Poverty, food insufficiency and HIV infection and sexual behaviour among young rural Zimbabwean women

Pathways to transactional sex among peri-urban South African women: the role of relationship control, food insecurity and alcohol misuse

Transactional sex increases sub-Saharan African women's risk of HIV acquisition. We quantitatively explored the pathways contributing towards women's future engagement in transactional sex with casual partners and khwapheni (secret concurrent sex partners). We conducted secondary data analysis from a cluster randomised controlled trial in urban informal settlements in eThekwini Municipality., South Africa. Data were collected at enrolment (t0) and 24 months' later (t2) using self-completed questionnaires. Structural equation modelling (SEM) assessed pathways leading to transactional sex over two years. 677 women 18-35 years were enrolled and 80.5% (n = 545) were followed up. At t2, 44.6% of respondents reported transactional sex with a casual partner or khwapheni. The SEM demonstrated a small effect (d = 0.23) between transactional sex at t0 and at t2. Controlling for past transactional sex, main partner relationship control had a large effect size on future transactional sex (d = 0.60). Hazardous drinking had a medium effect size (d = 0.45) and food insecurity a small effect (d = 0.24), (RMSEA 0.03, 90%CI 0.02-0.04; CFI 0.97; TLI 0.96). HIV prevention programming should highlight current transactional sex but also address structural issues predicting future transactional sex, including food insecurity and alcohol misuse. Gender transformative interventions to reduce controlling behaviours in main relationships are worth investigating.

Food insufficiency and its associated factors: Experiences of in-school adolescents in Sagamu Township, southwest Nigeria

Background: The burden of hunger, food insecurity and malnutrition in sub-Saharan Africa is enormous. A higher proportion of the population suffer the consequences of food insecurity, hunger and undernourishment than previously assumed. Food insecurity among adolescents has been documented to be associated with malnutrition, poor health outcomes, low educational attainment and other negative consequences. Aim: This study therefore assessed food insecurity and its associated factors among adolescents in Sagamu, Ogun State, Nigeria. Methods: A cross-sectional study was conducted among 1300 in-school adolescents in Sagamu Township, Ogun State in southwestern Nigeria, selected via multi-stage sampling. A semi-structured, self-administered questionnaire was used for data collection. Data were analyzed with the aid of SPSS 20.0. Relevant descriptive and inferential statistics were calculated, with p < 0.05. Result: The prevalence of food insecurity was 45%, of which 34.6% had mild food insecurity, 34.7% had moderate food insecurity, while others experienced the severe form of food insecurity. Gender, age; maternal occupation, maternal education, living arrangement, low sense of self-worth, alcohol intake and cigarette smoking were associated (p < 0.05) with food insecurity. Predictors of food insecurity were: age; maternal education, living arrangement and some behavioral factors. Conclusion: The prevalence of food insecurity among adolescents in Sagamu was high. Multi-sectorial action is essential in tackling the challenges of food insecurity and its numerous consequences among adolescents, at all levels of governance.

Knowledge and attitude to HIV pre exposure prophylaxis among women in five sub-Saharan African countries: a multilevel model analysis of population-based survey 2021-2022

BACKGROUND

HIV Pre-Exposure Prophylaxis (HIV PrEP) may help reduce the rate of HIV infection among women in sub-Saharan Africa (SSA). This study aimed to assess women's knowledge and attitudes toward PrEP, a crucial component of HIV prevention, using nationwide data. It is the first study of its kind conducted in five SSA countries: Burkina Faso, Ghana, Côte d'Ivoire, Kenya, and Tanzania. The primary objective was to examine women's knowledge and attitudes toward PrEP for the prevention of HIV infection, as well as to explore individual- and community-level factors associated with it.

METHODS

The current study utilized the 2021/22 demographic and health survey datasets from five African nations, namely Burkina Faso, Côte d'Ivoire, Ghana, Kenya, and Tanzania. The analysis was performed using Stata 17. A weighted sample of 77,052 women of reproductive age participated in the survey. Univariate and multivariable multilevel logistic regressions were conducted to assess parameters related to knowledge and attitudes toward PrEP in these countries. In both the univariate regression and the final model, the significance of variables was determined using P values of ≤ 0.2 and < 0.05.

RESULTS

Overall, only about 13.88 (95% CI: 13.64,14.12) of women had knowledge and attitudes toward HIV PrEP. The highest (34.29%) and lowest (5.61%) values were observed for Kenya and Tanzania respectively. Higher rates of knowledge, and attitude toward HIV PrEP among women were independently associated with age 25-34 years old (AOR = 1.52, 95% CI:1.41,1.64), and 35-49 years old (AOR = 1.56, 95% CI:1.43,1.69), primary education level (AOR = 1.79,95% CI:1.65,1.95), and secondary/higher education level (AOR = 2.92, 95% CI: 2.67,3.20), richer (AOR = 1.14, 95% CI:1.02,1.27), and richest (AOR = 1.21, 95% CI:1.06,1.37), employed women (AOR = 1.82, 95% CI:1.65,1.99), had media exposure (AOR = 1.49,95% CI:1.40,1.59),knowledge of modern contraception (AOR = 2.62, 95% CI: 1.94,3.43), had at least one ANC visit (AOR = 1.99, 95% CI:1.47,2.69), gave birth at health institutions (AOR = 1.17, 95% CI: 1.02,1.37), ever had given birth (AOR = 1.53, 95% CI: 1.41,1.66), female household heads (AOR = 1.24, 95% CI:1.17,1.31), rural women (AOR = 0.83, 95% CI: 0.76,0.89). Similarly, women from communities with high ANC coverage (AOR = 1.84, 95% CI: 1.61,2.11), high community mass media exposure (AOR = 1.62, 95% CI: 1.39,1.88), and high community wealth level (AOR = 1.48, 95% CI: 1.30,1.68), and women from the high illiteracy rate community (AOR = 0.71, 95% CI: 0.61,0.82) showed statistically significant associations with the outcome variable in the final model.

CONCLUSIONS

Less than one-seventh of women exhibited knowledge of and positive attitudes toward HIV PrEP. All stakeholders involved in HIV/AIDS prevention and control have recognized the significance of the factors mentioned above. Enhancing maternal health services, such as promoting institutional delivery, contraception, antenatal care (ANC), and women's empowerment, alongside harnessing the power of media and embracing these transformative changes, will contribute to a greater understanding of and more favorable attitudes toward HIV PrEP within the population.

Applying the Social-Ecological Framework to Link the Drivers of Intimate Partner Violence Among Women in the Caribbean and Their Risk for HIV Infection

For countries with a high prevalence of HIV such as in the Caribbean, intimate partner violence (IPV) may increase the chances for acquiring HIV infection. Using secondary data, we compared findings from studies conducted in five Caribbean countries measuring the prevalence of gender-based violence among women in Grenada, Jamaica, Guyana, Suriname, and Trinidad and Tobago. The Social-Ecological Framework was used to categorize women's dual risk for intimate partner violence and HIV. We found that younger age, lower education, childhood experiences of abuse, income dependency, controlling behaviors of partners, non-disclosure of violence, and early sexual experiences were associated with intimate partner violence. These factors also predispose women in the Caribbean to HIV infection. The Social-Ecological Framework is applicable to understanding the drivers of intimate partner violence and HIV infection at multiple levels and for the design and promotion of combined prevention interventions. Our study also demonstrated the applicability of the Social-Ecological Framework as an analytical and predictive model underscoring the need for increased coordination across multiple actors to strengthen advocacy, given the pervasiveness of harmful social norms and gender inequalities which undermine IPV and HIV control efforts.

Using Hierarchical Regression to Examine the Predictors of Sexual Risk-Taking Attitudes among Adolescents Living with Human Immunodeficiency Virus in Uganda

PURPOSE

We explored the factors influencing sexual risk-taking attitudes-defined as beliefs and values regarding sexual activity-among adolescents living with human immunodeficiency virus (ALHIV) in Uganda.

METHODS

The study used baseline data from a five-year cluster-randomized control trial (2012-2018) among 702 ALHIV in Uganda. Participants were aged 10-16 years, HIV-positive, taking antiretroviral therapy, and living within a family. We fitted hierarchical regression models to assess the demographic, economic, psychological, and social predictors of sexual risk-taking attitudes. Using R2, the final model explained 11.4% of the total variance.

RESULTS

Under economic factors, caregiver being formally employed (β = -0.08, 95% confidence interval [CI]: -0.10-0.06, p < .001), and the ALHIV working for pay (β = 1.78, 95% CI: 0.28-3.29, p = .022), were associated with sexual risk-taking attitudes. Among the psychological factors, more depressive symptoms (β = 0.22, 95% CI: 0.11-0.32, p < .001) were associated with more approving attitudes toward sexual risk-taking. Family and social factors including communicating with the caregiver about HIV (β = 1.32, 95% CI: 0.56-2.08, p = .001), sex (β = 1.09, 95% CI: 0.20-1.97, p = .017), and experiencing peer pressure (β = 3.37, 95% CI: 1.85-4.89, p < .001) were also associated with more approving attitudes toward sexual risk-taking. The final model explained 11.54% of the total variance.

