention programming inclusive of mental health support and IPV prevention for Liberian women.

Gender Norms and HIV Testing/Treatment Uptake: Evidence from a Large Population-Based Sample in South Africa

How does the endorsement of different dimensions of gender norms by men and/or women influence their use of HIV testing and antiretroviral treatment? This question was examined using data from a 2014 population-based survey of 1053 women and 1004 men, ages 18-49, in rural South Africa. We used a global measure for views toward gender norms (the GEM Scale), plus four subsets of scale items (all reliabilities ≥ 0.7). In multivariate analyses using the global measure, endorsement of inequitable gender norms was associated with more testing (AOR 2.47, p < 0.01) and less treatment use (AOR 0.15, p < 0.01) among women but not men. When examining specific subsets of inequitable norms (e.g., endorsing men as the primary decision-maker), decreased odds of treatment use was found for men as well (AOR 0.18, p < 0.01). Careful attention to the role specific gender norms play in HIV service uptake can yield useful programmatic recommendations.

Masculinity and engagement in HIV care among male fisherfolk on HIV treatment in Uganda

This study explored the intersection of masculinity and HIV care engagement among fishermen and other male fisherfolk on antiretroviral therapy (ART) in Wakiso District, Uganda. We conducted 30 in-depth interviews with men on ART recruited from HIV treatment sites and used a thematic analysis approach. Since HIV diagnosis and ART initiation, men had adopted masculine identities more conducive to HIV care engagement. The masculine roles of worker and provider, husband and sexual partner and the appearance of physical strength were compromised by HIV, but restored by ART's positive effects on health. Peers also emerged as facilitators to HIV care, with men supporting each other to seek testing and treatment. However, structural and occupational barriers to HIV care associated with the masculine role of worker remained a barrier to care engagement. Findings suggest that emphasising the benefits of ART in bolstering men's ability to fulfil the roles important to them may improve the effectiveness of HIV testing and treatment messaging for men. Differentiated care models that address structural-level barriers to care, and community-level gender-transformative programming to help fishermen engage in HIV care, may be beneficial.

Associations Between Peer Network Gender Norms and the Perpetration of Intimate Partner Violence Among Urban Tanzanian Men: a Multilevel Analysis

Male perpetration of intimate partner violence (IPV) against women in sub-Saharan Africa is widespread. Theory and empirical evidence suggest peer networks may play an important role in shaping IPV perpetration, though research on this topic in the region is limited. We assessed the degree to which peer network gender norms are associated with Tanzanian men's perpetration of IPV and examined whether the social cohesion of peer networks moderates this relationship. Using baseline data from sexually active men (n = 1103) nested within 59 peer networks enrolled in an on-going cluster-randomized HIV and IPV prevention trial, we fit multilevel logistic regression models to examine peer network-level factors associated with past-year physical IPV perpetration. Peer network gender norms were significantly associated with men's risk of perpetrating IPV, even after adjusting for their own attitudes toward gender roles (OR = 1.53 , p =  . 04). Peer network social cohesion moderated this relationship (OR = 1.50 , p =  . 04); the positive relationship between increasingly inequitable (i.e., traditional) peer network gender norms and men's risk of perpetrating IPV became stronger, as peer network social cohesion increased. Characteristics of the peer network context are associated with men's IPV perpetration and should be targeted in future interventions. While many IPV prevention interventions focus on changing individual attitudes, our findings support a unique approach, focused on transforming the peer context.

Is transactional sex exploitative? A social norms perspective, with implications for interventions with adolescent girls and young women in Tanzania