DISCUSSION

Economic, psychological, and social factors influence sexual risk-taking attitudes among ALHIV. There is a need for more research to understand why discussing sex with caregivers improves adolescents' positive attitudes toward sexual risk-taking. These findings have significant ramifications in preventing sexual transmission of HIV among adolescents in low-income settings.

Task-shifting for point-of-care cervical cancer prevention in low- and middle-income countries: a case study from Uganda

Cervical cancer remains the leading cause of female cancer deaths in sub-Saharan Africa. This is despite cervical cancer being both preventable and curable if detected early and treated adequately. This paper reports on a series of action-research 'cycles' designed to progressively integrate a comprehensive, task-shifted, point-of-care, prevention program in a community-based public health facility in Uganda. The work has been undertaken through a UK-Ugandan Health Partnership coordinated by Knowledge for Change, a UK-registered Charity. The intervention demonstrates the effectiveness of task-shifting responsibility to Community Health Workers combined with the use of Geographic Information Systems to strategically guide health awareness-raising and the deployment of medical devices supporting respectful and sustainable point-of-care screen-and-treat services. The integration of this with public human immunodeficiency virus services demonstrates the ability to engage hard-to-reach 'key populations' at greatest risk of cervical cancer. The findings also demonstrate the impact of external influences including the Results Based Financing approach, adopted by many foreign Non-Governmental Organizations. The model presents opportunities for policy transfer to other areas of health promotion and prevention with important lessons for international Health partnership engagement. The paper concludes by outlining plans for a subsequent action-research cycle embracing and evaluating the potential of Artificial Intelligence to enhance service efficacy.

Mode of HIV acquisition among adolescents living with HIV in resource-limited settings: A data-driven approach from South Africa

Adolescents living with HIV (ALHIV) face unique treatment and care challenges which may differ by how they acquired HIV, whether vertically (in-utero, perinatal or postnatal exposure during breastfeeding) or sexually (sexual exposure). Distinguishing and documenting the mode of HIV acquisition (MOHA) is crucial to further research on the different needs and outcomes for ALHIV and to tailor HIV services to their needs. Age-based cut-offs have been used to attribute MOHA but have not been validated. We analysed data from a three-wave cohort of n = 1107 ALHIV part of a longitudinal study in South Africa. Age-based MOHA was allocated using age at ART initiation, validated against a logic-tree model based on literature-hypothesised factors: self-reported HIV, sexual, and family history. After testing six ART initiation age cut-offs (10 to 15 years old), we determined the optimal MOHA cut-off age by calculating the sensitivity and specificity for each cut-off, measured against the final logic-tree allocation. Following validation using this longitudinal study, the methodology is extended to 214 additional third-wave participants-adolescent girls and young women living with HIV who became mothers before the age of 20. Finally, descriptive statistics of the final allocations are presented. Among the 1,063 (96.0%) cohort study participants classified, 68.7% acquired HIV vertically, following validation. ART initiation before cut-off age 10 had the highest sensitivity (58.9%) but cut-off age 12 had the largest area under the curve (AUC) (0.712). Among the additional young mothers living with HIV, 95.3% were estimated to have acquired it sexually, following the same algorithm. For this group, while cut-off ages 10 to 12 had the highest sensitivity (92.2%), age 14 had the highest AUC (0.703). ART initiation before 10 years old is strongly associated with vertical HIV acquisition. Therefore, a cut-off age of 10 would remain the recommendation in LMIC regions with similar epidemiology as South Africa for determining MOHA in research and clinic settings.

Associations Between Mobility, Food Insecurity, and Transactional Sex Among Women in Cohabitating Partnerships: An Analysis From 6 African Countries 2016-2017

BACKGROUND

Mobile women are at risk of HIV infection in sub-Saharan Africa, although we lack evidence for HIV risk among women in mobile partnerships, especially in the context of household food insecurity, a growing concern in the region.

SETTING

Women aged 15-59 years with a cohabitating male partner who participated in population-based HIV impact assessment surveys in Eswatini, Lesotho, Namibia, Tanzania, Uganda, and Zambia.

METHODS

We evaluated the association between women's and their partner's mobility (being away from home for more than 1 month or staying elsewhere) and transactional sex (selling sex or receiving money or goods in exchange for sex). We examined associations for effect measure modification by food insecurity level in the household in the past month. We used survey-weighted logistic regression, pooled and by country, adjusting for individual, partner, and household-level variables.

RESULTS

Among women with a cohabitating male partner, 8.0% reported transactional sex, ranging from 2.7% in Lesotho to 13.4% in Uganda. Women's mobility [aOR 1.35 (95% CI: 1.08 to 1.68)], but not their partner's mobility [aOR 0.91 (0.74-1.12)], was associated with transactional sex. Food insecurity was associated with transactional sex independent of mobility [aOR 1.29 (1.10-1.52)]. Among those who were food insecure, mobility was not associated with increased odds of transactional sex.

CONCLUSION

Food insecurity and women's mobility each increased the odds of transactional sex. Because transactional sex is associated with HIV risk, prevention programs can address the needs of mobile and food-insecure women, including those in cohabitating relationships.

Oral PrEP Consultations Among Adolescent Girls and Young Women in Kisumu County, Kenya: Insights from the DREAMS Program

Although Kenya nationally scaled up oral pre-exposure prophylaxis (PrEP) in May 2017, adolescent girls' (AG, aged 15-19 years) and young women's (YW, aged 20-24 years) PrEP use remains suboptimal. Thus, we analyzed PrEP consultations-interactions with a healthcare provider about PrEP-among Kenyan AGYW. In April-June 2018, AGYW enrolled in DREAMS in Kisumu County, Kenya self-reported their HIV-related knowledge, behaviors, and service use. Among HIV negative, sexually active AG (n = 154) and YW (n = 289), we examined associations between PrEP eligibility and PrEP consultations using prevalence ratios (PR, adjusted: aPR). Most AG (90.26%) and YW (94.12%) were PrEP-eligible due to inconsistent/no condom use, violence survivorship, or recent sexually transmitted infection symptoms. Between PrEP-eligible AG and YW, more YW were ever-orphaned (58.09%), ever-married (54.41%), ever-pregnant (80.88%), and out of school (78.31%); more PrEP-eligible YW reported PrEP consultations (41.18% vs. 24.46%, aPR = 1.51 [1.01-2.27]). AG who used PEP (post-exposure prophylaxis) reported more consultations (aPR = 5.63 [3.53-8.97]). Among YW, transactional sex engagers reported more consultations (58.62% vs. 39.09%, PR = 1.50 [1.06-2.12]), but only PEP use (aPR = 2.81 [2.30-3.43]) and multiple partnerships (aPR = 1.39 [1.06-1.82]) were independently associated with consultations. Consultations were lowest among those with 1 eligibility criterion (AG = 11.11%/YW = 27.18%). Comparatively, consultations were higher among AG and YW with 2 (aPR = 3.71 [1.64-8.39], PR = 1.60 [1.07-2.38], respectively) or ≥ 3 (aPR = 2.51 [1.09-5.78], PR = 2.05 [1.42-2.97], respectively) eligibility criteria. Though most AGYW were PrEP-eligible, PrEP consultations were rare and differed by age and vulnerability. In high-incidence settings, PrEP consultations should be conducted with all AGYW. PrEP provision guidelines must be re-assessed to accelerate AGYW's PrEP access.

Food insecurity and the risk of HIV acquisition: findings from population-based surveys in six sub-Saharan African countries (2016-2017)

OBJECTIVE

To assess the potential bidirectional relationship between food insecurity and HIV infection in sub-Saharan Africa.

DESIGN

Nationally representative HIV impact assessment household-based surveys.

SETTING

Zambia, Eswatini, Lesotho, Uganda and Tanzania and Namibia.

PARTICIPANTS

112 955 survey participants aged 15-59 years with HIV and recency test results.

MEASURES

Recent HIV infection (within 6 months) classified using the HIV-1 limited antigen avidity assay, in participants with an unsuppressed viral load (>1000 copies/mL) and no detectable antiretrovirals; severe food insecurity (SFI) defined as having no food in the house ≥three times in the past month.

RESULTS

Overall, 10.3% of participants lived in households reporting SFI. SFI was most common in urban, woman-headed households, and in people with chronic HIV infection. Among women, SFI was associated with a twofold increase in risk of recent HIV infection (adjusted relative risk (aRR) 2.08, 95% CI 1.09 to 3.97). SFI was also associated with transactional sex (aRR 1.28, 95% CI 1.17 to 1.41), a history of forced sex (aRR 1.36, 95% CI 1.11 to 1.66) and condom-less sex with a partner of unknown or positive HIV status (aRR 1.08, 95% CI 1.02 to 1.14) in all women, and intergenerational sex (partner ≥10 years older) in women aged 15-24 years (aRR 1.23, 95% CI 1.03 to 1.46). Recent receipt of food support was protective against HIV acquisition (aRR 0.36, 95% CI 0.14 to 0.88).

CONCLUSION

SFI increased risk for HIV acquisition in women by twofold. Heightened food insecurity during climactic extremes could imperil HIV epidemic control, and food support to women with SFI during these events could reduce HIV transmission.