Although transactional sex is common in many sexual relationships, there has been little research into the degree to which the practice is considered exploitative in the settings in which it is practiced. We describe the social norms that influence transactional sex in two sites in Mwanza, Tanzania, and explore local understandings of whether and under what conditions it is considered exploitative. We then compare these "emic" understandings of exploitation to international definitions and norms around sexual exploitation. This study employed a qualitative research design involving 18 focus group discussions and 43 in-depth interviews with young people aged 14-24 years and parents with children aged 14-24 years in a rural area and an urban center within Mwanza, Tanzania. Thematic analysis was conducted with the aid of NVivo 10. The social norms influencing the practice of transactional sex included: reciprocity as a core cultural value that permeates the way exchange in sexual relationships is judged; gendered expectations that men should provide for women's material needs in sexual relationships and that women should reciprocate by means of sex; and peer pressure to be perceived as "fashionable". Adolescent girls and young women (AGYW) are under strong peer pressure to conform to a "modern lifestyle" as reflected in stylish clothing and other items of modernity such as cellphones. The emic conceptualization of exploitation is defined by circumstances surrounding the relationship or a sexual encounter. Important factors that characterize local notions of when transactional relationships are considered exploitative include: when the encounter or relationship involves an imbalance of power (based on age, male economic power and social status); when a man fails to reciprocate; and when sex is coerced. According to community perspectives, young women's behavior should be considered exploitative of men when they take gifts or money yet refuse sex or when they demand large sums of money. Interventions aimed at reducing AGYW's exploitation through transactional sex need to be cognizant of the variations in the understanding of what constitutes sexual exploitation as well as the social and gender norms influencing the practice of transactional sex. Interventions need to involve communities and families in critical thinking that helps them identify positive alternatives to current gendered social norms that shape the involvement of AGYW and men in transactional sex.

Developing Experimental Vignettes to Identify Gender Norms Associated With Transactional Sex for Adolescent Girls and Young Women in Central Uganda

PURPOSE

Transactional sex or informal sexual exchange relationships increase adolescent girls' and young women's (AGYW) HIV and pregnancy risk in sub-Saharan Africa. These relationships are grounded in the shared expectation that men should provide financial support to their partners. We built a vignette experiment to assess whether gender norms influenced by expectations of provision help to explain how transactional sex increases AGYW's sexual and reproductive health risks.

METHODS

We used mixed methods to develop a vignette experiment in Central Uganda with AGYW including 10 focus group discussions, 32 cognitive interviews, and a pilot survey experiment with 108 sexually active unmarried AGYW. Respondents were randomly assigned to one of the two manipulations for three vignettes. The vignettes examined whether the amount a man provided changed perceived social approval of men's authority in relationships, sexual decision-making power, or women having multiple partners.

RESULTS

We find that a higher level of male provision is associated with higher levels of perceived community approval for his sexual decision-making power (p < .001) and lower levels of perceived peer approval for AGYW's to seek a second partner (p < .05). We also find that higher levels of male provision are associated with respondent's own approval of male authority and sexual decision-making.

CONCLUSION

Our findings suggest that approval of men's sexual decision-making power increases when they provide more and that girls who seek a second partner find higher levels of social approval for this behavior when their primary partner provides less. Vignette experiments may be valuable for identifying social norms that put AGYW's sexual and reproductive health at risk.

Adapted tool for the assessment of domestic violence against women in a low-income country setting: a reliability analysis

Background

One-in-three women has experienced domestic violence, which is a serious public health problem and a human right violation. Domestic violence is a common life experience among women in Ethiopia. The tool used to assess violence against women (VAW) has not been validated to assess its consistency. Cronbach's alpha (α, or coefficient alpha) is a measure of internal consistency, or reliability, that is, how closely a set of items are related as a group. Reliability is how well a test measures what it should. Therefore, the aim of this study was to estimate the inter-item correlation (reliability) of the tool adapted from literature.

Methods

A community-based study was conducted in Northwestern Ethiopia between November 15, 2017 and December 31, 2017. A total of 1,269 women at their permanent place of residence (specifically at their households) were recruited using the multistage stratified systematic sampling method. A structured questionnaire was adapted from literature. Also, 12 trained female data collectors collected the data using the face-to-face interview method. Data were entered into EpiData 3.1.0 and exported to SPSS 23.0 for analysis. Descriptive statistical analysis was carried out to estimate the reliability of the response(s).

Results

Overall, Cronbach's alpha was higher than the minimum recommended value of 0.70. Cronbach's alpha for specific sections were 0.764 for women's decision-making autonomy (13 items); women's accepting attitude toward justified wife-beating (five items, 0.894); physical violence (seven items, 0.876); psychological violence (15 items, 0.925); sexual violence (five items, 0.812); and inequitable gender-norms (seven items, 0.867).

Conclusion

The tool used to assess domestic VAW in Northwestern Ethiopia had a high reliability. Therefore, researchers can adapt the tool and further assess its reliability in other settings to have a common and validated tool to study VAW in a low-income countries.