Prevalence of the Human Immunodeficiency Virus and associated factors in pregnant women in the state of Pará

OBJECTIVES

to analyze the prevalence of the Human Immunodeficiency Virus and the associated factors in pregnant women in the state of Pará.

METHODS

retrospective, analytical, quantitative study with a sample of 332 medical records of HIV-positive pregnant women hospitalized at the Referral Maternity Hospital in the state of Pará between 2010 and 2019. Bivariate and multivariate statistical analysis were performed with the variables collected.

RESULTS

the average prevalence in the period was 2.39% and the Metropolitan Region concentrated 66.87% of cases. There was a strong relationship between the number of antenatal consultations and lack of knowledge of serological status (p value equal to 0.01E-17) variables, and a correlation between the education and number of antenatal consultations variables.

CONCLUSIONS

the increase in the infection rate during the study period revealed the need to intensify health actions, early diagnosis and strategies to improve adherence to antiretroviral treatment for maternal viral suppression and reduction of the risk of vertical transmission, contributing to improve public policies.

Women's Economic Contribution, Relationship Status and Risky Sexual Behaviours: A Cross-Sectional Analysis from a Microfinance-Plus Programme in Rural South Africa

In sub-Saharan Africa, women bear a disproportionate burden of HIV/AIDS while also facing economic and gender inequalities. To explore the association of women's economic contribution and relationship status with risky sexual behaviour, this study analysed cross-sectional data from 626 women aged 22 to 84 in rural South Africa. All women were enrolled in a microfinance plus gender training programme (Intervention with Microfinance for AIDS and Gender Equity (IMAGE)). We used univariable and multivariable logistic regression to explore the associations of relationship status and women's household income contribution with inconsistent condom use, multiple sexual partners and transactional sex, respectively. We found that married, older women had the highest odds of inconsistent condom use, while those contributing all the household income had higher odds of multiple sexual partnerships, but lower odds of transactional sex compared to those with no contribution. Income contribution and relationship status have a nuanced relationship with sexual risk behaviours. Thus, economic strengthening interventions should target relevant vulnerable women while also addressing the broader social and economic drivers of risky sexual behaviour.

Socioeconomic Inequalities and HIV Testing During Antenatal Care in High- Medium- and Low-Conflict Intensity Countries in Sub-Saharan Africa

Understanding HIV testing determinants in different settings is vital to reducing new infections. This study assessed HIV testing rates during antenatal care (ANC) in seven sub-Saharan African countries designated as high, medium, low or no conflict intensity settings. We ranked and plotted concentration curves for HIV testing by socioeconomic inequality and determined their concentration indices (CCI). Testing for HIV during ANC was highest in Zimbabwe (95.7%) and lowest in Sudan (3.6%). Countries with medium and high conflict intensity experienced higher HIV testing inequality (CCI = 0.38) than countries with low or no conflict (CCI = 0.15). Low HIV testing rates were associated with no education, rural areas, poorest wealth index quintiles and home birth, which demonstrate that determinants of HIV testing during ANC in conflict-affected areas are complex and context-based. Programme implementation and policymakers must acknowledge these complexities and local contexts in their program designs and planning.

HIV and Herpes Simplex Virus Type 2 Incidence Among Adolescent Mothers in South Africa: A Longitudinal Analysis of HIV Prevention Trials Network 068 Data

BACKGROUND

Adolescent motherhood is common in South Africa and occurs against a backdrop of high HIV risk. While childbearing during adolescence may result in social and economic strain that may negatively impact health, there has been limited study of whether adolescent motherhood increases the risk of HIV or herpes simplex virus type 2 (HSV-2) acquisition or engagement in high-risk sexual partnerships.

SETTING

Data are from HIV Prevention Trials Network 068, a longitudinal conditional cash transfer study of adolescent girls and young women (age, 13-23) in rural South Africa.

METHODS

We used survival analysis to estimate hazard ratios to determine if adolescent motherhood (live birth before 20 years) predicted incident HIV and incident HSV-2 and generalized estimating equations for behavioral risk ratios to determine if adolescent motherhood was associated with transactional sex and age-disparate partnerships.

RESULTS

Of 2452 adolescent girls and young women who were HIV negative at baseline, 5% were adolescent mothers; 16% were adolescent mothers by the end of the study period. After controlling for covariates, adolescent motherhood predicted incident HSV-2 acquisition [ adjusted hazard ratios, 1.30; 95% confidence interval (CI): 1.01 to 1.95] but not HIV acquisition ( adjusted hazard ratios, 1.19; 95% CI, 0.76 to 1.86). Adolescent motherhood was also associated with being in an age-disparate partnership (adjusted risk ratio, 1.30; 95% CI: 1.07 to 1.58) but not transactional sex.

CONCLUSION

Adolescent motherhood increased the risk of HSV-2 and engagement in age-disparate partnerships, both known risk factors for HIV infection. Sexually transmitted infection screening and/or tailored combination HIV prevention interventions that account for the context of adolescent motherhood are critical to maximize adolescent mothers' long-term health and to meet UNAIDS 95-95-95 targets by 2030.

Individual and Relationship-Level Correlates of Transactional Sex Among Adolescent Girls and Young Women in Malawi: A Multilevel Analysis

Transactional sex increases HIV risk among adolescent girls and young women (AGYW). Understanding the individual and dyadic nature of transactional sex may provide evidence for risk reduction interventions. Multilevel logistic regression was used to cross-sectionally examine correlates of transactional sex among AGYW in Lilongwe, Malawi. Participants (N = 920) reported 1227 relationships. Individual-level associations were found between being divorced/widowed (AOR 5.07, 95% CI 1.93, 13.25), married (AOR 0.26, 95% CI 0.09, 0.72), or unstably housed (AOR 7.11, 95% CI 2.74, 18.47) and transactional sex. At the relationship-level, transactional sex occurred in relationships with: non-primary primary partners (AOR 4.06, 95% CI 2.37, 6.94), perceived partner concurrency (AOR 1.85, 95% CI 1.11, 3.08), and feared violence with couples HIV testing (AOR 2.81, 95% CI 1.26, 6.29), and less likely to occur in relationships with children (AOR 0.15, 95% CI 0.06, 0.38). Multiple co-occurring social and structural vulnerabilities increase transactional sex engagement warranting the need for social protection and gender transformative approaches.

What are the current factors that impact on health-related quality of life for women living with HIV?

Since the start of the HIV epidemic, care has often had a strong focus on quality of life. In the early days, this was in part due to the limited treatment options available for people living with HIV, alongside the strong humanistic desire of those working in the specialty to provide optimum care. Advances in HIV treatments have led to care having more of a medical focus, with national and international targets concentrating on the prevention of new infections. Despite medical progress, the impact of being diagnosed and living with HIV has a significant impact on many people, across all aspects of their life. Factors that impact on health-related quality of life for women living with HIV are often poorly understood and under-explored in healthcare settings.

Prevalência do Vírus da Imunodeficiência Humana e fatores associados em gestantes no estado do Pará

RESUMO Objetivos: analisar a prevalência do Vírus da Imunodeficiência Humana e os fatores associados em gestantes no estado do Pará. Métodos: estudo analítico, quantitativo e retrospectivo com a amostra de 332 prontuários de gestantes HIV positivas internadas na Maternidade de Referência do estado do Pará, no período de 2010 a 2019. Com as variáveis coletadas, procedeu-se a análise estatística bivariada e multivariada. Resultados: a média de prevalência no período foi de 2,39% e a Região Metropolitana concentrou 66,87% dos casos. Houve forte relação entre as variáveis número de consultas pré-natais e desconhecimento do status sorológico (p valor igual a 0,01E-17) e correlação entre as variáveis escolaridade com o número de consultas pré-natais. Conclusões: o aumento da taxa de infecção no período estudado revelou a necessidade de intensificar as ações de saúde, o diagnóstico precoce e as estratégias para a melhoria da adesão ao tratamento antirretroviral para supressão viral materna e redução do risco de transmissão vertical, contribuindo para aprimorar as políticas públicas.

The role of food security in increasing adolescent girls' agency towards sexual risk taking: qualitative findings from an income generating agricultural intervention in southwestern Kenya

BACKGROUND

Food insecurity is an important underlying driver of HIV risk and vulnerability among adolescents in sub-Saharan Africa. In this region, adolescents account for 80% of all new HIV infections. The primary purpose of this analysis is to understand perceived mechanisms for how a multisectoral agricultural intervention influenced sexual risk taking among HIV-affected adolescents in southwestern Kenya.

METHODS

We conducted semi-structured, individual interviews with 34 adolescent-caregiver dyads who were participants in Adolescent Shamba Maisha (NCT03741634), a sub-study of adolescent girls and caregivers with a household member participating in the Shamba Maisha trial (NCT01548599), a multi-sectoral agricultural and microfinance intervention. Interviews were audiotaped, transcribed, translated, and analyzed using framework and interpretive description analysis methods.