Self-silencing and women's health: A review

The connection between gender and health has intrigued health professionals in the last few decades. Silencing-the-self theory has brought a considerable clarity in this matter. After around three decades of the theory, the literature related to the theory has immensely flourished and has covered different branches of psychology. The aim of the present work is to provide a comprehensive picture of the qualitative and quantitative research findings that have connected self-silencing to health and well-being of women. This article presents a critical review of relevant articles. These articles have used the self-silencing theory as an explanation of women's higher vulnerability to certain diseases as well as their experience with them. Self-silencing has been found to explain the gender gap in psychiatric disorders like depression, eating disorders and so on. It also influences the resilience and therapeutic effects among female patients with chronic conditions such as cancer, AIDS and so on. Moreover, self-silencing has also been found to be associated with women's health issues such as pre-menstrual dysphoric disorder. The present study discusses the existing literature in a narrative manner along with suggesting some relevant research gaps that can be worth exploring in the future.

The Roles of Family Factors and Relationship Dynamics on Dating Violence Victimization and Perpetration Among College Men and Women in Emerging Adulthood

Using data from the International Dating Violence Study, this study examined the roles of early socialization, family social structure, and relationship dynamics factors on physical aggression in dating among U.S. college students in emerging adulthood. The interaction effects between these three domains of interest (early socialization, family social structure, and relationship dynamics) were explored to understand the underlying mechanisms that influenced victimization and perpetration in dating. In general, we found that family and relational variables associated with dating victimization and perpetration were fairly similar. Among the early socialization variables, experience of childhood neglect and having witnessed domestic violence were significantly related to victimization and perpetration. Living in a two-parent household appeared to exert a protective effect, although associations with parental education were not statistically significant. Furthermore, the participants were more likely to experience victimization or impose aggression in dating relationships which were characterized by conflicts, distress, dominance, or psychological aggression. Overall, for the participants who came from a two-parent household, dominance in dating was linked to less violence. When the participants faced higher levels of psychological aggression, adverse early socialization factors were associated with higher levels of dating violence victimization and perpetration. Research and practice implications were discussed.

Gender, power, and violence: A systematic review of measures and their association with male perpetration of IPV

Introduction

Harmful gender norms, views on the acceptability of violence against women, and power inequities in relationships have been explored as key drivers of male perpetration of intimate partner violence (IPV). Yet such antecedents have been inconsistently measured in the empirical literature. This systematic review aimed to identify which measures of gender inequitable norms, views, relations and practices are currently being used in the field, and which are most closely tied with male IPV perpetration.

Methods

We searched five electronic databases to identify studies published between 2000 and 2015 that reported the association between such gender inequities and male perpetration of IPV. Identified scales were categorized by content area and level of generality, as well as other attributes, and we compared the consistency of scale performance across each category.

Results

Twenty-three studies were identified, employing 64 measures. Scales were categorized into three main thematic areas: views on gender roles/norms, acceptance of violence against women, and gender-related inequities in relationship power and control. We also classified whether the scale was oriented to respondents’ own views, or what they believed others do or think. While overall, measures were positively associated with IPV perpetration in 45% of cases, this finding varied by scale type. Measures inclusive of acceptance of violence against women or beliefs about men’s sexual entitlement, followed by scales that measured respondents’ views on gender roles/norms, were most consistently associated with IPV perpetration. Measures of relationship power showed less consistent associations. We found few scales that measured peer or community norms.

Conclusion

Validated scales that encompass views on the acceptance of violence against women, and scales inclusive of beliefs about men’s sexual entitlement, may be particularly promising for unpacking pathways to IPV perpetration, targeting interventions, and monitoring progress in IPV prevention efforts. A number of gaps in the literature are identified.

Men's perspectives on the impact of female-directed cash transfers on gender relations: Findings from the HPTN 068 qualitative study

BACKGROUND

HIV is an inherently gendered disease in eastern and southern Africa, not only because more women than men are infected, but also because socially constructed gender norms work to increase women's HIV-infection risk. The provision of cash transfers to young women alone in such a context adds another dimension to already existing complex social relations where patriarchal values are entrenched, gender inequality is the norm, and violence against women and girls is pervasive. It raises concerns about complicating young women's relationships with their male partners or possibly even setting them up for more violence. In our attempt to understand how cash transfers influence social relations in the context of a trial among young women in South Africa, we used qualitative data collected during the trial to explore men's perceptions of the impact of cash transfers on male-female relationships, both intimate and platonic, peer relationships.