RESULTS

Adolescents receiving the Shamba Maisha intervention described no longer needing to engage in transactional sex or have multiple concurrent sexual partners as a way to meet their basic needs, including food. Key mechanisms for these effects include greater sexual agency among adolescent girls, and increased confidence and self-efficacy in overcoming existing reciprocity norms and sexual relationship power inequity; as well as staying in school. The intervention also increased caregiver confidence in talking about adolescent sexual reproductive health issues. In contrast, driven primarily by the need for food and basic needs, girls in the control arms described engaging in transactional sex, having multiple sexual partners, being unable to focus in school, getting pregnant or becoming HIV infected.

CONCLUSION

These findings emphasize the need to address food insecurity as a part of structural interventions targeting adolescent HIV risk in low-resource countries. We recommend that future interventions build upon the Shamba Maisha model by combining sustainable agricultural production, with household level interventions that deliberately target gender norms that contribute to unequal power dynamics.

Sexual debut and risk behaviors among orphaned and vulnerable children in Zambia: which protective deficits shape HIV risk?

Orphaned and vulnerable children (OVC) are not only affected by, but also rendered at-risk of, HIV due to overlapping deficits in protective assets, from school to household financial security. Drawing from a protective deficit framework, this study examines correlates of sexual risk - including multiple sexual partnerships, unprotected sex, and age at sexual debut - among OVC aged 13-17 years in Zambia. In May-October 2016, a two-stage stratified random sampling design was used to recruit OVC and their adult caregivers (N = 2,034) in four provinces. OVC-caregiver dyads completed a structured interview addressing household characteristics, protective assets (i.e. finances, schooling, and nutrition), and general health and wellbeing. Associations of factors derived from the multi-component protective deficits framework were examined using multivariable ordered logistic regression, comparing sexually inexperienced OVC to those with a sexual debut and reporting ≥1 sexual behavior(s). A sub-analysis of older (ages 15-17) OVC identified correlates of early (before age 15) and later (at or after age 15) sexual debut using multinomial logistic regression. Among 735 OVC aged 13-17, 14% reported a sexual debut, among whom 14% and 22% reported 2+ past-year partners and non-condom last sex, respectively. Older age (Adjusted Odds Ratio [aOR] = 2.08, 95% Confidence Interval [CI] 1.32-3.27), male sex (aOR = 1.90, CI 1.22-2.96), not having a birth certificate (aOR = 2.05, CI 1.03-4.09), out-of-school status (aOR = 2.63, CI 1.66-4.16), and non-household labor (aOR = 1.84, CI 1.01-3.38) were significantly associated with higher sexual risk. Male sex was the only factor significantly associated with early sexual debut in multivariable analysis. Sexual risk-reduction strategies require age- and sex-specific differentiation and should be prioritized for OVC in financially distressed households.

Risky Sexual Behavior across Extremes of Wealth in sub-Saharan Africa: A Meta-Analysis of Demographic and Health Surveys

Background

Risky sexual behavior increases the risk of contracting sexually transmitted disease including HIV and other reproductive health problems. There have been varying assumptions and different reported result explaining the relationship between risky sexual behavior and wealth. This review was intended to examine the disparity of risky sexual behavior among the two extremes of wealth in sub-Saharan African countries.

Method

This study reviewed demographic and health survey reports of sub-Saharan African countries. We excluded older reports and reports published in languages other than English. Finally, reports from 16 countries were considered for review. Data were entered in excel and transported to stata for analysis. Metaprop and Metan command were used to compute proportions and odds ratio. Standard chi-square and I square tests were used to assess heterogeneity.

Result

Pooled prevalence of having multiple sexual partner ranges from 2 to 12%. Over 80% of the countries reported that more than half of the individuals did not use condom at their last risky sexual intercourse. Poorest females were 0.62 [OR: 0.62, 95% CI (0.50, 0.78)] times less likely to have multiple sexual partners than males. Both males and females from the poorest wealth quantile had higher odds of not using condom at their last risky sexual intercourse, 1.41 [OR: 1.41, 95% CI (1.29, 1.53)], 1.41 [OR: 1.46, 95% CI (1.23, 1.73)], respectively.

Conclusion

Multiple sexual partners is relatively low in the region. Condom non-use is high in both genders. Additionally, poorest males and females were at higher risk of not using a condom at last risky sexual intercourse.

"Burnt by the scorching sun": climate-induced livelihood transformations, reproductive health, and fertility trajectories in drought-affected communities of Zambia

Background

Climate-induced disruptions like drought can destabilize household and community livelihoods, particularly in low- and middle-income countries. This qualitative study explores the impact of severe and prolonged droughts on gendered livelihood transitions, women’s social and financial wellbeing, and sexual and reproductive health (SRH) outcomes in two Zambian provinces.

Methods

In September 2020, in-depth interviews (n = 20) and focus group discussions (n = 16) with 165 adult women and men in five drought-affected districts, as well as key informant interviews (n = 16) with civic leaders and healthcare providers, were conducted. A team-based thematic analysis approach, guided by the Framework Method, was used to code transcript text segments, facilitating identification and interpretation of salient thematic patterns.

Results

Across districts, participants emphasized the toll drought had taken on their livelihoods and communities, leaving farming households with reduced income and food, with many turning to alternative income sources. Female-headed households were perceived as particularly vulnerable to drought, as women’s breadwinning and caregiving responsibilities increased, especially in households where women’s partners out-migrated in search of employment prospects. As household incomes declined, women and girls’ vulnerabilities increased: young children increasingly entered the workforce, and young girls were married when families could not afford school fees and struggled to support them financially. With less income due to drought, many participants could not afford travel to health facilities or would resort to purchasing health commodities, including family planning, from private retail pharmacies when unavailable from government facilities. Most participants described changes in fertility intentions motivated by drought: women, in particular, expressed desires for smaller families, fearing drought would constrain their capacity to support larger families. While participants cited some ongoing activities in their communities to support climate change adaptation, most acknowledged current interventions were insufficient.

Conclusions

Drought highlighted persistent and unaddressed vulnerabilities in women, increasing demand for health services while shrinking household resources to access those services. Policy solutions are proposed to mitigate drought-induced challenges meaningfully and sustainably, and foster climate resilience.

Contextual factors associated with knowledge and attitudes of HIV/AIDS among Malawian women of reproductive age

BACKGROUND

Increasing the knowledge and attitude toward human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) is a key in the management of the condition. However, in Malawi, there is limited information regarding individual- and community-level factors associated with HIV/AIDS knowledge and attitudes. This study examined the contextual factors associated with HIV/AIDS knowledge and attitudes among women of childbearing age (WOCBA) (aged 15-49 years) in Malawi.

METHODS

The 2015-16 Malawi demographic and health survey was used to analyze 24 562 WOCBA who were nested in 850 communities. Mixed effects logistic regression models were fitted to estimate the fixed and random effects of individual- and community-level factors on HIV/AIDS knowledge and attitudes.

RESULTS

Approximately 30.9% of the participants had good HIV/AIDS knowledge while 80.5% had good HIV/AIDS attitudes. Among others, at the individual-level, woman's age, educational level and household wealth were positively associated with both good HIV/AIDS knowledge and attitudes. At the community-level, those from communities with a high percentage of women complaining about the distance to health facility were less likely to have both good HIV/AIDS knowledge and attitudes.

CONCLUSIONS

Individual- and community-level factors have been shown to be associated with HIV/AIDS knowledge and attitudes among WOCBA in Malawi. Additionally, residual heterogeneity in terms of HIV/AIDS knowledge and attitudes across communities was observed. Therefore, thorough profiling of communities when designing public health programs and strategies may prove beneficial.

Assessing longitudinal patterns of depressive symptoms and the influence of symptom trajectories on HIV pre-exposure prophylaxis adherence among adolescent girls in the HPTN 082 randomized controlled trial

INTRODUCTION

African adolescent girls and young women (AGYW) eligible for HIV pre-exposure prophylaxis (PrEP) experience high levels of depressive symptoms. Depression can reduce PrEP adherence among adults, although analyses have considered depression as a time-varying exposure rather than modelling distinct patterns of symptoms. The association between depressive symptoms and PrEP adherence has not been explored for AGYW. To address these gaps, we sought to understand depressive symptom trajectories among African AGYW initiating PrEP and the impact of time-varying depressive symptoms and symptom trajectories on PrEP adherence.

METHODS

HPTN 082 was an open-label PrEP study among AGYW (ages 16 to 24) in Zimbabwe and South Africa from 2016 to 2018. Depressive symptoms were measured at enrolment and Weeks 13, 26 and 52, using the 10-item Center for Epidemiologic Studies scale; a score ≥10 is indicative of elevated depressive symptoms. PrEP adherence was defined as any detectable tenofovir diphosphate (TFV-DP) levels. Group-based trajectory modelling was used to model longitudinal patterns of depressive symptoms. We assessed psychosocial and behavioural predictors of depressive symptom trajectory membership (e.g. PrEP stigma, intimate partner violence [IPV], sexual behaviour). We modelled associations between (1) group trajectory membership and PrEP adherence at Week 52 and (2) time-varying depressive symptoms and PrEP adherence through follow-up.