METHOD

Between April 2012 and August 2015, we conducted focus group discussions (n = 12) and interviews (n = 20) with the male peers and intimate partners of young women aged 13-20 years, who were participating in a phase III randomised controlled trial of CTs for HIV prevention in Mpumalanga, South Africa. A thematic content analysis approach was used to analyse the data. The codebook was developed on the basis of the topic guides, with additional codes added inductively as they emerged from the data.

RESULTS

Intimate partners were older (range 20-32 years) and more likely to be working than the male peers. Both intimate partners and male peers were supportive of the CT trial targeting young women; younger peers however expressed some concerns that the money might diminish their power and status in relationships. HIV testing requirements associated with the trial appeared to have improved communication about sex and HIV in intimate relationships, with some women even encouraging their partners to go for an HIV test.

CONCLUSION

CTs provide AGYW with a measure of autonomy and power to contribute in their gendered relationships, albeit in limited ways. However, there is potential for CTs to have a negative impact on male-female relationships if the cash received by AGYW is equal to or greater than the income earned by their male counterparts or sexual partners.

The Inter-ministerial National Structural Intervention trial (INSTRUCT): protocol for a parallel group cluster randomised controlled trial of a structural intervention to reduce HIV infection among young women in Botswana

Background

Wide recognition that structural factors are important in the HIV epidemic has not generated much evidence of impact of structural interventions. Few randomised controlled trials of structural interventions for HIV prevention have an HIV endpoint, and most of those did not show a significant impact. It has proved difficult to prevent new HIV infections in Botswana, especially among young women, many of whom are unable to act on HIV preventive choices. Proposed by a government think tank in Botswana, the Inter-ministerial National Structural Intervention trial (INSTRUCT) tests whether addressing social and economic factors, including gender inequality, gender violence, poverty, and poor access to education, can lower HIV infection rates among young women. Focussed on increasing access by marginalised young women to government support programs, the intervention seeks to change their structural position, reducing their vulnerability to transactional sex, and thus to HIV infection.

Methods

This parallel group cluster randomised controlled trial compares HIV rates among young women in districts with and without the structural interventions. The 30 administrative districts in the country, stratified by HIV prevalence and development status, will be randomly assigned to 5-district implementation waves. The intervention in the first-wave districts will include: (i) recruiting and preparing vulnerable young women to apply to government support programs, (ii) making the support programs more accessible to young women by engaging local program officers and young women in co-evaluation of programs and co-design of solutions; and (iii) generating an enabling environment for change in communities through an audio-drama edutainment program. In year five, an impact survey will measure HIV rates among vulnerable young women (15–29 years) in a random sample of communities in the five intervention districts and in the five second-wave (control) districts. Fieldworkers will undertake rapid HIV screening and interview young women and young men, collecting information on secondary outcomes of attitudes and behaviours.

Discussion

This is the first step in a planned stepped-wedge design that will roll out the intervention, modified as necessary, to all districts. Strong government commitment provides an important opportunity to reduce new HIV cases in Botswana, and guide prevention efforts in other countries.

Trial registration

Registration number: ISRCTN 54878784. Registry: ISRCTN. Date of registration: 11 June 2013.

Who are the male partners of adolescent girls and young women in Swaziland? Analysis of survey data from community venues across 19 DREAMS districts

BACKGROUND

Adolescent girls and young women (AGYW, ages 15-24) are at high risk of HIV in Swaziland. Understanding more about their male sexual partners can inform HIV prevention efforts for both.

METHODS

Using the PLACE methodology across all 19 DREAMS implementation districts, 843 men ages 20-34 were surveyed between December 2016-February 2017. Surveys were conducted at 182 venues identified by community informants as places where AGYW and men meet/socialize. Descriptive and multivariate analyses examined characteristics and risk behaviors of male partners of AGYW.