RESULTS

At enrolment, 179 (41.9%) participants had elevated depressive symptoms. Group-based trajectory models revealed persistent elevated depressive symptoms in 48.5%, declining symptoms in 9.4% and no consistent or mild depressive symptoms in 43.3%. AGYW who engaged in transactional sex, reported IPV, or had traumatic stress symptoms were more likely to be assigned to the persistent elevated symptom group compared with the consistent no/mild symptom group (Wald test p-value all <0.01). Participants assigned to the persistent elevated depressive symptom trajectory had a significantly lower risk of detectable TFV-DP at Week 52 than those in the no/mild symptom trajectory (adjusted prevalence ratio = 0.89; 95% CI: 0.80 to 0.98). Elevated depressive symptoms were significantly inversely associated with PrEP use throughout follow-up (adjusted relative risk = 0.73; 95% CI = 0.53 to 0.99).

CONCLUSIONS

Persistent depressive symptoms were common among African AGYW seeking PrEP. Integration of depressive symptom screening and treatment into PrEP programmes may improve PrEP effectiveness among African women.

Factors that influence HIV status disclosure among the elderly: perspectives from Shurugwi, Zimbabwe

Due to the widespread availability of antiretroviral medications, many people with HIV are living longer. Being an HIV-positive elderly, however, brings in complications as far as disclosure of status is concerned. This phenomenological study was carried out to explore factors that influence disclosure among the elderly. Sample data was obtained from 14 participants aged at least 50 years who attended a certain District Hospital for ART. Using the convenience sampling technique, the researchers were able to select those patients who were easily accessible until sample size was reached. The researchers used interpretive thematic analysis that allowed coding of findings. The main findings from the research indicated that stigma, loss of family support, partner's reaction and cultural norms were the main reasons that hindered the elderly to freely disclose their HIV-positive serostatus as it cuts across all their social interactions. In order to reduce the negative consequences of nondisclosure, the elderly, their significant others and the general public need to be educated about the importance of disclosure among the elderly and support groups for the elderly need to be availed.

Characteristics of adolescents aged 15-19 years living with vertically and horizontally acquired HIV in Nampula, Mozambique

BACKGROUND

Adolescents living with HIV (ALHIV) 15-19 years of age are a growing proportion of all people living with HIV globally and the population includes adolescents with vertically acquired HIV (AVH) and behaviorally acquired HIV (ABH).

METHODS

We conducted a survey to measure sociodemographic characteristics, educational status, health history, and antiretroviral therapy (ART) adherence among a convenience sample of ALHIV at three government health facilities in 2019 in Nampula, Mozambique. ALHIV 15-19 years on ART, including females attending antenatal care, were eligible. Routine HIV care data were extracted from medical charts. Classification of ALHIV by mode of transmission was based on medical charts and survey data. ALHIV who initiated ART <15 years or reported no sex were considered AVH; all others ABH. Frequencies were compared by sex, and within sex, by mode of transmission (AVH vs. ABH) using Chi-square, Fishers exact tests and Wilcoxon rank-sum tests.

RESULTS

Among 208 ALHIV, 143 (69%) were female and median age was 18 years [interquartile range (IQR) 16-19]. Just over half of ALHIV (53%) were in or had completed secondary or higher levels of education; the most common reason for not being in school reported by 36% of females was pregnancy or having a child. Of all ALHIV, 122 (59%) had VL data, 62% of whom were <1000 copies/mL. Almost half (46%) of ALHIV reported missing ARVs ≥ 1 day in the past month (62% of males vs. 39% of females; p = 0.003). Just over half (58%) of ALHIV in relationships had disclosed their HIV status: 13% of males vs. 69% of females (p<0.001). Among sexually active males, 61% reported using a condom at last sex compared to 26% of females (p<0.001). Among female ALHIV, 50 (35%) were AVH and 93 (65%) were ABH, 67% of whom were not in school compared to 16% of ABH, (p<0.001).

DISCUSSION

Data from our study underscore the high level of deprivation among ALHIV enrolled in HIV care in Mozambique, as well as important disparities by sex and mode of transmission. These data can inform the development of effective interventions for this complex and important population.

Spatial and temporal analysis of the human immunodeficiency virus in an area of social vulnerability in Northeast Brazil

Human Immunodeficiency Virus (HIV) infection still represents an important public health problem, because it involves clinical, epidemiological, social, economic and political issues. We analyzed the temporal and spatial pattern of the HIV incidence in an area of social inequality in northeast Brazil and its association with socioeconomic indicators. An ecological study was carried out with a focus on all HIV cases reported in Alagoas State, Northeast Brazil from 2007 to 2016 using its 102 municipalities as the units of our analysis. Data from the Brazilian information systems were used. Georeferenced data were analyzed using TerraView 4.2.2 software, QGis 2.18.2 and GeoDa 1.14.0. Time trend analyses were performed by the Joinpoint Regression software and the spatial analyses included the empirical Bayesian model and Moran autocorrelation. Spatial regression was used to determine the influence of space on HIV incidence rate and socioeconomic inequalities. There was an increasing trend of HIV rates, especially in the municipalities of the interior. Significant spatial correlations were observed with the formation of clusters with emphasis on the coast of the state and in tourist regions. Spatial regression explained 46% of the dependent variable. The HIV incidence rate was positively influenced by rate of primary health care units (P=0.00), and negatively by Gini index (P=0.00) and proportion of heads of household without or low education (P=0.02). We conclude that the relationship found between indicators of better socioeconomic conditions and HIV infection suggests unequal access to the diagnosis of infection. Prevention and control strategies can be established according to each epidemiological reality.

Drying Climates and Gendered Suffering: Links Between Drought, Food Insecurity, and Women's HIV in Less-Developed Countries

HIV/AIDS represents the leading cause of death among women of reproductive age globally, and gender inequalities in the burden of HIV/AIDS are most pronounced in poorer countries. Drawing on ideas from feminist political ecology, we explore linkages between suffering from drought, food insecurity, and women's vulnerability to HIV. Using data from 91 less-developed countries, we construct a structural equation model to analyze the direct and indirect influence of these factors, alongside other socio-economic indicators, on the percentage of the adult population living with HIV that are women. We find that droughts are significant in shaping gender inequalities in the HIV burden indirectly through increased food insecurity. We draw on prior research to argue that due to gendered inequalities, food insecurity increases women's vulnerability to HIV by intensifying biological susceptibilities to the disease, reducing access to social and health resources, and motivating women to engage in risky sexual behaviors, such as transactional sex. Overall, our findings demonstrate that droughts serve as an important underlying factor in promoting HIV transmission among vulnerable women in poor countries, and that food insecurity is a key mechanism in driving this relationship.

Exploring narratives and advocating support and peer mentorship to improve HIV-positive adolescent mothers' lives in South Africa

Research on adolescent sexuality, health and parenting has gained much attention in recent years. This growing body of research, however, has arguably limited qualitative outputs on HIV-positive adolescent mothers' sexual and reproductive health choices, needs, and rights in South Africa that could lead to informed policymaking. Through in-depth interviews conducted with a select group of ten HIV-positive adolescents and three key informants, the article explores the sexual, motherhood, risk discourses and reproductive health issues and rights of HIV-positive adolescent mothers as they come to terms with choices they have made and the challenges ahead. The findings highlight the dominant narratives on what are deemed to be the forces that shape these adolescent mothers' new social realities. With existing policies in place for adolescents, it is argued that a "one-size-fits-all" policy approach does not work, especially for HIV-positive adolescent mothers. Drawing on this identified gap and the tensions between individual needs, and the public welfare provision, the article highlights the need for tailored policy that will accommodate and promote the overall well-being of HIV-positive adolescent mothers and their children.

Hurricane impact associated with transactional sex and moderated, but not mediated, by economic factors in Okay, Haiti

Natural disasters, such as hurricanes, often negatively affect the economic wellbeing of affected individuals. Under such conditions, women may engage in transactional sexual behaviors in order to compensate for lost income and provide for their households. In this study, we evaluated the relationship between hurricane impact and transactional sex and if this relationship was moderated, or mediated, through economic factors. Between December 2017 and February 2018, approximately one year after the area was hit by a category 4 hurricane (Hurricane Matthew), we interviewed a random sample of female microfinance members (n = 304) in Okay, Haiti. We estimated the association between hurricane impact and transactional sex using log-binomial regression. Next, we tested for economic moderation of this relationship by incorporating interaction terms between hurricane impact and food insecurity, poverty, and loss of income generating materials in three separate log-binomial models. Finally, we assessed possible mediation of this relationship by loss of income generating resources and a latent variable, economic stress, using a structural equation model. We found participants who had experienced hurricane impact were 58% more likely to have engaged in transactional sex [prevalence ratio (95% confidence interval): 1.58 (1.19-2.09)]. This relationship was significant and strongly positive among women who were food insecure and had high poverty but not so among women who were food secure and had low poverty, respectively. The final structural equation model (with fit: χ2 = 19.700, degrees of freedom = 15; CFI = 0.958; TLI = 0.941; RMSEA = 0.040) revealed that the relationship was not mediated through economic factors. However, the association between hurricane impact and transactional sex remained significant while controlling for these economic factors. Notably, the findings that the relationship between hurricane impact and transactional sex was moderated, but not mediated, by economic factors implies populations at-risk of experiencing natural disasters should be preemptively targeted with economic interventions to build capacity and resilience before such a disaster hits.