RESULTS

Men's average age was 25.7. Sixty-three percent reported female partners ages 15-19, and 70% reported partners ages 20-24 in the last year; of those, 12% and 11% respectively had five or more such partners. Among the 568 male partners of AGYW, 36% reported consistent condom use with their current/last partner. Forty-two percent reported testing for HIV in the last year; 6% were HIV-positive, and of those, 97% were currently on treatment. One-third (37%) reported being circumcised; among uncircumcised, 81% were not considering it. In multivariate analyses, men who reported three or more AGYW partners in the last year were more likely to be HIV-positive (aOR 3.2, 95% CI 1.1,8.8). Men were also less likely to disclose their HIV status to adolescent versus older partners (aOR 0.6, 95% CI 0.4,0.9) and partners more than 5 years younger than themselves (aOR 0.6, 95% CI 0.4,0.9). Results also revealed relatively high unemployment and mobility, substantial financial responsibilities, and periodic homelessness.

CONCLUSIONS

Most men identified through community venues reported relationships with AGYW, and these relationships demonstrated substantial HIV risk. Challenging life circumstances suggest structural factors may underlie some risk behaviors. Engaging men in HIV prevention and targeted health services is critical, and informant-identified community venues are promising intervention sites to reach high-risk male partners of AGYW.

The Prevalence and Correlates of Physical and Sexual Violence Affecting Female Sex Workers in Swaziland

Female sex workers (FSW) have a heightened vulnerability to violence and negative sexual/reproductive health outcomes. Limited research has examined how experiencing physical and sexual violence (PSV) mediates risk for poor health outcomes among FSW in Swaziland. The present analyses aim to contribute to literature linking violence with poor health outcomes, high-risk behaviors, and reduced health service-seeking among FSW. Data were analyzed from a cross-sectional study conducted in Swaziland between July and September 2011 with 325 adult women who reported exchanging sex for money, goods, or favors in the last 12 months, recruited through respondent-driven sampling (RDS). Logistic regression was used to assess the relationship between PSV and ancillary violence/abuse exposures, risk behaviors, and sexual/reproductive and mental health outcomes. PSV was conceptualized as either ever having been beaten up as a result of selling sex or ever being forced to have sex since the age of 18, or both. Prevalence of PSV in this sample was 59.0% in crude estimation, and 48.4% (95% confidence interval [CI]:[39.2,57.6]) with RDS weighting. Separate RDS-weighted estimates of being beaten up as a result of sex work and ever being forced to have sex were 32.4% (95%CI=[24.4,40.4]) and 33.1% (95%CI =[25.0,41.2%]), respectively. Experiencing PSV was associated with being blackmailed (adjusted odds ratio [aOR]= 1.93, 95%CI= [1.07,3.52]), non-injection drug use in the last 12 months (aOR= 1.84, 95%CI= [1.02,3.33]), and feeling afraid to seek health services as a result of selling sex (aOR = 1.74, 95%CI= [1.01,2.99]). Given these findings, violence prevention strategies should be prioritized in programs that address Swazi FSW health, empowerment, and safety.

Perpetration and Victimization of Intimate Partner Violence Among Young Men and Women in Dar es Salaam, Tanzania

We describe and compare the baseline rates of victimization and perpetration of three forms of intimate partner violence (IPV)-psychological, physical, and sexual-among sexually active men ( n = 1,113) and women ( n = 226) enrolled in an ongoing cluster-randomized HIV and gender-based violence prevention trial in Dar es Salaam, Tanzania. IPV was measured using a modified version of the World Health Organization Violence Against Women instrument. We assess the degree to which men and women report overlapping forms of IPV victimization and perpetration. Sociodemographic and other factors associated with increased risk of victimization and perpetration of IPV are examined. Within the last 12 months, 34.8% of men and 35.8% of women reported any form of IPV victimization. Men were more likely than women to report perpetrating IPV (27.6% vs. 14.6%, respectively). We also found high rates of co-occurrence of IPV victimization and perpetration with 69.7% of male perpetrators and 81.8% of female perpetrators also reporting victimization during the last year. Among men, having ever consumed alcohol and experiencing childhood violence were associated with increased risk of most forms of IPV. Younger women were more likely to report perpetrating IPV than older women. We found evidence of gender symmetry with regard to most forms of IPV victimization, but men reported higher rates of IPV perpetration than women. Given the substantial overlap between victimization and perpetration reported, our findings suggest that IPV may be bidirectional within relationships in this setting and warrant further investigation. Implications for interventions are discussed.