Resource demands reduce partner discrimination in Himba women

Where autonomy for partner choice is high, partner preferences may be shaped by both social and ecological conditions. In particular, women's access to resources can influence both the type and number of partnerships she engages in. However, most existing data linking resources and partner choice rely on either priming effects or large demographic databases, rather than preferences for specific individuals. Here we leverage a combination of demographic data, food insecurity scores and trait and partner preference ratings to determine whether resource security modulates partner preferences among Himba pastoralists. We find that while food insecurity alone has a weak effect on women's openness to new partners, the interaction of food insecurity and number of dependent children strongly predicts women's openness to potential partners. Further, we show that women who have more dependants have stronger preferences for wealthy and influential men. An alternative hypothesis derived from mating-market dynamics, that female desirability affects female preferences, had no effect. Our data show that women who face greater resource constraints are less discriminating in the number of partners they are open to, and have stronger preferences for resource-related traits. These findings highlight the importance of ecological signals in explaining the plasticity of mate preferences.

A gendered analysis of living with HIV/AIDS in the Eastern Region of Ghana

BACKGROUND

A gender gap exists in knowledge regarding persons living with HIV/AIDS in Ghana. Women living with HIV/AIDS (WLHIV) greatly outnumber males living with HIV/AIDS (MLHIV) in Ghana and Sub-Saharan Africa generally. This necessitates more gender-nuanced evidence-based information on HIV/AIDS to guide individuals, healthcare workers, and other stakeholders in Ghana particularly. This paper undertook a gender-focused analysis of the experiences of WLHIV and MLHIV in a municipal area in Ghana which has been most impacted by HIV/AIDS.

METHODS

In-depth interviews of 38 HIV-positive persons recruited using combined purposive and random sampling for one month, were tape recorded and analyzed using thematic content analysis. Participants were out-patients who were receiving routine care for co-morbidities at two specially equipped HIV/AIDS Voluntary Counseling and Testing Centers in the Lower Manya Krobo Municipality (LMKM), Eastern Region, Ghana.

RESULTS

Our data yielded three major themes: characteristics of participants, health status and health seeking behavior, and challenges encountered living with HIV/AIDS. Except for feeling of sadness due to their HIV/AIDS-positive status, there were significant differences in the experiences of MLHIV, compared to WLHIV. WLHIV were more likely to be housing insecure, unemployed due mostly to stigmatization/self-stigmatization, less likely to have revealed their HIV-positive status to multiple family members, and had more profound challenges regarding their healthcare. Most MLHIV expected, demanded, and had support from their wives; WLHIV were mostly single-never married, divorced or widowed (mostly due to HIV/AIDS). The vast majority of WLHIV complained of near-abject poverty, including for most of them, lack of food for taking their anti-retroviral medicines and/or taking it on time.

CONCLUSIONS

The experiences of the MLHIV and WLHIV with living and coping with the virus mostly differed. These experiences were unequivocally shaped by differential socio-cultural tenets and gendered nuances; WLHIV had more negative experiences. Public education on the extra burden of HIV/AIDS on WLHIV, more social support, and affirmative action in policy decisions in favor of WLHIV in the study district are needed to seek public sympathy and improve health outcomes and livelihoods of WLHIV particularly. Further studies using multiple sites to explore these differences are warranted.

Urban-rural disparity in sociodemographic characteristics and sexual behaviors of HIV-positive adolescent girls and young women and their perspectives on their male sexual partners: A cross-sectional study in Zimbabwe

We conducted a cross sectional survey in Zimbabwe to describe urban-rural disparity in socio-demographic characteristics and sexual behaviors of HIV-positive adolescent girls and young women (AGYW) and their male sexual partners. Between September and November 2016, we interviewed 360 sexually active HIV positive AGYW, aged 15––24 years attending ART and PMTCT clinics in urban and rural health facilities in Harare and Mazowe district respectively. HIV positive AGYW in rural areas as compared to those in urban areas were older, less educated, more frequently married or cohabiting, had lower number of male sexual partners in their lifetime and in the last 12 months preceding the survey. They were mostly heterosexually infected, more likely to disclose their status to a family member and to be more adherent to ART (OR = 2.5–95% CI = 1.1–5.5). Most recent male sexual partners of HIV positive AGYW in urban areas as compared to those from rural areas were mainly current or former boyfriends, single, more educated, less likely to have a child with them and to engage in couple voluntary counseling and testing (CVCT). They were more likely to patronize dancing and drinking venues and involved in transactional sex (OR = 2.2–95% CI: 1.2–4). They were also more likely to be circumcised (OR = 2.3–95% CI: 1.3–4.1) and to use condom more consistently in the last 12 months preceding the survey. Our study findings called for the strengthening of HIV prevention interventions in urban areas among HIV positive AGYW who had more than one partner in their lifetime or are patronizing dancing and drinking venues. In Zimbabwe, promotion of CVCT, index testing, male circumcision and condom use should be sustained to engage male sexual partners of both urban and rural HIV positive AGYW in HIV prevention.

Herpes simplex virus: global infection prevalence and incidence estimates, 2016

Objective

To generate global and regional estimates for the prevalence and incidence of herpes simplex virus (HSV) type 1 and type 2 infection for 2016.

Methods

To obtain data, we undertook a systematic review to identify studies up to August 2018. Adjustments were made to account for HSV test sensitivity and specificity. For each World Health Organization (WHO) region, we applied a constant incidence model to pooled prevalence by age and sex to estimate the prevalence and incidence of HSV types 1 and 2 infections. For HSV type 1, we apportioned infection by anatomical site using pooled estimates of the proportions that were oral and genital.

Findings

In 2016, an estimated 491.5 million people (95% uncertainty interval, UI: 430.4 million–610.6 million) were living with HSV type 2 infection, equivalent to 13.2% of the world’s population aged 15–49 years. An estimated 3752.0 million people (95% UI: 3555.5 million–3854.6 million) had HSV type 1 infection at any site, equivalent to a global prevalence of 66.6% in 0–49-year-olds. Differing patterns were observed by age, sex and geographical region, with HSV type 2 prevalence being highest among women and in the WHO African Region.

Conclusion

An estimated half a billion people had genital infection with HSV type 2 or type 1, and several billion had oral HSV type 1 infection. Millions of people may also be at higher risk of acquiring human immunodeficiency virus (HIV), particularly women in the WHO African Region who have the highest HSV type 2 prevalence and exposure to HIV.

Consistent Provisions Mitigate Exposure to Sexual Risk and HIV Among Young Adolescents in South Africa

Exposure to sexual risk in early adolescence strongly predicts HIV infection, yet evidence for prevention in young adolescents is limited. We pooled data from two longitudinal South African surveys, with adolescents unexposed to sexual risk at baseline (n = 3662). Multivariable logistic regression tested associations between intermittent/consistent access to eight provisions and reduced sexual risk exposure. Participants were on average 12.8 years, 56% female at baseline. Between baseline and follow-up, 8.6% reported sexual risk exposure. Consistent access to caregiver supervision (OR 0.53 95%CI 0.35-0.80 p = 0.002), abuse-free homes (OR 0.55 95%CI 0.37-0.81 p = 0.002), school feeding (OR 0.55 95%CI 0.35-0.88 p = 0.012), and HIV prevention knowledge (OR 0.43, 95%CI 0.21-0.88 p = 0.021) was strongly associated with preventing early sexual risk exposure. While individual factors reduced the odds of sexual risk exposure, a combination of all four resulted in a greater reduction, from 12.9% (95%CI 7.2-18.7) to 1.0% (95%CI 0.2-1.8). Consistent access to provisions in early adolescence may prevent sexual risk exposure among younger adolescents.

Spatial Distribution of HIV Prevalence among Young People in Mozambique

Mozambique has a high burden of HIV and is currently ranked sixth worldwide for adult prevalence. In Mozambique, HIV prevalence is not uniformly distributed geographically and throughout the population. We investigated the spatial distribution of HIV infection among adolescents and young people in Mozambique using the 2009 AIDS Indicator Survey (AIS). Generalized geoadditive modeling, combining kriging and additive modeling, was used to study the geographical variability of HIV risk among young people. The nonlinear spatial effect was assessed through radial basis splines. The estimation process was done using two-stage iterative penalized quasi-likelihood within the framework of a mixed-effects model. Our estimation procedure is an extension of the approach by Vandendijck et al., estimating the range (spatial decay) parameter in a binary context. The results revealed the presence of spatial patterns of HIV infection. After controlling for important covariates, the results showed a greater burden of HIV/AIDS in the central and northern regions of the country. Several socio-demographic, biological, and behavioral factors were found to be significantly associated with HIV infection among young people. The findings are important, as they can help health officials and policy makers to design targeted interventions for responding to the HIV epidemic.

Economic sanctions and HIV/AIDS in women

HIV/AIDS has disproportionately affected women worldwide. Several studies focus on economic sanctions and the health of populations, but little attention has been paid to the effects of sanctions on HIV rates. This study examines the influence of economic sanctions on HIV in women and finds that sanctions increase women's HIV rate by decreasing female labor participation. These findings are in line with previous findings that sanctions negatively affect public health in general as well as women in particular. All these findings suggest that policy makers need to consider more carefully the scourge of HIV/AIDS among women when formulating their policies toward target countries.

HIV prevalence in South Africa through gender and racial lenses: results from the 2012 population-based national household survey

Background

In South Africa, persistence of the HIV epidemic and associated gender and racial disparities is a major concern after more than 20 years of democratic dispensation and efforts to create a more healthy and equal society. This paper profiles HIV prevalence and related factors among Black African men and women compared to other race groups in South Africa using the 2012 population-based national household HIV survey.

Methods

This secondary data analysis was based on the 2012 population-based nationally representative multi-stage stratified cluster random household sample. Bivariate and multiple logistic regression analysis were used to assess the relationship between HIV prevalence and associated factors by gender and racial profile.

Results

Overall HIV prevalence was significantly higher (p < 0.001) among both Black African males (16.6%; 95% CI: 15.0–18.4) and females (24.1%; 95% CI: 22.4–26.0) compared to their counterparts from other races. Among Black African males, increased risk of HIV was significantly associated with age group 25–49 years and those 50 years and older compared with young males 15–25 years. Among all males, reported condom use at last sex was significantly associated with increased risk of HIV. High socio-economic status (SES) and perceived risk of HIV were associated with a decreased risk of HIV. Among female condom use at last sex and ever testing for HIV was associated with increased prevalence of HIV only among Black African females. Lower prevalence of HIV was associated with marriage, tertiary education, high SES, having a partner five years younger, perceived risk of HIV, and awareness of HIV status among Black African females.

Conclusion

Gender and racial disparities rooted in structural and contextual inequalities remain important factors for the maintenance of the generalized HIV epidemic in the country. HIV prevention interventions need to cut across all strata of society but also target risk factors salient for specific groups. Alleviating vulnerability to HIV along gender and racial lines should also be viewed as part of a broader public health strategy.

"When He Asks for Sex, You Will Never Refuse": Transactional Sex and Adolescent Pregnancy in Zambia

Pregnancy among adolescent girls in Zambia is a significant concern on its own and as a factor in school dropout and early marriage, with one-third of girls aged 15-19 having experienced pregnancy. Using qualitative and quantitative data from the Adolescent Girls Empowerment Program, we explore transactional sex as a driver of adolescent pregnancy. In qualitative interviews, transactional sex was repeatedly discussed as the main driver of pregnancy, as respondents indicated that when a girl feels that she "owes" a man sex, it prevents her from declining sex or using condoms. In addition, multivariate Cox proportional hazards models using four rounds of longitudinal data from a sample of unmarried and never pregnant adolescent girls (n=1,853) show that girls who have engaged in transactional sex face a hazard of first premarital pregnancy almost 30 percent greater than their peers who have not, independent of the effect of other risk-related sexual behaviors such as condom use and number of sexual partners. Identifying and understanding the role of transactional sex in adolescent pregnancy is important for designing effective curricula and programs that delay pregnancy, and highlights the importance of addressing access to economic resources in adolescent health outcomes.

Knowledge and attitude of HIV/AIDS among women in Nigeria: a cross-sectional study

Background

The Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) epidemic is one of the world's most serious public health and social problems. Promoting knowledge and attitude towards HIV/AIDS is a key strategy to control the prevalence of this growing epidemic. This study aimed to measure knowledge and attitude about HIV/AIDS along with the factors of association Nigerian women.

Methods

This is a cross-sectional study based on data from the 2013 Demographic Health Survey (DHS) conducted among community dwelling women in Nigeria. A set of 13 questions was identified relevant to knowledge and attitude about HIV/AIDS. Each correct answer was scored as 1 and wrong answer as '0'. Normality of the variables was examined using Shapiro-Wilks tests. The socioeconomic and community factors associated with HIV/AIDS knowledge and attitude were examined by linear regression with dummy variables model.

Results

Means score (SD) on knowledge of transmission was 6.4 (2.0) and that for attitude was 2.1 (1.2). In the regression models, knowledge and attitude of HIV/AIDS were positively associated with survey years and respondents' age; geographical region was significantly associated with HIV/AIDS knowledge and attitude; rural respondents had significant reduction in knowledge [Exp(B)=0.86; 95% confidence interval (CI)=0.83-0.89] and positive attitude to HIV/AIDS [Exp(B)=0.91; 95% CI=0.89-0.93] compared with the urban counterpart, respectively.

Conclusion

Findings of the present study suggested that women's knowledge and attitude about HIV/AIDS in Nigeria needs more attention to attain the global target to end its epidemics and other communicable diseases by 2030.

Reproductive health problems in rural South African young women: risk behaviour and risk factors

BACKGROUND

South African young women continue to be vulnerable, with high prevalence of teenage pregnancy, HIV, sexually transmitted infections (STIs) and female genital schistosomiasis (FGS). This study seeks to examine the underlying factors that may be associated with these four adverse reproductive health outcomes.

METHODS

In a cross-sectional study of 1413 sexually active of young women, we explored these four adverse reproductive health outcomes by considering socio-demographic factors, socio-economic factors, sexual risk behaviour, substance abuse and knowledge about reproductive health by using a questionnaire. Consenting participants were asked about previous pregnancies and were tested for HIV, STIs and FGS. Multivariable regression analyses were used to explore the factors associated with these four reproductive health outcomes.

RESULTS

1. Early pregnancy: Among the young women, 44.4% had already been pregnant at least once. Associated factors were hormonal contraceptives, (adjusted odds ratio (AOR): 17.94, 95% confidence interval (CI): 12.73-25.29), and sexual debut < 16 years (AOR: 3.83, 95% CI: 2.68-5.47). Living with both parents (AOR 0.37, 95% CI: 0.25-0.57) and having a steady partner (AOR: 0.43, 95% CI: 0.24-0.76) were identified as protective factors against pregnancy. 2. HIV: HIV prevalence was 17.1%. The odds of having HIV were higher in intergenerational (AOR: 2.06, 95% CI: 1.05-4.06) and intragenerational relationships (AOR: 1.51 95% CI: 1.06-2.15), compared to age-homogenous relationships. Other associated factors were: condom use (AOR: 1.60, 95% CI: 1.16-2.20), number of times treated for an STI (AOR: 1.32, 95% CI: 1.02-1.71), and total number of partners (AOR: 1.14, 95% CI: 1.03-1.28). 3. STIs: Participants who had at least one STI (40.5%) were associated with total partner number (AOR 1.17, 95% CI: 1.06-1.30), and testing HIV positive (AOR: 1.88, 95% CI 1.41-2.50). 4. FGS: FGS prevalence (19.7%) was associated with previous anti-schistosomal treatment (AOR: 2.18, 95% CI: 1.57-3.05).

CONCLUSION

There is a high prevalence of pregnancy, HIV, STIs and FGS among sexually active young women in rural KwaZulu-Natal. Multidisciplinary approaches are urgently needed for educational and health literacy programs prior to sexual debut, and health care facilities, which should be made accessible for young women.

Socio-economic vulnerabilities and HIV: Drivers of transactional sex among female bar workers in Yaoundé, Cameroon

Introduction

The purpose of this study was to examine the relationship between socio-demographic characteristics, risky sexual behaviour, alcohol use and transactional sex among female bar workers in Yaounde, Cameroon.

Materials and methods

A cross-sectional survey was conducted among a representative sample of 410 female bar workers, recruited through a modified version of venue-based cluster sampling technique from May to June 2017. Transactional sex was defined as having received money/gifts in exchange for sex with any sexual partner in the past 12 months. Logistic regression models were performed to identify the factors associated with transactional sex. The level of statistical significance was set at p< = 0.05.

Results

About 14.9% (n = 61) of respondents reported to have engaged in transactional sex, 83.7% (n = 338) had multiple sexual partners at the time of the study, 14.4% (n = 55) had sex with one or more of their male customers in the past 6 months. Almost 73.4% (n = 301) reported alcohol use. Of these, 37.2% (n = 112) were frequent alcohol consumers. About 17.6% (n = 72) reported to have had unprotected sex under the influence of alcohol in the past 6 months. Multivariate logistic regression analysis showed that those who engaged in transactional sex were more likely to have had sex with a male customer in the past 6 months (aOR = 7.34; 95% CI, 3.63–16.98), had sex under the influence of alcohol in the past 6 months (aOR = 2.42; 95% CI, 1.18–4.96) and frequent alcohol consumers (aOR = 2.06; 95%CI, 1.04–4.10). Respondents who had their last sexual intercourse 4 weeks or more prior to the study (aOR = 0.26; 95% CI, 0.08–0.84) were less likely to have engaged in transactional sex.

Conclusions

Our study concludes that female bar workers are exposed to male customers and engage in risky sexual practices including transaction sex. Most of them also consume alcohol which increases their risk of HIV and STI acquisition. They are a high-risk group that need to be targeted with HIV prevention interventions.

Sexual behavior experiences and characteristics of male-female partnerships among HIV positive adolescent girls and young women: Qualitative findings from Zimbabwe

Background

New HIV infections among sub-Saharan Africa's adolescent girls and young women (AGYW, ages 15–24) greatly exceed those of their male peers. In addition, AGYW tend to acquire HIV at a much earlier age. Understanding the factors associated with HIV infection in AGYW could inform effective prevention and treatment interventions for these populations and their male sexual partners.

Methods

This qualitative study, conducted October-November 2016, was a follow on to a quantitative survey that sought to characterize male sexual partners and sexual behaviors of sexually active HIV positive AGYW in Zimbabwe. The qualitative study explored sexual behavior experiences and characteristics of male-female partnerships among the same participants. We conducted in-depth interviews with purposively sampled AGYW (16–24 years). Audio recorded qualitative data were transcribed, translated into English, and thematically coded using NVivo.

Results

28 AGYW (n = 14 urban, n = 14 rural) took part in the in-depth interviews. 50% were 16–19 years old. Discussions with 10/11 (91%) AGYW who were reportedly infected through sex suggested that they had acquired HIV from their husbands or romantic partners. Accounts also suggested that the age difference between respondents and their male sexual partners was ≥5 years. Overall, respondents described two types of male partners: those older (''sugar daddies'', men ≥35 years old) and younger (<35 years). Respondents felt unable to suggest condom use to both older and younger partners. Evident in respondents' accounts was a general low HIV risk perception, particularly with younger men, which was largely due to poor HIV knowledge. Discussions suggested that an AGYW's relationship with either male partner was characterized by some form of violence.

Conclusions

Discussions highlighted the nature and characteristics of relationships between AGYW and their male sexual partners. Findings could inform interventions to engender risk perception among AGYW, promote female-controlled HIV prevention efforts and, foster risk-reduction among men.

Food Insecurity and Aging Outcomes in Older Adults Living with HIV

Little is known about food insecurity and its association with geriatric outcomes in older people living with HIV (PLWH). This was a cross-sectional study of 230 HIV-infected patients aged 50 and older recruited in December 2012 through June 2016. Poisson logistic regression models estimated the prevalence ratio (PR) and 95% confidence intervals (CI) for the association between food insecurity and the following geriatric outcomes: frailty, physical health and function, social support, mental health and cognition, and behavioral health. 157 (68%) participants were food secure, 35 (15%) had low food security, and 38 (17%) had very low food security. After adjusting the analyses for other significant covariates, at risk alcohol or drug use (PR = 3.14; 95% CI 1.75-5.64), being sedentary (PR = 3.30; 95% CI 1.09-10.00) depressive symptoms (PR = 1.77; 95% CI 1.13-2.76), and dependent instrumental activities of daily living (PR = 2.46; 95% CI 1.13-5.36) were significantly associated with very low food security. These results highlight a need for structural HIV interventions that incorporate targeted food assistance strategies for older PLWH.

Economic Context and HIV Vulnerability in Adolescents and Young Adults Living in Urban Slums in Kenya: A Qualitative Analysis Based on Scarcity Theory

Urban slum adolescents and young adults have disproportionately high rates of HIV compared to rural and non-slum urban youth. Yet, few studies have examined youth's perceptions of the economic drivers of HIV. Informed by traditional and behavioral economics, we applied a scarcity theoretical framework to qualitatively examine how poverty influences sexual risk behaviors among adolescents and young adults. Focus group discussions with one hundred twenty youth in Kenyan's urban slums were transcribed, coded, and analyzed using interpretive phenomenology. Results indicated that slum youth made many sexual decisions considered rational from a traditional economics perspective, such as acquiring more sex when resources were available, maximizing wealth through sex, being price-sensitive to costs of condoms or testing services, and taking more risks when protected from adverse sexual consequences. Youth's engagement in sexual risk behaviors was also motivated by scarcity phenomena explained by behavioral economics, such as compensating for sex lost during scarce periods (risk-seeking), valuing economic gains over HIV risks (tunneling, bandwidth tax), and transacting sex as an investment strategy (internal referencing). When scarcity was alleviated, young women additionally described reducing the number of sex partners to account for non-economic preferences (slack). Prevention strategies should address the traditional and behavioral economics of the HIV epidemic.

Ecological correlates of multiple sexual partnerships among adolescents and young adults in urban Cape Town: a cumulative risk factor approach

Studies in South Africa have reported unsafe levels of risky sexual behvaiours among adolescents and young adults, with the country reporting the highest burden of HIV/AIDS globally, as well as a high rate of teenage pregnancy. While determinants of risky sexual behaviours have been investigated for factors occurring at the individual and household levels, not fully explored in the literature is the effect of community level factors. Furthermore, it is unclear whether risk factors occurring within the ecology of adolescents and young adults act cumulatively to influence their sexual practices. This article aims to address this knowledge gap using a case study of the Cape Area Panel Study of adolescents and young adults in urban Cape Town, South Africa. The ecological framework was adopted to guide the selection of risk factors at the individual, household, and community levels. Multivariate linear discriminant function analyses were used to select significant risk factors for multiple sexual partnerships and used to produce risk indices for the respondents. The cumulative risk approach was applied to test whether significant risk factors acted cumulatively. Findings point to the importance of ecological factors in influencing outcomes of multiple sexual partnerships among respondents and further demonstrate that ecological risk factors may act cumulatively. These findings are important for South Africa that is grappling with teenage pregnancy and disproportionate HIV epidemic among the youth.

Sex in the shadow of HIV: A systematic review of prevalence, risk factors, and interventions to reduce sexual risk-taking among HIV-positive adolescents and youth in sub-Saharan Africa

BACKGROUND

Evidence on sexual risk-taking among HIV-positive adolescents and youth in sub-Saharan Africa is urgently needed. This systematic review synthesizes the extant research on prevalence, factors associated with, and interventions to reduce sexual risk-taking among HIV-positive adolescents and youth in sub-Saharan Africa.

METHODS

Studies were located through electronic databases, grey literature, reference harvesting, and contact with researchers. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Quantitative studies that reported on HIV-positive participants (10-24 year olds), included data on at least one of eight outcomes (early sexual debut, inconsistent condom use, older partner, transactional sex, multiple sexual partners, sex while intoxicated, sexually transmitted infections, and pregnancy), and were conducted in sub-Saharan Africa were included. Two authors piloted all processes, screened studies, extracted data independently, and resolved any discrepancies. Due to variance in reported rates and factors associated with sexual risk-taking, meta-analyses were not conducted.

RESULTS

610 potentially relevant titles/abstracts resulted in the full text review of 251 records. Forty-two records (n = 35 studies) reported one or multiple sexual practices for 13,536 HIV-positive adolescents/youth from 13 sub-Saharan African countries. Seventeen cross-sectional studies reported on individual, relationship, family, structural, and HIV-related factors associated with sexual risk-taking. However, the majority of the findings were inconsistent across studies, and most studies scored <50% in the quality checklist. Living with a partner, living alone, gender-based violence, food insecurity, and employment were correlated with increased sexual risk-taking, while knowledge of own HIV-positive status and accessing HIV support groups were associated with reduced sexual risk-taking. Of the four intervention studies (three RCTs), three evaluated group-based interventions, and one evaluated an individual-focused combination intervention. Three of the interventions were effective at reducing sexual risk-taking, with one reporting no difference between the intervention and control groups.

CONCLUSION

Sexual risk-taking among HIV-positive adolescents and youth is high, with inconclusive evidence on potential determinants. Few known studies test secondary HIV-prevention interventions for HIV-positive youth. Effective and feasible low-cost interventions to reduce risk are urgently needed for this group.

Trends and determinants of HIV/AIDS knowledge among women in Bangladesh

BACKGROUND

Globally, women share an indiscriminate burden of the HIV epidemic and the associated socioeconomic consequences. Previous studies have demonstrated a positive correlation between levels of HIV knowledge with its prevalence. However, for Bangladesh such evidence is non-existent. In this study, we aimed to explore the extent of HIV knowledge in relation to the socio-demographic variables such as age, region, area of residence i.e., urban or rural, wealth index and education, and investigate the factors influencing the level of HIV knowledge among Bangladeshi women.

METHODS

We used data from the Bangladesh Demographic and Health Survey (BDHS) survey conducted in 2011. In total 12,512 women ageing between 15 and 49 ever hearing about HIV regardless of HIV status were selected for this study. HIV knowledge level was estimated by analyzing respondents' answers to a set of 11 basic questions indicative of general awareness and mode of transmission. Descriptive statistics, cross-tabulation and multinominal logistic regression were performed for data analysis.

RESULTS

Little over half the respondents had good knowledge regarding HIV transmission risks. The mean HIV knowledge score was -0.001 (SD 0.914). Average correct response rate about mode of transmission was higher than for general awareness. Educational level of women and sex of household head were found to be significantly associated with HIV knowledge in the high score group. Those with no education, primary education or secondary education were less likely to be in the high score group for HIV knowledge when compared with those with higher than secondary level of education. Similarly those with male as household head were less likely to be in the higher score group for HIV knowledge.

CONCLUSIONS

Level of HIV knowledge among Bangladeshi women is quite low, and the limiting factors are rooted in various demographic and household characteristics. Education and sex of the household head have been found to be significantly correlated with the level of HIV knowledge and propound sound grounds for their incorporation in the future HIV prevention strategies. Education of women may also have wider ramifications allowing reduction in gender inequality, which in turn favors higher knowledge about HIV.